Abstract Introduction Secondary spontaneous pneumothorax (SSP) complicates 1-1.5% of hospitalized tuberculosis (TB) cases, typically from rupture of cavitary lesions, which can cause persistent bronchopleural fistula (BPF) formation. Unlike primary spontaneous pneumothorax, SSP in necrotizing infections carries substantially higher recurrence rates (40-80%) and treatment failure risk. Management of persistent air leaks (PAL) in cavitary TB remains challenging, with conventional options of chest tube drainage, chemical pleurodesis, or surgical resection carrying significant morbidity in critically ill patients. Endobronchial valves (EBVs), FDA-approved exclusively for bronchoscopic lung volume reduction in severe emphysema, have demonstrated efficacy for PAL in limited reports, though experience in infection-related SSP remains sparse. We report successful off-label staged EBV placement for recurrent TB-related SSP. Case Description A 20-year-old male with severe malnutrition, asthma, and opioid use disorder presented with active cavitary pulmonary TB complicated by bilateral SSP. Initial management with bilateral thoracostomy tubes and standard four-drug anti-TB therapy proved insufficient. Persistent right-sided pneumothorax with alveopleural fistula prompted bronchoscopic placement of two Spiration EBVs (size 7) targeting right upper lobe (RUL) anterior and apicoposterior segments, following institutional review board approval and informed consent. His course was complicated by rifampin-induced tubulointerstitial nephritis and recurrent right lower lobe pneumothorax despite initial valve placement, indicating additional BPF formation. Chest CT demonstrated extensive fibrocavitary disease with multifocal consolidation. Persistent fever and leukocytosis suggested post-obstructive pneumonia; broad-spectrum antibiotics were administered. Ten days post-discharge, recurrent pneumothorax with PAL necessitated revision bronchoscopy with two additional valves in the right middle lobe (Spiration size 6, Zephyr size 4). The air leak resolved within 24 hours. RUL valves were successfully removed seven weeks post-placement. Discussion This case represents novel application of EBV technology for infection-related PAL, extending beyond FDA-approved emphysema indications. Key insights include: (1) Feasibility of off-label EBV use: Staged valve placement successfully addressed recurrent BPFs while avoiding high-risk surgery in a critically ill patient with extensive bilateral disease. (2) Reversibility potential: Unlike permanent placement required for emphysema, temporary seven-week retention achieved fistula closure, suggesting distinct healing kinetics in infectious versus structural lung disease. (3) Multifistula management: Sequential placement accommodated ongoing parenchymal destruction. This case supports expanding EBV applications to infectious disease-related PAL and underscores necessity of multidisciplinary collaboration. Prospective studies are warranted to establish safety and efficacy profiles for this innovative off-label application. This research was supported by HCA Healthcare or an affiliated entity. The views expressed are the authors’, not those of HCA Healthcare or its affiliates. This abstract is funded by: None
Lakhanpal et al. (Fri,) studied this question.