Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial

Improving Lung Function in Severe Heterogenous Emphysema with the Spiration Valve System (EMPROVE). A Multicenter, Open-Label Randomized Controlled Clinical Trial

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema.

Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management.

Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control).

Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV₁ from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV₁ responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV₁ showed statistically significant improvements between the treatment and control groups—between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060–0.141) and 0.099 L (95% BCI, 0.048–0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax.

Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile.

Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

Cardio-Pulmonary Changes After Bronchoscopic Lung Volume Reduction with Endobronchial One-Way Valves

INTRODUCTION

To evaluate the cardio-pulmonary hemodynamics changes before and after valve treatment, and their correlation with lobe volume reduction.

METHODS

This retrospective multicentre study included consecutive patients undergoing bronchoscopic valve treatment for heterogeneous emphysema. In addition to standard functional evaluation, patients underwent cardiac evaluation by Doppler trans-thoracic echocardiography. The difference in respiratory and cardio-pulmonary hemodynamics indexes before and 3-month after the procedure, and their relationship with changes in lobar volume were evaluated.

RESULTS

Seventy-seven patients were included in the study; of these 13 (17%) presented pulmonary hypertension. Only patients with target lobar volume reduction ≥ 563 mL (n = 50) presented a significant improvement of forced expiratory volume in one second, residual volume, 6 min-walk test, and St. George's Respiratory Questionnaire score; a significant reduction of pulmonary artery pressure, and an improvement of left and right ventricle end-systolic volume; of left and right ventricle end-diastolic volume, and of left and right ventricle stroke volume. The change in residual volume was significantly correlated with changes in forced expiratory volume in one second (r = 0.68; p < 0.001); in 6 min-walk test (r = 0.71; p < 0.001); in St. George's Respiratory Questionnaire (r = 0.54; p < 0.001); in pulmonary artery pressure (r = 0.39; p = 0.001), in left (r = 0.28; p = 0.01) and right (r = 0.33; p = 0.002) ventricle end-systolic volume, in left (r =  - 0.29; p = 0.008) and right (r =  - 0.34; p = 0.007) end-diastolic volume, and in left (r =  - 0.76; p = 0.009) and right (r =  - 0.718; p = 0.001) ventricle stroke volume.

CONCLUSION

Bronchoscopic valve treatment seemed to have positive effects on cardio-pulmonary hemodynamics, and these changes were correlated with reductions of lobar volume.

The STELVIO trial, a game changer for bronchoscopic lung volume reduction in patients with severe emphysema

Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and airflow limitation, which is caused by small airway disease (bronchiolitis) and alveolar destruction (emphysema) [1]. Patients primarily suffering from severe emphysema are often limited in exercise capacity due to the consequences of hyperinflation [2].

The STELVIO trial was crucial to ensure that bronchoscopic lung volume reduction using one-way valves has evolved from an experimental intervention into a state-of-the-art treatment option for specific patients with advanced emphysemahttp://bit.ly/2IgMrsp

Considerations and methods for placebo controls in surgical trials (ASPIRE guidelines)

Placebo comparisons are increasingly being considered for randomised trials assessing the efficacy of surgical interventions. The aim of this Review is to provide a summary of knowledge on placebo controls in surgical trials. A placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. This Review outlines what a placebo control entails and present understanding of this tool in the context of surgery. We consider when placebo controls in surgery are acceptable (and when they are desirable) in terms of ethical arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be done and interpreted. Use of placebo controls is justified in randomised controlled trials of surgical interventions provided there is a strong scientific and ethical rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with high risk of bias, particularly because of the placebo effect. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. This Review forms an outline for best practice and provides guidance, in the form of the Applying Surgical Placebo in Randomised Evaluations (known as ASPIRE) checklist, for those considering the use of a placebo control in a surgical randomised controlled trial.

Bronchoscopic device intervention in chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease is a heterogeneous syndrome associated with varying degrees of parenchymal emphysema and airway inflammation resulting in decreased expiratory flow, lung hyperinflation, and symptoms leading to decreased exercise tolerance and quality of life. Impairment in lung function and quality of life persists following guideline-based medical therapy, thus surgical and minimally invasive bronchoscopic approaches were developed to address this unmet need. We offer a narrative review of the available technologies.

RECENT FINDINGS

Although lung volume reduction surgery has been shown to improve survival in appropriately selected patients, it is infrequently performed. Less invasive bronchoscopic procedures have thus been explored including endobronchial valves, coils, lung sealant, thermal vapor, and other airway approaches. Selection criteria including severity of physiologic and radiographic impairment, degree of lung hyperinflation, presence of intact fissures, type of symptoms, and presence of comorbidities are critical in selecting appropriate candidates.

SUMMARY

Recent advances in minimally invasive approaches to lung volume reduction have offered alternatives to surgical approaches. Two endobronchial valve devices are Food and Drug Administration approved for clinical use, and investigations into alternative bronchoscopic therapies to treat both emphysema and chronic bronchitis have been performed or are currently underway. Notably, each of these treatments requires unique selection criteria and thus a personalized approach to treatment.

Endobronchial Valve Treatment in Emphysema Patients with a Very Low DLCO

BACKGROUND

For selected patients with severe emphysema, bronchoscopic lung volume reduction with endobronchial valves (EBV) is recognized as an additional treatment option. In most trials investigating EBV treatment, patients with a very low diffusing capacity (DLCO) were excluded from participation.

OBJECTIVES

Our goal was to investigate whether EBV treatment in patients with emphysema with a very low DLCO is safe and effective.

METHODS

This was a single-center retrospective analysis including patients with emphysema and a DLCO ≤20%pred who underwent EBV treatment. Follow-up was performed 6 months post-treatment. Outcome parameters were compared to a historical matched control group (DLCO >20%pred, matched for sex, age, forced expiratory volume in 1 s [FEV1], and residual volume [RV]).

RESULTS

Twenty patients (80% female, 64 ± 6 years, FEV1 26 ± 6%pred, RV 233 ± 45%pred, DLCO 18 ± 1.6%pred) underwent EBV treatment. At 6 months follow-up, we found a statistically significant improvement in FEV1 (0.08 ± 0.12 L), RV (-0.45 ± 0.95 L), 6-min walking distance (38 ± 65 m), and St. George's Respiratory Questionnaire (-12 ± 13 points). With the exception of FEV1, all exceeded the minimal clinically important difference. The most common serious adverse event was a pneumothorax requiring intervention (15%). There were no significant differences in outcome compared to the DLCO >20%pred control group.

CONCLUSIONS

In this single-center retrospective analysis, we showed statistically significant and clinically relevant improvements in lung function, exercise capacity, and quality of life up to 6 months after EBV treatment in emphysema patients with a DLCO ≤20% (14-20%) of predicted with no increased risk of serious adverse events.

Lung Volume Reduction Surgery in Patients with Heterogenous Emphysema: Selecting Perspective

BACKGROUND:

Lung volume reduction surgery (LVRS) was introduced to alleviate clinical conditions in selected patients with heterogenous emphysema. Clarifying the most suitable patients for LVRS remained unclear.

AIM:

This study was undertaken to specifically analyze the preoperative factor affecting to LVRS.

METHODS:

The prospective study was conducted at 103 Military Hospital between July 2014 and April 2016. Severe heterogenous emphysema patients were selected to participate in the study. The information, spirometry, and body plethysmographic pulmonary function tests in 31 patients who underwent LVRS were compared with postoperative outcomes (changing in FEV1 and CAT scale).

RESULTS:

Of the 31 patients, there was statistically significant difference in the outcome of functional capacity, lung function between two groups (FEV1 ≤ 50% and > 50%) (∆FEV1: 22.46 vs 18.32%; p = 0.042. ∆ CAT: 6.85 vs 5.07; p = 0.048). Changes of the FEV1 and CAT scale were no statistically significant differences in three groups residual volume. Patients with total lung capacity < 140% had more improved than others (∆FEV1: 23.81 vs 15.1%; p = 0.031).

CONCLUSION:

Preoperative spirometry and body plethysmographic pulmonary function tests were useful measures to selected severe heterogenous emphysema patients for LVRS. Patients with FEV1 ≤ 50%, TLC in the range of 100-140% should be selected.

Screening for Bronchoscopic Lung Volume Reduction: Reasons for Not Receiving Interventional Treatment

BACKGROUND

Evidence for bronchoscopic lung volume reduction (BLVR) is based on phase 2 studies and small randomized controlled trials with in- and exclusion criteria defining a therapeutic window and contraindications. Little is known about the applicability in routine clinical practice.

AIM

Which percentage of patients with severe emphysema referred to a specialized treatment center for BLVR is ultimately suitable for interventional bronchoscopic treatment? What is the relevance of the different contraindications?

METHODS

Retrospective evaluation of emphysema patients referred to Asklepios Fachkliniken Munich-Gauting for BLVR between January 2014 and June 2015.

RESULTS

138 patients were referred for evaluation of BLVR. 38 patients (27.5%) underwent BLVR procedures (valves n = 18; coils n = 18; thermal vapor ablation n = 2). 100 patients (72.5%) were deemed not eligible for BLVR based on the following contraindications: 34% emphysema morphology and emphysema-related findings (severe homogeneous emphysema, extensive pleuropulmonary adhesions, postinflammatory scaring with natural volume reduction, giant bullae), 16% active smoking; 9% pulmonary function not within indication range; 8% unexpected CT findings (nodules, cancer, interstitial disease); 8% chronic ventilatory failure; 8% patient refused BLVR; 5% relevant comorbidity; 5% frequent exacerbations, 3% preserved quality of life, 4% other.

CONCLUSION

BLVR is a therapeutic option for highly selected patients. In our cohort, one in four could be treated. These data highlight the limitations of BLVR under real-life conditions.

Interventional Bronchoscopy in the Management of Chronic Obstructive Lung Disease

Background:

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation, hyperinflation and reduced gas exchange that lead to progressive dyspnea. Pulmonary rehabilitation, lifestyle changes, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation and surgical therapeutic approaches are the basic management strategies.

Purpose:

In the last 15 years, various bronchoscopic therapeutic modalities have emerged for severe COPD. The aim of this review is to summarize the effects of these bronchoscopic treatments compared with lung rehabilitation and pharmacological therapies.

Methods:

A PubMed search for the eligible studies and reviews on interventional bronchoscopy and COPD has been conducted.

Results:

Bronchoscopic lung volume reduction (LVR) techniques are targeted to reduce hyperinflation. The efficacy of reversible valve implantation has been confirmed in several randomized controlled trials. It provides clinical benefit in the absence of interlobar collateral ventilation. Nonblocking bronchoscopic LVR with coils, thermal vapor or sealants is independent of collateral ventilation but has not been studied sufficiently. Partially irreversible coil implantation leads to parenchymal compression while irreversible LVR with thermal vapor or sealants induce an inflammatory reaction. Targeted lung denervation ablates parasympathetic pulmonary nerves in COPD for sustainable bronchodilation, and liquid nitrogen metered cryospray destroys hyperplastic goblet cells and excessive submucous glands in the central airways to induce mucosal regeneration in chronic bronchitis.

Conclusion:

The best-examined bronchoscopic LVR method is the valve therapy. The data from the other modalities are still limited. Further studies are required to select the patients that will optimally benefit from a particular treatment and to predict and treat the procedure-related complications.

Computed Tomography Imaging for Novel Therapies of Chronic Obstructive Pulmonary Disease

Novel therapeutic options in chronic obstructive pulmonary disease (COPD) require delicate patient selection and thus demand for expert radiologists visually and quantitatively evaluating high-resolution computed tomography (CT) with additional functional acquisitions such as paired inspiratory-expiratory scans or dynamic airway CT. The differentiation between emphysema-dominant and airway-dominant COPD phenotypes by imaging has immediate clinical value for patient management. Assessment of emphysema severity, distribution patterns, and fissure integrity are essential for stratifying patients for different surgical and endoscopic lung volume reduction procedures. This is supported by quantitative software-based postprocessing of CT data sets, which delivers objective emphysema and airway remodelling metrics. However, the significant impact of scanning and reconstruction parameters, as well as intersoftware variability still hamper comparability between sites and studies. In earlier stage COPD imaging, it is less clear as to what extent quantitative CT might impact decision making and therapy follow-up, as emphysema progression is too slow to realistically be useful as a mid-term outcome measure in an individual, and longitudinal data on airway remodelling are still very limited.

Efficacy of the Spiration Valve System in Patients with Severe Heterogeneous Emphysema: A Systematic Review and Meta-Analysis

BACKGROUND

Spiration Valve System (SVS) is an alternative for patients with severe heterogeneous emphysema; however, data about efficacy from randomized controlled trials (RCT) are unclear.

OBJECTIVES

To explore both efficacy and safety of SVS in patients with severe emphysema and hyperinflation.

METHODS

We included PubMed, EMBASE, Coch-rane database. All searches were performed until August 2019. Only RCTs were included for analysis. Risk of bias was assessed using Cochrane risk of bias tool. A meta-analysis evaluated change in forced expiratory volume in 1 s (FEV1), 6-min walking test (6MWT), residual volume, modified medical research council (mMRC) and Saint George respiratory questionnaire (SGRQ), all-cause mortality, risk of pneumothorax, and risk of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Quality of the evidence was rated using GRADE approach.

RESULTS

Four RCTs including 629 subjects were included. SVS showed an overall change of 0.03 L (-0.07 to 0.13, I2 = 90%) in the in FEV1 (L) and a 2.03% (-2.50 to 6.57, I2 = 96%) in the predicted FEV1 (%) compared to baseline; however, studies without collateral ventilation (CV) showed an improvement of 0.12 L (95% CI 0.09-0.015, I2 = 0%), This subgroup also reported better results in SGRQ -12.27 points (95% CI -15.84 to -8.70, I2 = 0%) and mMRC -0.54 (95% CI -0.74 to -0.33, I2 = 0%). We found no benefit in 6MWT mean difference = 4.56 m (95% CI -21.88 to 31.00, I2 = 73%). Relative risk of mortality was 2.54 (95% CI 0.81-7.96, I2 = 0%), for pneumothorax 3.3 (95% CI 0.61-18.12, I2 = 0%) and AECOPD 1.68 (95% CI 1.04-2.70, I2 = 0%).

CONCLUSION

In patients with severe heterogeneous emphysema and hyperinflation without CV, SVS is an alternative that showed an improvement in pulmonary function, quality of life, and dyspnea score with an acceptable risk profile.

Protocol of a Randomized Controlled Study of the PneumRx Endobronchial Coil System versus Standard-of-Care Medical Management in the Treatment of Subjects with Severe Emphysema (ELEVATE)

BACKGROUND

The PneumRx endobronchial coil system for patients with severe emphysema has been shown to improve quality of life, exercise capacity, and pulmonary function in patients with emphysema. A post hoc analysis of the RENEW trial has identified patient characteristics and lobar selection methods associated with improved outcomes, which have to be confirmed prospectively.

METHODS

The ELEVATE trial is a prospective, multicenter, open label, randomized (2:1), controlled trial comparing outcomes in patients treated with endobronchial coils (treatment) to a medically managed control group (control). The trial aims to enroll 210 patients (140 in the treatment group and 70 in the control group) with severe emphysema. Control patients will be eligible to crossover to coil treatment after 6 months of follow-up. The co-primary effectiveness endpoints are percent change in forced expiratory volume in 1 s and quality of life measured by change in St. George's Respiratory Questionnaire from baseline to 6 months. Secondary objectives are determination of responder rates of clinical endpoints and mean change in other functional and physiologic endpoints. All patients will be followed for 24 months after initial treatment. Adverse events will be collected on an ongoing basis throughout the trial.

DISCUSSION

The primary objective of the ELEVATE trial is to prospectively confirm the safety and effectiveness profile of the coil system for the treatment of severe emphysema in consideration of the findings of previous randomized controlled trials. Secondary objectives are the determination of responder rates in all clinical endpoints and mean change in physiologic endpoints.

Asthma-COPD Overlap and Chronic Airflow Obstruction: Definitions, Management, and Unanswered Questions

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is a common clinical presentation of chronic airways disease in which patients show some features usually associated with asthma, and some usually associated with COPD. There is ongoing debate over whether ACO is a discrete clinical entity, or if it is part of a continuum of airways disease. Furthermore, there is considerable variation among current definitions of ACO, which makes diagnosis potentially challenging for clinicians. Treating ACO may be equally challenging because ACO is an understudied population, and the evidence base for its management comes largely from asthma and COPD studies, the relevance of which deserves careful consideration. In this review, we synthesize the various approaches to ACO diagnosis and evaluate the role of currently available diagnostic tests. We describe the potential benefits of existing asthma and COPD therapies in treating patients with ACO, and the value of a "treatable traits" approach to ACO management. Throughout the review, we highlight some of the pressing, unanswered questions surrounding ACO that are relevant to the clinical community. Ultimately, addressing these questions is necessary if we are to improve clinical outcomes for this complex and heterogeneous patient population.

Endobronchial one-way valve for persistent air leak and lung volume reduction

There are randomized controlled study data showing that endobronchial one-way valves (EBV) are useful for bronchoscopic lung volume reduction (BLVR). There is also case series data showing EBV to be effective in stopping persistent air leaks complicating pneumothoraces. We describe a 66-year-old man with severe chronic obstructive pulmonary disease (COPD) who failed assessments for BLVR because of the inability to perform the carbon monoxide diffusion test but subsequently had EBV deployed to his right upper lobe bronchi for persistent air leak complicating a spontaneous pneumothorax. Afterwards, there was subjective improvement in breathlessness, exercise capacity, and reduced frequency of exacerbations requiring hospitalization. Lung function parameters showed marked improvement. This case suggests that patients with compatible spirometric lung volume and computed tomography findings should proceed with BLVR. In addition, one should be aware of the possibility of improved lung function in patients with pulmonary emphysema following implantation of EBV for persistent air leak.

A Multicenter Randomized Controlled Trial of Zephyr Endobronchial Valve Treatment in Heterogeneous Emphysema (LIBERATE)

RATIONALE

This is the first multicenter randomized controlled trial to evaluate the effectiveness and safety of Zephyr Endobronchial Valve (EBV) in patients with little to no collateral ventilation out to 12 months.

OBJECTIVES

To evaluate the effectiveness and safety of Zephyr EBV in heterogeneous emphysema with little to no collateral ventilation in the treated lobe.

METHODS

Subjects were enrolled with a 2:1 randomization (EBV/standard of care [SoC]) at 24 sites. Primary outcome at 12 months was the ΔEBV-SoC of subjects with a post-bronchodilator FEV₁ improvement from baseline of greater than or equal to 15%. Secondary endpoints included absolute changes in post-bronchodilator FEV₁, 6-minute-walk distance, and St. George's Respiratory Questionnaire scores.

MEASUREMENTS AND MAIN RESULTS

A total of 190 subjects (128 EBV and 62 SoC) were randomized. At 12 months, 47.7% EBV and 16.8% SoC subjects had a ΔFEV₁ greater than or equal to 15% (P < 0.001). ΔEBV-SoC at 12 months was statistically and clinically significant: for FEV₁, 0.106 L (P < 0.001); 6-minute-walk distance, +39.31 m (P = 0.002); and St. George's Respiratory Questionnaire, -7.05 points (P = 0.004). Significant ΔEBV-SoC were also observed in hyperinflation (residual volume, -522 ml; P < 0.001), modified Medical Research Council Dyspnea Scale (-0.8 points; P < 0.001), and the BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index (-1.2 points). Pneumothorax was the most common serious adverse event in the treatment period (procedure to 45 d), in 34/128 (26.6%) of EBV subjects. Four deaths occurred in the EBV group during this phase, and one each in the EBV and SoC groups between 46 days and 12 months.

CONCLUSIONS

Zephyr EBV provides clinically meaningful benefits in lung function, exercise tolerance, dyspnea, and quality of life out to at least 12 months, with an acceptable safety profile in patients with little or no collateral ventilation in the target lobe. Clinical trial registered with www.clinicaltrials.gov (NCT 01796392).

Endobronchial Valves Therapy for Advanced Emphysema: A Meta-Analysis of Randomized Trials

BACKGROUND

Trials suggest that bronchoscopic lung volume reduction (BLVR) with endobronchial valve (EBV) implantation may produce similar effects as lung volume reduction surgery, by inducing atelectasis and reducing hyperinflation through a minimally invasive procedure. This study sought to investigate the efficacy and safety of BLVR with EBV for advanced emphysema.

METHODS

We searched PubMed, EMBASE, Web of Science, CINAHL, ClinicalTrials.gov, and Cochrane Library databases for randomized controlled trials comparing EBV implantation versus standard medical treatment or sham bronchoscopy. The main outcome of interest was the percentage change of forced expiratory volume in 1 second.

RESULTS

Data analyzed from 5 randomized controlled trials with 703 patients revealed improvement in percentage change of forced expiratory volume in 1 second in EBV group compared with control group [weighted mean difference (WMD)=11.43; 95% confidence interval (CI), 6.05-16.80; P<0.0001] and improvement in the St. George's Respiratory Questionnaire score (WMD=-5.69; 95% CI, -8.67 to -2.70; P=0.0002). There is no difference shown in the 6-minute walking test (WMD=14.12; 95% CI, -4.71 to 32.95; P=0.14). The overall complication rate of EBV was not significantly different except for an increased rate of pneumothorax [relative risk (RR)=8.16; 95% CI, 2.21-30.11; P=0.002), any hemoptysis (RR=5.01; 95% CI, 1.12-22.49; P=0.04)] and valve migration (RR=8.64; 95% CI, 2.01-37.13; P=0.004).

CONCLUSION

BLVR using EBV shows short-term improvement in lung function and quality of life, but with increased risk of minor hemoptysis, pneumothorax, and valve migration. Follow-up data on the studies are needed to determine its long-term efficacy.

Interventional therapy in patients with severe emphysema: evaluation of contraindications and their incidence

Background:

Endoscopic and surgical interventions may be beneficial for selected patients with emphysema. Rates of treatment failure decrease when the predictors for successful therapy are known. The aim of the study was to evaluate the number of patients with severe emphysema who were not eligible for any intervention, and the reasons for their exclusion.

Methods:

The study was a retrospective analysis of 231 consecutive patients with advanced emphysema who were considered for interventional therapy in 2016 at the Thoraxklinik, Heidelberg, Germany. The reasons for not receiving valve or coil therapy were assessed for all patients who did not receive any therapy.

Results:

Of the 231 patients, 50% received an interventional therapy for lung volume reduction (LVR) (82% valve therapy, 6% coil therapy, 4.3% polymeric LVR or bronchial thermal vapour ablation, 4.3% total lung denervation, and 3.4% lung volume reduction surgery [LVRS]). A total of 115 patients did not undergo LVR. Out of these, valve or coil therapy was not performed due to one or more of the following reasons: incomplete fissure in 37% and 0%; missing target lobe in 31% and 30%; personal decision in 18% and 28%; pulmonary function test results in 8% and 15%; ventilatory failure in 4% and 4%; missing optimal standard medical care and/or continued nicotine abuse in 4% and 3%; general condition too good in less than 1% and 3%; cardiovascular comorbidities in 0% and 3%; age of patient in 0% and less than 1%. Both techniques were not performed due to one or more of the following reasons: solitary pulmonary nodule(s)/consolidation in 27%; bronchopathy in 7%; neoplasia in 2%; destroyed lung in 2%; prior LVRS in less than 1%.

Conclusions:

The main reason for not placing valves was an incomplete fissure and for coils a missing target lobe. Numerous additional contraindications that may exclude a patient from interventional emphysema therapy should be respected.

Eligibility for Lung Volume Reduction Surgery in Patients With COPD Identified in a UK Primary Care Setting

BACKGROUND

Although lung volume reduction surgery (LVRS) improves survival in appropriately selected patients with COPD, few procedures are performed. The National Institute for Health and Care Excellence has recommended a more systematic approach to identifying potential candidates. We investigated LVRS referrals from a UK primary care population and aimed to establish an accurate estimate of eligible patients and determine a strategy for identifying potential candidates systematically.

METHODS

Clinical Practice Research Datalink GOLD (a primary care database) and the linked Hospital Episode Statistics inpatient and Diagnostic Imaging Dataset were used. Patients with COPD who had undergone LVRS, patients who met basic eligibility criteria for further screening for LVRS, and patients meeting a more stringent eligibility criteria were identified from April 2012 to September 2015. Thoracic CT scan, pulmonary rehabilitation status, referral to respiratory outpatient clinics, and acute exacerbation of COPD requiring hospitalization were compared between actual LVRS recipients and potentially eligible patients.

RESULTS

Among the 73,697 patients with COPD included, 36 (0.05%) received LVRS, 5,984 (8.1%) met basic eligibility criteria, and 159 (0.2%) met more stringent eligibility criteria. LVRS recipients were younger (mean age ± SD, 64 ± 9.2 years) than the stringently eligible patients (mean age ± SD, 69 ± 8.9 years; P = .01). Few patients meeting stringent eligibility criteria (6.9%) had a CT scan of the thorax in the preceding 3 years or had been referred for assessment in secondary care.

CONCLUSIONS

A substantial unmet need exists among patients with COPD who could potentially benefit from a lung volume reduction procedure but who are not being investigated or referred to consider this possibility.

The Impact of a Newly Established Multidisciplinary Team on the Interventional Treatment of Patients With Emphysema

Background:

The emphysema interventional treatment involves mainly lung volume reduction surgery (LVRS) and endobronchial valve (EBV) implantation. Few institutes discuss these cases at a dedicated emphysema multidisciplinary team (MDT) meeting.

Objectives:

To investigate the impact of a newly established dedicated emphysema MDT meeting on the interventional treatment of such patients.

Methods:

During a study period of 4 years, the outcome of 44 patients who underwent intervention according to the proposal of the emphysema MDT (group A) was compared with the outcome of 44 propensity score matched patients (group B) treated without the emphysema MDT proposal.

Results:

More LVRS and less EBV insertions were performed in group A (P = .009). In group B, the interventions were performed sooner than in group A (P = .003). Postoperative overall morbidity and length of in-hospital stay were similar in the 2 groups (P = .918 and .758, respectively). Improvement of breathing ability was reported in more patients from group A (P = .012). In group B, the total number of re-interventions was higher (P = .001) and the time to re-intervention had the tendency to be less (P = .069). Survival was similar between the 2 groups (P = .884). Intervention without discussion at the MDT and EBV as initial intervention was an independent predictor of re-intervention.

Conclusions:

Interventional treatment for patients with chronic obstructive pulmonary disease (COPD) after discussion at a dedicated MDT involved more LVRS performed, required fewer interventions for their disease, and had longer re-intervention-free intervals and better breathing improvement.

Bronchoscopic Lung Volume Reduction with Endobronchial Zephyr Valves for Severe Emphysema: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic lung volume reduction using Zephyr® valves has been recently adopted as a treatment option for patients with severe emphysema without collateral ventilation (CV).

OBJECTIVES

To assess the efficacy and safety of Zephyr valves in such a population.

METHODS

Studies were identified from MEDLINE and EMBASE databases. All searches were current until June 2018. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy and safety of Zephyr. We defined as outcome: change in forced expiratory volume in 1 s (FEV1), in the 6-min walking test (6MWT), in the St George's Respiratory Questionnaire (SGRQ), and in residual volume (RV). Safety analysis included relative risk (RR) of pneumothorax. We assessed the quality of the evidence using GRADE.

RESULTS

7 RCTs reported on Zephyr valves and 5 RCTs included only patients without CV. Zephyr improved FEV1 with a mean difference (MD) of 17.36% (CI, 9.28-25.45, I2 = 78%). Subgroup analysis showed significant FEV1 improvement following Zephyr placement in patients with heterogeneous distribution: MD = 21.78% (CI, 8.70-34.86, I2 = 89%) and 16.27% (CI, 8.78-23.76, I2 = 0%) in patients with homogeneous emphysema. Studies with a follow-up of 3 months reported FEV1 MD = 17.19% (CI, 3.16-31.22, I2 = 89%) compared to studies with a follow-up of 6-12 months, which showed a consistent improvement of FEV1 MD = 17.90% (CI, 11.47-24.33, I2 = 0%). Zephyr also showed improvement of SGRQ, 6MWT, and RV. RR of pneumothorax was 6.32 (CI, 3.74-10.67, I2 = 0%).

CONCLUSION

In this population, Zephyr valves provided significant and clinically meaningful short-term improvements in either homogeneous or heterogeneous emphysema without CV but with an increase in adverse events.

Changes in ventilation and perfusion following lower lobe endoscopic lung volume reduction (ELVR) with endobronchial valves in severe COPD

BACKGROUND

We have previously reported significant improvements in ventilation and perfusion (VQ) and V/Q matching in the contralateral lung, especially the non-targeted lower zone in patients with severe COPD following upper lobe ELVR with endobronchial valves. However, V/Q changes after lower lobe ELVR have not been described.

METHODS

Seven patients with lower lobe heterogeneous emphysema underwent unilateral lower lobe ELVR at Macquarie University Hospital. Lung function tests, 6-minute walk tests (6MWT), St George's Respiratory Questionnaire (SGRQ) and planar differential VQ scans were performed at baseline and at 1, 3 and 12 months post-ELVR.

RESULTS

Compared to baseline, patients showed significant improvements in FEV1 (0.83 ± 0.09L-0.97 ± 0.12L, p < 0.05), 6MWD (200.33 ± 56.54 m-274.24 ± 48.03 m, p < 0.05) and SGRQ (61.13 ± 5.33-42.86 ± 6.99, p < 0.05) at 3 months after ELVR. This improvement was maintained at 12 months. There was a corresponding significant improvement in the differential ventilation (30.21 ± 3.04%-37.82 ± 3.76%, p < 0.05) and perfusion (31.77 ± 2.53%-35.60 ± 2.58%, p < 0.05) of the contralateral non-targeted upper zone.

CONCLUSIONS

Within the limitations of a small sample size, we have found that in heterogeneous severe COPD patients undergoing ELVR targeting the lower lobes, there are clinical and PFT improvements similar to that reported in ELVR targeting upper lobes. Contralateral improvement in V/Q matching also occurs following lower lobe ELVR with the greatest improvement in the contralateral upper zone, suggesting the contralateral upper lobe should be the least affected lobe if the lower lobe is targeted in ELVR. These findings need to be confirmed in a study with a larger number of patients.

Bronchoscopic lung volume reduction using an endobronchial valve to treat a huge emphysematous bullae: a case report

BACKGROUND

In patients with chronic obstructive pulmonary disease (COPD), bronchoscopic lung volume reduction (BLVR) techniques using unidirectional endobronchial valves improve lung function and increase exercise tolerance. BLVR treatment is included in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) treatment guidelines for COPD patients without interlobar collateral ventilation. However, BLVR using an endobronchial valve has not been attempted in patients with giant bullae.

CASE PRESENTATION

We report successful and safe BLVR using an endobronchial valve in a patient with a huge bullous emphysema in the right middle lobe. A 65-year-old male was diagnosed with COPD 5 years prior and had a large bullae in the right middle lobe at that time. During regular follow-up, the symptoms of respiratory distress gradually worsened, and the size of the bullae gradually increased on computed tomography (CT). Therefore, we decided to treat the patient via BLVR using an unidirectional endobronchial valve. The Chartis system (Pulmonx, Inc., Palo Alto, CA) confirmed the absence of collateral ventilation of the right middle lobe. We successfully inserted an endobronchial valve into the right middle bronchus. After insertion, the bullae decreased dramatically in size, and the patient's symptoms and quality of life improved markedly.

CONCLUSION

This case supports recent suggestions that BLVR can serve as a good alternative treatment for appropriately selected patients.

Role of Quantitative Computed Tomographic Scan Analysis in Lung Volume Reduction for Emphysema

Recent advances in bronchoscopic lung volume reduction (BLVR) offer new therapeutic alternatives for patients with emphysema and hyperinflation. Endobronchial valves and coils are 2 potential BLVR techniques which have been shown to improve pulmonary function and the quality of life in patients with emphysema. Current patient selection for LVR procedures relies on 3 main inclusion criteria: low attenuation area (in %), also known as emphysema score, heterogeneity score, and fissure integrity score. Volumetric analysis in combination with densitometric analysis of the affected lung lobe or segment with quantitative CT to determine emphysema severity play an important role in treatment planning and post-operative assessment. Due to the variations in lung anatomy, manual corrections are often required to ensure successful and accurate lobe segmentation for pathological and post-treatment CT scan analysis. The advanced development and utilisation of quantitative CT do not simply represent regional changes in pulmonary function but aids in analysis for better patient selection with severe emphysema who are most likely to benefit from BLVR.

Endobronchial valves for severe emphysema

The results of the randomised controlled trials investigating the bronchoscopic lung volume reduction treatment using endobronchial valves (EBV) are promising, and have led to their inclusion in treatment guidelines, US Food and Drug Administration approval and inclusion in routine care in an increasing number of countries. The one-way valve treatment has advanced and is now a regular treatment option. However, this new phase will lead to new challenges in terms of implementation. We believe that key issues in future research concern advanced patient selection, improved methods for target lobe selection, increased knowledge on the predictive risk of a pneumothorax, positioning of pulmonary rehabilitation in conjunction with the EBV treatment, the positioning of lung volume reduction surgery versus EBV treatment, and the long-term efficacy, adverse events, impact on exacerbations and hospitalisations, costs and survival. Hopefully, the increasing number of patients treated, the setup of (inter)national registries and future research efforts will further optimise all aspects of this treatment.

[Imaging before and after endoscopic lung volume reduction]

The treatment of symptomatic lung emphysema by lung volume reduction has become established over the last 15 years. While surgical partial lung resection has profited from improved and less invasive surgical techniques, various endoscopic interventional procedures have been developed and are now available for use. All treatment approaches are dependent on individual anatomical variants and a regional distribution of the lung emphysema, which is why no procedure can be designated as the gold standard for all patients. High-resolution computed tomography can be qualitatively evaluated and provides decisive information for treatment, which is why radiologists play a particularly important role in treatment planning and aftercare of an intervention for reduction of the lung volume. This article presents the various endoscopic techniques, names the demands of the treating physician on the advising radiologist and finally describes how a treatment decision is derived from the results obtained.

Bronchoscopic Lung Volume Reduction

Since the publication of the National Emphysema Treatment Trial study, lung volume reduction (LVR) has been considered a therapeutic alternative for patients with advanced obstructive lung disease. The high complication rate of surgical LVR has led to the development of bronchoscopic LVR (BLVR). Of the currently available BLVR alternatives, coils and unidirectional endobronchial valves lead the list. The choice of each device depends on emphysema characteristics and presence of collateral ventilation. Evaluation of these patients at centers with expertise in interventional pulmonology and management of BLVR is strongly recommended.

Advances in Interventional Pulmonology

Much has changed since the last review of interventional pulmonology (IP) published in this Clinics series. The rate of development of new techniques and their complexities require IP physicians to be constantly maintaining and updating their skill set. International agreed training pathways help ensure that the interventionalists of the present and future have the required knowledge of anatomy, manual dexterity, and clinical judgment to keep up with the continuing advances that are constantly expanding IP's diagnostic and therapeutic boundaries. IP remains one of the most desirable subspecialities in pulmonology, and the technologic advances make the future an exciting one.

A Patient with GOLD Stage 3 COPD « cured » by One-Way Endobronchial Valves

Lung hyperinflation is a main determinant of dyspnoea in patients with chronic obstructive pulmonary disease (COPD). Surgical or bronchoscopic lung volume reduction are the most efficient therapeutic approaches for reducing hyperinflation in selected patients with emphysema. We here report the case of a 69-year old woman with COPD (GOLD stage 3-D) referred for lung volume reduction. She complained of persistent disabling dyspnoea despite appropriate therapy. Chest imaging showed marked emphysema heterogeneity as well as severe hyperinflation of the right lower lobe. She was deemed to be a good candidate for bronchoscopic treatment with one-way endobronchial valves. In the absence of interlobar collateral ventilation, 2 endobronchial valves were placed in the right lower lobe under general anaesthesia. The improvement observed 1 and 3 months after the procedure was such that the patient no longer met the pulmonary function criteria for COPD. The benefit persisted after 3 years.

Predictors of Response to Endobronchial Coil Therapy in Patients With Advanced Emphysema

BACKGROUND

The Lung Volume Reduction Coil Treatment in Patients With Emphysema (RENEW) trial reported improvements in quality of life, pulmonary function, and exercise performance following endobronchial coil treatment.

OBJECTIVES

The purpose of this post hoc analysis was to identify baseline predictors, including quantitative CT measures, that identify patients most likely to significantly benefit from endobronchial coil therapy.

METHODS

Quantitative CT analysis by an independent radiology laboratory and a qualitative evaluation by five blinded experts of the baseline thoracic CT imaging were performed. Univariate and multivariate logistic regression analyses were performed to elucidate characteristics associated with clinical response.

RESULTS

In total, 125 patients underwent coil treatment and had evaluable 12-month follow-up results. Of these, 78 patients received treatment of lobes with the highest emphysematous destruction determined by quantitative CT analysis (quantitative visual match [QVM]+), and 47 received treatment in at least one lobe that was not the most destroyed (QVM-). From the 78 patients with QVM+ treatment, a subgroup of 50 patients (64%) was identified with baseline residual volume > 200% predicted, emphysema score > 20% low attenuation area, and absence of airway disease. In this subgroup, greater lobar residual volume reduction in the treated lobes was achieved, which was associated with significant mean ± SE improvement in FEV₁ (15.2 ± 3.1%), St. George's Respiratory Questionnaire (-12 ± 2 points), and residual volume (-0.57 ± 0.13 L).

DISCUSSION

This post hoc analysis found that both significant hyperinflation (residual volume ≥ 200% predicted) and CT analysis are critical for patient selection and treatment planning for endobronchial coil therapy. Quantitative CT analysis is important to identify optimal lobar treatment and to exclude patients with insufficient emphysema (< 20% low attenuation area), whereas visual assessment identifies patients with signs of airway disease associated with worse outcomes.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01608490; URL: www.clinicaltrials.gov.

Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis

BACKGROUND

Severe emphysema is a debilitating condition with few treatment options. Lung volume reduction procedures in the treatment of severe emphysema have shown excellent results in selected patients but their exact role remains unclear with studies reporting a wide variation in outcomes. We therefore aimed to evaluate the effects of volume reduction.

METHODS

We did a systematic review and meta-analysis. We searched MEDLINE on Sept 29, 2016, for trials of lung volume reduction in patients with emphysema, and we did an updated search on Embase and PubMed on June 18, 2018. We only included randomised controlled studies published in English evaluating the intervention with either sham or standard of care. Inclusion was limited to trials of techniques in which there was sustainable volume reduction. Primary outcomes were residual volume, FEV₁, St George's Respiratory Questionnaire (SGRQ), and 6-min walk distance (6MWT). Secondary outcomes were severe adverse events (including mortality), short-term mortality, and overall mortality. We extracted summary level data from the trial publications and where necessary we obtained unpublished data. A random-effects model with the I² statistic was used to determine heterogeneity and trial weight in each analysis. The study is registered with the PROSPERO database, number CRD42016045705.

FINDINGS

We identified 4747 references in the search, and included 20 randomised controlled trials of lung volume reduction involving 2794 participants with emphysema. Following lung volume reduction from any of the interventions in pooled analyses (ie, surgery, endobronchial valve, endobronchial coil, or sclerosing agents), the mean differences compared with the control were reduction in residual volume of 0·58 L (95% CI -0·80 to -0·37), increase in FEV₁ of 15·87% (95% CI 12·27 to 19·47), improvement in 6MWT of 43·28 m (31·36 to 55·21), and reduction in the SGRQ of 9·39 points (-10·92 to -7·86). The odds ratio for a severe adverse event, which included mortality, was 6·21 (95% CI 4·02 to 9·58) following intervention. Regression analysis showed improvements relative to the degree of volume reduction: FEV₁ (r²=0·86; p<0·0001), 6MWT (r²=0·77; p<0·0001), and SGRQ (r²=0·70; p<0·0001). Most studies were at high risk of bias for lack of blinding, and heterogeneity was high for some outcomes when pooled across all interventions, but was generally lower in the subgroups by intervention type.

INTERPRETATION

Despite limitations of high risk of bias and heterogeneity for some analyses, our results provide support that lung volume reduction in patients with severe emphysema on maximal medical treatment has clinically meaningful benefits. These benefits should be considered alongside potential adverse events.

FUNDING

None.

Efficacy and Safety of Stent, Valves, Vapour ablation, Coils and Sealant Therapies in Advanced Emphysema: A Meta-Analysis

Bronchoscopic lung volume reduction (BLVR) methods have emerged as a new treatment option for patients with severe emphysema. Endobronchial valves and coils have been extensively studied. This review assesses efficacy, safety, and cost effectiveness of the BLVR procedures (stent, valves, vapor ablation, endobronchial coils, lung sealant) in patients with severe emphysema. Databases were searched until October 2016, and randomized controlled trials (RCTs) comparing available BLVR procedures to standard medical care or sham bronchoscopy were included. Random effect model and generic inverse variance approach were used for meta-analysis. Out of 381 identified records, 16 RCTs were included. As compared to recommended medical care or sham bronchoscopy, the BLVR procedures are more effective in improving quality of life [SGRQ score (WMD=-6.38; -9.12 to -3.65)] and 6MWT (WMD=24.21; 9.68-38.74) and percentage FEV₁ (WMD=10.48; 7.07-13.89). Increased risk of serious adverse events (RR=2.18; 1.63-2.93), specifically for chronic pulmonary obstructive disease exacerbations and lower respiratory tract infection combined (RR=1.37; 1.07-1.75), were observed with bronchoscopic interventions, while there was no difference in number of deaths (RR=1.25; 0.79-1.99) and respiratory failure (RR=1.13; 0.57-2.21). The BLVR procedures, especially endobronchial coils, were found to be effective in the management of patients with severe emphysema irrespective of collateral ventilation. However, characterization of patients who would be most benefited from these procedures is required, and effectiveness of these procedures in long run needs to be established.

Long-term follow up after endoscopic valve therapy in patients with severe emphysema

BACKGROUND AND OBJECTIVE

Endoscopic valve therapy is a treatment modality in patients with advanced emphysema and absent interlobar collateral ventilation (CV). So far, long-term outcome following valve implantation has been insufficiently evaluated. The aim of this study was to investigate the real-world efficacy of this interventional therapy over 3 years.

METHODS

From 2006 to 2013, 256 patients with severe emphysema in whom absent CV was confirmed underwent valve therapy. The 3-year effectiveness was evaluated by pulmonary function testing (VC, FEV1, RV, TLC), 6-minute-walk test (6-MWT) and dyspnea questionnaire (mMRC). Long-term outcome was also assessed according to the radiological outcome following valve placement.

RESULTS

Of 256 patients treated with valves, 220, 200, 187, 100 and 66 patients completed the 3-month, 6-month, 1-year, 2-year and 3-year follow-up (FU) visit, respectively. All lung function parameters, 6-MWT and mMRC were significantly improved at 3- and 6-month FU. At 1-year FU, patients still experienced a significant improvement of all outcome parameters expect VC (L) and TLC (%). At 2 years, RV (L and %) and TLC (L and %) remained significantly improved compared to baseline. Three years after valve therapy, sustained significant improvement in mMRC was observed and the proportion of patients achieving a minimal clinically important difference from baseline in RV and 6-MWT was still 71% and 46%, respectively. Overall, patients with complete lobar atelectasis exhibited superior treatment outcome with 3-year responder rates to FEV1, RV and 6-MWT of 10%, 79% and 53%, respectively.

CONCLUSIONS

Patients treated by valves experienced clinical improvement over 1 year following valve therapy. Afterwards, clinical benefit gradually declines more likely due to COPD progression.

Anaesthetic management for endobronchial valve insertion: lessons learned from a single centre retrospective series and a literature review

Background

Endoscopic lung volume reduction using one or more endobronchial valves is a treatment option for a select group of patients with severe emphysema. Patients presenting for this procedure pose various challenges to the anaesthetist; in addition to their lung condition, they are often elderly with multiple comorbidities. The procedure is usually performed outside the operating room. Monitored anaesthesia care with intravenous sedation, and general anaesthesia with an endotracheal tube have both been described for these procedures, aiming for adequate ventilation and haemodynamic stability.

Methods

We present our experience on 20 of these procedures in relation to the anaesthetic techniques employed and discuss the perioperative challenges involved in managing these cases.

Results

Twenty one planned endobronchial valve insertion procedures were identified on 18 patients. There were ten cases of monitored anaesthesia care with sedation and 10 cases which used general anaesthesia with an endotracheal tube. Two have been excluded; one had features of anaphylaxis and the procedure was abandoned, and the other required conversion from monitored anaesthesia care to general anaesthesia with endotracheal tube.

Conclusions

Both monitored anaesthesia care with sedation and general anaesthesia with endotracheal tube were well tolerated during endobronchial valve insertion procedures. General anaesthesia with endotracheal tube may offer better interventional conditions, patient comfort and reduced anaesthetic time.

The REACH Trial: A Randomized Controlled Trial Assessing the Safety and Effectiveness of the Spiration® Valve System in the Treatment of Severe Emphysema

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has become a leading cause of morbidity and mortality in China, with tobacco smoke, air pollution, and occupational biohazards being the major risk factors.

OBJECTIVES

The REACH trial is a multicenter, prospective, randomized controlled trial undertaken in China to assess the safety and effectiveness of the Spiration® Valve System (SVS) compared to standard medical care in COPD patients with severe emphysema.

METHODS

Patients with severe airflow obstruction, hyperinflation, and severe dyspnea with interlobar fissure integrity were evaluated for enrollment. A total of 107 subjects were randomized in a 2: 1 allocation ratio to either the treatment group (SVS valves and medical management) or the control group (medical management alone).

RESULTS

The 3-month primary endpoint showed statistically significant improvement in forced expiratory volume in 1 s in the treatment group compared to the control group (0.104 ± 0.18 vs. 0.003 ± 0.15 L, p = 0.001), with the difference being durable through 6 months. Statistically significant target lobe volume reduction was achieved at 3 months (mean change 684.4 ± 686.7 mL) and through 6 months (757.0 ± 665.3 mL). Exercise function and quality of life measures improved in the treatment group, but showed a deterioration in the control group. The serious adverse event (SAE) rate was 33% in the treatment group and 24.2% in the control group. The predominance of SAEs were acute exacerbations of COPD in both groups. There was 1 death in the control group and no deaths in the treatment group.

CONCLUSION

The SVS represents a novel approach for the treatment of severe emphysema with a clinically acceptable risk-benefit profile.

Patient Preferences for Endobronchial Valve Treatment of Severe Emphysema

Background: Patients with severe emphysema have limited treatment options. Little is known about patients' willingness to accept risks for new treatments that offer meaningful benefits. Methods: We determined treatment preferences of patients with severe emphysema using a web-based discrete-choice experiment survey. Respondents answered 9 questions that offered choices between 2 hypothetical interventional treatments or continuing current medical management. Variations in 5 attributes defined the 2 interventional treatments: improvement in ability to breathe and carry out day-to-day activities, frequency of hospitalized exacerbations, treatment type, risk of pneumothorax within 30 days of procedure, and risk of death within 3 months. Respondents were recruited through the COPD Foundation's COPD Patient-Powered Research Network and had a self-reported emphysema diagnosis and 2+ score on the modified Medical Research Council Dyspnea Scale. The relative importance of the attributes and the percentage of respondents who would select different treatment options was modeled using random-parameters logit. Results: Among 294 respondents, 51% always chose an interventional treatment option, while 19% always selected continued medical management. The most important change on average was moving from continued medical management (with no improvement in breathlessness) to an interventional treatment with improvement in breathlessness. The model predicted 71% of respondents would select a treatment option similar to removable endobronchial valve implants, 6% would select lung volume reduction surgery (LVRS), and 23% continued medical management. Conclusion: Patients with severe emphysema perceive that a procedure with risks and benefits similar to the Zephyr^® endobronchial valve implants is desirable over continued medical management or LVRS.

Management of De Novo Mycobacterial Infection After Lung Transplantation Without Rifampicin: Case Series of a Single Institution

BACKGROUND AND OBJECTIVES

To treat organ transplant patients with mycobacterial infection, physicians need to pay attention to interaction between drugs used against mycobacteria and immunosuppressants. The purpose of this report is to describe the clinical features of and treatment for mycobacterial infection in lung transplant (LTx) recipients.

METHODS

To investigate the incidence, treatment, and outcome for mycobacterial infection, we retrospectively reviewed 100 LTx recipients in our program since 2000.

RESULTS

Four recipients (4.0%) developed mycobacterial infection. Three recipients took tacrolimus, and 1 received cyclosporine with mycophenolate mofetil and a steroid for immunosuppression. Tuberculosis (TB) was isolated from 2 recipients, and non-tuberculous mycobacteriosis (NTM) was detected in the other 2. We treated the patients with levofloxacin + isoniazid + pyrazinamide + ethambutol (EB) for TB and clarithromycin (CLM) + EB for NTM to avoid interaction of calcineurin inhibitors (CNI: 8-10 ng/mL in trough level) with rifampicin (RFP). In treating the patients with NTM, we were able to maintain an adequate blood concentration of CNI by decreasing the dosage from one-half to one-quarter. All mycobacterial infections were controlled with treatment. In 1 patient with chronic obstructive pulmonary disease (COPD) infected with TB in the native lung, the forced expiratory volume in 1 second (FEV1) unexpectedly increased from 1890 mL before infection to 2320 mL possibly due to organization of the native lung.

CONCLUSIONS

We were able to manage the mycobacterial infections using drugs other than RFP without any cases of acute rejection under adequate immunosuppression. Organization of the native lung with TB infection unexpectedly resulted in improvement of FEV1 in a COPD patient.

Bronchoscopic treatment of emphysema: an update

Chronic obstructive pulmonary disease (COPD) is the major causes of disability and mortality. The efficacy of maximal medical treatment, although effective at the early stages of the disease, becomes limited when extensive alveolar destruction is the main cause of respiratory failure. At this stage of the disease more aggressive options, when feasible, should be considered. Lung transplantation and lung volume reduction surgery (LVRS) are currently available for a selected group of patients. Endoscopic alternatives to LVRS have progressively gained acceptance and are currently employed in patients with COPD. They promote lung deflation searching the same outcome as LVRS in terms of respiratory mechanics, ameliorating the distressing symptom of chronic dyspnea by decreasing the physiological dead space.