Endobronchial Valves for Persistent Air Leak in Children: Two Case Reports and Review of the Literature

Background: Persistent air leak (PAL) is a rare but serious issue in children, often caused by necrotizing pneumonia, thoracic surgery, or chest trauma. While many cases respond to basic treatment, severe PAL may require prolonged respiratory support and invasive procedures. Endobronchial valves (EBVs), mainly used in adults, are becoming an option for select pediatric patients. Case Summary: We report two cases of necrotizing pneumonia in children that were complicated by severe PAL, leading to extended extracorporeal membrane oxygenation (ECMO) support. In both cases, placing Zephyr® EBVs (Pulmonx, Redwood City, CA, USA) successfully resolved the air leak, allowing for decannulation and hospital discharge without major complications. We also reviewed pediatric literature and identified 22 published cases of EBV use in children with PAL. Most cases reported favorable outcomes with minimal adverse effects. Conclusion: EBVs help heal bronchopleural and alveolopleural fistulas by causing targeted atelectasis in affected lung areas. Success depends on careful planning before the procedure. This includes imaging and bronchoscopic localization of the leak, especially in smaller children’s airways. Zephyr valves come in smaller sizes, which may benefit this group. Our report and the literature review show that EBVs are a safe and effective, minimally invasive option for treating severe PAL in critically ill children. More research is needed to establish selection criteria, procedural techniques, and long-term follow-up.