151
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Deslee G. Endobronchial Lung Volume Reduction in Severe Emphysema. Time to Translate Randomized Controlled Trial Results into Routine Clinical Practice? Am J Respir Crit Care Med 2018; 198:1110-1112. [DOI: 10.1164/rccm.201805-0983ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gaetan Deslee
- Department of Pulmonary Medicine INSERM 1250University Hospital of ReimsReims, France
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152
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Poggi C, Mantovani S, Pecoraro Y, Carillo C, Bassi M, D'Andrilli A, Anile M, Rendina EA, Venuta F, Diso D. Bronchoscopic treatment of emphysema: an update. J Thorac Dis 2018; 10:6274-6284. [PMID: 30622803 DOI: 10.21037/jtd.2018.10.43] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Camilla Poggi
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Sara Mantovani
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Ylenia Pecoraro
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Carolina Carillo
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Massimiliano Bassi
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Antonio D'Andrilli
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Marco Anile
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Erino A Rendina
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Federico Venuta
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Daniele Diso
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
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153
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Kayani K, Mahadeva R, Stinchcombe S, Rutter M, Babar J, Fuld J. Lung function improvements in emphysema following pneumonia. Respir Med Case Rep 2018; 26:1-5. [PMID: 30416955 PMCID: PMC6216104 DOI: 10.1016/j.rmcr.2018.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 11/12/2022] Open
Abstract
We describe two cases of patients with emphysema who, in the lead up to hyperinflation intervention, developed pneumonia with significant physiological, anatomical, functional and quality of life improvement observed following. This directly goes against the natural history of both disease processes, demonstrating the benefit resulting from infective autobullectomy.
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Key Words
- 6MWD, 6 Minute Walking Distance
- Autobullectomy
- BODE, Body mass index, airflow Obstruction, Dyspnea and Exercise capacity
- CAT, COPD Assessment Test
- COPD
- COPD, Chronic Obstructive Pulmonary Disease
- CT, Computed Tomography
- EBC, Endobronchial Coil
- EBV, Endobronchial Valves
- FEV1, Forced Expiratory Volume in one second
- FeNO, Fractional exhaled Nitric Oxide
- GOLD, Global initiative for chronic Obstructive Lung Disease
- IgE, Immunoglobulin E
- KCO, transfer coefficient of diffusion
- LVRS, Lung Volume Reduction Surgery
- Lung volume reduction
- MCID, Minimal Clinically Important Difference
- NICE, National Institute for Health and Care Excellence
- RV, Residual Volume
- SGRQ, St Georges Respiratory Questionnaire
- VA, alveolar volume
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Affiliation(s)
- Kayani Kayani
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Ravi Mahadeva
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, United Kingdom
| | - Sîan Stinchcombe
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, United Kingdom
| | - Matthew Rutter
- Lung Function Unit, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, United Kingdom
| | - Judith Babar
- Department of Radiology Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, United Kingdom
| | - Jonathan Fuld
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, United Kingdom
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154
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Van Der Molen MC, Klooster K, Hartman JE, Slebos DJ. Lung volume reduction with endobronchial valves in patients with emphysema. Expert Rev Med Devices 2018; 15:847-857. [DOI: 10.1080/17434440.2018.1538780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Marieke C. Van Der Molen
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jorine E. Hartman
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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155
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Buttery S, Kemp SV, Shah PL, Waller D, Jordan S, Lee JT, Banya W, Steiner MC, Hopkinson NS. CELEB trial: Comparative Effectiveness of Lung volume reduction surgery for Emphysema and Bronchoscopic lung volume reduction with valve placement: a protocol for a randomised controlled trial. BMJ Open 2018; 8:e021368. [PMID: 30337307 PMCID: PMC6196851 DOI: 10.1136/bmjopen-2017-021368] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Although lung volume reduction surgery and bronchoscopic lung volume reduction with endobronchial valves have both been shown to improve lung function, exercise capacity and quality of life in appropriately selected patients with emphysema, there are no direct comparison data between the two procedures to inform clinical decision-making. METHODS AND ANALYSIS We describe the protocol of the CELEB study, a randomised controlled trial which will compare outcomes at 1 year between the two procedures, using a composite disease severity measure, the iBODE score, which includes body mass index, airflow obstruction, dyspnoeaand exercise capacity (incremental shuttle walk test). ETHICS AND DISSEMINATION Ethical approval to conduct the study has been obtained from the Fulham Research Ethics Committee, London (16/LO/0286). The outcome of this trial will provide information to guide treatment choices in this population and will be presented at national and international meetings and published in peer-reviewed journals. We will also disseminate the main results to all participants in a letter. TRIAL REGISTRATION NUMBER ISRCTN19684749; Pre-results.
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Affiliation(s)
- Sara Buttery
- NIHR Respiratory Disease, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - Samuel V Kemp
- NIHR Respiratory Disease, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - Pallav L Shah
- NIHR Respiratory Disease, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - David Waller
- Thorax Centre, Barts Health NHS Trust, London, UK
| | - Simon Jordan
- NIHR Respiratory Disease, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - John T Lee
- School of Public Health, National University of Singapore, Singapore
| | - Winston Banya
- NIHR Respiratory Disease, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - Michael C Steiner
- Leicester Respiratory Biomedical Research Unit, University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - Nicholas S Hopkinson
- NIHR Respiratory Disease, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
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156
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Hartman JE, Vanfleteren LEGW, van Rikxoort EM, Slebos DJ. Bronchoscopic Lung Volume Reduction Treatment Using Endobronchial Valves for Emphysema: Emerging Questions. Respiration 2018; 96:588-589. [PMID: 30286446 DOI: 10.1159/000491675] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/29/2018] [Indexed: 01/14/2023] Open
Affiliation(s)
- Jorine E Hartman
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The .,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The
| | - Lowie E G W Vanfleteren
- Department of Development and Education, CIRO+, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,COPD Center, Sahlgrenska University Hospital and Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Eva M van Rikxoort
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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157
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Marruchella A, Faverio P, Bonaiti G, Pesci A. History of lung volume reduction procedures. J Thorac Dis 2018; 10:S3326-S3334. [PMID: 30450238 DOI: 10.21037/jtd.2018.04.165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lung volume reduction (LVR) procedures for emphysematous patients were firstly introduced in the second half of the twentieth century. Over time, from the first invasive surgical procedures, new less invasive techniques have been conceived. In regards to the surgical approach, the adoption of VATS and the execution, in selected centers, of a non-resectional approach, with folding of less functional lung tissue, reduced mortality and adverse events risks. As regards to the bronchoscopic approach, endobronchial valves (EBV) and intrabronchial valves (IBV) were initially proposed in the early 2000s to obtain segmental or lobar atelectasis of the more compromised lung parenchyma. Despite showing promising results with respect to improvement of pulmonary function tests, particularly forced expiratory volume in 1st second (FEV1), and quality of life, and a good safety profile, valves showed disappointing results in presence of collateral ventilation, such as in cases of incomplete fissures. To overcome this technical issue, in the last 10 years, endobronchial coils have been designed and used. Having a compressive effect on the lung parenchyma where they are located, they are not affected by collateral ventilation. Randomized control trials (RCTs) on endobronchial coils showed a significant improvement in FEV1 and quality of life, however this technique was not immune to side effects, particularly low respiratory tract infections and pneumothoraces. Besides bronchial valves (BV) and coils, airway by-pass stents have also been evaluated in a RCT but without reaching the desired endpoints. Other innovative procedures recently considered and delivered through bronchoscopy regards thermal energy, with vapour therapy, to achieve a scarring reaction of the emphysematous lung parenchyma, and polymeric foams used as lung sealants to achieve absorptive atelectasis. In conclusion, LVR procedures may be considered in carefully selected patients with symptomatic emphysema and severe lung hyperinflation, and might be personalized according to the anatomical characteristics of emphysematous area.
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Affiliation(s)
- Almerico Marruchella
- Dipartimento Cardio-Toraco-Vascolare, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Paola Faverio
- Dipartimento Cardio-Toraco-Vascolare, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Giulia Bonaiti
- Dipartimento Cardio-Toraco-Vascolare, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Alberto Pesci
- Dipartimento Cardio-Toraco-Vascolare, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
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158
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Fiorelli A, D'Andrilli A, Bezzi M, Ibrahim M, Anile M, Diso D, Cusumano G, Terminella A, Luzzi V, Innocenti M, Novali M, Carelli E, Freda C, Natale G, Peritore V, Poggi C, Failla G, Basile M, Mazzucca E, Conforti S, Serra N, Torre M, Venuta F, Rendina EA, Santini M, Andreetti C. Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: results of a multicenter study. J Thorac Dis 2018; 10:S3315-S3325. [PMID: 30450237 DOI: 10.21037/jtd.2018.06.69] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes. Methods It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV1); of -8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant. Results One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those <350 mL (n=43) had a statistically significant higher improvement in FEV1 (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (-10.0%±4.8% vs. -4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (-15.0±2.9 vs. -8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV1 (19.0%±3.9%), RV (-10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (-15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described. Conclusions Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach.
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Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio D'Andrilli
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Michela Bezzi
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | - Mohsen Ibrahim
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Marco Anile
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Daniele Diso
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Giacomo Cusumano
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Alberto Terminella
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Valentina Luzzi
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | | | - Mauro Novali
- Interventional Pneumology Unit, Spedili Civili Brescia, Brescia, Italy
| | - Emanuele Carelli
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Chiara Freda
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanni Natale
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Valentina Peritore
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Camilla Poggi
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Giuseppe Failla
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Marco Basile
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Emilia Mazzucca
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | | | - Nicola Serra
- Department of Pediatrics, University Federico II of Naples, Naples, Italy
| | - Massimo Torre
- Thoracic Surgery Unit, Ospedale Niguarda, Milan, Italy
| | - Federico Venuta
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Claudio Andreetti
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
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159
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Chew J, Mahadeva R. The role of a multidisciplinary severe chronic obstructive pulmonary disease hyperinflation service in patient selection for lung volume reduction. J Thorac Dis 2018; 10:S3335-S3343. [PMID: 30450239 PMCID: PMC6204340 DOI: 10.21037/jtd.2018.07.36] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/06/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a complex disease and the management is focused on improving breathlessness, quality of life and healthcare utilisation. Our understanding of COPD phenotypes has improved in recent years and there is an increased drive towards delivering phenotype-based therapies. Lung volume reduction can offer the prospect of life changing benefit in breathlessness and quality of life in a select group of patients with severe emphysema already receiving maximum medical treatment. In spite of the available evidence, very few procedures are being performed relative to the disease burden and prevalence of suitable individuals. Currently the major barriers to patient accessibility are lack in standardised multidisciplinary severe COPD services with easy access to lung volume reduction procedures, as well as poorly informed perceptions of healthcare professionals. There is a recognised need to improve such services in many healthcare systems. We share our experiences with setting up and running a successful regional multidisciplinary severe COPD hyperinflation service.
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Affiliation(s)
- Joyce Chew
- Cambridge COPD Centre, Box 40, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - Ravi Mahadeva
- Cambridge COPD Centre, Box 40, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
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160
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Roche N, Martin C, Burgel PR. [Personalised COPD care: Where are we going?]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:315-326. [PMID: 30316649 DOI: 10.1016/j.pneumo.2018.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The concept of personalised medicine is recent but the underlying notions are not new: knowing how to adapt care to patients' characteristics is one of the components of the "art of medicine". The advances of science allow to refine considerably the applications of the concept in many fields of medicine including COPD: research has identified phenotypes, endotypes and treatable traits. Personalisation can be applied to all components of care. For instance, the decision to perform screening spirometry relies not only on risk factors (age, smoking, other exposures) but also on symptoms. Assessment of comorbidities often associated with COPD is based on risk factors and their combinations, variable between individuals. Rehabilitation and its components are in essence highly individualised, which a major condition for their success. Last but not least, personalisation of pharmacological therapy, which has long been rather poor, could not benefit from biomarkers of interest (predictive of response), such as blood eosinophil count. Practical strategies using these still need to be established, and new biomarkers may usefully enrich the collection!
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Affiliation(s)
- N Roche
- EA2511, service de pneumologie, université Paris Descartes, hôpital Cochin, hôpitaux universitaires Paris Centre, AP-HP 5, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - C Martin
- EA2511, service de pneumologie, université Paris Descartes, hôpital Cochin, hôpitaux universitaires Paris Centre, AP-HP 5, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - P-R Burgel
- EA2511, service de pneumologie, université Paris Descartes, hôpital Cochin, hôpitaux universitaires Paris Centre, AP-HP 5, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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161
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Welling JBA, Hartman JE, Ten Hacken NHT, Franz I, Charbonnier JP, van Rikxoort EM, Kerstjens HAM, Klooster K, Slebos DJ. Chartis Measurement of Collateral Ventilation: Conscious Sedation versus General Anesthesia - A Retrospective Comparison. Respiration 2018; 96:480-487. [PMID: 30114707 DOI: 10.1159/000490733] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Absence of interlobar collateral ventilation using the Chartis measurement is the key predictor for successful endobronchial valve treatment in severe emphysema. Chartis was originally validated in spontaneous breathing patients under conscious sedation (CS); however, this can be challenging due to cough, mucus secretion, mucosal swelling, and bronchoconstriction. Performing Chartis under general anesthesia (GA) avoids these problems and may result in an easier procedure with a higher success rate. However, using Chartis under GA with positive pressure ventilation has not been validated. OBJECTIVES In this study we investigated the impact of anesthesia technique, CS versus GA, on the feasibility and outcomes of Chartis measurement. METHODS We retrospectively analyzed all Chartis measurements performed at our hospital from October 2010 until December 2017. RESULTS We analyzed 250 emphysema patients (median forced expiratory volume in 1 s 26%, range 12-52% predicted). In 121 patients (48%) the measurement was performed using CS, in 124 (50%) using GA, and in 5 (2%) both anesthesia techniques were used. In total, 746 Chartis readings were analyzed (432 CS, 277 GA, and 37 combination). Testing under CS took significantly longer than GA (median 19 min [range 5-65] vs. 11 min [3-35], p < 0.001) and required more measurements (3 [1-13] vs. 2 [1-6], p < 0.001). There was no significant difference in target lobe volume reduction after treatment (-1,123 mL [-3,604 to 332] in CS vs. -1,251 mL [-3,333 to -1] in GA, p = 0.35). CONCLUSIONS In conclusion, Chartis measurement under CS took significantly longer and required more measurements than under GA, without a difference in treatment outcome. We recommend a prospective trial comparing both techniques within the same patients to validate this approach.
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Affiliation(s)
- Jorrit B A Welling
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jorine E Hartman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Nick H T Ten Hacken
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ina Franz
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Groningen, the Netherlands
| | - Jean-Paul Charbonnier
- Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands
| | - Eva M van Rikxoort
- Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Karin Klooster
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk-Jan Slebos
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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162
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Abstract
PURPOSE OF REVIEW As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications. RECENT FINDINGS The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia. SUMMARY The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described.
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163
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Endoscopic Lung Volume Reduction in COPD: Improvements in Gas Transfer Capacity Are Associated With Improvements in Ventilation and Perfusion Matching. J Bronchology Interv Pulmonol 2018; 25:48-53. [PMID: 29261579 DOI: 10.1097/lbr.0000000000000445] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endoscopic lung volume reduction (ELVR) has been shown to improve lung function, quality of life, and exercise tolerance in patients with severe heterogeneous emphysema. Our study aims to determine the effect of ELVR on gas transfer capacity corrected for alveolar volume (KCO) and investigate the relationship between KCO and ventilation and perfusion (VQ) matching. We speculate on possible mechanisms for the observed changes METHODS:: Patients with severe chronic obstructive pulmonary disease were prospectively recruited and underwent unilateral upper lobe ELVR between 2012 and 2014. Each had respiratory function test and differential VQ scans at baseline, 1-, 3-, and 12-month post-ELVR. RESULTS In total, 11 patients had 3 sets of respiratory function test (at baseline, 1, and 3 mo), whereas 7 had 4 sets (at baseline, 1, 3, and 12 mo). KCO improved by 10.3 (±7.5)% at 1 month (P=NS) and 39.8 (±15.4)% at 12 months (P<0.05). VQ of the nontargeted lung increased by 12.8 (±5.6)% and 7.9 (±2.3)%, respectively at 1 month, whereas those of the targeted lung both decreased (P<0.05). At 3 and 12 months, the VQ changes were similar to those at 1 month, though some were not statistically significant. CONCLUSIONS ELVR results in improved KCO for at least 12 months. This may be explained by the VQ redistribution to the nontargeted and less emphysematous lung with improved VQ matching.
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Chaudhari P, Revelo AE, Kadambi A. Complications of Central Venous Catheters, Rapid On-Site Specimen Evaluation for Lung Cancer Genotyping, and Endobronchial Valves for Emphysema. Am J Respir Crit Care Med 2018; 194:1541-1545. [PMID: 27806208 DOI: 10.1164/rccm.201607-1380rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Parimalkumar Chaudhari
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center at New York Medical College, Valhalla, New York
| | - Alberto E Revelo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center at New York Medical College, Valhalla, New York
| | - Aparna Kadambi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center at New York Medical College, Valhalla, New York
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165
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Roetting M, Gompelmann D, Herth FJF. Thermic and chemical procedures for bronchoscopic lung volume reduction. J Thorac Dis 2018; 10:S2806-S2810. [PMID: 30210834 PMCID: PMC6129803 DOI: 10.21037/jtd.2018.05.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/14/2018] [Indexed: 11/06/2022]
Abstract
In the last 14 years several endoscopic procedures have been developed to offer patients with advanced chronic obstructive pulmonary disease (COPD) and emphysema further therapeutic options, complementary to a medical treatment. In addition to the established valve implantation, new approaches have been available since 2009. These procedures include bronchoscopic thermal vapor ablation (BTVA) and polymeric lung volume reduction. Both therapies are independent of collateral ventilation (CV), are irreversible and can be used on segmental (BTVA) and sub-segmental level [polymeric lung volume reduction (PLVR)], in contrast to valve therapy. The intention is to induce a local inflammation with a following fibrosis and shrinkage and thus a volume reduction in the treated lung areas. Currently, only patients with predominant upper-lobe emphysema are treated. An improvement of lung function, exercise capacity and quality of life could be proved in RCTs for BTVA as well as for PLVR. However, the data for PLVR is very limited and has recently been available only in studies. Furthermore, the risk profile is unfavourable with a high number of adverse respiratory events. While BTVA is an established new approach, the PLVR requires re-evaluation regarding materials, predictive factors, safety profile and dosage.
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Affiliation(s)
- Matthias Roetting
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
| | - Daniela Gompelmann
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
| | - Felix J. F. Herth
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
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166
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Straub G, Caviezel C, Frauenfelder T, Bloch KE, Franzen D. Successful lung volume reduction surgery in combined pulmonary emphysema and fibrosis without body-plethysmographic hyperinflation-a case report. J Thorac Dis 2018; 10:S2830-S2834. [PMID: 30210838 DOI: 10.21037/jtd.2018.06.60] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical and bronchoscopic lung volume reduction (LVR) have been demonstrated to improve lung function, dyspnea and quality of life in patients with severe pulmonary emphysema. The most important functional prerequisite for a successful LVR is hyperinflation measured by body plethysmography. A residual volume (RV) of more than 180% predicted and a RV/total lung capacity (TLC) ratio of more than 0.58 were inclusion criteria in major LVR trials. Here we report a successful LVR in a 68-year-old man with advanced, heterogeneous emphysema without plethysmographic evidence of severe hyperinflation (RV/TLC 0.45). Computed tomography (CT) revealed severe, partly bullous upper lobe emphysema and subtle fibrotic changes with volume loss of lower lobes. Since lower lobes appeared compressed by upper lobe emphysema, these target areas were removed by thoracoscopic LVR. Four months later, the patient reported major improvements of dyspnea, FEV1 (by 1.27 L) and 6-minute walking distance (by 150 meters). LVR reduced total lung volume measured by CT-volumetry by 0.5 L and upper lobe volume by 1.85 L while lower lobe volume increased by +1.34 L. Low density volume (-950 HU) reflecting emphysema was reduced by 1.73 L. We conclude that the opposing effects of emphysema and fibrosis resulted in a barely increase in total lung volume that was only slightly reduced by LVR. Nevertheless, resection of emphysematous target areas identified by quantitative CT analysis provided major clinical and physiologic improvements related to decompression of low-compliance lower lobe areas retracted by early fibrosis. Therefore, in the combined presence of severe, heterogeneously distributed emphysema and fibrosis, LVR may improve respiratory mechanics even if RV/TLC, an established body-plethysmographic predictor of LVR success is not severely elevated.
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Affiliation(s)
- Gilles Straub
- Department of Pulmonology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Konrad E Bloch
- Department of Pulmonology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Daniel Franzen
- Department of Pulmonology, University Hospital Zurich, 8091 Zurich, Switzerland
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167
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Abstract
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide. One of the main findings is pulmonary emphysema in association with chronic bronchitis. Clinical signs, pulmonary function tests and imaging are the current used methods to diagnose and stage emphysema. Lung volume reduction (LVR) and endoscopic lung volume reduction (ELVR) are the current therapeutic options beside lung transplantation in cases of severe emphysema. Nowadays imaging is one of the key factors for the success of these therapies. Especially quantitative computed tomography (CT) with its increasing possibilities has become a viable tool, providing detailed information about distribution and heterogeneity of emphysema. Other imaging techniques like dual-energy CT (DECT) and functional magnetic resonance (MR) have shown to add functional information. These structural and functional information support thoracic surgeons and interventional pulmonologists in selecting patients and optimizing LVR procedures but also enables the development of new endobronchial therapies. Imaging will further improve the individual outcome by supporting the choice of optimal therapy.
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Affiliation(s)
- Katharina Martini
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
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168
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Gordon M, Duffy S, Criner GJ. Lung volume reduction surgery or bronchoscopic lung volume reduction: is there an algorithm for allocation? J Thorac Dis 2018; 10:S2816-S2823. [PMID: 30210836 PMCID: PMC6129811 DOI: 10.21037/jtd.2018.05.118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 05/15/2018] [Indexed: 11/06/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the world with the annual number of deaths increasing every year. Alterations in chest wall mechanics, respiratory muscle mechanics, and impaired cardiac function that result from increased air-trapping are well known sequelae of COPD and contribute to increased morbidity and mortality. A reduction in hyperinflation can improve cardiopulmonary function. In selected patients with COPD and an emphysema phenotype, lung volume reduction surgery (LVRS) has demonstrated improvements in symptom burden and mortality. Minimally invasive bronchoscopic techniques that reduce end-expiratory lung volume have shown improvements in lung function, dyspnea and quality of life. In this review, we review selection criteria, risks, and benefits of surgical and bronchoscopic lung volume reduction (BLVR). Recommendations are provided to guide treatment decisions based on the current literature.
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Affiliation(s)
- Matthew Gordon
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Sean Duffy
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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169
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Valipour A. Valve therapy in patients with emphysematous type of chronic obstructive pulmonary disease (COPD): from randomized trials to patient selection in clinical practice. J Thorac Dis 2018; 10:S2780-S2796. [PMID: 30210832 PMCID: PMC6129808 DOI: 10.21037/jtd.2018.08.86] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 08/16/2018] [Indexed: 01/16/2023]
Abstract
In recent years a number of endoscopic methods have emerged to treat patients with severe emphysematous type of chronic obstructive pulmonary disease (COPD), who are primarily symptomatic due to hyperinflation despite optimal medical management. Of these techniques, implantation of endobronchial one-way valves into targeted airways of isolated emphysematous lobes appears to be one of the most promising innovations. Results from randomized controlled trials of valve therapy for emphysema show consistent benefits in terms of lung function, exercise capacity, symptoms, and quality of life. This review aims to provide a comprehensive summary of the currently available scientific data, discussion of typical treatment related side effects, and recommendations for patient selection in clinical practice.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig-Boltzmann-Institute for COPD and Respiratory Epidemiology, Otto-Wagner-Spital, Sanatoriumsstrasse 2, 1140 Wien, Austria
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170
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Franzen D, Straub G, Freitag L. Complications after bronchoscopic lung volume reduction. J Thorac Dis 2018; 10:S2811-S2815. [PMID: 30210835 DOI: 10.21037/jtd.2018.06.66] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) has been demonstrated an efficient and safe alternative to surgery in multiple randomized trials and retrospective cohort studies. However, despite its minimal invasiveness BLVR is not without potential harm. Complications and their incidents differ significantly between the individual BLVR techniques (valves, coils, vapour or sealant) which are bearing varying device- and intervention-dependent risks. Interventional pulmonologists must be aware of potential side effects and their management to anticipate and ensure highest quality treatment of the severely ill emphysema patient.
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Affiliation(s)
- Daniel Franzen
- Interventional Lung Center, Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Gilles Straub
- Interventional Lung Center, Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Lutz Freitag
- Clinic St. Anna, Hirslanden Group, Lucerne, Switzerland
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171
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Oey I, Waller D. The role of the multidisciplinary emphysema team meeting in the provision of lung volume reduction. J Thorac Dis 2018; 10:S2824-S2829. [PMID: 30210837 DOI: 10.21037/jtd.2018.02.68] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Despite a positive result in favour of lung volume reduction surgery (LVRS), from one of the largest randomized controlled trial in thoracic surgery, the identification of poor outcome in certain high-risk groups has resulted in a worldwide decrease in its utilization. Patient selection is the key to successful lung volume reduction which, with the advent of a range of less invasive techniques, has become more complex. The greater variety of potential therapeutic options will inevitably lead to debate amongst treating clinicians. Therefore, to be able to make an informed decision on the best treatment for an individual patient, discussion between clinicians in a multidisciplinary team (MDT) meeting is advisable. The membership of this MDT must include all specialists involved in assessment and subsequent treatment of the patient including non-medical input. There must be robust administrative organization and record of decisions together with inter-disciplinary communication of decisions. Whilst ultimately it is the patient who will benefit from the MDT, individual participants will enhance their continued professional development. The referral pathway into the MDT must be clearly defined and disseminated. Which investigations are to be performed by referrers and which by the specialist centre need to be in an agreed protocol. Specialist input may be required to interpret the results of the latest assessment tools. The decision-making process of the MDT begins with confirmation of basic selection criteria but addresses three main areas of discussion: the definition of target areas of lung for reduction; the presence of collateral, interlobar ventilation and an assessment of individualized risk and benefit. The emphysema or lung volume reduction MDT has been established in several specialist units and its benefits include an increase in referrals overall for LVR. The establishment of an MDT approach to lung volume reduction has now been incorporated into several national guidelines.
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Affiliation(s)
- Inger Oey
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - David Waller
- Department of Thoracic Surgery, St. Bartholomew's Hospital, London, UK
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172
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Kontogianni K, Russell K, Eberhardt R, Schuhmann M, Heussel CP, Wood S, Herth FJ, Gompelmann D. Clinical and quantitative computed tomography predictors of response to endobronchial lung volume reduction therapy using coils. Int J Chron Obstruct Pulmon Dis 2018; 13:2215-2223. [PMID: 30050294 PMCID: PMC6055902 DOI: 10.2147/copd.s159355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objectives Bronchoscopic lung volume reduction using coils (LVRC) is a well-known treatment option for severe emphysema. The purpose of this study was to identify quantitative computed tomography (QCT) and clinical parameters associated with positive treatment outcome. Patients and methods The CT scans, pulmonary function tests (PFT), and 6-minute walk test (6-MWT) data were collected from 72 patients with advanced emphysema prior to and at 3 months after LVRC treatment. The procedure involved placing 10 coils unilaterally. Various QCT parameters were derived using Apollo imaging software (VIDA). Independent predictors of clinically relevant outcome (Δ6-MWT ≥ 26 m, ΔFEV1 ≥ 12%, ΔRV ≥ 10%) were identified through stepwise linear regression analysis. Results The response outcome for Δ6-MWT, for ΔFEV1 and for ΔRV was met by 55%, 32% and 42%, respectively. For Δ6-MWT ≥ 26 m a lower baseline 6-MWT (p = 0.0003) and a larger standard deviation (SD) of low attenuation cluster (LAC) sizes in peripheral regions of treated lung (p = 0.0037) were significantly associated with positive outcome. For ΔFEV1 ≥ 12%, lower baseline FEV1 (p = 0.02) and larger median LAC sizes in the central regions of treated lobe (p = 0.0018) were significant predictors of good response. For ΔRV ≥ 10% a greater baseline TLC (p = 0.0014) and a larger SD of LAC sizes in peripheral regions of treated lung (p = 0.007) tended to respond better. Conclusion Patients with lower FEV1 and 6-MWT, with higher TLC and specific QCT characteristics responded more positively to LVRC treatment, suggesting a more targeted CT-based approach to patient selection could lead to greater efficacy in treatment response.
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Affiliation(s)
- Konstantina Kontogianni
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany, .,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany,
| | | | - Ralf Eberhardt
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany, .,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany,
| | - Maren Schuhmann
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany, .,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany,
| | - Claus Peter Heussel
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany, .,Diagnostic and Interventional Radiology with Nuclear Medicine, Chest Clinic (Thoraxklinik), University of Heidelberg, Heidelberg, Germany
| | | | - Felix Jf Herth
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany, .,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany,
| | - Daniela Gompelmann
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany, .,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany,
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Abstract
INTRODUCTION Surgical treatment of severe pulmonary emphysema has so far been associated with relatively high perioperative morbidity and mortality. In the past two decades, novel approaches to lung volume reduction and alternative minimally invasive endoscopic techniques have been developed. This review presents the different techniques (blocking and nonblocking) available until present as well as the appropriate patient selection and possible complications. Areas covered: All available randomized controlled trials (RCTs) have been evaluated. The only blocking technique is the reversible valve implantation. It results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation and its efficacy has been confirmed in various RCTs. Non-blocking techniques that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation, and the polymeric lung volume reduction both inducing inflammatory reaction. These methods have been up to date examined in a few RCTs only. Finally, the targeted lung denervation aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. Expert commentary: Future studies must address the predictors of clinical outcome as well as the reduction of complications to improve both outcome and safety.
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Affiliation(s)
- Konstantina Kontogianni
- a Department of Pneumology and Critical Care Medicine , Thoraxklinik at University of Heidelberg , Heidelberg , Germany.,b Center for Lung Research , Heidelberg , Germany
| | - Ralf Eberhardt
- a Department of Pneumology and Critical Care Medicine , Thoraxklinik at University of Heidelberg , Heidelberg , Germany.,b Center for Lung Research , Heidelberg , Germany
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174
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Gülşen A. Bronchoscopic Lung Volume Reduction: A 2018 Review and Update. Turk Thorac J 2018; 19:141-149. [PMID: 30083406 PMCID: PMC6077007 DOI: 10.5152/turkthoracj.2018.18044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/11/2018] [Indexed: 11/22/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) procedure has expanded the treatment spectrum of patients with end-stage emphysema. These treatments include valve, coil, thermal vapor ablation, bio-lung volume reduction, targeted lung denervation, and airway bypass stent. This short review provides an up-to-date information on BLVR treatments, their clinical benefits, and an overview of complications. BLVR treatments generally affect dyspnea by reducing hyperinflation and residual volume (RV). Benefits of treatment are associated with improvement in lung function parameters (forced expiration volume in the first second, total lung capacity, RV, and 6-minute walking test) and quality of life. Serious potential pulmonary complications, such as pneumothorax, pneumonia, respiratory failure, and chronic obstructive pulmonary disease exacerbation, may also occur after BLVR treatment. In addition to these, low-cost BLVR methods, such as autologous blood and fibrin glue, are in the developmental stage. Bronchoscopic lung volume reduction treatments are a promising method with positive results for patients with severe emphysema. The widespread use of these techniques, inadequate selection of patients, and non-critical and, therefore, unsuccessful use of BLVR in non-specialist centers lead to a false negative impression of the effectiveness of these techniques. In addition to these considerations, it is obvious that these treatments, which are quite expensive, are burdening social health systems. The reduction of costs or the development of lower-cost treatment methods is important for the future and for the availability of treatments.
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Affiliation(s)
- Aşkın Gülşen
- Division of Clinical and Molecular Allergology, Research Center Borstel, Airway Research, Center North (ARCN), Member of the German Center for Lung Research, Borstel, Germany
- Interdisciplinary Allergy Outpatient Clinic, Department of Pneumology, University of Lübeck, Germany
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175
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Elayaperumal AK, Jackson RE. Anaesthesia for lung volume reduction surgery and endobronchial valves. BJA Educ 2018; 18:193-198. [PMID: 33456832 DOI: 10.1016/j.bjae.2018.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - R E Jackson
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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176
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Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) and emphysema are widespread diseases associated with progressive dyspnea because of airflow limitation and hyperinflation. Fundamental therapeutic strategies consist of pulmonary rehabilitation, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation, and surgical therapeutic approaches. RECENT FINDINGS In the last 14 years, endoscopic therapeutic modalities emerged as a substantial part of severe COPD and emphysema treatment. Techniques of the endoscopic lung volume reduction (ELVR) aim at reduction of hyperinflation. Thereby, the reversible valve implantation of which the efficacy was confirmed in various randomized controlled trials (RCT) results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation. Nonblocking ELVR methods that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation and polymeric lung volume reduction both inducing inflammatory reaction. The nonblocking methods have been examined in only a few RCTs. The targeted lung denervation as a novel bronchoscopic therapy for COPD patients aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. SUMMARY The review summarizes the various endoscopic treatment approaches for managment of COPD and emphysema, their mechanism of action, their complications and the current available results of the most important RCTs.
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177
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Abstract
Pheno-/endotyping chronic obstructive pulmonary disease (COPD) is really important because it provides patients with precise and personalized medicine. The central concept of precision medicine is to take individual variability into account when making management decisions. Precision medicine should ensure that patients get the right treatment at the right dose at the right time, with minimum harmful consequences and maximum efficacy. Ideally, we should search for genetic and molecular biomarker-based profiles. Given the clinical complexity of COPD, it seems likely that a panel of several biomarkers will be required to characterize pathogenetic factors and their course over time. The need for biomarkers to guide the clinical care of individuals with COPD and to enhance the possibilities of success in drug development is clear and urgent, but biomarker development is tremendously challenging and expensive, and translation of research efforts to date has been largely ineffective. Furthermore, the development of personalized treatments will require a much more detailed understanding of the clinical and biological heterogeneity of COPD. Therefore, we are still far from being able to apply precision medicine in COPD and the treatable traits and FEV1-free approaches are attempts to precision medicine in COPD that must be considered still quite unsophisticated.
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178
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Abstract
Emphysema causes significant morbidity and mortality, incurring both financial and psychosocial costs. Alternatives to medical therapy and surgical lung volume reduction surgery (LVRS) have increased interest in bronchoscopic techniques. Bronchoscopic lung volume reduction (BLVR) is still in its infancy and additional trials and follow-up are critical. However, several new randomized clinical trials (RCTs) have demonstrated improvement in lung function, quality of life and exercise capacity in select patients receiving endobronchial valves and coil therapy. This article highlights recent data regarding bronchoscopic treatment of emphysema.
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Affiliation(s)
- Anuradha Ramaswamy
- Section of Pulmonary, Critical Care and Sleep, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan Puchalski
- Section of Pulmonary, Critical Care and Sleep, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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179
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Marchetti N, Kaufman T, Chandra D, Herth FJ, Shah PL, Slebos DJ, Dass C, Bicknell S, Blaas SH, Pfeifer M, Stanzell F, Witt C, Deslee G, Gesierich W, Hetzel M, Kessler R, Leroy S, Hetzel J, Sciurba FC, Criner GJ. Endobronchial Coils Versus Lung Volume Reduction Surgery or Medical Therapy for Treatment of Advanced Homogenous Emphysema. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:87-96. [PMID: 30374446 DOI: 10.15326/jcopdf.5.2.2017.0134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Rationale: Bronchoscopic lung volume reduction utilizing shape-memory nitinol endobronchial coils (EBC) may be safer and more effective in severely hyperinflated homogeneous emphysema compared to medical therapy or lung volume reduction surgery (LVRS). Methods: The effect of bilateral EBC in patients with homogeneous emphysema on spirometry, lung volumes and survival was compared to patients with homogeneous emphysema randomized in the National Emphysema Treatment Trial (NETT) to LVRS or medical therapy. NETT participants were selected to match EBC participants in age, baseline spirometry, and gender. Outcomes were compared from baseline, at 6 and 12 months. Results: There were no significant baseline differences in gender in the EBC, NETT-LVRS or medical treatment patients. At baseline no differences existed between EBC and NETT-LVRS patients in forced expiratory volume in 1 second ( FEV1) or total lung capacity (TLC) %-predicted; residual volume (RV) and diffusing capacity of the lung for carbon monoxide (DLco) %-predicted were higher in the EBC group compared to NETT-LVRS (p < 0.001). Compared to the medical treatment group, EBC produced greater improvements in FEV1 and RV but not TLC at 6 months. FEV1 and RV in the EBC group remained significantly improved at 12-months compared to the medical treatment group. While all 3 therapies improved quality of life, survival at 12 months with EBC or medical therapy was greater than NETT-LVRS. Conclusion: EBC may be a potential therapeutic option in patients with severe homogeneous emphysema and hyperinflation who are already receiving optimal medical treatment.
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Affiliation(s)
- Nathaniel Marchetti
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Theresa Kaufman
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Divay Chandra
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Felix J Herth
- Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Pallav L Shah
- The National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, United Kingdom
| | - Dirk-Jan Slebos
- University Medical Center Groningen, University of Groningen, The Netherlands
| | - Chandra Dass
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Gaetan Deslee
- Service de Pneumologie Hôpital Maison Blanche, INSERM 903, Reims, France
| | | | | | | | - Sylvie Leroy
- FHU OncoAge Côte d'Azur University, Nice, France
| | - Juergen Hetzel
- Department of Internal Medicine II-Pneumology, University Hospital, Teubingen, Germany
| | - Frank C Sciurba
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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180
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Sarmand N, Gompelmann D, Kontogianni K, Polke M, Herth FJ, Eberhardt R. New bacterial growth in bronchial secretions after bronchoscopic valve implantation. Int J Chron Obstruct Pulmon Dis 2018; 13:565-570. [PMID: 29445273 PMCID: PMC5810521 DOI: 10.2147/copd.s148196] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Bronchoscopic valve implantation is an established treatment in selected patients with severe lung emphysema. There is evidence in literature of increased bacterial colonization of various implants. So far, it is unclear if an increased bacterial colonization can also be observed after endoscopic valve therapy. Methods Retrospective analysis of patients with examination of the bronchial secretions for presence or change of bacterial growth before and after valve implantation. Results Overall, 144 patients who underwent bronchoscopic follow-up after valve implantation were included in this analysis. Prior to valve placement, only 7 out of 144 consecutive emphysema patients (5%) presented with evidence of bacterial colonization, whereas 137 patients (95%) showed no bacterial growth prior to valve placement. One hundred seven out of the 137 patients (78%) showed new bacterial growth after valve implantation. Almost 38% of the patients who presented with a new bacterial growth had evidence of Viridans streptococci, Rothia mucilaginousa and Neisseria species simultaneously, as bacterial colonization. Pathogenic bacterial growth was recorded for Staphylococcus aureus (18%), Pseudomonas aeruginosa (13%) and Stenotrophomonas maltophilia (9%) microorganisms. There was also a significant bacterial growth by Moraxella catarrhalis (26%) and anaerobic bacteria (23%), especially in patients with complete atelectasis after successful endoscopic lung volume reduction. For all of the 7 patients, the presented initial bacterial colonization showed a change in the flora after bronchoscopy valve implantation. Conclusion In this study we observed an increased bacterial colonization in the long term after valve implantation. This finding needs further evaluation regarding its possible clinical relevance but should be taken into consideration in the follow-up of these patients.
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Affiliation(s)
- Nilab Sarmand
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg
| | - Daniela Gompelmann
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg.,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, at the University of Heidelberg, Heidelberg, Germany
| | - Konstantina Kontogianni
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg
| | - Markus Polke
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg
| | - Felix Jf Herth
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg.,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, at the University of Heidelberg, Heidelberg, Germany
| | - Ralf Eberhardt
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg.,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, at the University of Heidelberg, Heidelberg, Germany
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181
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Adams CJ, Capaldi DPI, Di Cesare R, McCormack DG, Parraga G. On the Potential Role of MRI Biomarkers of COPD to Guide Bronchoscopic Lung Volume Reduction. Acad Radiol 2018; 25:159-168. [PMID: 29051040 DOI: 10.1016/j.acra.2017.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/23/2017] [Accepted: 08/26/2017] [Indexed: 01/08/2023]
Abstract
RATIONALE AND OBJECTIVES In patients with severe emphysema and poor quality of life, bronchoscopic lung volume reduction (BLVR) may be considered and guided based on lobar emphysema severity. In particular, x-ray computed tomography (CT) emphysema measurements are used to identify the most diseased and the second-most diseased lobes as BLVR targets. Inhaled gas magnetic resonance imaging (MRI) also provides chronic obstructive pulmonary disease (COPD) biomarkers of lobar emphysema and ventilation abnormalities. Our objective was to retrospectively evaluate CT and MRI biomarkers of lobar emphysema and ventilation in patients with COPD eligible for BLVR. We hypothesized that MRI would provide complementary biomarkers of emphysema and ventilation that help determine the most appropriate lung lobar targets for BLVR in patients with COPD. MATERIALS AND METHODS We retrospectively evaluated 22 BLVR-eligible patients from the Thoracic Imaging Network of Canada cohort (diffusing capacity of the lung for carbon monoxide = 37 ± 12%predicted, forced expiratory volume in 1 second = 34 ± 7%predicted, total lung capacity = 131 ± 17%predicted, and residual volume = 216 ± 36%predicted). Lobar CT emphysema, measured using a relative area of <-950 Hounsfield units (RA950) and MRI ventilation defect percent, was independently used to rank lung lobe disease severity. RESULTS In 7 of 22 patients, there were different CT and MRI predictions of the most diseased lobe. In some patients, there were large ventilation defects in lobes not targeted by CT, indicative of a poorly ventilated lung. CT and MRI classification of the most diseased and the second-most diseased lobes showed a fair-to-moderate intermethod reliability (Cohen κ = 0.40-0.59). CONCLUSIONS In this proof-of-concept retrospective analysis, quantitative MRI ventilation and CT emphysema measurements provided different BLVR targets in over 30% of the patients. The presence of large MRI ventilation defects in lobes next to CT-targeted lobes might also change the decision to proceed or to guide BLVR to a different lobar target.
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Affiliation(s)
- Colin J Adams
- Robarts Research Institute, Western University, 1151 Richmond Street N, London, ON N6A 5B7, Canada; Department of Medicine, Western University, London, Ontario, Canada
| | - Dante P I Capaldi
- Robarts Research Institute, Western University, 1151 Richmond Street N, London, ON N6A 5B7, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Robert Di Cesare
- Robarts Research Institute, Western University, 1151 Richmond Street N, London, ON N6A 5B7, Canada
| | | | - Grace Parraga
- Robarts Research Institute, Western University, 1151 Richmond Street N, London, ON N6A 5B7, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada.
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182
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Gompelmann D, Kontogianni K, Schuhmann M, Eberhardt R, Heussel CP, Herth FJ. The minimal important difference for target lobe volume reduction after endoscopic valve therapy. Int J Chron Obstruct Pulmon Dis 2018; 13:465-472. [PMID: 29440884 PMCID: PMC5798552 DOI: 10.2147/copd.s152029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Endoscopic valve therapy aims at target lobe volume reduction (TLVR) that is associated with improved lung function, exercise tolerance and quality of life in emphysema patients. So far, a TLVR of >350 mL was considered to be indicative of a positive response to treatment. However, it is not really known what amount of TLVR is crucial following valve implantation. Patients and methods TLVR, forced expiratory volume in 1 second (FEV1), residual volume (RV) and 6-minute walk distance (6-MWD) were assessed before and 3 months after valve implantation in 119 patients. TLVR was calculated based on computed tomography (CT) scan analysis using imaging software (Apollo; VIDA Diagnostics). Minimal important difference estimates were calculated by anchor-based and distribution-based methods. Results Patients treated with valves experienced a mean change of 0.11 L in FEV1, −0.51 L in RV, 44 m in 6-MWD and a TLVR of 945 mL. Using a linear regression and receiver operating characteristic analysis based on two of three anchors (ΔFEV1, ΔRV), the estimated minimal important difference for TLVR was between 890 and 1,070 mL (ie, 49%–54% of the baseline TLV). Conclusion In future, a TLVR between 49% and 54% of the baseline TLV, should be used when interpreting the clinical relevance.
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Affiliation(s)
- D Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg.,Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg (DZL)
| | - K Kontogianni
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg
| | - M Schuhmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg
| | - R Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg.,Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg (DZL)
| | - C P Heussel
- Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg (DZL).,Diagnostic and Interventional Radiology, Thoraxklinik at University of Heidelberg, Heidelberg.,Diagnostic and Interventional Radiology at University of Heidelberg, Heidelberg, Germany
| | - F J Herth
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg.,Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg (DZL)
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183
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Straub G, Franzen D. [Not Available]. PRAXIS 2018; 107:379-386. [PMID: 29587594 DOI: 10.1024/1661-8157/a002937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Zusammenfassung. Die endoskopische Lungenvolumenreduktion (ELVR) hat sich in den vergangenen Jahren in ausgewählten Patienten mit schwerem Lungenemphysem als valable Alternative zur chirurgischen Lungenvolumenreduktion etabliert. Die Wahl der ELVR-Technik richtet sich danach, ob zwischen dem zu behandelnden und dem benachbarten Lungenlappen Kollateralventilation vorhanden ist, was mittels computertomografischer und endoskopischer Techniken festgestellt werden kann. Als Vorteile der ELVR-Verfahren sind die geringe Invasivität mit entsprechend geringer Mortalität und Morbidität bei niedrigen Kosten zu nennen, zudem ist die Ventileinlage bei Bedarf reversibel. Die Wirksamkeit der ELVR-Verfahren (Ventile, Coils) wurde in mehreren prospektiven, randomisierten Studien belegt. Die Wahl des für den Patienten geeigneten Verfahrens zur Lungenvolumenreduktion sollte weiterhin in einer interdisziplinären Besprechung mit Thoraxchirurgen und spezialisierten Pneumologen erfolgen. La réduction du volume pulmonaire par endoscopie est devenue une importante alternative à la chirurgie chez les malades présentant un emphysème pulmonaire sévère. Le choix de la technique au niveau individuel dépend principalement de l’intégrité de la fissure interlobaire et de la présence d’une ventilation collatérale, cette dernière pouvant être déterminée par tomographie computérisée quantitative et des techniques endoscopiques. Les avantages de la réduction du volume pulmonaire par endoscopie consistent en son caractère minimalement invasif ( procédure utilisant un orifice naturel) et des coûts potentiellement réduits. Par ailleurs ce mode de réduction du volume pulmonaire permet de restaurer la ventilation en cas de besoin. Le choix de la technique appropriée chez un malade donné devrait être discuté de manière interdisciplinaire dans le cadre d’un groupe comportant des pneumologues interventionnels et des chirurgiens thoraciques.
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Affiliation(s)
- Gilles Straub
- 1 Interventionelles Lungenzentrum, Klinik für Pneumologie, Universitätsspital Zürich
| | - Daniel Franzen
- 1 Interventionelles Lungenzentrum, Klinik für Pneumologie, Universitätsspital Zürich
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184
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Kemp SV, Slebos DJ, Kirk A, Kornaszewska M, Carron K, Ek L, Broman G, Hillerdal G, Mal H, Pison C, Briault A, Downer N, Darwiche K, Rao J, Hübner RH, Ruwwe-Glosenkamp C, Trosini-Desert V, Eberhardt R, Herth FJ, Derom E, Malfait T, Shah PL, Garner JL, Ten Hacken NH, Fallouh H, Leroy S, Marquette CH. A Multicenter Randomized Controlled Trial of Zephyr Endobronchial Valve Treatment in Heterogeneous Emphysema (TRANSFORM). Am J Respir Crit Care Med 2017; 196:1535-1543. [PMID: 28885054 DOI: 10.1164/rccm.201707-1327oc] [Citation(s) in RCA: 195] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Single-center randomized controlled trials of the Zephyr endobronchial valve (EBV) treatment have demonstrated benefit in severe heterogeneous emphysema. This is the first multicenter study evaluating this treatment approach. OBJECTIVES To evaluate the efficacy and safety of Zephyr EBVs in patients with heterogeneous emphysema and absence of collateral ventilation. METHODS This was a prospective, multicenter 2:1 randomized controlled trial of EBVs plus standard of care or standard of care alone (SoC). Primary outcome at 3 months post-procedure was the percentage of subjects with FEV1 improvement from baseline of 12% or greater. Changes in FEV1, residual volume, 6-minute-walk distance, St. George's Respiratory Questionnaire score, and modified Medical Research Council score were assessed at 3 and 6 months, and target lobe volume reduction on chest computed tomography at 3 months. MEASUREMENTS AND MAIN RESULTS Ninety seven subjects were randomized to EBV (n = 65) or SoC (n = 32). At 3 months, 55.4% of EBV and 6.5% of SoC subjects had an FEV1 improvement of 12% or more (P < 0.001). Improvements were maintained at 6 months: EBV 56.3% versus SoC 3.2% (P < 0.001), with a mean ± SD change in FEV1 at 6 months of 20.7 ± 29.6% and -8.6 ± 13.0%, respectively. A total of 89.8% of EBV subjects had target lobe volume reduction greater than or equal to 350 ml, mean 1.09 ± 0.62 L (P < 0.001). Between-group differences for changes at 6 months were statistically and clinically significant: ΔEBV-SoC for residual volume, -700 ml; 6-minute-walk distance, +78.7 m; St. George's Respiratory Questionnaire score, -6.5 points; modified Medical Research Council dyspnea score, -0.6 points; and BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index, -1.8 points (all P < 0.05). Pneumothorax was the most common adverse event, occurring in 19 of 65 (29.2%) of EBV subjects. CONCLUSIONS EBV treatment in hyperinflated patients with heterogeneous emphysema without collateral ventilation resulted in clinically meaningful benefits in lung function, dyspnea, exercise tolerance, and quality of life, with an acceptable safety profile. Clinical trial registered with www.clinicaltrials.gov (NCT02022683).
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Affiliation(s)
- Samuel V Kemp
- 1 Royal Brompton Hospital and Imperial College London, London, United Kingdom.,2 Sherwood Forest Hospitals, NHS Foundation Trust, Nottinghamshire, United Kingdom
| | - Dirk-Jan Slebos
- 3 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Alan Kirk
- 4 Department of Thoracic Surgery, West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, West Dunbartonshire, Scotland, United Kingdom
| | - Malgorzata Kornaszewska
- 5 Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Kris Carron
- 6 Department of Pulmonology, AZ Delta, Menen, Belgium
| | - Lars Ek
- 7 Department of Pulmonary Diseases, Skane University Hospital, Lund, Sweden
| | - Gustav Broman
- 8 Department of Pulmonary Diseases, Uppsala University Hospital, Uppsala, Sweden
| | - Gunnar Hillerdal
- 8 Department of Pulmonary Diseases, Uppsala University Hospital, Uppsala, Sweden
| | - Herve Mal
- 9 Service de Pneumologie A, Hôpital Bichat, Paris, France
| | - Christophe Pison
- 10 Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France
| | - Amandine Briault
- 10 Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France
| | - Nicola Downer
- 2 Sherwood Forest Hospitals, NHS Foundation Trust, Nottinghamshire, United Kingdom
| | - Kaid Darwiche
- 11 Department of Interventional Pneumology, Ruhrlandklinik, West German Lung Center, University Clinic Essen, Essen, Germany
| | - Jagan Rao
- 12 Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Ralf-Harto Hübner
- 13 Charité Universitätsmedizin Berlin, Medizinische Klinik m. Schw. Infektiologie und Pneumologie, Campus Virchow, Berlin, Germany
| | - Christof Ruwwe-Glosenkamp
- 13 Charité Universitätsmedizin Berlin, Medizinische Klinik m. Schw. Infektiologie und Pneumologie, Campus Virchow, Berlin, Germany
| | - Valéry Trosini-Desert
- 14 Service de Pneumologie et Réanimation, Unité d'Endoscopie Bronchique, Groupe Hospitalier Pitié Salpétrière, Paris, France
| | - Ralf Eberhardt
- 15 Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, Heidelberg, Germany
| | - Felix J Herth
- 15 Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, Heidelberg, Germany
| | - Eric Derom
- 16 Department of Pulmonary Diseases, Ghent University Hospital, Ghent, Belgium; and
| | - Thomas Malfait
- 16 Department of Pulmonary Diseases, Ghent University Hospital, Ghent, Belgium; and
| | - Pallav L Shah
- 1 Royal Brompton Hospital and Imperial College London, London, United Kingdom
| | - Justin L Garner
- 1 Royal Brompton Hospital and Imperial College London, London, United Kingdom
| | - Nick H Ten Hacken
- 3 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hazem Fallouh
- 5 Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Sylvie Leroy
- 17 Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, FHU OncoAge, Service de Pneumologie, Nice, France
| | - Charles H Marquette
- 17 Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, FHU OncoAge, Service de Pneumologie, Nice, France
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185
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Garner J, Kemp SV, Toma TP, Hansell DM, Polkey MI, Shah PL, Hopkinson NS. Survival after Endobronchial Valve Placement for Emphysema: A 10-Year Follow-up Study. Am J Respir Crit Care Med 2017; 194:519-21. [PMID: 27525462 DOI: 10.1164/rccm.201604-0852le] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Justin Garner
- 1 National Institute for Health Research Respiratory Biomedical Research Unit at Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College London London, United Kingdom and
| | - Samuel V Kemp
- 1 National Institute for Health Research Respiratory Biomedical Research Unit at Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College London London, United Kingdom and
| | - Tudor P Toma
- 2 Lewisham and Greenwich National Health Service Trust London, United Kingdom
| | - David M Hansell
- 1 National Institute for Health Research Respiratory Biomedical Research Unit at Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College London London, United Kingdom and
| | - Michael I Polkey
- 1 National Institute for Health Research Respiratory Biomedical Research Unit at Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College London London, United Kingdom and
| | - Pallav L Shah
- 1 National Institute for Health Research Respiratory Biomedical Research Unit at Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College London London, United Kingdom and
| | - Nicolas S Hopkinson
- 1 National Institute for Health Research Respiratory Biomedical Research Unit at Royal Brompton and Harefield National Health Service Foundation Trust and Imperial College London London, United Kingdom and
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186
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Trudzinski FC, Seiler F, Wilkens H, Metz C, Kamp A, Bals R, Gärtner B, Lepper PM, Becker SL. Microbiological airway colonization in COPD patients with severe emphysema undergoing endoscopic lung volume reduction. Int J Chron Obstruct Pulmon Dis 2017; 13:29-35. [PMID: 29296080 PMCID: PMC5741074 DOI: 10.2147/copd.s150705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Endoscopic lung volume reduction (eLVR) is a therapeutic option for selected patients with COPD and severe emphysema. Infectious exacerbations are serious events in these vulnerable patients; hence, prophylactic antibiotics are often prescribed postinterventionally. However, data on the microbiological airway colonization at the time of eLVR are scarce, and there are no evidence-based recommendations regarding a rational antibiotic regimen. Objective The aim of this study was to perform a clinical and microbiological analysis of COPD patients with advanced emphysema undergoing eLVR with endobronchial valves at a single German University hospital, 2012–2017. Patients and methods Bronchial aspirates were obtained prior to eLVR and sent for microbiological analysis. Antimicrobial susceptibility testing of bacterial isolates was performed, and pathogen colonization was retrospectively compared with clinical parameters. Results At least one potential pathogen was found in 47% (30/64) of patients. Overall, Gram-negative bacteria constituted the most frequently detected pathogens. The single most prevalent species were Haemophilus influenzae (9%), Streptococcus pneumoniae (6%), and Staphylococcus aureus (6%). No multidrug resistance was observed, and Pseudomonas aeruginosa occurred in <5% of samples. Patients without microbiological airway colonization showed more severe airflow limitation, hyperinflation, and chronic hypercapnia compared to those with detected pathogens. Conclusion Microbiological airway colonization was frequent in patients undergoing eLVR but not directly associated with poorer functional status. Resistance testing results do not support the routine use of antipseudomonal antibiotics in these patients.
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Affiliation(s)
- Franziska C Trudzinski
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, ECLS Center Saar, University Medical Center Saarland and Saarland University
| | - Frederik Seiler
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, ECLS Center Saar, University Medical Center Saarland and Saarland University
| | - Heinrike Wilkens
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, ECLS Center Saar, University Medical Center Saarland and Saarland University
| | - Carlos Metz
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, ECLS Center Saar, University Medical Center Saarland and Saarland University
| | - Annegret Kamp
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, ECLS Center Saar, University Medical Center Saarland and Saarland University
| | - Robert Bals
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, ECLS Center Saar, University Medical Center Saarland and Saarland University
| | - Barbara Gärtner
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, ECLS Center Saar, University Medical Center Saarland and Saarland University
| | - Sören L Becker
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany.,Swiss Tropical and Public Health Institute.,University of Basel, Basel, Switzerland
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187
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Criner G. More Options for Treating Severe Hyperinflation in Advanced Emphysema. Am J Respir Crit Care Med 2017; 196:1496-1498. [DOI: 10.1164/rccm.201709-1799ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gerard Criner
- Temple University School of MedicinePhiladelphia, Pennsylvania
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188
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Fiorelli A, Santoriello C, De Felice A, Ferrigno F, Carlucci A, De Ruberto E, Mastromarino R, Occhiati L, Messina G, Santoriello E, Vicidomini G, Polverino M, Santini M. Bronchoscopic lung volume reduction with endobronchial valves for heterogeneous emphysema: long-term results. J Vis Surg 2017; 3:170. [PMID: 29302446 DOI: 10.21037/jovs.2017.10.04] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 10/04/2017] [Indexed: 11/06/2022]
Abstract
Background Bronchoscopic lung volume reduction (BLVR) with implant of one-way endobronchial valves (EBV) is a feasible treatment for management of heterogeneous emphysema (HE) with clinical benefits in the early follow-up. We aimed to evaluate the long-terms results and safety of this procedure in a consecutive series of patients with HE. Methods It was a retrospective single center study including all consecutive patients with HE undergoing EBV treatment and completing at least 5 years of long-term follow-up. Patients were splitted into Collapse and No-Collapse Group if a lobar collapse or not were obtained after valves implant. The difference of functional data and quality of life (QoL) before and after the procedure (measured at 3, 6, 9, 12 months from the valve implantation, and then annually up to a maximum of 5 years) were statistically evaluated to show the long-term benefits of the procedure (primary endpoint). Yet, morbidity, mortality and survival rates were also recorded to show the safe of the treatment (secondary endpoint). Results Thirty-three patients were included in the study. Of these, three patients underwent a bilateral treatment. Collapse Group patients (n=27) presented a significant improvement in FEV1% (+17%; P=0.001); in FVC% (+18%; P=0.002); in RV% (-39%; P=0.003); in 6MWT (P=0.001) and in SGRQ (P=0.001) in the early 12 months of follow-up and no significant decline was seen later. Conversely, No-Collapse Group (n=9) did not have significant benefits. No major complications and death related to the procedure were observed. The 1-,2-,3-,4- and 5-year survival rates were 100%, 90%, 78%, 71% and 71%, respectively. Collapse Group had a better survival than No-Collapse Group (45 vs. 24 months; P=0.001). Conclusions Our study confirmed that the lobar collapse is the key success of EBV treatment and the early improvements of respiratory function could be maintained up to five years from the valves implant.
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Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Carlo Santoriello
- Department of Pneumology and Endoscopic Unit, Ospedale Scarlato, Scafati, Italy
| | | | - Francesco Ferrigno
- Department of Pneumology, Villa Stabia Hospital, Castellamare di Stabia, Italy
| | - Annalisa Carlucci
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Emanuele De Ruberto
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Rossella Mastromarino
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Lisa Occhiati
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Gaetana Messina
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Elena Santoriello
- Department of Pneumology and Endoscopic Unit, Ospedale Scarlato, Scafati, Italy
| | - Giovanni Vicidomini
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Polverino
- Department of Pneumology and Endoscopic Unit, Ospedale Scarlato, Scafati, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
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189
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Eberhardt R. Endobronchial valve placement in emphysema: When is it lung volume reduction? Respirology 2017; 23:242-243. [PMID: 29105909 DOI: 10.1111/resp.13217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/17/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ralf Eberhardt
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research (DZL), Heidelberg, Germany
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190
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Klooster K, Slebos DJ, Zoumot Z, Davey C, Shah PL, Hopkinson NS. Endobronchial valves for emphysema: an individual patient-level reanalysis of randomised controlled trials. BMJ Open Respir Res 2017; 4:e000214. [PMID: 29441206 PMCID: PMC5687542 DOI: 10.1136/bmjresp-2017-000214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 10/10/2017] [Accepted: 10/11/2017] [Indexed: 01/02/2023] Open
Abstract
Introduction Endobronchial valve placement has potential as a treatment for patients with chronic obstructive pulmonary disease (COPD). However, a robust evidence base will be needed to convince commissioners of healthcare that it is a high-value treatment. We sought to develop the evidence base by performing an individual patient-level analysis of randomised controlled trials in people with heterogeneous emphysema and an absence of collateral ventilation. Methods A literature search (PROSPERO register CRD42016048127) identified two trials meeting these criteria, the BelieVeR-HIFi and STELVIO studies. Anonymised individual patient data were obtained from investigators and analysed. The primary outcome measure was a comparison of change in forced expiratory volume in 1 s (FEV1) from baseline between the treatment and control groups. Secondary end points were change from baseline in 6 min walk distance (6MWD), Medical Research Council dyspnoea score and St George’s Respiratory Questionnaire (SGRQ). Results 114 individuals were treated with 3-month to 6-month follow-up data available for 101 individuals. FEV1 improved by 23.1 (±28.3)% in patients treated with valves with a mean (95% CI) difference in response between groups of 17.8 (26.5, 9.2)% (p<0.0001). Relative to controls valve placement was associated with a fall in residual volume of 0.64 (0.43, 0.86) L (p<0.0001), a 9.5 (3.5, 15.6) unit fall in SGRQ (p=0.0022) and a 64.2 (94.0, 34.5) m increase in 6MWD. There were three deaths in the treatment arm and the pneumothorax rate was 15%. Conclusions These data strengthen the evidence that endobronchial valve treatment can produce clinically meaningful improvements in appropriately selected COPD patients.
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Affiliation(s)
- Karin Klooster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Zaid Zoumot
- Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Claire Davey
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Pallav L Shah
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Nicholas S Hopkinson
- NIHR Respiratory Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK
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191
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Perikleous P, Bilancia R, Oey I, Waller DA. Hybrid bilobectomy for treatment of an early-stage lung cancer in a patient with severe emphysema using the benefits of lung volume reduction. Eur J Cardiothorac Surg 2017; 52:1000-1002. [PMID: 28977365 DOI: 10.1093/ejcts/ezx259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/27/2017] [Indexed: 11/13/2022] Open
Abstract
Patients with resectable lung cancer and concomitant emphysema can fall outside the accepted guidelines for surgery. Lung volume reduction can improve their lung function but involves resecting an emphysematous lobe containing the tumour. Volume reduction can also be achieved by endobronchial one-way valve insertion, causing lobar collapse, but intact fissures are required. A 'hybrid bilobectomy' was performed on a 77-year-old ex-smoker with suspected T2aN0M0 bronchogenic carcinoma and severe pulmonary emphysema. The procedure consisted of endobronchial right lower lobe volume reduction and video-assisted middle lobectomy with stapled completion of the oblique fissure. Complete collapse of the right lower lobe was confirmed intraoperatively and on follow-up chest films. The recovery period was complicated by a prolonged air leak. We believe that concomitant endobronchial volume reduction of an ipsilateral lobe can facilitate video-assisted lobectomy in high-risk patients with severe emphysema. The success of endobronchial valves to achieve a hybrid bilobectomy is increased by stapled completion of fissure to prevent collateral ventilation.
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Affiliation(s)
| | - Rocco Bilancia
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Inger Oey
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - David A Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
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192
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van Geffen WH, Kerstjens HA, Slebos DJ. Emerging bronchoscopic treatments for chronic obstructive pulmonary disease. Pharmacol Ther 2017; 179:96-101. [DOI: 10.1016/j.pharmthera.2017.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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193
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Aggelou K, Siafakas N. Medical lung volume reduction for severe emphysema: A review. Respir Med 2017; 131:141-147. [DOI: 10.1016/j.rmed.2017.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/13/2017] [Accepted: 08/07/2017] [Indexed: 12/27/2022]
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194
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Wang Y, Lai TW, Xu F, Zhou JS, Li ZY, Xu XC, Chen HP, Ying SM, Li W, Shen HH, Chen ZH. Efficacy and safety of bronchoscopic lung volume reduction therapy in patients with severe emphysema: a meta-analysis of randomized controlled trials. Oncotarget 2017; 8:78031-78043. [PMID: 29100445 PMCID: PMC5652834 DOI: 10.18632/oncotarget.19352] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 06/29/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Increasing randomized controlled trials (RCTs) indicate that bronchoscopic lung volume reduction (BLVR) is effective for severe emphysema. In this meta-analysis, we investigated the efficacy and safety of BLVR in patients with severe emphysema. METHODS PubMed, Embase and the Cochrane Library and reference lists of related articles were searched, and RCTs that evaluated BLVR therapy VS conventional therapy were included. Meta-analysis was performed only when included RCTs ≥ 2 trials. RESULTS In total, 3 RCTs for endobronchial coils, 6 RCTs for endobronchial valves (EBV) and 2 RCTs for intrabronchial valves (IBV) were included. Compared with conventional therapy, endobronchial coils showed better response in minimal clinically important difference (MCID) for forced expiratory volume in 1s (FEV1) (RR = 2.37, 95% CI = 1.61 - 3.48, p < 0.0001), for 6-min walk test (6MWT) (RR = 2.05, 95% CI = 1.18 - 3.53, p = 0.01), and for St. George's Respiratory Questionnaire (SGRQ) (RR = 2.32, 95% CI = 1.77 - 3.03, p < 0.00001). EBV therapy also reached clinically significant improvement in FEV1 (RR = 2.96, 95% CI = 1.49 - 5.87, p = 0.002), in 6MWT (RR = 2.90, 95% CI = 1.24 - 6.79, p = 0.01), and in SGRQ (RR = 1.53, 95% CI = 1.22 - 1.92, p = 0.0002). Both coils and EBV treatment achieved statistically significant absolute change in FEV1, 6MWT, and SGRQ from baseline, also accompanied by serious adverse effects. Furthermore, subgroup analysis showed there was no difference between homogeneous and heterogeneous emphysema in coils group. However, IBV group failed to show superior to conventional group. CONCLUSIONS Current meta-analysis indicates that coils or EBV treatment could significantly improve pulmonary function, exercise capacity, and quality of life compared with conventional therapy. Coils treatment could be applied in homogeneous emphysema, but further trials are needed.
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Affiliation(s)
- Yong Wang
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tian-Wen Lai
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Xu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jie-Sen Zhou
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zhou-Yang Li
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xu-Chen Xu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hai-Pin Chen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Song-Min Ying
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Li
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hua-Hao Shen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- State Key Lab of Respiratory Disease, Guangzhou, China
| | - Zhi-Hua Chen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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195
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Welling JBA, Hartman JE, van Rikxoort EM, Ten Hacken NHT, Kerstjens HAM, Klooster K, Slebos DJ. Minimal important difference of target lobar volume reduction after endobronchial valve treatment for emphysema. Respirology 2017; 23:306-310. [PMID: 28913877 DOI: 10.1111/resp.13178] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/20/2017] [Accepted: 07/27/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Target lobar volume reduction (TLVR) is an important efficacy outcome measure for bronchoscopic lung volume reduction (BLVR) treatment using one-way endobronchial valves (EBV) in patients with severe emphysema. The commonly used cut-off value for TLVR that expresses a perceivable clinical benefit is -350 mL. However, a scientifically determined minimal important difference (MID) for TLVR never has been published. The objective of the present study was to determine the MID for TLVR on HRCT in patients who were treated with EBV. METHODS A total of 318 patients with severe emphysema from two BLVR trials were analysed. Anchor-based methods were used to define the TLVR MID at 6 months follow-up. Forced expiratory volume in 1 s (FEV1 ), residual volume (RV) and St. George's Respiratory Questionnaire (SGRQ) were used as anchors. RESULTS The calculated TLVR MID with each anchor was: FEV1 -587 mL, RV -534 mL and SGRQ -560 mL. The combined MID (average of the three anchor-based MIDs) was -563 mL. CONCLUSION Using the anchor-based method, we established a TLVR MID of -563 mL in patients with severe emphysema at 6 months follow-up after EBV treatment. This value can be useful for both interpreting the results from trials and clinical practice, as well as for designing future studies on lung volume reduction.
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Affiliation(s)
- Jorrit B A Welling
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jorine E Hartman
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eva M van Rikxoort
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nick H T Ten Hacken
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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196
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Fiorelli A, Santini M, Shah P. When can computed tomography-fissure analysis replace Chartis collateral ventilation assessment in the prediction of patients with emphysema who might benefit from endobronchial valve therapy? Interact Cardiovasc Thorac Surg 2017; 26:313-318. [DOI: 10.1093/icvts/ivx272] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/30/2017] [Indexed: 11/13/2022] Open
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197
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Debray MP, Marceau A, Dombret MC, Bunel V, Leroy S, Deslée G, Mal H. Bronchiectasis Complicating Lung Volume Reduction Coil Treatment. Chest 2017; 152:e57-e60. [DOI: 10.1016/j.chest.2017.04.189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/20/2017] [Accepted: 04/27/2017] [Indexed: 10/18/2022] Open
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198
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Hetzel J, Boeckeler M, Horger M, Ehab A, Kloth C, Wagner R, Freitag L, Slebos DJ, Lewis RA, Haentschel M. A new functional method to choose the target lobe for lung volume reduction in emphysema - comparison with the conventional densitometric method. Int J Chron Obstruct Pulmon Dis 2017; 12:2621-2628. [PMID: 28919730 PMCID: PMC5586979 DOI: 10.2147/copd.s139304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Lung volume reduction (LVR) improves breathing mechanics by reducing hyperinflation. Lobar selection usually focuses on choosing the most destroyed emphysematous lobes as seen on an inspiratory CT scan. However, it has never been shown to what extent these densitometric CT parameters predict the least deflation of an individual lobe during expiration. The addition of expiratory CT analysis allows measurement of the extent of lobar air trapping and could therefore provide additional functional information for choice of potential treatment targets. Objectives To determine lobar vital capacity/lobar total capacity (LVC/LTC) as a functional parameter for lobar air trapping using on an inspiratory and expiratory CT scan. To compare lobar selection by LVC/LTC with the established morphological CT density parameters. Methods 36 patients referred for endoscopic LVR were studied. LVC/LTC, defined as delta volume over maximum volume of a lobe, was calculated using inspiratory and expiratory CT scans. The CT morphological parameters of mean lung density (MLD), low attenuation volume (LAV), and 15th percentile of Hounsfield units (15%P) were determined on an inspiratory CT scan for each lobe. We compared and correlated LVC/LTC with MLD, LAV, and 15%P. Results There was a weak correlation between the functional parameter LVC/LTC and all inspiratory densitometric parameters. Target lobe selection using lowest lobar deflation (lowest LVC/LTC) correlated with target lobe selection based on lowest MLD in 18 patients (50.0%), with the highest LAV in 13 patients (36.1%), and with the lowest 15%P in 12 patients (33.3%). Conclusion CT-based measurement of deflation (LVC/LTC) as a functional parameter correlates weakly with all densitometric CT parameters on a lobar level. Therefore, morphological criteria based on inspiratory CT densitometry partially reflect the deflation of particular lung lobes, and may be of limited value as a sole predictor for target lobe selection in LVR.
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Affiliation(s)
- Juergen Hetzel
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
| | - Michael Boeckeler
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology
| | - Ahmed Ehab
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
| | | | - Robert Wagner
- Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Department of Internal Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Lutz Freitag
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Richard Alexander Lewis
- National Pollen and Aerobiology Research Unit, Institute of Science and the Environment, University of Worcester, Worcester, UK
| | - Maik Haentschel
- Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine
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199
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Buttery S, Lewis A, Oey I, Hargrave J, Waller D, Steiner M, Shah PL, Kemp SV, Jordan S, Hopkinson NS. Patient experience of lung volume reduction procedures for emphysema: a qualitative service improvement project. ERJ Open Res 2017; 3:00031-2017. [PMID: 28835891 PMCID: PMC5553440 DOI: 10.1183/23120541.00031-2017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/01/2017] [Indexed: 11/27/2022] Open
Abstract
The aim of this service improvement project was to gain understanding of the patient experience of lung volume reduction surgery (LVRS) and endobronchial valve (EBV) placement, from referral through to post-discharge care. Focus group interviews were carried out in two tertiary centres in London and Leicester, UK. Sixteen patients who had undergone lung volume reduction surgery (LVRS), endobronchial valve (EBV) placement, or both, were recruited. Prior to participation in each focus group, participants completed a questionnaire to guide and focus discussion. Thematic analysis identified common themes to the participant experience of receiving lung volume reduction interventions. Themes included patient focus on declining health and the need to “fight” for a referral; consequences of having procedures and potential unexpected complications; and vulnerability post discharge and limited continuity of care. Participants were clear that the benefits of having had either LVRS or EBV procedures outweighed any difficulties experienced. Participants were keen to have further similar interventions if appropriate. These data confirm the need to develop more systematic lung volume reduction pathways, provide appropriate information, and ensure that post-discharge care is optimal. Patients feel they have to fight to get a lung volume reduction procedure; a more systematic approach is neededhttp://ow.ly/82Oy30cLORk
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Affiliation(s)
- Sara Buttery
- NIHR Respiratory Disease, Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Adam Lewis
- NIHR Respiratory Disease, Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Inger Oey
- Leicester Respiratory Biomedical Research Unit, University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - Joanne Hargrave
- Leicester Respiratory Biomedical Research Unit, University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - David Waller
- Leicester Respiratory Biomedical Research Unit, University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - Michael Steiner
- Leicester Respiratory Biomedical Research Unit, University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - Pallav L Shah
- NIHR Respiratory Disease, Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Samuel V Kemp
- NIHR Respiratory Disease, Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Simon Jordan
- NIHR Respiratory Disease, Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
| | - Nicholas S Hopkinson
- NIHR Respiratory Disease, Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK
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Perikleous P, Sharkey A, Oey I, Bilancia R, Tenconi S, Rathinam S, Waller DA. Long-term survival and symptomatic relief in lower lobe lung volume reduction surgery†. Eur J Cardiothorac Surg 2017; 52:982-988. [DOI: 10.1093/ejcts/ezx242] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/30/2017] [Indexed: 11/13/2022] Open
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