Abstract Introduction Necrotizing pneumonia complicated by bronchopleural fistula (BPF) and persistent air leak is a life-threatening condition that often precludes ventilator weaning and prolongs critical illness. When surgery is contraindicated due to hemodynamic instability or multi-organ dysfunction, bronchoscopic endobronchial valve (EBV) placement offers a minimally invasive, lung-sparing option that can rapidly control the leak and stabilize the patient. Description of Case A 34-year-old man presented with acute encephalopathy and multi-organ failure requiring intubation, vasopressors, and continuous renal replacement therapy. During his ICU course, he developed bilateral pulmonary infiltrates with Pseudomonas aeruginosa infection and a recurrent right-sided pneumothorax requiring chest-tube placement. Persistent bubbling indicated a BPF secondary to necrotizing pneumonia, and surgical repair was deferred due to critical illness. On hospital day 29, flexible bronchoscopy with balloon occlusion testing localized the leak to right lower-lobe segments. Five Zephyr EBVs were deployed (superior, medial, anterior, lateral/posterior, and ancillary). Intraoperative saline testing confirmed immediate cessation of air leak. Post-procedure imaging demonstrated lung re-expansion without recurrent pneumothorax. The chest tube was clamped for 48 hours and subsequently removed. The patient was weaned to high-flow oxygen, downgraded from the ICU within three days, and discharged to a long-term acute-care facility on postoperative day 9. No valve-related complications were observed. Discussion Persistent air leak due to BPF remains a major challenge in necrotizing pneumonia, especially among non-surgical candidates. A leak persisting beyond several days despite appropriate drainage and ventilator optimization is associated with prolonged hospitalization, infectious complications, and difficulty achieving ventilator liberation. EBVs, originally developed for bronchoscopic lung-volume reduction, are now being explored off-label to isolate affected segments, induce localized atelectasis, and reduce fistula flow while attempting to preserve functional parenchyma. Limited case reports and small series, including some in pediatric populations, suggest potential benefit with rapid leak control, facilitation of chest-tube removal, and reversibility through elective valve extraction once healing occurs. In this case, physiologic improvement followed swift leak cessation, enabling mobilization and safe step-down care. The multidisciplinary approach involving critical care, interventional pulmonology, and thoracic surgery was essential for patient selection, localization with balloon occlusion, and post-procedure monitoring. In critically ill patients with necrotizing pneumonia and BPF who are not surgical candidates, EBV placement can provide immediate and durable control of persistent air leak, enabling ventilator weaning, ICU downgrading, and earlier rehabilitation. Early consideration of EBVs for refractory leaks may shorten hospitalization and serve as a bridge to recovery, with planned reassessment for valve removal. This abstract is funded by: None
Bannoud et al. (2026) studied this question.