ABSTRACT
The use of endobronchial valves (EBV) is a recommended treatment for persistent air leak (PAL) and endoscopic lung volume reduction (ELVR) in selected patients with severe emphysema and absence of collateral ventilation. We report the case of a 52‐year‐old man who was scheduled for a bilateral sequential lung transplantation, converted to a left single lung transplantation (SLTx) after failure to remove the right lung due to prior thoracic surgery. The post‐operative course was complicated by a PAL on the right non‐transplanted side, unresponsive to prolonged drainage. Placement of EBV in the right upper and middle lobes, following collateral ventilation evaluation with the Chartis system, resulted in the resolution of the air leak and a concomitant lung volume reduction. Based on a literature review regarding ELVR in single‐lung transplanted recipients, we suggest that ELVR with EBV could be a therapeutic option with an acceptable safety profile in this unique population.
Keywords: emphysema, endobronchial valve, lung transplantation, lung volume reduction, persistent air leak
We report a case of a single‐lung transplanted recipient treated with endobronchial valves (EBV) for post‐operative persistent air leak and lung volume reduction of the native lung. This case and literature review suggest that EBV may be a treatment in lung transplant recipients with an acceptable safety profile.
1. Introduction
The use of endobronchial valves (EBV) for endoscopic lung volume reduction (ELVR) is a recommended treatment in selected severe emphysema patients with absence of collateral ventilation [1]. Current guidelines recommend ELVR in symptomatic and hyperinflated patients as it improves their lung function, exercise capacity, and quality of life [1]. Furthermore, indications for EBV use are expanding, as it is now a recommended treatment for persistent air leak (PAL), defined as a continuous broncho‐pleural air leak lasting for more than 5 days. Initial treatment of PAL is based on watchful waiting combined with appropriate chest tube drainage. If conservative measures fail, EBV offers a less invasive alternative to surgery for resolving PAL [2].
However, EBV placement is associated with complications such as pneumothorax or an increased risk of infection [3]. Consequently, it is a less recommended treatment in immunocompromised patients. Nevertheless, there are reported cases in which EBV has been used to treat native lung hyperinflation, a recognised complication following single lung transplantation (SLTx) where the hyperinflated native lung induces a disadvantageous mechanical situation and may cause respiratory failure [4]. These patients exhibited mitigated outcomes after ELVR of the native lung. However, these cases were performed more than a decade ago, before the introduction of the Chartis method for assessing collateral ventilation, which is essential for predicting post‐ELVR atelectasis and improvement [5].
We here present a case of a concomitant PAL and ELVR treatment following SLTx. Additionally, we conducted a literature review of reported cases of native lung hyperinflation treated with EBV and highlighted those in which lung volume reduction was achieved.
2. Case Report
A 52‐year‐old man was referred for bilateral sequential lung transplantation due to severe emphysema. His past medical history included a segmentectomy of the right upper lobe combined with radical mediastinal lymph node dissection for a suspect nodule 6 years ago. Histology and microbiological analyses of the resected lung tissue concluded with Mycobacterium xenopi infection; the patient was then treated with antibiotics for 1 year. The patient was also colonised by Pseudomonas aeruginosa.
Lung transplantation was started on the left side with an uncomplicated left transplantation. Right‐sided explantation was aborted due to extensive adhesions and fibrosis at the hilum attributed to previous thoracic surgery. Consequently, the native right lung was left in situ. Damaged parenchyma on the right side was resected using the commercially available stapling device and covered with an aerostatic sealant. The post‐operative course was complicated by a PAL on the right non‐transplanted side lasting over 1 month despite effective chest drainage.
Following confirmation of absent interlobar collateral ventilation and cessation of the air leaks using the Chartis catheter (PulmonX, Redwood City, CA) and a Fogarty balloon in the right middle and upper lobes, four Zephyr EBV (PulmonX, Redwood City, CA) were placed, three in the right upper lobe and one in the middle lobe.
This intervention resulted in complete resolution of the air leaks, allowing chest tube removal within 1 week post‐EBV placement. Additionally, lung volume reduction was shown on repeat chest computed tomography quantitation, showing partial atelectasis of the right upper and middle lobes (Figure 1), with a volume reduction of 1500 mL (from 1800 to 300 mL, 83% decrease) 1 month after EBV placement.
FIGURE 1.
Chest CT before lung transplantation (a), 1 month after single left‐lung transplantation (b) and 1 month after endobronchial valve placement (c). The yellow arrow indicates the pneumothorax and persistent air leak after failed dissection of the right lung hilum due to prior radical mediastinal lymph node dissection. The red arrow shows endobronchial valve with a partial atelectasis of the right upper and middle lobes (green arrow).
The patient reported symptom improvement, with a reduction in dyspnoea severity on the mMRC scale, from Grade 3 before transplantation to Grade 1 after transplantation and EBV treatment.
Pulmonary function tests (PFT) showed an increase in FEV1 from 530 mL pre‐transplant to 1200 mL (+126%) after SLTx and before EBV placement, and to 1730 mL post‐ELVR (+226%). Forced vital capacity (FVC) increased from 1300 mL before SLTx to 1850 mL (+42.3%) after ELVR. Residual volume (RV) decreased from 6400 mL pre‐transplant to 2990 mL (−53.3%) 1 month after EBV placement (Figure 2). At 18 months of follow‐up, the patient showed stable lung function, with no episodes of severe infection.
FIGURE 2.
Evolution of the forced expiratory volume in 1 s (blue line), forced vital capacity (orange line), and residual volume (green line) after single lung transplantation and ELVR. EBV: endobronchial valve; FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; RV: residual volume.
3. Discussion
This is the first reported case of a SLTx recipient treated with EBV for both PAL and ELVR of the native lung during the post‐operative period. This dual‐purpose intervention simultaneously sealed the air leaks and prevented the onset of native lung hyperinflation through effective lung volume reduction.
There was no complication following EBV placement and the patient presented prompt respiratory improvements. Furthermore, despite the patient's immunocompromised status and microbiological history of Mycobacterium xenopi infection and Pseudomonas aeruginosa colonisation prior to the transplantation, no significant infectious complications were observed following EBV placement.
EBV are increasingly used in selected patients with severe emphysema and hyperinflation. However, SLTx represents a unique clinical scenario, and post‐ELVR outcomes in this population remain highly variable across case report studies. Notably, all previously published studies were conducted prior to the widespread use of the Chartis system for assessing collateral ventilation, a procedure that has significantly improved the predictability of atelectasis and clinical response following ELVR [5].
After literature review, we identified 22 patients treated with EBV for native lung hyperinflation following SLTx [6, 7, 8, 9, 10]. Among them, five patients were excluded: four because of an absence of atelectasis, and one because of an absence of emphysema [8]. The clinical data of the 17 remaining patients (including our own) are summarised in Table 1.
TABLE 1.
Clinical data of the 17 selected single lung transplant recipients who underwent native lung endoscopic lung volume reduction.
| Study | Patient | Time from SLTx to EBV (month) | Treated lobes | FEV1 (L) | FVC (L) | Complication | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Pre‐EBV | Post‐EBV a | Change (%) | Pre‐EBV | Post‐EBV a | Change (%) | |||||
| Kemp, 2010 [8] | 1 | 72 | RLL | / | / | 16.7 | / | / | 21.9 | |
| 2 | 36 | LUL | / | / | 9 | / | / | 11.7 | ||
| 3 | 84 | LUL | / | / | 7.3 | / | / | 3.8 | ||
| Pato, 2010 [7] | 4 | 120 | RUL | 1.2 | 1.1 | −7.3 | 2.7 | 2.5 | −7.8 | |
| Destors, 2012 [9] | 5 | 120 | RUL + ML | 0.7 | 1.0 | 39.7 | 1.2 | 1.8 | 52 | Infection |
| Perch, 2015 [10] | 6 | 108 b | LLL | 1.6 | 1.7 | 6 | 2.6 | 4.1 | 58 | / |
| 7 | LUL | 0.7 | 0.8 | 12 | 2.0 | 2.9 | 43 | Dyspnoea | ||
| 8 | LLL | 0.5 | 0.6 | 8 | 1.6 | 1.8 | 9 | Infection, haemoptysis | ||
| 9 | LLL | 1.1 | 1.2 | 13 | 1.2 | 1.4 | 14 | Infection | ||
| 10 | LLL | 2.5 | 3.1 | 24 | 3.8 | 4.9 | 30 | / | ||
| 11 | RUL + RLL | 0.8 | 0.9 | 12 | 1.4 | 1.5 | 18 | / | ||
| 12 | RUL + ML | 0.7 | 0.8 | 14 | 1.4 | 1.7 | 19 | / | ||
| 13 | LLL + LUL | / | / | / | / | / | / | Pneumothorax, infection | ||
| 14 | ML | 0.8 | 0.9 | 21 | 1.4 | 1.6 | 15 | Infection | ||
| 15 | LUL | / | / | / | / | / | / | Pneumothorax, death | ||
| 16 | LUL | 1 | 1.2 | 17 | 1.3 | 1.1 | −10 | / | ||
| Present Study, 2025 | 17 | 1 | RUL + ML | 1.2 | 1.7 | 52 | / | 1.8 | / | / |
| Median | 108 | 0.9 | 1.1 | 12 | 1.4 | 1.8 | 16 | |||
| IC range 25% | 96 | 0.7 | 0.9 | 8.5 | 1.3 | 1.5 | 9.7 | |||
| IC range 75% | 108 | 1.2 | 1.4 | 15.35 | 2.3 | 2.7 | 21.2 | |||
Note: Data are expressed as absolute values or percentages.
Abbreviations: EBV, endobronchial valve; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; IC range, interquartile range; LLL, left lower lobe; LUL, left upper lobe; ML, middle lobe; RLL, right lower lobe; RUL, right upper lobe; SLTx, single lung transplantation.
Between 1 and 3 months post‐EBV placement.
Average time of the 14 patients included in the Perch study.
For these 17 patients, a median increase of 12% (IC 8.5–15.35) and 16% (IC 9.7–21.2) in FEV1 and FVC, respectively, was observed following ELVR. The average time from transplantation to valve placement was nearly 8 years. PFTs were not available for the two patients who developed pneumothorax. Other reported complications included respiratory infections (five cases [29%]), acute dyspnoea requiring intensive care monitoring the day after the procedure (one case [6%]), and haemoptysis (one case [6%]). One patient with pneumothorax developed severe hypercapnic respiratory acidosis and died despite mechanical ventilation.
In conclusion, we report here a successful treatment of concomitant PAL and native lung hyperinflation with EBV. After a literature review, we suggest that ELVR could be a therapeutic option for native lung hyperinflation in single‐lung transplanted recipients after assessing the absence of collateral ventilation with an acceptable safety profile.
Author Contributions
All the authors participated in the conception or design of the work, the acquisition, analysis or interpretation of data for the work. They helped in drafting the work or reviewing it critically for important intellectual content and were involved in final approval of the version to be published.
Consent
The authors declare that written informed consent was obtained for the publication of this manuscript and accompanying images using the consent form provided by the Journal.
Conflicts of Interest
Dr. Olivier Taton received consultancy fees from PulmonX. All other authors declare no conflicts of interest.
Godts J., Etienne I., Knoop C., et al., “Endobronchial Valve Treatment for Persistent Air Leak and Endoscopic Lung Volume Reduction of Native Lung in a Single Lung Transplant Recipient: A Case Report and Literature Review,” Respirology Case Reports 13, no. 8 (2025): e70305, 10.1002/rcr2.70305.
Associate Editor: Trevor Williams
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.