{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T15:21:01Z","timestamp":1785252061107,"version":"3.55.0"},"reference-count":38,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2023,2,8]],"date-time":"2023-02-08T00:00:00Z","timestamp":1675814400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series of patients requiring veno-venous ECMO for COVID-19 ARDS who underwent endobronchial valve (EBV) management of PAL. This is a single-centre retrospective observational study. Data were collated from electronic health records. Patients treated with EBV met the following criteria: ECMO for COVID-19 ARDS; the presence of BPF causing PAL; air leak refractory to conventional management preventing ECMO and ventilator weaning. Between March 2020 and March 2022, 10 out of 152 patients requiring ECMO for COVID-19 developed refractory PALs, which were successfully treated with bronchoscopic EBV placement. The mean age was 38.3 years, 60% were male, and half had no prior co-morbidities. The average duration of air leaks prior to EBV deployment was 18 days. EBV placement resulted in the immediate cessation of air leaks in all patients with no peri-procedural complications. Weaning of ECMO, successful ventilator recruitment and removal of pleural drains were subsequently possible. A total of 80% of patients survived to hospital discharge and follow-up. Two patients died from multi-organ failure unrelated to EBV use. This case series presents the feasibility of EBV placement in severe parenchymal lung disease with PAL in patients requiring ECMO for COVID-19 ARDS and its potential to expedite weaning from both ECMO and mechanical ventilation, recovery from respiratory failure and ICU\/hospital discharge.<\/jats:p>","DOI":"10.3390\/jcm12041348","type":"journal-article","created":{"date-parts":[[2023,2,8]],"date-time":"2023-02-08T04:21:59Z","timestamp":1675830119000},"page":"1348","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5978-5194","authenticated-orcid":false,"given":"Barbara","family":"Ficial","sequence":"first","affiliation":[{"name":"Department of Adult Critical Care, Guy\u2019s and St Thomas\u2019 NHS Foundation Trust, St Thomas\u2019 Hospital, Westminster Bridge Road, London SE1 7EH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2604-8657","authenticated-orcid":false,"given":"Stephen","family":"Whebell","sequence":"additional","affiliation":[{"name":"Department of Adult Critical Care, Guy\u2019s and St Thomas\u2019 NHS Foundation Trust, St Thomas\u2019 Hospital, Westminster Bridge Road, London SE1 7EH, UK"},{"name":"Intensive Care Unit, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD 4814, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8598-8657","authenticated-orcid":false,"given":"Daniel","family":"Taylor","sequence":"additional","affiliation":[{"name":"Department of Adult Critical Care, Guy\u2019s and St Thomas\u2019 NHS Foundation Trust, St Thomas\u2019 Hospital, Westminster Bridge Road, London SE1 7EH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rita","family":"Fern\u00e1ndez-Garda","sequence":"additional","affiliation":[{"name":"Department of Adult Critical Care, Guy\u2019s and St Thomas\u2019 NHS Foundation Trust, St Thomas\u2019 Hospital, Westminster Bridge Road, London SE1 7EH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lawrence","family":"Okiror","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, Guy\u2019s and St Thomas\u2019 NHS Foundation Trust, Guy\u2019s Hospital, Great Maze Pond, London SE1 9RT, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher I. S.","family":"Meadows","sequence":"additional","affiliation":[{"name":"Department of Adult Critical Care, Guy\u2019s and St Thomas\u2019 NHS Foundation Trust, St Thomas\u2019 Hospital, Westminster Bridge Road, London SE1 7EH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,2,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e615","DOI":"10.7861\/clinmed.2021-0220","article-title":"Increased frequency of pneumothorax and pneumomediastinum in COVID-19 patients admitted in the ICU: A multicentre study from Mumbai, India","volume":"21","author":"Udwadia","year":"2021","journal-title":"Clin. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"00385","DOI":"10.1183\/23120541.00385-2020","article-title":"Pneumomediastinum and subcutaneous emphysema in COVID-19: Barotrauma or lung frailty?","volume":"6","author":"Lemmers","year":"2020","journal-title":"ERJ Open Res."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2102522","DOI":"10.1183\/13993003.02522-2021","article-title":"Pneumomediastinum in COVID-19: A phenotype of severe COVID-19 pneumonitis? The results of the United Kingdom (POETIC) survey","volume":"60","author":"Melhorn","year":"2022","journal-title":"Eur. Respir. J."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"E252","DOI":"10.1148\/radiol.2020202352","article-title":"Increased Incidence of Barotrauma in Patients with COVID-19 on Invasive Mechanical Ventilation","volume":"297","author":"McGuinness","year":"2020","journal-title":"Radiology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1177\/0885066621989959","article-title":"High Incidence of Barotrauma in Patients with Severe Coronavirus Disease 2019","volume":"36","author":"Kahn","year":"2021","journal-title":"J. Intensive Care Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.1177\/08850666211019719","article-title":"Pulmonary Barotrauma in COVID-19 Patients with ARDS on Invasive and Non-Invasive Positive Pressure Ventilation","volume":"36","author":"Rajdev","year":"2021","journal-title":"J. Intensive Care Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1177\/0885066620954364","article-title":"Incidence of Barotrauma in Patients With COVID-19 Pneumonia During Prolonged Invasive Mechanical Ventilation\u2014A Case-Control Study","volume":"36","author":"Udi","year":"2021","journal-title":"J. Intensive Care Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1056\/NEJM199802053380603","article-title":"Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group","volume":"338","author":"Stewart","year":"1998","journal-title":"N. Engl. J. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"612","DOI":"10.1007\/s00134-004-2187-7","article-title":"Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients","volume":"30","author":"Anzueto","year":"2004","journal-title":"Intensive Care Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1056\/NEJMoa032193","article-title":"National Heart, Lung, and Blood Institute ARDS Clinical Trials Network Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome","volume":"351","author":"Brower","year":"2004","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1176","DOI":"10.1177\/08850666211023360","article-title":"Outcomes of Barotrauma in Critically Ill COVID-19 Patients With Severe Pneumonia","volume":"36","author":"Gazivoda","year":"2021","journal-title":"J. Intensive Care Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"W267","DOI":"10.2214\/AJR.15.14445","article-title":"Acute Middle East Respiratory Syndrome Coronavirus: Temporal Lung Changes Observed on the Chest Radiographs of 55 Patients","volume":"205","author":"Das","year":"2015","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"R440","DOI":"10.1186\/cc3736","article-title":"Pneumothorax and mortality in the mechanically ventilated SARS patients: A prospective clinical study","volume":"9","author":"Kao","year":"2005","journal-title":"Crit. Care"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"785","DOI":"10.1016\/j.ajem.2020.08.098","article-title":"Air leaks, pneumatoceles, and air spaces in Covid-19 pneumonia","volume":"46","author":"Jolobe","year":"2021","journal-title":"Am. J. Emerg. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1162","DOI":"10.4269\/ajtmh.20-0680","article-title":"Case Report: COVID-19\u2013Associated Bilateral Spontaneous Pneumothorax\u2014A Literature Review","volume":"103","author":"Alhakeem","year":"2020","journal-title":"Am. J. Trop. Med. Hyg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"E510","DOI":"10.1503\/cmaj.200609","article-title":"SARS-CoV-2 infection associated with spontaneous pneumothorax","volume":"192","author":"Rohailla","year":"2020","journal-title":"CMAJ Can. Med. Assoc. J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"258.e1","DOI":"10.1016\/j.ajem.2020.07.018","article-title":"Bilateral spontaneous pneumothorax in SARS-CoV-2 infection: A very rare, life-threatening complication","volume":"39","author":"Sandoval","year":"2021","journal-title":"Am. J. Emerg. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1230","DOI":"10.1016\/S0140-6736(21)01960-7","article-title":"Extracorporeal membrane oxygenation for COVID-19: Evolving outcomes from the international Extracorporeal Life Support Organization Registry","volume":"398","author":"Barbaro","year":"2021","journal-title":"Lancet"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"6158","DOI":"10.21037\/jtd.2018.10.61","article-title":"Unidirectional endobronchial valves for management of persistent air-leaks: Results of a multicenter study","volume":"10","author":"Fiorelli","year":"2018","journal-title":"J. Thorac. Dis."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1186\/s12931-017-0666-y","article-title":"Endobronchial one-way valves for treatment of persistent air leaks: A systematic review","volume":"18","author":"Ding","year":"2017","journal-title":"Respir. Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1181","DOI":"10.1016\/j.athoracsur.2015.04.104","article-title":"Endobronchial Valves for Challenging Air Leaks","volume":"100","author":"Reed","year":"2015","journal-title":"Ann. Thorac. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1891","DOI":"10.1016\/j.athoracsur.2015.10.113","article-title":"Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage","volume":"101","author":"Gilbert","year":"2016","journal-title":"Ann. Thorac. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1318","DOI":"10.1164\/rccm.201904-0761LE","article-title":"One-Way Endobronchial Valves as Management for Persistent Air Leaks: A Preview of What\u2019s to Come?","volume":"200","author":"Bermea","year":"2019","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1093\/icvts\/ivs258","article-title":"Successful treatment of a life-threatening air leakage, complicating severe abdominal sepsis, with a one-way endobronchial valve","volume":"15","author":"Brichon","year":"2012","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_25","first-page":"219","article-title":"Bedside placement of an endobronchial valve to aid invasive ventilation and weaning from extracorporeal membrane oxygenation","volume":"17","author":"Hodges","year":"2015","journal-title":"Crit. Care Resusc. J. Australas. Acad. Crit. Care Med."},{"key":"ref_26","first-page":"9736217","article-title":"Endobronchial One-Way Valve Therapy Facilitates Weaning from Extracorporeal Membrane Oxygenation in a Patient with ARDS and Persistent Air Leak","volume":"2018","author":"Ghiani","year":"2018","journal-title":"Case Rep. Crit. Care"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"(2021). Dexamethasone in Hospitalized Patients with COVID-19. N. Engl. J. Med., 384, 693\u2013704.","DOI":"10.1056\/NEJMoa2021436"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1186\/s13054-021-03634-1","article-title":"Extracorporeal membrane oxygenation for COVID-19: A systematic review and meta-analysis","volume":"25","author":"Ramanathan","year":"2021","journal-title":"Crit. Care"},{"key":"ref_29","unstructured":"(2022, January 14). Available online: https:\/\/www.engage.england.nhs.uk\/consultation\/extra-corporeal-membrane-oxygenation\/user_uploads\/ecmo-service-specification-proposition-v1.pdf."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"109017","DOI":"10.1016\/j.ejrad.2020.109017","article-title":"Early CT features and temporal lung changes in COVID-19 pneumonia in Wuhan, China","volume":"128","author":"Hu","year":"2020","journal-title":"Eur. J. Radiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1186\/s13613-021-00904-7","article-title":"High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: A computational modelling study","volume":"11","author":"Weaver","year":"2021","journal-title":"Ann. Intensive Care"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1055\/s-0037-1606179","article-title":"Bleeding and Thrombotic Complications in the Use of Extracorporeal Membrane Oxygenation","volume":"44","author":"Thomas","year":"2018","journal-title":"Semin. Thromb. Hemost."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1622","DOI":"10.1016\/j.cmi.2020.07.016","article-title":"Bacterial co-infection and secondary infection in patients with COVID-19: A living rapid review and meta-analysis","volume":"26","author":"Langford","year":"2020","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1378\/chest.08-2389","article-title":"Treatment of Persistent Pulmonary Air Leaks Using Endobronchial Valves","volume":"136","author":"Travaline","year":"2009","journal-title":"Chest"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1097\/LBR.0b013e318251c897","article-title":"Intrabronchial Valves","volume":"19","author":"Mahajan","year":"2012","journal-title":"J. Bronchol. Interv. Pulmonol."},{"key":"ref_36","first-page":"3092457","article-title":"Bronchopleural Fistula Resolution with Endobronchial Valve Placement and Liberation from Mechanical Ventilation in Acute Respiratory Distress Syndrome: A Case Series","volume":"2017","author":"Kalatoudis","year":"2017","journal-title":"Case Rep. Crit. Care"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1875","DOI":"10.1002\/ppul.24475","article-title":"Endobronchial valve placement for a severe pneumothorax in a child on ECLS","volume":"54","author":"Jaspers","year":"2019","journal-title":"Pediatr. Pulmonol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1271","DOI":"10.1089\/lap.2018.0078","article-title":"Selective Management of Multiple Bronchopleural Fistulae in a Pediatric Patient on Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach","volume":"28","author":"Criss","year":"2018","journal-title":"J. Laparoendosc. Adv. Surg. Technol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/4\/1348\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:27:59Z","timestamp":1760120879000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/4\/1348"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,8]]},"references-count":38,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2023,2]]}},"alternative-id":["jcm12041348"],"URL":"https:\/\/doi.org\/10.3390\/jcm12041348","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,8]]}}}