D24-07 Promise and Peril: Pneumothorax Ex Vacuo After Endobronchial Valve Therapy in Very Severe Chronic Obstructive Pulmonary Disease

Introduction Endobronchial valve (EBV) therapy is an established bronchoscopic intervention for patients with advanced emphysema who remain symptomatic despite maximal medical therapy. Although EBV can improve lung function and quality of life, serious complications can occur in patients with severely compromised pulmonary reserve. Case Report A 62-year-old male with very severe COPD (GOLD stage 4 Group E & FEV1 12% predicted) underwent bronchoscopic lung volume reduction (BLVR) therapy with Zephyr EBV. After confirming negative collateral ventilation by Chartis measurement, Two Zephyr EBVs (5.5 × 8.5 mm) were deployed in the right upper lobe posterior (RB2) and anterior (RB3) segments via flexible bronchoscope. Post procedure was uneventful. After one month the third Zephyr EBV (4 x 7 mm) was placed in the right upper lobe apical (RB1) segment. Within one hour post procedure, the patient developed pneumothorax. The air leak persisted despite treatment with intercostal chest drainage (ICD) for 5 days and the patient had haemoptysis. Flexible bronchoscopic evaluation was done and the valve in RB3 was removed and bleeding controlled. However, the air leak persisted, and haemoptysis recurred. Consequently, the remaining two valves (RB1 and RB2) were removed. Following complete valve explantation, the right lung re-expanded and air leak resolved after 10 days. The patient was discharged in stable vitals. Discussion EBV therapy offers functional improvements but carries significant risk. The most common complication is pneumothorax, reported in up to 25-30% of cases. After treatment with valves, the volume of the target lobe is reduced rapidly which is compensated by the expansion of the untreated ipsilateral lobe. This promotes bullae or bleb rupture in the expanded ipsilateral lung tissue due to change in the negative pleural pressure. Our patient developed pneumothorax ex vacuo which did not respond to ICD. Pneumothorax ex vacuo is a life-threatening complication that requires prompt recognition and management. In our patient, pneumothorax persisted despite ICD and the patient recovered only after removal of the valves. Conclusion This case underscores the fine balance between therapeutic benefit and potential life-threatening complications in endobronchial valve therapy for advanced COPD. Learning Points: 1. Patient selection is critical. 2. Recognize complications early, prompt diagnosis and valve removal may be lifesaving. 3. Balance innovation with caution, multidisciplinary evaluation and counselling are vital. 4. Teaching takeaway: Technical success does not always equal clinical benefit; patient safety remains the end point.