Background Information:

What are the other Names for the Procedure?

• Bronchoscopic Endobronchial Valve Placement
• EBV Placement

What is Endobronchial Valve Placement procedure?

• Endobronchial Valve Placement procedure is a therapeutic procedure that allows placement of an endobronchial valve (EBV) in the bronchial airway of an emphysematous segment of lung.
• This valve acts as a one-way system, allowing air to exit the lung segment, but not its entry. This leads to collapse of the abnormal emphysematous lung segment, thereby allowing improved functioning of the rest of the lung and better mechanics of the diaphragm
• The Endobronchial Valve Placement procedure allows for improvement in breathing, in people with severe emphysematous lung disease; emphysema is a lung condition that is marked by damage to the air sacs
• The bronchial airways are airway tubes that carry oxygen to the lungs and are a part of the respiratory tract

What part of the Body does the Procedure involve?

• An Endobronchial Valve Placement procedure is usually performed with the aid of flexible bronchoscopy
• The procedure involves passing a bronchoscope through the mouth.  The scope is passed into the oro-pharynx (throat), larynx (voice box), and trachea (windpipe)

Why is the Endobronchial Valve placement procedure Performed?

The main reasons for performing an Endobronchial Valve Placement procedure is severe emphysema of the lungs causing poor lung function and poor walking distance in a 6-minute walk test.

What are some Alternative Choices for the Procedure?

Sometimes, the patient may be referred to a thoracic surgeon for evaluation for lung volume reduction surgery (LVRS).

What are the Recent Advances in the Procedure?

Ongoing advances in Endobronchial Valve Placement procedure are to do with the various types of materials being used - for the valves, coils, sealants, etc.

What is the Cost of performing the Endobronchial Valve placement procedure?

The cost of Endobronchial Valve Placement procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Endobronchial Valve Placement procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://breathe.ersjournals.com/content/12/1/61 (accessed on 11/11/19)

https://err.ersjournals.com/content/28/152/180121 (accessed on 11/11/19)

https://www.atsjournals.org/doi/full/10.1164/rccm.201604-0852LE (accessed on 11/11/19)

https://journals.lww.com/clinpulm/Abstract/2016/05000/Endobronchial_Valve_Placement__Too_Much_Risk_for.8.aspx (accessed on 11/11/19)

Prior to Endobronchial Valve placement procedure:

How is the Endobronchial Valve placement procedure Performed?

The Endobronchial Valve Placement is usually performed as an outpatient procedure. 

• Since it requires bronchoscopy, the patient is required to be under fasting prior to procedure per the physician recommendation
• The procedure can be done with following anesthesia: Intravenous medications, such as fentanyl and midazolam combination (conscious sedation), monitored anesthesia care (MAC) using propofol, or general anesthesia (with oral airway)
• Oxygen is administered for all types of anesthesia. Sometimes, topical anesthesia is sprayed onto the oro-pharynx (throat) as well
• Once the procedure is completed, the bronchoscope is withdrawn

Where is the Procedure Performed?

An Endobronchial Valve Placement procedure is usually performed in a university hospital in an endoscopy/surgical procedure suite.

Who Performs the Procedure?

The procedure is usually performed by an interventional pulmonologist or thoracic surgeon who has undergone additional training in complex airway procedures. 

How long will the Procedure take?

• The actual procedure may take between 30-60 minutes depending on the number of segments being planned for valve placement.
• On considering the pre-procedure examination and post-procedure recovery time, the total time in the procedure suite is between 4-6 hours

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the procedure and in avoiding certain complications.

• Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
• Medication history and any allergies to medications, latex etc.
• If the patient is under any of the following medications, it has to be promptly informed to the healthcare provider:
• Aspirin, clopidogrel (Plavix), ticagrelor (Brilinta), warfarin (coumadin), rivaroxaban (Xarelto), apixaban (Eliquis), dabigatran (Pradaxa), enoxaparin (Lovenox) etc. and any other blood thinners that he/she is currently taking
• Any medical or family history of bleeding disorders or blood clots
• Any unusual effects of anesthesia from prior surgery
• History of sleep apnea and CPAP use at home
• History of rheumatoid arthritis, which can affect the neck joints
• Dental problems such as loose tooth
• History of arthritis or stiffness of neck joints
• Neck flexion/extension limitations due to any prior surgery or radiation to the neck and throat region
• History of cervical spondylosis or cervical spine discectomy surgery

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to procedure and discuss procedure details with risks for complications and obtain his/her permission (termed informed consent). 

• If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
• Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
• It is strongly advised not to use any cocaine about 7 to 14 days before procedure; and if so, it is important to discuss the same with the physician and anesthesia team
• Smoking should generally be avoided prior to procedure
• Generally, the patient is required to be on fast (no solids or liquids) for at least 8 hours prior to the procedure
• Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications taken) with their attending physician well in advance

What is the Consent Process before the Procedure?

The physician will obtain permission for the Endobronchial Valve Placement procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Endobronchial Valve placement procedure?

• Blood tests and pregnancy test (if applicable) may be required prior to the procedure
• The patient may have already undergone a chest X-ray or CT scan of the chest, or both
• An EKG may be needed for anesthetic evaluation

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is an Endobronchial Valve Placement procedure?
• Why is this procedure necessary?  How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required after the procedure?
• What are the costs involved?

During the Endobronchial Valve placement procedure:

What kind of Anesthesia is given, during the Procedure?

• The procedure can be done with following anesthesia: Intravenous medications, such as fentanyl and midazolam combination (conscious sedation), monitored anesthesia care (MAC) using propofol, or general anesthesia (with oral airway)
• Oxygen is administered for all types of anesthesia. Sometimes, topical anesthesia is sprayed onto the oro-pharynx (throat) as well

How much Blood will you lose, during the Procedure?

Endobronchial Valve Placement is a minimally-invasive procedure performed on patients with severe emphysema disease in the lungs. Bleeding is not a significant risk in this procedure.

What are the possible Risks and Complications during the Endobronchial Valve placement procedure?

The possible risks or complications that arise during the Endobronchial Valve Placement procedure include:

• Bleeding in the airways
• Valve getting dislodged and causing collapse of lung
• Oxygen desaturations, low blood pressure, and arrhythmias (irregular heart rhythm)
• Anesthesia complications, such as respiratory depression, the need for mechanical ventilation, anaphylactic reactions, etc.

What Post-Operative Care is needed at the Healthcare Facility after the Endobronchial Valve placement procedure?

• The patient is usually observed by healthcare professionals (nurses) in the post-anesthesia care unit (PACU); and his/her vital signs are monitored
• A chest X-ray is usually performed to confirm valve placement/position
• Nebulizer treatment may be needed after the procedure

After the Endobronchial Valve placement procedure:

What are the possible Risks and Complications after the Endobronchial Valve placement procedure?

The possible risks and complications that arise after an Endobronchial Valve Placement procedure include:

• Sore throat and cough for up to 6 to 24 hours after the procedure
• Low-grade fevers for about 6 to 24 hours after the procedure
• Bronchospasm, which is manifested by difficulty in breathing
• Coughing of blood
• Lung collapse (pneumothorax)
• Valve migration, especially during coughing causing atelectasis (another form of lung collapse)
• Delayed clearance of anesthesia medications leading to prolonged respiratory depression and a need for mechanical ventilation
• Uncommonly, low oxygen saturations or cardiac arrhythmias post procedure may result in patient being admitted for overnight observation in the hospital

What is the Prognosis after the Surgery?

• The recovery from the Endobronchial Valve Placement procedure is generally good
• The patient is usually discharged after 60 minutes to 2 hours after the procedure. Typically, there may be a follow up with the physician in 2 weeks to review the results

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

• Persistent coughing 
• Worsening shortness of breath 
• Worsening or tearing chest pain
• High-grade fevers; over 101 degree F
• Coughing up blood or lots of mucus

What Post-Operative Care is needed at Home after the Endobronchial Valve placement procedure?

At home, the following post-operative care is recommended, after an Endobronchial Valve Placement procedure:

• Take simple analgesics, such as acetaminophen (Tylenol) or ibuprofen (Advil), if needed
• Avoid any strenuous activity for a period recommended by the physician
• Do not drive (post-procedure) for a period of 24 hours
• Avoid smoking or drinking alcohol post-procedure
• Continue prescribed medications except for aspirin or blood thinners. It is important to check with the physician on when to resume aspirin or blood thinners
• Do not sign any legal documents post-procedure for a period of 24 hours

How long does it normally take to fully recover, from the Procedure?

Usually, it takes about 12 to 24 hours to completely recover from the effects of the anesthesia and bronchoscopic procedure.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The samples/tissue are usually sent to the microbiology and pathology departments in the hospital and subsequently disposed, as per the standard hospital protocol.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The sample/tissue is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Endobronchial Valve placement procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• The pulmonologist, or thoracic surgeon
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing, before the Endobronchial Valve Placement procedure is performed.