Bilateral Tension Pneumothorax Following Unilateral Endobronchial Valve Placement: A Case Report

Endobronchial valves (EBVs) are increasingly used as a minimally invasive treatment option for selected patients with severe emphysema and hyperinflation. Pneumothorax is a recognized complication of EBV placement, typically occurring ipsilateral to the treated lung. To our knowledge, bilateral tension pneumothorax is exceedingly rare and potentially life-threatening. We report the case of a 61-year-old man with severe emphysema and hyperinflation who was admitted to the intensive care unit for monitoring after unilateral EBV placement in the right upper lobe. On the second day of admission, while breathing spontaneously, he developed sudden severe respiratory distress and hemodynamic instability. Bedside thoracic ultrasound, performed immediately during equipment preparation and prior to definitive imaging, demonstrated bilateral absence of lung sliding, supporting the diagnosis of bilateral tension pneumothorax. Immediate bilateral needle decompression was followed by chest tube insertion. The patient experienced cardiac arrest with pulseless electrical activity but achieved return of spontaneous circulation after prompt intervention. A persistent high-output right-sided air leak remained despite five days of spontaneous ventilation, necessitating valve removal and chemical pleurodesis, with complete resolution of the pneumothorax. This case illustrates a rare and catastrophic complication of unilateral EBV placement, likely related to abrupt post-procedural changes in lung mechanics and stress redistribution in severely emphysematous lungs. Early recognition, rapid bilateral decompression, and the adjunctive use of bedside thoracic ultrasound were critical for patient survival. Bilateral tension pneumothorax, although rare, should be considered in patients with acute respiratory or hemodynamic deterioration after EBV placement. Prompt diagnosis, supported by point-of-care ultrasound, and decisive management are essential. Persistent air leaks may require valve removal and pleurodesis, highlighting the need for individualized therapeutic strategies in this high-risk population.