Endobronchial valve placement for persistent air leak in critically ill patients: chest-tube removal and competing risk of death

Background- Persistent air leaks due to alveolar-pleural or peripheral bronchiolar-pleural fistulas remain challenging in critically ill patients requiring respiratory support. We assessed the effectiveness and safety of endobronchial valves placement in this setting, accounting for the competing risk of death. Methods- We conducted a single-center retrospective cohort study of consecutive critically ill adults requiring invasive mechanical ventilation or high-flow nasal oxygen for acute respiratory failure who underwent endobronchial valve placement for alveolar-pleural or peripheral bronchiolar-pleural fistulas. The primary outcome was time to chest-tube removal, analyzed with a competing-risk approach in which in-hospital death was treated as the competing event. Secondary outcomes were in-hospital mortality, procedural safety, and exploratory analysis of early post-procedural air-leak response. Results- Thirty-eight patients were included. The cumulative incidence of chest-tube removal reached: 60.5, 71.1, and 94.7% by day 10, 14, and 20 respectively, after endobronchial valves placement; the corresponding cumulative incidence of in-hospital death was 2.6% by day 14. Median time to chest-tube removal was 7.5 days. In Fine–Gray models adjusted for clinically relevant covariates, older age was associated with a lower incidence of chest-tube removal (sub distribution hazard ratio, 0.96 per year; 95% CI, 0.93–0.98; p=0.002), whereas pneumomediastinum was associated with a higher incidence of chest-tube removal (sub distribution hazard ratio, 2.36; 95% CI, 1.12–4.97; p=0.023). In-hospital mortality was 10.5%, and no procedure-related life-threatening adverse events or urgent valve removals occurred. Conclusions- In critically ill patients with persistent air leak, endobronchial valve placement was associated with rapid chest-tube removal and a low early competing risk of death. These findings support further prospective evaluation of this approach in high-risk patients.