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Abstract
Novel pharmacotherapies introduce additional options to providers and patients in how to best treat chronic obstructive pulmonary disease (COPD). Emerging data question the role of inhaled corticosteroids in COPD treatment, particularly as combination dual bronchodilator pharmacotherapies demonstrate robust results. For those maximized on pharmacotherapy with continued dyspnea or exacerbations or both, emerging bronchoscopic procedures may offer additional therapy in select patients. This review focuses on data supporting the use of novel ultra bronchodilators, particularly in combination, and on the role for inhaled corticosteroid withdrawal and new bronchoscopic procedures.
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Affiliation(s)
- Sharon R Rosenberg
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, UK
| | - Ravi Kalhan
- Asthma and COPD Program, Northwestern University Feinberg School of Medicine, Chicago, IL, UK
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202
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Abstract
BACKGROUND Flexible bronchoscopy is a safe and minimally invasive diagnostic tool used by pulmonologists, but few studies have prospectively compared outcomes in patients with objectively defined obstructive lung disease to those without obstruction. METHODS We determined whether complications in patients undergoing moderate sedation bronchoscopy differ in those without obstruction compared with chronic obstructive pulmonary disease (COPD). We prospectively followed all patients undergoing moderate sedation bronchoscopy in an inpatient or outpatient setting. RESULTS Over 12 months, data were collected prospectively in 258 patients. A total o 151 patients had pulmonary function testing with classification of COPD according to GOLD Criteria. Sixty-seven of those patients (44%) had COPD: 6 mild (9%), 29 moderate (42%), 27 severe (41%), and 5 very severe (8%). COPD patients were more likely to receive outpatient inhaled corticosteroids and long-acting bronchodilators and anticholinergics (P<0.001) as would be clinically appropriate. Among all patients with COPD, there were 13% minor complications and 5% major complications, with no deaths. Respiratory complications occurred more often in patients with severe to very severe COPD (22%) compared with patients without COPD (6%) (P=0.018). When adjusted for age, body mass index, and use of home oxygen, this difference was still significant (P=0.045). CONCLUSION Bronchoscopy is generally safe with few complications in most patients with COPD. Patients with objectively confirmed severe to very severe COPD had more frequent respiratory complications than patients without COPD. The risks were not prohibitively high, but should be taken into consideration for COPD patients undergoing moderate sedation flexible bronchoscopy.
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203
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Theilig D, Doellinger F, Poellinger A, Schreiter V, Neumann K, Hubner RH. Comparison of distinctive models for calculating an interlobar emphysema heterogeneity index in patients prior to endoscopic lung volume reduction. Int J Chron Obstruct Pulmon Dis 2017; 12:1631-1640. [PMID: 28615936 PMCID: PMC5459972 DOI: 10.2147/copd.s133348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background The degree of interlobar emphysema heterogeneity is thought to play an important role in the outcome of endoscopic lung volume reduction (ELVR) therapy of patients with advanced COPD. There are multiple ways one could possibly define interlobar emphysema heterogeneity, and there is no standardized definition. Purpose The aim of this study was to derive a formula for calculating an interlobar emphysema heterogeneity index (HI) when evaluating a patient for ELVR. Furthermore, an attempt was made to identify a threshold for relevant interlobar emphysema heterogeneity with regard to ELVR. Patients and methods We retrospectively analyzed 50 patients who had undergone technically successful ELVR with placement of one-way valves at our institution and had received lung function tests and computed tomography scans before and after treatment. Predictive accuracy of the different methods for HI calculation was assessed with receiver-operating characteristic curve analysis, assuming a minimum difference in forced expiratory volume in 1 second of 100 mL to indicate a clinically important change. Results The HI defined as emphysema score of the targeted lobe (TL) minus emphysema score of the ipsilateral nontargeted lobe disregarding the middle lobe yielded the best predicative accuracy (AUC =0.73, P=0.008). The HI defined as emphysema score of the TL minus emphysema score of the lung without the TL showed a similarly good predictive accuracy (AUC =0.72, P=0.009). Subgroup analysis suggests that the impact of interlobar emphysema heterogeneity is of greater importance in patients with upper lobe predominant emphysema than in patients with lower lobe predominant emphysema. Conclusion This study reveals the most appropriate ways of calculating an interlobar emphysema heterogeneity with regard to ELVR.
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Affiliation(s)
- Dorothea Theilig
- Department of Radiology, Charité Campus Virchow Klinikum, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Doellinger
- Department of Radiology, Charité Campus Virchow Klinikum, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Poellinger
- Department of Radiology, Charité Campus Virchow Klinikum, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Vera Schreiter
- Department of Radiology, Charité Campus Virchow Klinikum, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Konrad Neumann
- Institute of Biometrics and Clinical Epidemiology, Charité Campus Benjamin Franklin, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Ralf-Harto Hubner
- Department of Pneumology, Charité Campus Virchow Klinikum, Charité, Universitätsmedizin Berlin, Berlin, Germany
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204
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Greening NJ, Vaughan P, Oey I, Steiner MC, Morgan MD, Rathinam S, Waller DA. Individualised risk in patients undergoing lung volume reduction surgery: the Glenfield BFG score. Eur Respir J 2017; 49:49/6/1601766. [PMID: 28572121 DOI: 10.1183/13993003.01766-2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 02/19/2017] [Indexed: 11/05/2022]
Abstract
Lung volume reduction surgery (LVRS) has been shown to be beneficial in patients with chronic obstructive pulmonary disease, but there is low uptake, partly due to perceived concerns of high operative mortality. We aimed to develop an individualised risk score following LVRS.This was a cohort study of patients undergoing LVRS. Factors independently predicting 90-day mortality and a risk prediction score were identified. Reliability of the score was tested using area under the receiver operating characteristic curve (AUROC).237 LVRS procedures were performed. The multivariate analysis factors associated independently with death were: body mass index (BMI)<18.5 kg·m-2 (OR 2.83, p=0.059), forced expiratory volume in 1 s (FEV1)<0.71 L (OR 5.47, p=0.011) and transfer factor of the lung for carbon monoxide (TLCO) <20% (OR 5.56, p=0.031). A risk score was calculated and total score assigned. AUROC for the risk score was 0.80 and a better predictor than individual components (p<0.01). The score was stratified into three risk groups. Of the total patients, 46% were classified as low risk. Similar improvements in lung function and health status were seen in all groups. The score was introduced and tested in a further 71 patients. AUROC for 90-day mortality in this cohort was 0.84.It is possible to provide an individualised predictive risk score for LVRS, which may aid decision making for both clinicians and patients.
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Affiliation(s)
- Neil J Greening
- Centre for Exercise and Rehabilitation Science, Institute of Lung Health, Leicester Respiratory Biomedical Research Unit, Dept of Respiratory Medicine, Glenfield Hospital, Leicester, UK .,Dept of Infection, Inflammation and Immunity, University of Leicester, Leicester, UK.,Authors contributed equally to work
| | - Paul Vaughan
- Dept of Thoracic Surgery, Glenfield Hospital, Leicester, UK.,Authors contributed equally to work
| | - Inger Oey
- Dept of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Michael C Steiner
- Centre for Exercise and Rehabilitation Science, Institute of Lung Health, Leicester Respiratory Biomedical Research Unit, Dept of Respiratory Medicine, Glenfield Hospital, Leicester, UK.,Dept of Infection, Inflammation and Immunity, University of Leicester, Leicester, UK.,School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Mike D Morgan
- Centre for Exercise and Rehabilitation Science, Institute of Lung Health, Leicester Respiratory Biomedical Research Unit, Dept of Respiratory Medicine, Glenfield Hospital, Leicester, UK
| | | | - David A Waller
- Dept of Thoracic Surgery, Glenfield Hospital, Leicester, UK
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205
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Lee SW, Lee SM, Shin SY, Park TS, Oh SY, Kim N, Hong Y, Lee JS, Oh YM, Lee SD, Seo JB. Improvement in Ventilation-Perfusion Mismatch after Bronchoscopic Lung Volume Reduction: Quantitative Image Analysis. Radiology 2017; 285:250-260. [PMID: 28510483 DOI: 10.1148/radiol.2017162148] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To evaluate whether bronchoscopic lung volume reduction (BLVR) increases ventilation and therefore improves ventilation-perfusion (V/Q) mismatch. Materials and Methods All patients provided written informed consent to be included in this study, which was approved by the Institutional Review Board (2013-0368) of Asan Medical Center. The physiologic changes that occurred after BLVR were measured by using xenon-enhanced ventilation and iodine-enhanced perfusion dual-energy computed tomography (CT). Patients with severe emphysema plus hyperinflation who did not respond to usual treatments were eligible. Pulmonary function tests, the 6-minute walking distance (6MWD) test, quality of life assessment, and dual-energy CT were performed at baseline and 3 months after BLVR. The effect of BLVR was assessed with repeated-measures analysis of variance. Results Twenty-one patients were enrolled in this study (median age, 68 years; mean forced expiratory volume in 1 second [FEV1], 0.75 L ± 0.29). After BLVR, FEV1 (P < .001) and 6MWD (P = .002) improved significantly. Despite the reduction in lung volume (-0.39 L ± 0.44), both ventilation per voxel (P < .001) and total ventilation (P = .01) improved after BLVR. However, neither perfusion per voxel (P = .16) nor total perfusion changed significantly (P = .49). Patients with lung volume reduction of 50% or greater had significantly better improvement in FEV1 (P = .02) and ventilation per voxel (P = .03) than patients with lung volume reduction of less than 50%. V/Q mismatch also improved after BLVR (P = .005), mainly owing to the improvement in ventilation. Conclusion The dual-energy CT analyses showed that BLVR improved ventilation and V/Q mismatch. This increased lung efficiency may be the primary mechanism of improvement after BLVR, despite the reduction in lung volume. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Sei Won Lee
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Sang Min Lee
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - So Youn Shin
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Tai Sun Park
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Sang Young Oh
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Namkug Kim
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Yoonki Hong
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Jae Seung Lee
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Yeon-Mok Oh
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Sang-Do Lee
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
| | - Joon Beom Seo
- From the Department of Pulmonary and Critical Care Medicine and Clinical Research Center for Chronic Obstructive Airway Diseases (S.W.L., T.S.P., J.S.L., Y.M.O., S.D.L.) and Department of Radiology and Research Institute of Radiology (S.M.L., S.Y.S., S.Y.O., N.K., J.B.S.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea (S.Y.S.); Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (T.S.P.); and Department of Internal Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea (Y.H.)
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206
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Edgar RG, Patel M, Bayliss S, Crossley D, Sapey E, Turner AM. Treatment of lung disease in alpha-1 antitrypsin deficiency: a systematic review. Int J Chron Obstruct Pulmon Dis 2017; 12:1295-1308. [PMID: 28496314 PMCID: PMC5422329 DOI: 10.2147/copd.s130440] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is a rare genetic condition predisposing individuals to chronic obstructive pulmonary disease (COPD). The treatment is generally extrapolated from COPD unrelated to AATD; however, most COPD trials exclude AATD patients; thus, this study sought to systematically review AATD-specific literature to assist evidence-based patient management. METHODS Standard review methodology was used with meta-analysis and narrative synthesis (PROSPERO-CRD42015019354). Eligible studies were those of any treatment used in severe AATD. Randomized controlled trials (RCTs) were the primary focus; however, case series and uncontrolled studies were eligible. All studies had ≥10 participants receiving treatment or usual care, with baseline and follow-up data (>3 months). Risk of bias was assessed appropriately according to study methodology. RESULTS In all, 7,296 studies were retrieved from searches; 52 trials with 5,632 participants met the inclusion criteria, of which 26 studies involved alpha-1 antitrypsin augmentation and 17 concerned surgical treatments (largely transplantation). Studies were grouped into four management themes: COPD medical, COPD surgical, AATD specific, and other treatments. Computed tomography (CT) density, forced expiratory volume in 1 s, diffusing capacity of the lungs for carbon monoxide, health status, and exacerbation rates were frequently used as outcomes. Meta-analyses were only possible for RCTs of intravenous augmentation, which slowed progression of emphysema measured by CT density change, 0.79 g/L/year versus placebo (P=0.002), and associated with a small increase in exacerbations 0.29/year (P=0.02). Mortality following lung transplant was comparable between AATD- and non-AATD-related COPD. Surgical reduction of lung volume demonstrated inferior outcomes compared with non-AATD-related emphysema. CONCLUSION Intravenous augmentation remains the only disease-specific therapy in AATD and there is evidence that this slows decline in emphysema determined by CT density. There is paucity of data around other treatments in AATD. Treatments for usual COPD may not be as efficacious in AATD, and further studies may be required for this disease group.
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Affiliation(s)
- Ross G Edgar
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Mitesh Patel
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Susan Bayliss
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Diana Crossley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Department of Respiratory Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
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207
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Zhang JJ, Yin Y, Hou G. The bronchoscopic interventions for chronic obstructive pulmonary disease according to different phenotypes. J Thorac Dis 2017; 9:1361-1365. [PMID: 28616289 DOI: 10.21037/jtd.2017.05.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bronchoscopic interventions are valuable adjuncts to the pharmacologic therapy for chronic obstructive pulmonary disease (COPD). But different phenotypes of COPD patients showed different clinical responses to the same or similar therapy. The optimal selection of bronchoscopic interventions for COPD patients also needs to be based on the phenotypes. According to the different phenotypes, novel interventional pulmonology techniques which were used for COPD treatments in daily clinical practice or clinical trials have been described extensively throughout our current review.
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Affiliation(s)
| | - Yan Yin
- Department of Respiratory Medicine, First Hospital of China Medical University, Shenyang 110001, China
| | - Gang Hou
- Department of Respiratory Medicine, First Hospital of China Medical University, Shenyang 110001, China
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208
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Spathis A, Booth S, Moffat C, Hurst R, Ryan R, Chin C, Burkin J. The Breathing, Thinking, Functioning clinical model: a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease. NPJ Prim Care Respir Med 2017; 27:27. [PMID: 28432286 PMCID: PMC5435098 DOI: 10.1038/s41533-017-0024-z] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 01/31/2023] Open
Abstract
Refractory breathlessness is a highly prevalent and distressing symptom in advanced chronic respiratory disease. Its intensity is not reliably predicted by the severity of lung pathology, with unhelpful emotions and behaviours inadvertently exacerbating and perpetuating the problem. Improved symptom management is possible if clinicians choose appropriate non-pharmacological approaches, but these require engagement and commitment from both patients and clinicians. The Breathing Thinking Functioning clinical model is a proposal, developed from current evidence, that has the potential to facilitate effective symptom control, by providing a rationale and focus for treatment.
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Affiliation(s)
- Anna Spathis
- Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- University of Cambridge, Cambridge, UK.
| | | | - Catherine Moffat
- Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rhys Hurst
- Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Chloe Chin
- Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Julie Burkin
- Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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209
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van Agteren JEM, Hnin K, Grosser D, Carson KV, Smith BJ. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; 2:CD012158. [PMID: 28230230 PMCID: PMC6464526 DOI: 10.1002/14651858.cd012158.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD). OBJECTIVES To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique. SEARCH METHODS Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016. SELECTION CRITERIA We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available. DATA COLLECTION AND ANALYSIS Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software. MAIN RESULTS AeriSealOne RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV1) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate. Airway bypass stentsTreatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV1 (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high. Endobronchial coilsThree studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV1 (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high. Endobronchial valvesFive studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV1 (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high. Intrabronchial valvesIn the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV1 (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV1 and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high. Vapour ablationOne study of 69 participants found significant mean between-group differences in FEV1 (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate. AUTHORS' CONCLUSIONS Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.
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Affiliation(s)
| | - Khin Hnin
- Flinders UniversityAdelaideAustralia
| | | | | | - Brian J Smith
- The University of AdelaideSchool of MedicineAdelaideAustralia
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210
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Slebos DJ, Shah PL. Collateral Ventilation: Friend or Foe in Patients with Severe Emphysema. Respiration 2017; 93:232-233. [PMID: 28122373 PMCID: PMC5516401 DOI: 10.1159/000456672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pallav L. Shah
- The National Institute for Health Research Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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211
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Abstract
Endoscopic lung volume reduction (ELVR) presents an effective therapy in patients with advanced emphysema. Different ELVR techniques are available differing in mechanism of action, degree of reversibility and safety. Precise patient selection with respect to pulmonary function test, emphysema distribution, and collateral ventilation are prerequisites for a successful use of the various ELVR techniques. To date, there are only a few randomized controlled trials for bronchoscopic therapy in patients with chronic obstructive pulmonary disease, so the various techniques should be performed within clinical trials or registry studies.
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Affiliation(s)
- Daniela Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Röntgenstr. 1, Heidelberg 69126, Germany
| | - Felix J F Herth
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Röntgenstr. 1, Heidelberg 69126, Germany.
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212
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Slebos DJ, Shah PL, Herth FJF, Valipour A. Endobronchial Valves for Endoscopic Lung Volume Reduction: Best Practice Recommendations from Expert Panel on Endoscopic Lung Volume Reduction. Respiration 2016; 93:138-150. [PMID: 27992862 DOI: 10.1159/000453588] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/17/2016] [Indexed: 11/19/2022] Open
Abstract
Endoscopic lung volume reduction (ELVR) is being adopted as a treatment option for carefully selected patients suffering from severe emphysema. ELVR with the one-way endobronchial Zephyr valves (EBV) has been demonstrated to improve pulmonary function, exercise capacity, and quality of life in patients with both heterogeneous and homogenous emphysema without collateral ventilation. In this "expert best practices" review, we will highlight the practical aspects of this therapy. Key selection criteria for ELVR are hyperinflation with a residual volume >175% of predicted, forced expiratory volume <50% of predicted, and a 6-min walking distance >100 m. Patients with repeated infectious complications, severe bronchiectasis, and those with unstable cardiovascular comorbidities should be excluded from EBV treatment. The procedure may be performed with either conscious sedation or general anesthesia and positive pressure mechanical ventilation using a flexible endotracheal tube or a rigid bronchoscope. Chartis and EBV placement should be performed in 1 procedure when possible. The sequence of valve placement should be orchestrated to avoid obstruction and delivery of subsequent valves. If atelectasis has not occurred by 1 month after procedure, evaluate valve position on CT and consider replacing the valves that are not optimally positioned. Pneumothorax is a common complication and typically occurs in the first 2 days following treatment. A management algorithm for pneumothorax has been previously published. Long-term sequelae from EBV therapy do occur but are easily manageable.
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Affiliation(s)
- Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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213
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Zoumot Z, Davey C, Jordan S, McNulty WH, Carr DH, Hind MD, Polkey MI, Shah PL, Hopkinson NS. Endobronchial valves for patients with heterogeneous emphysema and without interlobar collateral ventilation: open label treatment following the BeLieVeR-HIFi study. Thorax 2016; 72:277-279. [PMID: 27999170 PMCID: PMC5339569 DOI: 10.1136/thoraxjnl-2016-208865] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/31/2016] [Accepted: 09/19/2016] [Indexed: 11/04/2022]
Abstract
Outcomes in early trials of bronchoscopic lung volume reduction using endobronchial valves for the treatment of patients with advanced emphysema were inconsistent. However improvements in patient selection with focus on excluding those with interlobar collateral ventilation and homogeneous emphysema resulted in significant benefits in the BeLieVeR-HIFi study compared with sham treated controls. In this manuscript we present data from the control patients in the BeLieVeR-HIFi study who went on to have open label endobronchial valve treatment after completion of the clinical trial (n=12), combined with data from those in the treatment arm who did not have collateral ventilation (n=19). Three months after treatment FEV1 increased by 27.3 (36.4)%, residual volume reduced by 0.49 (0.76) L, the 6 min walk distance increased by 32.6 (68.7) m and the St George Respiratory Questionnaire for COPD score improved by 8.2 (20.2) points. These data extend the evidence for endobronchial valve placement in appropriately selected patients with COPD. TRIAL REGISTRATION NUMBER ISRCTN04761234; Results.
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Affiliation(s)
- Zaid Zoumot
- NIHR Respiratory Disease, Biomedical Research Unit, The Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, London, UK.,Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Claire Davey
- Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Simon Jordan
- Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - William H McNulty
- Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Denis H Carr
- Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Matthew D Hind
- Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Michael I Polkey
- Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Pallav L Shah
- Respiratory and Critical Care Institute, Cleveland Clinic, Abu Dhabi, UAE
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214
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Klooster K, Hartman JE, Ten Hacken NHT, Slebos DJ. One-Year Follow-Up after Endobronchial Valve Treatment in Patients with Emphysema without Collateral Ventilation Treated in the STELVIO Trial. Respiration 2016; 93:112-121. [PMID: 27974713 DOI: 10.1159/000453529] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 11/15/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND One-way endobronchial valve (EBV) treatment has shown safety and efficacy at 6 months after treatment in patients with severe emphysema and confirmed absence of interlobar collateral ventilation. Longer follow-up in this subgroup is not available. OBJECTIVES To investigate the efficacy and safety of EBV treatment of the STELVIO cohort at a 1-year follow-up. METHODS Emphysema patients who have been treated with EBV in the STELVIO trial were invited for a voluntary 1-year follow-up visit. Both the original treatment group and the control group who crossed over to treatment have been included. Analyses are performed on the patients who attended the 1-year follow-up visit. RESULTS Sixty-four patients received EBV treatment. At 1 year, 40 patients (26 female; mean age 59 ± 8 years; FEV1 0.86 ± 0.29 L; RV 4.56 ± 1.00 L; 6MWD 367 ± 78 m; and SGRQ 56 ± 13 points) visited the hospital. Significant improvements (p < 0.001) were found for FEV1 (+17%, 95% CI, 11 to 24), RV (-687 mL, 95% CI, -918 to -456), 6MWD (+61 m, 95% CI, 42 to 80), and SGRQ (-11 points, 95% CI, -17 to -6). Two patients died: 1 after 58 days due to progressive respiratory failure and 1 after 338 days of follow-up due to a myocardial infarction. Seventeen percent of the patients underwent valve replacement and 22% of the initially treated patients had permanent valve removal. In 22% of the patients, pneumothoraces occurred before 6 months, and none occurred between 6 and 12 months. CONCLUSIONS EBV treatment results in clinically relevant benefits at 1 year of follow-up. Maintenance bronchoscopies to achieve this are needed. This study supports the use of EBV treatment in carefully selected patients with severe emphysema without collateral ventilation.
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Affiliation(s)
- Karin Klooster
- University of Groningen, and Department of Pulmonary Diseases, University Medical Center Groningen, Groningen, The Netherlands
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215
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Gompelmann D, Benjamin N, Kontogianni K, Herth FJF, Heussel CP, Hoffmann H, Eberhardt R. Clinical and radiological outcome following pneumothorax after endoscopic lung volume reduction with valves. Int J Chron Obstruct Pulmon Dis 2016; 11:3093-3099. [PMID: 27994448 PMCID: PMC5153254 DOI: 10.2147/copd.s117890] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Valve implantation has evolved as a therapy for patients with advanced emphysema. Although it is a minimally invasive treatment, it is associated with complications, the most common being pneumothorax. Pneumothorax occurs due to the rapid target lobe volume reduction and may be a predictor of clinical benefit despite this complication. OBJECTIVE The objective of this study was to conduct an exploratory data analysis of patients who developed a pneumothorax following endoscopic valve therapy for emphysema. MATERIALS AND METHODS This study performed a retrospective evaluation of pneumothorax management and the impact of pneumothorax on clinical outcomes in 70 patients following valve therapy in 381 consecutive patients. RESULTS Pneumothorax rate following valve therapy was 18%. Pneumothorax management consisted of chest tube insertion, valve removal, and surgical intervention in 87% (61/70), 44% (31/70), and 19% (13/70) of the patients, respectively. Despite pneumothorax, patients experienced modest but significant improvements in lung function parameters (forced expiratory volume in 1 second: 55±148 mL, residual volume: -390±964 mL, total lung capacity: -348±876; all P<0.05). Persistent lobar atelectasis 3 months after recovering from pneumothorax, which was associated with relevant clinical improvement, was observed in only 21% (15/70) of the patients. CONCLUSION Pneumothorax is a frequent severe complication following valve therapy that requires further intervention. Nevertheless, the pneumothorax does not impair the clinical status in the majority of patients. Patients with lobar atelectasis benefit after recovering from pneumothorax in terms of lung function parameters.
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Affiliation(s)
- D Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- German Center for Lung Research
| | - N Benjamin
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
| | - K Kontogianni
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
| | - FJF Herth
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- German Center for Lung Research
| | - CP Heussel
- German Center for Lung Research
- Diagnostic and Interventional Radiology, Thoraxklinik at University of Heidelberg
- Diagnostic and Interventional Radiology, University Hospital Heidelberg
| | - H Hoffmann
- German Center for Lung Research
- Thoracic Surgery, Thoraxklinik at University of Heidelberg, Heidelberg, Germany
| | - R Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- German Center for Lung Research
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216
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Gompelmann D, Eberhardt R, Schuhmann M, Valipour A, Shah PL, Herth FJ, Kontogianni K. Lung Volume Reduction with Vapor Ablation in the Presence of Incomplete Fissures: 12-Month Results from the STEP-UP Randomized Controlled Study. Respiration 2016; 92:397-403. [DOI: 10.1159/000452424] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 10/07/2016] [Indexed: 11/19/2022] Open
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217
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Darwiche K, Karpf-Wissel R, Eisenmann S, Aigner C, Welter S, Zarogoulidis P, Hohenforst-Schmidt W, Freitag L, Oezkan F. Bronchoscopic Lung Volume Reduction with Endobronchial Valves in Low-FEV1 Patients. Respiration 2016; 92:414-419. [PMID: 27838695 DOI: 10.1159/000452629] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 10/13/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bronchoscopic lung volume reduction (BLVR) with valves has been shown to improve lung function, exercise capacity, and quality of life in patients with emphysema, but only few patients with forced expiratory volume in 1 s (FEV1) ≤20% predicted have been included in former studies. Although the procedure can be performed safely, pneumothorax is a frequent complication, which can be critical for these very severely diseased patients. OBJECTIVES The aim of the study was to assess the safety of BLVR in patients with a very advanced stage of emphysema, as indicated by FEV1 ≤20% predicted. PATIENTS AND METHODS Patients in whom BLVR was performed between January 2013 and August 2015 were included in this analysis if their baseline predicted FEV1 was ≤20%. BLVR, performed only if collateral ventilation was absent, achieved complete occlusion of the target lobe. All patients were closely monitored and were not discharged before the fourth day after BLVR. RESULTS Twenty patients with FEV1 ≤20% predicted were included in the analysis. Lung volume reduction was achieved in 65% of the cases. Pneumothorax occurred in 4 cases (20%). No patient died. Lung function and exercise tolerance improved after 1 and 3 months, respectively. CONCLUSIONS BLVR with valves can be safely performed in patients with FEV1 ≤20% predicted when close postprocedural monitoring is provided. Improvement in lung function and exercise capacity can be achieved.
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Affiliation(s)
- Kaid Darwiche
- Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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218
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Zoumot Z, Kemp SV, Shah PL. Endobronchial Valves for Emphysema: Time to Push the Envelope? Respiration 2016; 92:359-361. [PMID: 27806368 DOI: 10.1159/000452630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Zaid Zoumot
- Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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219
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Hopkinson NS. Endobronchial Valves as a Treatment for Emphysema. Moving out of the Shadow of Lung Volume Reduction Surgery. Am J Respir Crit Care Med 2016; 194:1039-1040. [DOI: 10.1164/rccm.201609-1808ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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220
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Trudzinski FC, Lepper PM, Leppert D, Langer F, Lensch C, Flaig M, Bals R, Wilkens H, Minko P, Fähndrich S. Bilateral Endoscopic Lung Volume Reduction in Patients with Severe Emphysema. Respiration 2016; 92:356-358. [PMID: 27701180 DOI: 10.1159/000450758] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Reducing hyperinflated areas in chronic obstructive pulmonary disease, either surgically or endoscopically, leads to improvement of functional parameters. It is unclear if bilateral treatment with endobronchial valves (EBV) aiming at total lobar occlusion is beneficial. The aim of this study was to assess the results after staged bilateral endoscopic treatment with EBV. This is a retrospective analysis of patients with severe airflow obstruction, who were treated bilaterally with EBV in two stages, aiming at subsequent atelectasis. Pre- and postintervention lung function parameters, the 6-minute walk test (6-MWT), complications, and follow-up were recorded. Sixteen patients were treated bilaterally in two stages. There was an overall improvement in lung function from baseline to second-treatment follow-up with an increase in FEV1 (23.57-29.21% of predicted) and a decrease in residual volume (299.21-240.10% of predicted) and total lung capacity (140.78-128.71% of predicted). The 6-MWT improved up to 54 m. After each procedure, 9 of 16 patients (56.25%) developed an atelectasis of the target lobe. Overall, pneumothorax occurred in 8 of 32 procedures (25%). No patient died. Patients benefitted from the first EBV treatment. The second treatment did not lead to marked improvements compared to the first treatment. Bilateral lung volume reduction with valves is possible; however, the current results seem not to justify bilateral valve treatment as a routine approach.
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Affiliation(s)
- Franziska C Trudzinski
- Department of Internal Medicine V - Pneumology, Allergology, and Critical Care Medicine, University Hospital of Saarland, Homburg, Germany
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221
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Lung volume reduction for emphysema. THE LANCET RESPIRATORY MEDICINE 2016; 5:147-156. [PMID: 27693408 DOI: 10.1016/s2213-2600(16)30221-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 11/22/2022]
Abstract
Advanced emphysema is a lung disease in which alveolar capillary units are destroyed and supporting tissue is lost. The combined effect of reduced gas exchange and changes in airway dynamics impairs expiratory airflow and leads to progressive air trapping. Pharmacological therapies have limited effects. Surgical resection of the most destroyed sections of the lung can improve pulmonary function and exercise capacity but its benefit is tempered by significant morbidity. This issue stimulated a search for novel approaches to lung volume reduction. Alternative minimally invasive approaches using bronchoscopic techniques including valves, coils, vapour thermal ablation, and sclerosant agents have been at the forefront of these developments. Insertion of endobronchial valves in selected patients could have benefits that are comparable with lung volume reduction surgery. Endobronchial coils might have a role in the treatment of patients with emphysema with severe hyperinflation and less parenchymal destruction. Use of vapour thermal energy or a sclerosant might allow focal treatment but the unpredictability of the inflammatory response limits their current use. In this Review, we aim to summarise clinical trial evidence on lung volume reduction and provide guidance on patient selection for available therapies.
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222
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Trudzinski FC, Höink AJ, Leppert D, Fähndrich S, Wilkens H, Graeter TP, Langer F, Bals R, Minko P, Lepper PM. Endoscopic Lung Volume Reduction Using Endobronchial Valves in Patients with Severe Emphysema and Very Low FEV1. Respiration 2016; 92:258-265. [PMID: 27603781 DOI: 10.1159/000448761] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 07/26/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with a forced expiratory volume in 1 s (FEV1) below 20% of the predicted normal values (pred.) and either homogeneous emphysema or low diffusing capacity for carbon monoxide (DLCO) have a high risk for adverse events including death when undergoing surgical lung volume reduction. OBJECTIVES We hypothesized that selected patients can benefit from endoscopic lung volume reduction (eLVR) despite a very low FEV1. METHODS This study is a retrospective analysis of consecutive patients with severe airflow obstruction, an FEV1 ≤20% of pred., and low DLCO who were treated by eLVR with endobronchial valves (EBV) between June 2012 and January 2015. Pre- and postinterventional lung function parameters, the 6-min walking test (6-MWT) distance, adverse events, and follow-up were recorded. RESULTS In 20 patients, there was an overall improvement in lung function with an increase in FEV1 (16.97-21.03% of pred.) and a decrease in residual volume (322-270% of pred.) and total lung capacity (144-129.06% of pred.). The 6-MWT distance improved (from 239 ± 77 to 267± 97 m overall, and from 184 ± 50 to 237 ± 101 m if patients developed an atelectasis of the target lobe). Pneumothorax occurred in 5 of the 20 patients (25%). 30-day mortality was 0%, and all patients survived to discharge. CONCLUSIONS The patients benefitted moderately from EBV treatment despite an initially low FEV1. Some patients improved remarkably. EBV treatment in patients with an FEV1 ≤20% of pred. is generally feasible and safe. The greatest risk is pneumothorax with prolonged chest tube duration.
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Affiliation(s)
- Franziska C Trudzinski
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center, Homburg, Germany
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223
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Yu H, Wang L, Wu Z, Yang Z. Status of and prospects for bronchoscopic lung volume reduction for patients with severe emphysema. Biosci Trends 2016; 10:344-356. [PMID: 27594047 DOI: 10.5582/bst.2016.01113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) is a minimally invasive treatment for severe emphysema, providing treatment options for patients who are unable to undergo lung volume reduction surgery (LVRS) or lung transplantation. Current BLVR techniques include bronchoscopic volume reduction with valve implants, use of a lung volume reduction coil (LVRC), bronchoscopic thermal vapor ablation (BTVA), biological lung volume reduction (BioLVR), and use of airway bypass stents (ABS). To date, several randomized controlled trials of these bronchoscopic therapies have been conducted in patients with emphysema, and bronchoscopic volume reduction with valve implants remains the best approach thus far. Recent studies indicate that BLVR may be of great value in improving lung function, exercise capacity, and quality of life and that BLVR has the potential to replace conventional surgery for patients with severe emphysema. Optimal patient selection and the proper selection of the BLVR technique in accordance with patient characteristics are crucial to the success of BLVR. More multicenter, prospective, randomized controlled trials need to be conducted in the future to optimize the current selection strategy and evaluate the safety, efficiency, and long-term benefit of BLVR techniques.
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Affiliation(s)
- Hang Yu
- Department of Respiratory Medicine, Chinese PLA General Hospital
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224
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The importance of patient selection for lung volume reduction. CURRENT PULMONOLOGY REPORTS 2016. [DOI: 10.1007/s13665-016-0153-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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225
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Koster TD, van Rikxoort EM, Huebner RH, Doellinger F, Klooster K, Charbonnier JP, Radhakrishnan S, Herth FJ, Slebos DJ. Predicting Lung Volume Reduction after Endobronchial Valve Therapy Is Maximized Using a Combination of Diagnostic Tools. Respiration 2016; 92:150-7. [DOI: 10.1159/000448849] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/02/2016] [Indexed: 11/19/2022] Open
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226
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Skowasch D, Fertl A, Schwick B, Schäfer H, Hellmann A, Herth FJF. A Long-Term Follow-Up Investigation of Endobronchial Valves in Emphysema (the LIVE Study): Study Protocol and Six-Month Interim Analysis Results of a Prospective Five-Year Observational Study. Respiration 2016; 92:118-26. [PMID: 27562904 DOI: 10.1159/000448119] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/27/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Randomized controlled trials indicate that significant lung volume reduction (ELVR) can be obtained with Zephyr® valves by occluding the target lobe in the absence of collateral ventilation, leading to relevant functional benefits in advanced emphysema patients. OBJECTIVES To observe the long-term effects of endobronchial valve (EBV) implantation in emphysema patients screened by Chartis assessment in the context of daily pulmonology practice. METHODS The LIVE Study is a prospective, observational, open-label, single-arm, multicenter trial conducted in Germany. 498 patients included in this interim analysis were enrolled between July 2, 2012, and September 16, 2014. The 6-month follow-up visit data were recorded for 343 patients (safety population), and complete data sets were available for 321 treated patients (efficacy population) - 56.4% male, age: 64.5 years, forced expiratory volume in 1 s (FEV1) % predicted: 31.3%, residual volume (RV) % predicted: 252%. RESULTS Efficacy results at 6 months: FEV1 (l) increased by +100 ml (+11.9%), RV (l) decreased by -0.42 liter, and the COPD Assessment Test score decreased by -3.14 points (each p < 0.0001). Safety outcomes: A total of 66 adverse events (AEs; with 50 serious AEs - SAEs) were reported in 55 patients (16%) during the hospital stay for EBV placement - pneumothorax (35 cases), chronic obstructive pulmonary disease (COPD) exacerbation (5 cases), and pneumonia (4 cases). During the subsequent 6-month follow-up window, 170 SAEs were recorded in 125 patients (36.4%), predominantly COPD exacerbation (53% of the SAEs). CONCLUSION The current results of this large-scale German observational study performed in the context of daily practice further demonstrates that ELVR with Zephyr® valves is an effective and well-tolerated treatment option in advanced emphysema.
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Affiliation(s)
- Dirk Skowasch
- Department of Internal Medicine II - Pneumology, University of Bonn, Bonn, Germany
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227
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Valipour A. Endoscopic valve therapy for emphysema: Patient selection as the Holy Grail to success. Respirology 2016; 21:1148-9. [PMID: 27549373 DOI: 10.1111/resp.12876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/01/2016] [Indexed: 01/17/2023]
Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig-Boltzmann-Institute for COPD and Respiratory Epidemiology, Vienna, Austria
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228
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Gompelmann D, Lim HJ, Eberhardt R, Gerovasili V, Herth FJF, Heussel CP, Eichinger M. Predictors of pneumothorax following endoscopic valve therapy in patients with severe emphysema. Int J Chron Obstruct Pulmon Dis 2016; 11:1767-73. [PMID: 27536088 PMCID: PMC4976918 DOI: 10.2147/copd.s106439] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Endoscopic valve implantation is an effective treatment for patients with advanced emphysema. Despite the minimally invasive procedure, valve placement is associated with risks, the most common of which is pneumothorax. This study was designed to identify predictors of pneumothorax following endoscopic valve implantation. METHODS Preinterventional clinical measures (vital capacity, forced expiratory volume in 1 second, residual volume, total lung capacity, 6-minute walk test), qualitative computed tomography (CT) parameters (fissure integrity, blebs/bulla, subpleural nodules, pleural adhesions, partial atelectasis, fibrotic bands, emphysema type) and quantitative CT parameters (volume and low attenuation volume of the target lobe and the ipsilateral untreated lobe, target air trapping, ipsilateral lobe volume/hemithorax volume, collapsibility of the target lobe and the ipsilateral untreated lobe) were retrospectively evaluated in patients who underwent endoscopic valve placement (n=129). Regression analysis was performed to compare those who developed pneumothorax following valve therapy (n=46) with those who developed target lobe volume reduction without pneumothorax (n=83). FINDING Low attenuation volume% of ipsilateral untreated lobe (odds ratio [OR] =1.08, P=0.001), ipsilateral untreated lobe volume/hemithorax volume (OR =0.93, P=0.017), emphysema type (OR =0.26, P=0.018), pleural adhesions (OR =0.33, P=0.012) and residual volume (OR =1.58, P=0.012) were found to be significant predictors of pneumothorax. Fissure integrity (OR =1.16, P=0.075) and 6-minute walk test (OR =1.05, P=0.077) were also indicative of pneumothorax. The model including the aforementioned parameters predicted whether a patient would experience a pneumothorax 84% of the time (area under the curve =0.84). INTERPRETATION Clinical and CT parameters provide a promising tool to effectively identify patients at high risk of pneumothorax following endoscopic valve therapy.
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Affiliation(s)
- Daniela Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research
| | - Hyun-ju Lim
- Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg
- Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Ralf Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research
| | - Vasiliki Gerovasili
- First Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Felix JF Herth
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research
| | - Claus Peter Heussel
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research
- Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg
- Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Monika Eichinger
- Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg
- Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
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229
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[Prediction of the efficiency of endoscopic lung volume reduction by valves in severe emphysema]. Rev Mal Respir 2016; 33:794-798. [PMID: 27444697 DOI: 10.1016/j.rmr.2016.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 02/15/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION In severe emphysema, endoscopic lung volume reduction with valves is an alternative to surgery with less morbidity and mortality. In 2015, selection of patients who will respond to this technique is based on emphysema heterogeneity, a complete fissure visible on the CT-scan and absence of collateral ventilation between lobes. Our case report highlights that individualized prediction is possible. CASE REPORT A 58-year-old woman had severe, disabling pulmonary emphysema. A high resolution thoracic computed tomography scan showed that the emphysema was heterogeneous, predominantly in the upper lobes, integrity of the left greater fissure and no collateral ventilation with the left lower lobe. A valve was inserted in the left upper lobe bronchus. At one year, clinical and functional benefits were significant with complete atelectasis of the treated lobe. CONCLUSION The success of endoscopic lung volume reduction with a valve can be predicted, an example of personalized medicine.
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Abstract
PURPOSE OF REVIEW Several lung volume reduction (LVR) techniques have been increasingly evaluated in patients with advanced pulmonary emphysema, especially in the last decade. Radiologist plays a pivotal role in the characterization of parenchymal damage and, thus, assessment of eligibility criteria. This review aims to discuss the most common LVR techniques, namely LVR surgery, endobronchial valves, and coils LVR, with emphasis on the role of computed tomography (CT). RECENT FINDINGS Several trials have recently highlighted the importance of regional quantification of emphysema by computerized CT-based segmentation of hyperlucent parenchyma, which is strongly recommended for candidates to any LVR treatment. In particular, emphysema distribution pattern and fissures integrity are evaluated to tailor the choice of the most appropriate LVR technique. Furthermore, a number of CT measures have been tested for the personalization of treatment, according to imaging detected heterogeneity of parenchymal disease. SUMMARY CT characterization of heterogeneous parenchymal abnormalities provides criteria for selection of the preferable treatment in each patient and improves outcome of LVR as reflected by better quality of life, higher exercise tolerance, and lower mortality.
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231
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Shah PL, Gompelmann D, Valipour A, McNulty WH, Eberhardt R, Grah C, Egan J, Ficker JH, Wagner M, Witt C, Liebers U, Hopkins P, Gesierich W, Phillips M, Stanzel F, Petermann C, Strange C, Snell G, Herth FJF. Thermal vapour ablation to reduce segmental volume in patients with severe emphysema: STEP-UP 12 month results. THE LANCET RESPIRATORY MEDICINE 2016; 4:e44-e45. [PMID: 27451345 DOI: 10.1016/s2213-2600(16)30199-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 06/28/2016] [Accepted: 07/04/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Pallav L Shah
- The National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton, London SW3 6NP, UK; Harefield NHS Foundation Trust, London, UK; Imperial College, London, UK.
| | - Daniela Gompelmann
- Department of Pneumology and Critical Care Medicine Thoraxklinik, University of Heidelberg, Heidelberg, Germany; Translational Lung Research Center Heidelberg, Heidelberg, Germany; The German Lung Research Foundation (DZL), Heidelberg, Germany
| | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig-Boltzmann-Institute for COPD and Respiratory Epidemiology, Otto-Wagner-Hospital, Vienna, Austria
| | - William H McNulty
- The National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton, London SW3 6NP, UK; Harefield NHS Foundation Trust, London, UK; Imperial College, London, UK
| | - Ralf Eberhardt
- Department of Pneumology and Critical Care Medicine Thoraxklinik, University of Heidelberg, Heidelberg, Germany; Translational Lung Research Center Heidelberg, Heidelberg, Germany; The German Lung Research Foundation (DZL), Heidelberg, Germany
| | - Christian Grah
- Medical Clinic of Pneumology, Gemeinschaftskrankenhaus Havelhöhe, Berlin, Germany
| | - Jim Egan
- Advanced Lung Disease Program, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Joachim H Ficker
- Department of Respiratory Medicine, Allergology and Sleep Medicine, General Hospital Nuernberg, Nuremberg, Germany; Paracelsus Medical University, Nuremberg, Germany
| | - Manfred Wagner
- Department of Respiratory Medicine, Allergology and Sleep Medicine, General Hospital Nuernberg, Nuremberg, Germany; Paracelsus Medical University, Nuremberg, Germany
| | | | - Uta Liebers
- Pneumology, Charité Campus-Mitte, Berlin, Germany
| | - Peter Hopkins
- Lung Transplant Unit, Prince Charles Hospital, Chermside, Australia
| | - Wolfgang Gesierich
- Asklepios-Fachkliniken Munich-Gauting, Comprehensive Pneumology Center Munich, Gauting, Germany
| | - Martin Phillips
- Western Australia Lung Research, Sir Charles Gairdner Hospital, Perth, Australia
| | | | | | | | - Greg Snell
- Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Felix J F Herth
- Department of Pneumology and Critical Care Medicine Thoraxklinik, University of Heidelberg, Heidelberg, Germany; Translational Lung Research Center Heidelberg, Heidelberg, Germany; The German Lung Research Foundation (DZL), Heidelberg, Germany
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232
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Ishii Y. New era of respiratory endoscopy. Respir Investig 2016; 54:223. [PMID: 27424819 DOI: 10.1016/j.resinv.2016.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yoshiki Ishii
- Department of Pulmonary Medicine and Clinical Immunology, Dokkyo Medical University School of Medicine, Japan
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233
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Tuleta I, Pizarro C, Molitor E, Kristiansen G, Nickenig G, Skowasch D. Recurrent Chronic Obstructive Pulmonary Disease Exacerbations after Endobronchial Valve Implantation Are Associated with the Presence of Pseudomonas aeruginosa. Respiration 2016; 91:510-6. [PMID: 27300677 DOI: 10.1159/000446925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/06/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endoscopic lung volume reduction by means of endobronchial valve implantation is an established therapy in patients with severe emphysema. However, long-term complications such as chronic obstructive pulmonary disease (COPD) exacerbations are a limitation of this method. OBJECTIVES As the mechanisms underlying increased rates of COPD exacerbations are unknown, the aim of our study was to determine whether infectious or inflammatory factors may contribute to these events and to investingate the consequent need for valve explantation. METHODS Tissue surrounding explanted endobronchial Zephyr valves was examined by microbiological, histological and cytological methods. Additionally, we performed a microbiological analysis of tracheal aspirates before both valve implantation and valve explantation. Moreover, blood samples were collected for the analysis of inflammatory markers. RESULTS Endobronchial valves were explanted from 16 patients. Reasons for explantation were frequent postprocedural COPD exacerbations (group 1: 8 patients) or loss of clinical benefit (group 2: 8 patients). Compared to group 2, the microbiological examinations of valve lavage and tracheal aspirates from patients in group 1 showed a higher detection of Gram-negative bacteria. In particular, infection with Pseudomonas aeruginosa was more predominant in group 1, while no presence could be detected in group 2. Blood inflammatory markers tended to be slightly higher in group 1 than in group 2; however, without reaching statistical significance. CONCLUSIONS Increased rates of COPD exacerbations after endobronchial valve implantation are associated with the presence of P. aeruginosa. The finding warrants further investigation.
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Affiliation(s)
- Izabela Tuleta
- Department of Internal Medicine II - Cardiology and Pulmonology, University of Bonn, Bonn, Germany
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234
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Thomsen C, Theilig D, Herzog D, Poellinger A, Doellinger F, Schreiter N, Schreiter V, Schürmann D, Temmesfeld-Wollbrueck B, Hippenstiel S, Suttorp N, Hubner RH. Lung perfusion and emphysema distribution affect the outcome of endobronchial valve therapy. Int J Chron Obstruct Pulmon Dis 2016; 11:1245-59. [PMID: 27354783 PMCID: PMC4907487 DOI: 10.2147/copd.s101003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The exclusion of collateral ventilation (CV) and other factors affect the clinical success of endoscopic lung volume reduction (ELVR). However, despite its benefits, the outcome of ELVR remains difficult to predict. We investigated whether clinical success could be predicted by emphysema distribution assessed by computed tomography scan and baseline perfusion assessed by perfusion scintigraphy. Data from 57 patients with no CV in the target lobe (TL) were retrospectively analyzed after ELVR with valves. Pulmonary function tests (PFT), St George's Respiratory Questionnaire (SGRQ), and 6-minute walk tests (6MWT) were performed on patients at baseline. The sample was grouped into high and low levels at the median of TL perfusion, ipsilateral nontarget lobe (INL) perfusion, and heterogeneity index (HI). These groups were analyzed for association with changes in outcome parameters from baseline to 3 months follow-up. Compared to baseline, patients showed significant improvements in PFT, SGRQ, and 6MWT (all P≤0.001). TL perfusion was not associated with changes in the outcome. High INL perfusion was significantly associated with increases in 6MWT (P=0.014), and high HI was associated with increases in forced expiratory volume in 1 second (FEV1), (P=0.012). Likewise, there were significant correlations for INL perfusion and improvement of 6MWT (r=0.35, P=0.03) and for HI and improvement in FEV1 (r=0.45, P=0.001). This study reveals new attributes that associate with positive outcomes for patient selection prior to ELVR. Patients with high perfusions in INL demonstrated greater improvements in 6MWT, while patients with high HI were more likely to respond in FEV1.
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Affiliation(s)
- Christian Thomsen
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine
| | - Dorothea Theilig
- Institute of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Herzog
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine
| | | | - Felix Doellinger
- Institute of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Schreiter
- Institute of Nuclear Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vera Schreiter
- Institute of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk Schürmann
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine
| | | | - Stefan Hippenstiel
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine
| | - Norbert Suttorp
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine
| | - Ralf-Harto Hubner
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine
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235
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Hubner RH, Herzog D. COPD treatment: about collateral channels and collapsing airways. Eur Respir J 2016; 47:1606-10. [PMID: 27246073 DOI: 10.1183/13993003.00343-2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Ralf-Harto Hubner
- Dept of Internal Medicine/Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Herzog
- Dept of Internal Medicine/Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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236
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Harris K, Kebbe J, Modi K, Alraiyes AH, Kumar A, Attwood K, Dhillon SS. Aspirin use and the risk of bleeding complications after therapeutic bronchoscopy. Ther Adv Respir Dis 2016; 10:318-23. [PMID: 27165086 DOI: 10.1177/1753465816646049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Aspirin use has been shown to be safe for patients undergoing certain diagnostic bronchoscopy procedures such as transbronchial biopsies and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. However, there are no studies documenting the safety of aspirin in patients undergoing therapeutic bronchoscopy. The aim of this study is to evaluate whether aspirin increases the risk of bleeding following therapeutic bronchoscopy. METHODS This was a retrospective study to determine if there was a higher risk of bleeding in patients on aspirin undergoing therapeutic bronchoscopy compared with those not on aspirin. Patient characteristics were reported by cohort using the mean, median, and standard deviation for continuous variables, and using frequencies and relative frequencies for categorical variables. RESULTS Of the 108 patients who had multimodality therapeutic bronchoscopy, 17 (15.7%) were taking aspirin and 91 (84.3%) were not on aspirin. Patients in the aspirin group were older than those in the no aspirin group (median age: 66 versus 60 years, p = 0.007). The treatment modalities were similar in both groups except that more patients in the no aspirin group were treated with argon plasma coagulation (APC) compared to the aspirin group (60.4% versus 29.4%, p = 0.031). The estimated blood loss (EBL) between the aspirin and no aspirin groups was not significantly different (mean: 6.0 versus 6.7 ml; median: 5.0 versus 5.0, p = 0.36). Overall, there was no difference in complications between both groups. CONCLUSION Aspirin use was not associated with increased risk of bleeding or procedure-related complications after therapeutic bronchoscopy.
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Affiliation(s)
- Kassem Harris
- Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14623, USA
| | - Jad Kebbe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University, Buffalo, State University of New York, Buffalo, NY, USA
| | - Kush Modi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University, Buffalo, State University of New York, Buffalo, NY, USA
| | - Abdul Hamid Alraiyes
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University, Buffalo, State University of New York, Buffalo, NY, USA
| | - Abhishek Kumar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University, Buffalo, State University of New York, Buffalo, NY, USA
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Samjot S Dhillon
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University, Buffalo, State University of New York, Buffalo, NY, USA
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237
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An update on bronchoscopic treatments for chronic obstructive pulmonary disease. Curr Opin Pulm Med 2016; 22:265-70. [DOI: 10.1097/mcp.0000000000000260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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238
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Gesierich W, Samitas K, Reichenberger F, Behr J. Collapse phenomenon during Chartis collateral ventilation assessment. Eur Respir J 2016; 47:1657-67. [PMID: 27076587 DOI: 10.1183/13993003.01973-2015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 01/25/2016] [Indexed: 11/05/2022]
Abstract
Chartis is increasingly used for bronchoscopic assessment of collateral ventilation before endobronchial valve (EBV) treatment for severe emphysema. Its prognostic value is, however, limited by the airway collapse phenomenon. The frequency and clinical significance of the collapse phenomenon remain largely unknown.We performed a retrospective analysis of 92 patients undergoing Chartis evaluation under spontaneous breathing (n=55) or jet ventilation (n=37) from May 2010 to November 2013. Collateral ventilation status (positive/negative/collapse phenomenon/unclear) was reassessed and correlated with high-resolution computed tomography (HRCT) fissure analysis and clinical response.In the absence of the collapse phenomenon, the predictive value of Chartis measurements and HRCT fissural analysis was comparable. The collapse phenomenon was observed in 31.5% of all assessments, and was more frequent in lower lobes (44.9% versus 16.9% in upper lobes) and under jet ventilation (41.4% versus 22.1% under spontaneous breathing). 69.8% of lobes with the collapse phenomenon had complete fissures. Most patients with the collapse phenomenon in the target lobe and complete fissures treated with EBVs were responders (n=11/15). All valve-treated collapse phenomenon patients with fissure defects were nonresponders (n=3).In the absence of the collapse phenomenon Chartis measurement is reliable to predict response to valve treatment. In patients with the collapse phenomenon, treatment decisions should be based on HRCT detection of fissure integrity. Chartis assessment should be performed under spontaneous breathing.
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Affiliation(s)
- Wolfgang Gesierich
- Klinik für Pneumologie, Asklepios Fachkliniken, Gauting, Comprehensive Pneumology Center Munich (CPC) and Member of the German Center for Lung Research (DZL), Germany These authors contributed equally to this work
| | - Konstantinos Samitas
- Klinik für Pneumologie, Asklepios Fachkliniken, Gauting, Comprehensive Pneumology Center Munich (CPC) and Member of the German Center for Lung Research (DZL), Germany 7th Respiratory Dept and Asthma Center, Athens Chest Hospital "Sotiria", Athens, Greece These authors contributed equally to this work
| | - Frank Reichenberger
- Klinik für Pneumologie, Asklepios Fachkliniken, Gauting, Comprehensive Pneumology Center Munich (CPC) and Member of the German Center for Lung Research (DZL), Germany
| | - Juergen Behr
- Klinik für Pneumologie, Asklepios Fachkliniken, Gauting, Comprehensive Pneumology Center Munich (CPC) and Member of the German Center for Lung Research (DZL), Germany Dept of Internal Medicine V, University of Munich, Munich, Germany
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239
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Koster TD, Slebos DJ. The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema. Int J Chron Obstruct Pulmon Dis 2016; 11:765-73. [PMID: 27110109 PMCID: PMC4835138 DOI: 10.2147/copd.s103807] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In patients with severe emphysema, bronchoscopic lung volume reduction using one-way valves is a promising therapeutic option to improve lung function and quality of life. The goal of this treatment is to achieve a complete lobar atelectasis. In a significant proportion of patients, this atelectasis cannot be achieved due to interlobar collateral ventilation. This collateral ventilation is generated through incomplete lobar fissures. Therefore, only patients with complete fissures and no collateral ventilation can be selected for endobronchial therapy with one-way valves. Incomplete fissures are very common and exhibit a great variation in anatomy. The reported prevalence is 17%–85% for the right major fissure, 19%–74% for the left major fissure, and 20%–90% for the minor fissure. There are several methods of measuring or predicting the presence of collateral ventilation, with computed tomography (CT)-fissure analysis and the Chartis measurement being the most important. CT-fissure analysis is an indirect method to measure the completeness of fissures as a surrogate for collateral ventilation. The Chartis system is an endobronchial method to directly measure the presence of collateral ventilation. Both methods have unique value, and the combination of both can accurately predict the treatment response to the bronchoscopic placement of endobronchial valves. This review provides an in-depth view of lung fissure and collateral ventilation to help understand its importance in selecting the appropriate patients for new emphysema treatments and thus avoid useless treatment in unsuitable patients.
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Affiliation(s)
- Theodoor David Koster
- 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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240
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Slebos DJ, Shah PL. Go with the Flow: The Importance of the Assessment of Collateral Ventilation in Endobronchial Valve Treatment. Respiration 2016; 91:269-70. [DOI: 10.1159/000444330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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241
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Herth FJF, Valipour A, Shah PL, Eberhardt R, Grah C, Egan J, Ficker JH, Wagner M, Witt C, Liebers U, Hopkins P, Gesierich W, Phillips M, Stanzel F, McNulty WH, Petermann C, Snell G, Gompelmann D. Segmental volume reduction using thermal vapour ablation in patients with severe emphysema: 6-month results of the multicentre, parallel-group, open-label, randomised controlled STEP-UP trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:185-93. [DOI: 10.1016/s2213-2600(16)00045-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/20/2016] [Accepted: 01/22/2016] [Indexed: 10/22/2022]
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242
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Herth FJ, Slebos DJ, Rabe KF, Shah PL. Endoscopic Lung Volume Reduction: An Expert Panel Recommendation. Respiration 2016; 91:241-50. [DOI: 10.1159/000444090] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/16/2016] [Indexed: 11/19/2022] Open
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Abstract
Breathlessness and impaired quality of life are prominent features in patients with severe emphysema even when conventional methods of treatment are optimal. Lung volume reduction using endobronchial management for emphysema has emerged as a new method to relieve symptoms and improve lung function tests in this group. The endobronchial valves (EBVs) are the most widely used treatment. This article outlines current criteria of patients' selection with literature review and evidence of efficacy. Complications of EBV insertion as well as current shortfalls of this method of treatment are also discussed.
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Affiliation(s)
- Nabil Jarad
- Department of Respiratory Medicine, Bristol Royal Infirmary, Bristol, UK
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244
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Liberator C, Shenoy K, Marchetti N, Criner G. The Role of Lobe Selection on FEV1 Response in Endobronchial Valve Therapy. COPD 2016; 13:477-82. [PMID: 26789984 DOI: 10.3109/15412555.2015.1115007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Endobronchial valve (EBV) therapy has shown improvement in symptoms and lung function despite limited understanding of ideal patient selection. The impact of lobe selection on EBV therapy is unclear. We performed a retrospective analysis to determine the role of lobe selection and identify preprocedure predictors of response to EBV therapy. A total of 492 patients from the USA and Europe were randomized to EBV or control therapy. Spirometry and functional measurements were taken at baseline and 12 months later. At 365 days patients undergoing EBV therapy showed improvement in FEV1 change compared to control regardless of treatment to upper or lower. There was no difference in FEV1 change between the upper and lower lobe treatment groups ( 5 .99, 7.04, p = 0.75). In addition lobe selection was not identified as a significant modifier of FEV1 change in multiple linear regression analysis. Complete lobe fissure was the only significant predictor of FEV1 change (OR 4.14 (2.29, 7.47)). Our results suggest that lobe selection does not play a major role in EBV therapy response. Complete fissure status preprocedure has the greatest influence on FEV1 improvement. These results have implications on patient selection for current treatment and in future EBV studies.
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Affiliation(s)
- Cole Liberator
- a Department of Internal Medicine , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Kartik Shenoy
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Nathaniel Marchetti
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Gerard Criner
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
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245
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Herzog D, Thomsen C, Poellinger A, Doellinger F, Schreiter N, Froeling V, Schuermann D, Temmesfeld-Wollbruck B, Hippenstiel S, Suttorp N, Huebner RH. Outcomes of Endobronchial Valve Treatment Based on the Precise Criteria of an Endobronchial Catheter for Detection of Collateral Ventilation under Spontaneous Breathing. Respiration 2015; 91:69-78. [PMID: 26699369 DOI: 10.1159/000442886] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 11/25/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endoscopic lung volume reduction with valves is a valid therapeutic option for COPD patients with severe emphysema. The exclusion of interlobar collateral ventilation (CV) is an important predictor of clinical success. OBJECTIVES Recently, a catheter-based endobronchial in vivo measurement system (Chartis, Pulmonx, USA) has become routine in the clinical evaluation of CV status in target lobes, but the criteria for phenotyping CV by Chartis evaluation have not yet been defined. We asked the questions, how many phenotypes can be identified using Chartis, what are the exact criteria to distinguish them, and how do the Chartis phenotypes respond to valve insertion? METHODS In a retrospective study, 406 Chartis assessments of 166 patients with severe COPD were analyzed. Four Chartis phenotypes, CV positive (CV+), CV negative (CV-), low flow (LF) and low plateau were identified. Fifty-two patients without CV were treated with valves and followed for 3 months. RESULTS The Chartis phenotypes were discriminated with respect to decline in expiratory peak flow, increase in resistance index and change in total exhaled volume after 1, 2, 3, 4 and 5 min of measurement time (p < 0.0001, ANOVA), and the cutoff criteria were defined accordingly. To examine the application of these phenotyping criteria, students applied them to 100 Chartis assessments, and they demonstrated almost perfect inter- and intraobserver agreements (x03BA; > 0.9). Compared to baseline, CV- and LF patients with ipsilateral CV- lobe showed an improvement in FEV1 (p < 0.05), vital capacity (p < 0.05) and target lobe volume reduction (p < 0.005) after valve insertion. CONCLUSION This study describes the most prevalent Chartis phenotypes.
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Affiliation(s)
- Dominik Herzog
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine, Charitx00E9; - Universitx00E4;tsmedizin Berlin, Berlin, Germany
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246
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Affiliation(s)
- Joseph B Shrager
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305-5407, USA.
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