Staged and repeat endobronchial valve treatment for a right middle lobe giant bulla and left lower lobe emphysema in a patient with severe COPD.

With increasing evidence of meaningful clinical benefit in patients with advanced emphysema, bronchoscopic lung volume reduction (BLVR) using endobronchial valves (EBVs) was included in the Global Initiative for Chronic Obstructive Lung Disease report, as well as US Food and Drug Administration approval. However, bilateral BLVR using an EBV has been rarely reported. We report a case of successful and safe bilateral BLVR with staged EBV insertion. A 65-year-old male was diagnosed with chronic obstructive pulmonary disease 5 years prior and has severe heterogeneous emphysema mainly situated in the right upper lobe and left lower lobe (LLL) with giant bullae in the right middle lobe. First, we successfully inserted an EBV into the right middle bronchus, and the bullae decreased dramatically in size. After 6 months of initial valve implantation, we inserted five additional valves into the left lower bronchi of the patient. About 3 years after the secondary EBV insertion, this patient experienced hemoptysis and aggravation of dyspnea. In bronchoscopy, EBV inserted into LB6 was displaced with the formation of granulation tissue, so the EBV was removed. Later, LB6 was fully obstructed by granulation tissue. Then, we inserted an additional EBV into the LLL basal segmental bronchus, and complete atelectasis of the LLL occurred. The patient's pulmonary function, symptoms, and quality of life were further improved. BLVR can serve as a good alternative treatment for appropriately selected patients, and the procedure can be repeated on the contralateral side of the lung. It is important to recognize granulation tissue formation and deal with them appropriately.