Pneumothorax after Endobronchial Valve Treatment: No Drain, No Gain?

tional pulmonology, with a number of devices now either in clinical trials or available for commercial use. These include unidirectional airway valves, endobronchial coils, sealant and steam therapy [5–15] . Endobronchial valves (EBVs) were designed to achieve volume reduction by inducing lobar atelectasis. They are the most-studied devices for bronchoscopic lung volume reduction. Largescale, randomised trials have been conducted to demonstrate their safety and efficacy [5–7] ; the safety has been found to be good but, thus far, the efficacy has been modest. Improved patient selection (those patients with a low likelihood of collateral ventilation and heterogeneous disease) results in better clinical outcomes [16] . In this issue of Respiration , Gompelmann et al. [17] discuss the most commonly occurring and clinically significant major adverse event following EBV implantation, namely pneumothorax, and give us much food for thought. PostEBV pneumothoraces occur when anatomical changes in the treated lobe facilitate the expansion of the ipsilateral non-treated lobe, resulting in either ruptured pleural blebs or bullae, or parenchymal tears. In this context, the presence of significant paraseptal emphysema in the ipsilateral non-treated lobe or often unanticipated pleural adhesions can be a major concern. The only cure for patients with COPD/emphysema is lung transplantation. However, with the strict eligibility criteria and an inadequate supply of donor organs, this is not a realistic option for many. A variety of surgical procedures for the palliation of symptoms in lung hyperinflation due to emphysema have been attempted over many years, but little success was seen until the advent of lung volume reduction surgery (LVRS). LVRS was first reported in 1957 [1] , but was not widely adopted until Joel Cooper perfected the technique of stapled resection in the mid-1990s and reported his results [2, 3] . However, the excessive early mortality observed in the high-risk patient group in the NETT (National Emphysema Treatment Trial) study [4] has led to a dramatic decrease in procedures. Prolonged hospitalisation for a variety of reasons following surgery has also contributed to this reduction. Despite this, the potential significant benefits of lung volume reduction in selected groups with upper lobe-predominant emphysema and low baseline exercise tolerance are well recognised and can far outstrip those of pharmacological therapies. This has led to a significant investment in and development of endobronchial techniques to reduce hyperinflation. Bronchoscopic lung volume reduction is a rapidly expanding field in intervenPublished online: April 5, 2014