Nursing Care After Endobronchial Valve Placement: Optimizing Patient Recovery and Outcomes

Q What is endobronchial valve (EBV) therapy? What does the evidence tell us about optimal nursing practices for the care of patients after EBV placement?A Michael Gabrilovich, MD, PhD, and Meredith Padilla, PhD, RN, CCRN-CMC, reply:Endoscopic lung volume reduction (ELVR) is a US Food and Drug Administration–approved minimally invasive procedure to treat hyperinflation and reduce the symptoms of severe emphysema.1 During bronchoscopy, a 1-way EBV is inserted into airways proximal to the areas of the lungs most affected by the disease (Figures 1 and 2).2,3 This procedure can substantially improve lung function by redirecting the air away from the hyperinflated sections and toward the healthier sections of the lung. In the absence of collateral ventilation (ie, air coming into the targeted lobe from other lobes), the 1-way valve allows air and secretions to leave the lobe but not go back in, reducing hyperinflation.1,4–9Hyperinflation of the lung is like having a large balloon of air inside the chest, compressing the healthier parts of the lung and the major blood vessels while flattening the diaphragm. Deflating hyperinflated areas can improve ventilation and perfusion matching in less-affected lung lobes and optimize diaphragmatic function. Inserting these valves is a minimally invasive procedure, and they can be removed and replaced if needed. Endoscopic lung volume reduction has been shown to have the following benefits for patients: Candidates for ELVR undergo diagnostic testing to determine disease severity and to estimate the likelihood that the procedure will be of benefit. Testing before ELVR includes pulmonary function testing to evaluate lung function (ie, severity of obstruction, presence of hyperinflation, or air trapping) and computed tomography scanning of the chest to visualize bullae and nodules and quantify collateral ventilation. Clinicians may also order an arterial blood gas test if hypercapnia is suspected, an echocardiogram if pulmonary hypertension or reduced cardiac function is a concern, and a 6-minute walk test to measure the patient’s functional status. Nuclear medicine imaging is also useful to evaluate lung perfusion.10,11Inclusion criteria for EBV placement may vary by institution but include the following for patients who4,6,10–14Exclusion criteria for EBV placement may vary by institution but include the following for patients who4,6,10–14Endobronchial valve placement is performed under general anesthesia and takes 30 to 60 minutes. Before valve implantation, assessment for collateral ventilation is essential, as this impacts the efficacy of the valve in alleviating hyperinflation. The airway is measured to guide the selection of an appropriately sized valve. Multiple valves may be implanted to ensure complete occlusion of airways leading to the target lung lobe. After the procedure, the patient is admitted for monitoring, as adverse events and complications can occur. The most common complication is pneumothorax. The Table provides a complete list of potential EBV placement complications.Nursing care for patients undergoing ELVR includes monitoring for postprocedural complications such as pneumothorax, migration of the valve, bronchospasm, chronic obstructive pulmonary disease exacerbation, mucus plugging, hemoptysis, allergic or adverse reactions to anesthesia or sedation or materials used in the valves, or infection.1,5,9–12 Medications that may be prescribed include antibiotics, bronchodilators, inhaled corticosteroids, or cough suppressants. Nursing interventions include the following: Endoscopic lung volume reduction, when used in appropriate, carefully selected patients, is a safe and highly efficient procedure associated with considerable clinical benefit and quality-of-life improvement. To ensure patient safety, nurses must know about the potential complications and appropriate nursing monitoring procedures and interventions.To learn more about ELVR, review the clinical practice guidelines from the Global Initiative for Chronic Obstructive Lung Disease,5 Herth et al,8 and National Institute for Health Care Excellence.12