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Schwalk AJ, Patel NM, Madisi NY. Developing Interventions for Chronic Obstructive Pulmonary Disease. Semin Respir Crit Care Med 2024. [PMID: 38968963 DOI: 10.1055/s-0044-1787875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) is an incurable, progressive respiratory disease that may have a significant negative impact on the morbidity and mortality of affected patients. A substantial portion of the world's population is affected by COPD, and despite optimal medical management with medications, supplemental oxygen, and pulmonary rehabilitation, many patients are left debilitated because of this disease. Bronchoscopic treatment modalities offer a less-invasive method for the treatment of refractory COPD compared to surgical interventions and have expanded the potential therapeutic options for these patients. Bronchoscopic lung volume reduction is aimed at decreasing the hyperinflation and air trapping that occur in emphysema, and the most studied and successful intervention is endobronchial valve placement. Endobronchial coils, polymeric sealants, and thermal ablation are other researched alternatives. Additional interventional procedures are being investigated for the treatment of the mucus hypersecretion and cough that are associated with the chronic bronchitis phenotype of COPD and include targeted lung denervation, metered dose spray cryotherapy, deobstruction balloon, and bronchial rheoplasty. This review summarizes the most recent evidence pertaining to available therapies for the management of COPD, including chronic bronchitis, with a particular focus on bronchoscopic interventions.
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Affiliation(s)
- Audra J Schwalk
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Niral M Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego, San Diego, California
| | - Nagendra Y Madisi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Albany Medical College, Albany, New York
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2
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Magarinos J, Egelko A, Criner GJ, Abbas A, Enofe N, Thomas J, Carney K, Friedberg J, Bakhos C. Lung volume reduction surgery is safe and leads to functional improvement in patients who fail or cannot undergo bronchoscopic lung volume reduction. JTCVS OPEN 2024; 18:369-375. [PMID: 38690414 PMCID: PMC11056479 DOI: 10.1016/j.xjon.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 05/02/2024]
Abstract
Background Bronchoscopic lung volume reduction (BLVR) has supplanted surgery in the treatment of patients with advanced emphysema, but not all patients qualify for it. Our study aimed to investigate the outcomes of lung volume reduction surgery (LVRS) among patients who either failed BLVR or were not candidates for it. Methods We conducted a retrospective analysis of patients who underwent LVRS for upper lobe-predominant emphysema at a single tertiary center between March 2018 and December 2022. The main outcomes measures were preoperative and postoperative respiratory parameters, perioperative morbidity, and mortality. Results A total of 67 LVRS recipients were evaluated, including 10 who had failed prior valve placement. The median patient age was 69 years, and 35 (52%) were male. All procedures were performed thoracoscopically, with 36 patients (53.7%) undergoing bilateral LVRS. The median hospital length of stay was 7 days (interquartile range, 6-11 days). Prolonged air leak (>7 days) occurred in 20 patients. There was one 90-day mortality from a nosocomial pneumonia (non-COVID-related) and no further deaths at 12 months. There were mean improvements of 10.07% in forced expiratory volume in 1 second and 4.74% in diffusing capacity of the lung for carbon monoxide, along with a mean decrease 49.2% in residual volume (P < .001 for all). The modified Medical Research Council dyspnea scale was improved by 1.84 points (P < .001). Conclusions LVRS can be performed safely in patients who are not candidates for BLVR and those who fail BLVR and leads to significant functional improvement. Long-term follow-up is necessary to ensure the sustainability of LVRS benefits in this patient population.
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Affiliation(s)
- Jessica Magarinos
- Department of General Surgery, Temple University Hospital, Philadelphia, Pa
| | - Aron Egelko
- Department of General Surgery, Temple University Hospital, Philadelphia, Pa
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pa
| | - Abbas Abbas
- Lifespan Health System, Department of Thoracic Oncology, Brown University, Providence, RI
| | - Nosayaba Enofe
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pa
| | - JiJi Thomas
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pa
| | - Kevin Carney
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pa
| | - Joseph Friedberg
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pa
| | - Charles Bakhos
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pa
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3
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Low SW, Swanson KL, Lee JZ, Tan MC, Cartin-Ceba R, Sakata KK, Maldonado F. Complications of Endobronchial Valve Placement for Bronchoscopic Lung Volume Reduction: Insights From the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE). J Bronchology Interv Pulmonol 2022; 29:206-212. [PMID: 35698284 DOI: 10.1097/lbr.0000000000000859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/26/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with advanced emphysema experience breathlessness due to impaired respiratory mechanics and diaphragm dysfunction. Bronchoscopic lung volume reduction (BLVR) is a minimally invasive bronchoscopic procedure done to reduce hyperinflation and air trapping, promoting atelectasis in the targeted lobe and allowing improved respiratory mechanics. Real-world data on safety and complications outside of clinical trials of BLVR are limited. METHODS We queried the US Food and Drug Administrations (FDA) Manufacturers and User Device Experience database from May 2019 to June 2020 for reports involving BLVR with endobronchial valve (EBV) placement. Events were reviewed for data analysis. RESULTS We identified 124 cases of complications during BLVR with EBV implantation. The most-reported complication was pneumothorax (110/124, 89%), all of which required chest tube placement. A total of 54 of these cases (54/110, 49%) were complicated by persistent air leak requiring additional interventions. Repeat bronchoscopy was needed to remove the valves in 28 patients, 12 were discharged with a Heimlich valve, and 10 had an additional pleural catheter placed. The other complications of BLVR with EBV placement included respiratory failure (6/124, 5%), pneumonia (4/124, 3%), hemoptysis (2/124, 1.6%), valve migration (1/124, 1%), and pleural effusion (1/124, 1%). A total of 14 deaths were reported during that year. CONCLUSION Pneumothorax is the most-reported complication for BLVR with EBV placement, and in 65% of cases, pneumothorax is managed without removing valves. Importantly, 14 deaths were reported during that timeframe. Further studies are needed to estimate the true magnitude of the complications associated with BLVR.
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Affiliation(s)
- See-Wei Low
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Justin Z Lee
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ
| | - Min-Choon Tan
- Medical School, Chang Gung University, Taoyuan City, Taiwan
| | | | | | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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4
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Posthuma R, Vaes AW, Walraven KHM, Sardari Nia P, Schreiber JU, Gietema HA, Wesseling G, Wouters EFM, Vanfleteren LEGW. Implementation of Bronchoscopic Lung Volume Reduction Using One-Way Endobronchial Valves: A Retrospective Single-Centre Cohort Study. Respiration 2021; 101:476-484. [PMID: 34937034 DOI: 10.1159/000520885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 10/23/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bronchoscopic lung volume reduction (BLVR) using 1-way endobronchial valves (EBV) has become a guideline treatment in patients with advanced emphysema. Evidence from this minimally invasive treatment derives mainly from well-designed controlled trials conducted in high-volume specialized intervention centres. Little is known about real-life outcome data in hospitals setting up this novel treatment and which favourable conditions are required for a continuous successful program. OBJECTIVES In this study, we aim to evaluate the eligibility rate for BLVR and whether the implementation of BLVR in our academic hospital is feasible and yields clinically significant outcomes. METHOD A retrospective evaluation of patients treated with EBV between January 2016 and August 2019 was conducted. COPD assessment test (CAT), forced expiratory volume in 1 s (FEV1), residual volume (RV), and 6-min walking test (6MWT) were measured at baseline and 3 months after intervention. Paired sample t tests were performed to compare means before and after intervention. RESULTS Of 350 subjects screened, 283 (81%) were not suitable for intervention mostly due to lack of a target lobe. The remaining 67 subjects (19%) underwent bronchoscopic assessment, and if suitable, valves were placed in the same session. In total, 55 subjects (16%) were treated with EBV of which 10 did not have complete follow-up: 6 subjects had their valves removed because of severe pneumothorax (n = 2) or lack of benefit (n = 4) and the remaining 4 had missing follow-up data. Finally, 45 patients had complete follow-up at 3 months and showed an average change ± SD in CAT -4 ± 6 points, FEV1 +190 ± 140 mL, RV -770 ± 790 mL, and +37 ± 65 m on the 6MWT (all p < 0.001). After 1-year follow-up, 34 (76%) subjects had their EBV in situ. CONCLUSION Implementing BLVR with EBV is feasible and effective. Only 16% of screened patients were eligible, indicating that this intervention is only applicable in a small subset of highly selected subjects with advanced emphysema, and therefore a high volume of COPD patients is essential for a sustainable BLVR program.
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Affiliation(s)
- Rein Posthuma
- Department of Research and Development, Ciro, Horn, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Anouk W Vaes
- Department of Research and Development, Ciro, Horn, The Netherlands
| | - Kim H M Walraven
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan U Schreiber
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hester A Gietema
- Department of Radiology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW School of Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Geertjan Wesseling
- Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Emiel F M Wouters
- Department of Research and Development, Ciro, Horn, The Netherlands.,Ludwig Boltzmann Institute for Lung Health, Vienna, Austria
| | - Lowie E G W Vanfleteren
- Department of Respiratory Medicine and Allergology, COPD Centre, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Medicine, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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5
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Heiden BT, Tetteh E, Robbins KJ, Tabak RG, Nava RG, Marklin GF, Kreisel D, Meyers BF, Kozower BD, McKay VR, Puri V. Dissemination and Implementation Science in Cardiothoracic Surgery: A Review and Case Study. Ann Thorac Surg 2021; 114:373-382. [PMID: 34499861 PMCID: PMC9112075 DOI: 10.1016/j.athoracsur.2021.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/06/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
Dissemination and implementation (D&I) science is the practice of taking evidence-based interventions (EBI) and sustainably incorporating them in routine clinical practice. As a relatively young field, D&I techniques are underutilized in cardiothoracic surgery. This review offers an overview of D&I science from the context of the cardiothoracic surgeon. First, we provide a general introduction to D&I science and basic terminology that is used in the field. Second, to illustrate D&I techniques in a real-world example, we discuss a case study for implementing lung protective management (LPM) strategies for lung donor optimization nationally. Finally, we discuss challenges to successful implementation that are unique to cardiothoracic surgery and give several examples of EBIs that have been poorly implemented into surgical practice. We also provide examples of successful D&I interventions - including de-implementation strategies - from other surgical subspecialties. We hope that this review offers additional tools for cardiothoracic surgeons to explore when introducing EBIs into routine practice.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Emmanuel Tetteh
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO
| | - Keenan J Robbins
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rachel G Tabak
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO; Institute for Implementation Science, Washington University in St. Louis, St. Louis, MO
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Gary F Marklin
- Institute for Implementation Science, Washington University in St. Louis, St. Louis, MO
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Virginia R McKay
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
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6
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Abdelsattar ZM, Allen M, Blackmon S, Cassivi S, Mandrekar J, Nichols F, Reisenauer J, Wigle D, Shen KR. Contemporary Practice Patterns of Lung Volume Reduction Surgery in the United States. Ann Thorac Surg 2021; 112:952-960. [DOI: 10.1016/j.athoracsur.2020.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/07/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
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7
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McCarthy DP, Taylor LJ, DeCamp MM. Analysis of Recent Literature on Lung Volume Reduction Surgery. Thorac Surg Clin 2021; 31:119-128. [PMID: 33926666 DOI: 10.1016/j.thorsurg.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Publication of the National Emphysema Treatment Trial (NETT) in 2003 established lung volume reduction surgery (LVRS) as a viable treatment of select patients with moderate to severe emphysema, and the only intervention since the availability of ambulatory supplemental oxygen to improve survival. Despite these findings, surgical treatment has been underused in part because of concern for high morbidity and mortality. This article reviews recent literature generated since the original NETT publication, focusing on physiologic implications of LVRS, recent data regarding the safety and durability of LVRS, and patient selection and extension of NETT criteria to other patient populations.
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Affiliation(s)
- Daniel P McCarthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792, USA
| | - Lauren J Taylor
- Division of Cardiothoracic Surgery, University of Colorado, Anschutz Medical Campus, 12631 East 17th Avenue, Room 5401, Mail Stop C-291, Aurora, CO 80045, USA
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, H4/340, Madison, WI 53792-0001, USA.
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8
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Platz JJ, Naunheim KS. Critical Analysis of the National Emphysema Treatment Trial Results for Lung-Volume-Reduction Surgery. Thorac Surg Clin 2021; 31:107-118. [PMID: 33926665 DOI: 10.1016/j.thorsurg.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The National Emphysema Treatment Trial compared medical treatment of severe pulmonary emphysema with lung-volume-reduction surgery in a multiinstitutional randomized prospective fashion. Two decades later, this trial remains one of the key sources of information we have on the treatment of advanced emphysematous lung disease. The trial demonstrated the short- and long-term effectiveness of surgical intervention as well as the need for strict patient selection and preoperative workup. Despite these findings, the key failure of the trial was an inability to convince the medical community of the value of surgical resection in the treatment of advanced emphysema.
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Affiliation(s)
- Joseph J Platz
- Division of Cardiothoracic Surgery, Saint Louis University School of Medicine, 1008 South Spring Avenue, Saint Louis, MO 63110, USA.
| | - Keith S Naunheim
- Division of Cardiothoracic Surgery, Saint Louis University School of Medicine, 1008 South Spring Avenue, Saint Louis, MO 63110, USA
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9
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Economic Considerations of Lung Volume Reduction Surgery and Bronchoscopic Valves. Thorac Surg Clin 2021; 31:211-219. [PMID: 33926674 DOI: 10.1016/j.thorsurg.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chronic obstructive pulmonary disease is a challenging disease to treat, and at advanced stages of the disease, procedural interventions become some of the only effective methods for improving quality of life. However, these procedures are often very costly. This article reviews the medical literature on cost-effectiveness of lung volume reduction surgery and bronchoscopic valve placement for lung volume reduction. It discusses the anticipated costs and economic impact in the future as technique is perfected and outcomes are improved.
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10
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Lin J, Weir WB, Grenda T, Zhang P, Derstine BA, Enchakalody B, Underhill J, Reddy RM, Chang AC, Wang SC. Analytic Morphomics Are Related to Outcomes After Lung Volume Reduction Surgery. Semin Thorac Cardiovasc Surg 2021; 34:1084-1090. [PMID: 34166813 PMCID: PMC8763534 DOI: 10.1053/j.semtcvs.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 01/05/2023]
Abstract
:Lung volume reduction surgery continues to have a high morbidity despite National Emphysema Treatment Trial selection criteria. This study evaluated the association between analytic morphomics on chest computed tomography scans and outcomes after lung volume reduction surgery. In a retrospective review of 85 lung volume reduction surgery patients from 1998-2013, dorsal muscle group area, subcutaneous and visceral fat area, and bone mineral density were assessed using analytic morphomics. Lung density was divided into five levels of increasing density (Lung density 1, emphysema; 2, normal lung; 4-5, scarring). Outcomes including survival, hospital length of stay, readmission at 30 days, and pulmonary complications were analyzed using univariate and multivariable techniques. Pulmonary complications developed in 27.1% (23/85). Mortality at 90 days was 9.4% (8/85). On multivariable analysis, lower bone mineral density (Odds ratio 0.61; 95% confidence interval 0.39-0.95) was associated with decreased survival, longer length of stay (0.83; 0.77-0.89), and readmissions (0.39; 0.15-1.00). Higher lung density 5:lung density 2 volume (1.84; 1.05-3.23), possibly due to scarring, was associated with pulmonary complications and longer length of stay (1.32; 1.23-1.41) while lower subcutaneous fat area:height was associated with readmissions which may reflect decreased metabolic reserve (0.35; 0.13-0.93). Patients with signs of frailty including lower bone mineral density may be at increased risk of adverse outcomes including decreased survival after lung volume reduction surgery. The results of this hypothesis-generating study will need to be confirmed in larger, multicenter trials to determine whether analytic morphomics can improve risk stratification and patient selection.
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Affiliation(s)
- Jules Lin
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Michigan..
| | - William B Weir
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Tyler Grenda
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Peng Zhang
- Division of Acute Care Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Brian A Derstine
- Division of Acute Care Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Binu Enchakalody
- Division of Acute Care Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joshua Underhill
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Rishindra M Reddy
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Andrew C Chang
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Stewart C Wang
- Division of Acute Care Surgery, University of Michigan Medical School, Ann Arbor, Michigan
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11
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Lung Denervation for Advanced COPD: Basics and Beyond. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-021-00273-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Abia-Trujillo D, Johnson MM, Patel NM, Hazelett B, Edell ES, Kern RM, Midthun D, Reisenauer J, Nelson D, Mullon JJ, Sakata KK, Swanson K, Fernandez-Bussy S. Bronchoscopic Lung Volume Reduction: A New Hope for Patients With Severe Emphysema and Air Trapping. Mayo Clin Proc 2021; 96:464-472. [PMID: 32829903 DOI: 10.1016/j.mayocp.2020.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 10/23/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is common and has significant morbidity and mortality as the fourth leading cause of death in the United States. In many patients, particularly those with emphysema, COPD is characterized by markedly increased residual volume contributing to exertional dyspnea. Current therapies have limited efficacy. Surgical resection of diseased areas of the lung to reduce residual volume was effective in identified subgroups but also had significant mortality in and suboptimal cost effectiveness. Lung-volume reduction, using bronchoscopic techniques, has shown substantial benefits in a broader patient population with less morbidity and mortality. This review is meant to spread the awareness about bronchoscopic lung-volume reduction and to promote its consideration and early referral for patients with advanced COPD and emphysema frequently encountered by both primary care physicians and specialists. A search was conducted on PubMed (MEDLINE), EMbase, and Cochrane library for original studies, using the following keywords: "lung-volume reduction." "endobronchial valves," "intrabronchial valves," "bronchoscopic lung-volume reduction," and "endoscopic lung-volume reduction." We included reports from systematic reviews, narrative reviews, clinical trials, and observational studies. Two reviewers evaluated potential references. A total of 27 references were included in our review. Included studies report experience in the diagnosis and bronchoscopic treatment for emphysema; case reports and non-English or non-Spanish studies were excluded.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Margaret M Johnson
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Neal M Patel
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Britney Hazelett
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL
| | - Eric S Edell
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - Ryan M Kern
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Midthun
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | | | - Darlene Nelson
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - John J Mullon
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | | | - Karen Swanson
- Division of Pulmonary Medicine, Mayo Clinic, Phoenix, AZ
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13
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Abstract
Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder with significant morbidity and mortality. Despite its prevalence, COPD is underdiagnosed, and many patients do not receive a diagnosis until the disease is clinically advanced. Recent basic science and clinical research have focused on the early physiologic and pathobiologic changes in COPD with the hopes of improving diagnosis, providing targets for disease-modifying therapy, and identifying patients most likely to benefit from early intervention. Available treatments for COPD have grown substantially in the past 20 years with the introduction of new oral and inhaled medications as well as novel surgical and bronchoscopic procedures. This article summarizes some of the recent advances in our understanding of disease pathogenesis and treatment paradigms.
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Affiliation(s)
- Michael C Ferrera
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA; , ,
| | - Wassim W Labaki
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA; , ,
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA; , ,
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14
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Zatloukal J, Brat K, Neumannova K, Volakova E, Hejduk K, Kocova E, Kudela O, Kopecky M, Plutinsky M, Koblizek V. Chronic obstructive pulmonary disease - diagnosis and management of stable disease; a personalized approach to care, using the treatable traits concept based on clinical phenotypes. Position paper of the Czech Pneumological and Phthisiological Society. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164:325-356. [PMID: 33325455 DOI: 10.5507/bp.2020.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/20/2020] [Indexed: 12/27/2022] Open
Abstract
This position paper has been drafted by experts from the Czech national board of diseases with bronchial obstruction, of the Czech Pneumological and Phthisiological Society. The statements and recommendations are based on both the results of randomized controlled trials and data from cross-sectional and prospective real-life studies to ensure they are as close as possible to the context of daily clinical practice and the current health care system of the Czech Republic. Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable heterogeneous syndrome with a number of pulmonary and extrapulmonary clinical features and concomitant chronic diseases. The disease is associated with significant mortality, morbidity and reduced quality of life. The main characteristics include persistent respiratory symptoms and only partially reversible airflow obstruction developing due to an abnormal inflammatory response of the lungs to noxious particles and gases. Oxidative stress, protease-antiprotease imbalance and increased numbers of pro-inflammatory cells (mainly neutrophils) are the main drivers of primarily non-infectious inflammation in COPD. Besides smoking, household air pollution, occupational exposure, low birth weight, frequent respiratory infections during childhood and also genetic factors are important risk factors of COPD development. Progressive airflow limitation and airway remodelling leads to air trapping, static and dynamic hyperinflation, gas exchange abnormalities and decreased exercise capacity. Various features of the disease are expressed unequally in individual patients, resulting in various types of disease presentation, emerging as the "clinical phenotypes" (for specific clinical characteristics) and "treatable traits" (for treatable characteristics) concept. The estimated prevalence of COPD in Czechia is around 6.7% with 3,200-3,500 deaths reported annually. The elementary requirements for diagnosis of COPD are spirometric confirmation of post-bronchodilator airflow obstruction (post-BD FEV1/VCmax <70%) and respiratory symptoms assessement (dyspnoea, exercise limitation, cough and/or sputum production. In order to establish definite COPD diagnosis, a five-step evaluation should be performed, including: 1/ inhalation risk assessment, 2/ symptoms evaluation, 3/ lung function tests, 4/ laboratory tests and 5/ imaging. At the same time, all alternative diagnoses should be excluded. For disease classification, this position paper uses both GOLD stages (1 to 4), GOLD groups (A to D) and evaluation of clinical phenotype(s). Prognosis assessment should be done in each patient. For this purpose, we recommend the use of the BODE or the CADOT index. Six elementary clinical phenotypes are recognized, including chronic bronchitis, frequent exacerbator, emphysematous, asthma/COPD overlap (ACO), bronchiectases with COPD overlap (BCO) and pulmonary cachexia. In our concept, all of these clinical phenotypes are also considered independent treatable traits. For each treatable trait, specific pharmacological and non-pharmacological therapies are defined in this document. The coincidence of two or more clinical phenotypes (i.e., treatable traits) may occur in a single individual, giving the opportunity of fully individualized, phenotype-specific treatment. Treatment of COPD should reflect the complexity and heterogeneity of the disease and be tailored to individual patients. Major goals of COPD treatment are symptom reduction and decreased exacerbation risk. Treatment strategy is divided into five strata: risk elimination, basic treatment, phenotype-specific treatment, treatment of respiratory failure and palliative care, and treatment of comorbidities. Risk elimination includes interventions against tobacco smoking and environmental/occupational exposures. Basic treatment is based on bronchodilator therapy, pulmonary rehabilitation, vaccination, care for appropriate nutrition, inhalation training, education and psychosocial support. Adequate phenotype-specific treatment varies phenotype by phenotype, including more than ten different pharmacological and non-pharmacological strategies. If more than one clinical phenotype is present, treatment strategy should follow the expression of each phenotypic label separately. In such patients, multicomponental therapeutic regimens are needed, resulting in fully individualized care. In the future, stronger measures against smoking, improvements in occupational and environmental health, early diagnosis strategies, as well as biomarker identification for patients responsive to specific treatments are warranted. New classes of treatment (inhaled PDE3/4 inhibitors, single molecule dual bronchodilators, anti-inflammatory drugs, gene editing molecules or new bronchoscopic procedures) are expected to enter the clinical practice in a very few years.
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Affiliation(s)
- Jaromir Zatloukal
- Department of Respiratory Diseases and Tuberculosis, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Kristian Brat
- Department of Respiratory Diseases, University Hospital Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Katerina Neumannova
- Department of Physiotherapy, Faculty of Physical Culture, Palacky University Olomouc, Czech Republic
| | - Eva Volakova
- Department of Respiratory Diseases and Tuberculosis, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Karel Hejduk
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,National Screening Centre, Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Eva Kocova
- Department of Radiology, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Ondrej Kudela
- Pulmonary Department, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Michal Kopecky
- Pulmonary Department, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Marek Plutinsky
- Department of Respiratory Diseases, University Hospital Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vladimir Koblizek
- Pulmonary Department, University Hospital Hradec Kralove and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
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Kösek V, Thiel B, Nikolova K, Al-Masri E, Begher C, Frank C, Redwan B. Lung volume reduction surgery: from National Emphysema Treatment Trial to non-intubated awake video-assisted thoracoscopic surgery. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1468. [PMID: 33313213 PMCID: PMC7723631 DOI: 10.21037/atm-20-6430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.
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Affiliation(s)
- Volkan Kösek
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Burkhard Thiel
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Katina Nikolova
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Eyad Al-Masri
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Christian Begher
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Christina Frank
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Bassam Redwan
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
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Eichhorn ME, Gompelmann D, Hoffmann H, Dreher S, Hornemann K, Haag J, Kontogianni K, Heussel CP, Winter H, Herth FJF, Eberhardt R. Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure. Ann Thorac Surg 2020; 111:1858-1865. [PMID: 32991839 DOI: 10.1016/j.athoracsur.2020.06.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 05/09/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bronchoscopic valve placement constitutes an effective endoscopic lung volume reduction (ELVR) therapy in patients with severe emphysema and low collateral ventilation. After the most destroyed lobe is occluded with valves, significant target lobe volume reduction leads to improvements in lung function, exercise capacity, and quality of life. The effects are not consistent in some patients, leading to long-term therapy failure. We hypothesized that surgical lung volume reduction (LVRS) would reestablish ELVR short-term clinical improvements after ELVR long-term failure. METHODS This retrospective single-center analysis included all patients who underwent consolidating LVRS by lobectomy after long-term failure of valve therapy between 2010 and 2015. Changes in forced expiratory volume in 1 second, residual volume, 6-minute walking distance, and Modified Medical Research Council dyspnea score 90 days after ELVR and LVRS were analyzed, and the outcomes of both procedures were compared. RESULTS LVRS was performed in 20 patients after ELVR failure. A lower lobectomy was performed in 90%. The 30-day mortality of the cohort was 0% and 90-day mortality was 5% (1 of 20). The remaining 19 patients showed a significant increase in forced expiratory volume in 1 second (+27.5% ± 19.4%) and a reduction in residual volume (-21.0% ± 17.4%) and total lung capacity (-11.1% ± 11.1%). This resulted in significant improvements in exercise tolerance (6-minute walking distance: +56 ± 60 m) and relief of dyspnea (ΔModified Medical Research Council: -1.8 ± 1.4 points.). CONCLUSIONS Consolidating LVRS by lobectomy after failure of a previously successful ELVR is feasible and results in significant symptom relief and improvement of lung function.
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Affiliation(s)
- Martin E Eichhorn
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL).
| | - Daniela Gompelmann
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Hans Hoffmann
- Division of Thoracic Surgery, Technical University of Munich, Munich, Germany
| | - Sascha Dreher
- Department of Thoracic Surgery, Klinik Schillerhöhe, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Katrin Hornemann
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Johannes Haag
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Konstantina Kontogianni
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Claus P Heussel
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Department of Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL)
| | - Felix J F Herth
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Ralf Eberhardt
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
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Emerging Interventional Pulmonary Therapies for Chronic Obstructive Pulmonary Disease. J Thorac Imaging 2020; 34:248-257. [PMID: 31145187 DOI: 10.1097/rti.0000000000000424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic obstructive pulmonary disease is a condition characterized by progressive airflow limitation caused by airway and parenchymal inflammation. Current medical therapies, including bronchodilators, corticosteroids, and anti-inflammatory medications, have been shown to variably improve pulmonary function or quality of life without providing a long-term mortality benefit. Mortality benefits to therapy have been demonstrated in only 2 therapeutic interventions to date: long-term use of daily supplemental oxygen and surgical lung volume reduction (LVRS) for upper-lobe-predominant disease in patients with a low baseline exercise capacity. Newer bronchoscopic techniques for lung volume reduction (bLVR) have attracted interest from clinicians and researchers. To achieve successful results, these advanced therapies require an interdisciplinary approach between general and interventional pulmonologists and thoracic radiologists. In this article, we aim to review the latest interventional pulmonary techniques for treatment of chronic obstructive pulmonary disease with an emphasis on bLVR. We will review the bLVR preprocedure imaging evaluation, postprocedure imaging findings, and explore the potential benefits and risks of therapy based on the most recent clinical trial evidence.
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Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease is a heterogeneous syndrome associated with varying degrees of parenchymal emphysema and airway inflammation resulting in decreased expiratory flow, lung hyperinflation, and symptoms leading to decreased exercise tolerance and quality of life. Impairment in lung function and quality of life persists following guideline-based medical therapy, thus surgical and minimally invasive bronchoscopic approaches were developed to address this unmet need. We offer a narrative review of the available technologies. RECENT FINDINGS Although lung volume reduction surgery has been shown to improve survival in appropriately selected patients, it is infrequently performed. Less invasive bronchoscopic procedures have thus been explored including endobronchial valves, coils, lung sealant, thermal vapor, and other airway approaches. Selection criteria including severity of physiologic and radiographic impairment, degree of lung hyperinflation, presence of intact fissures, type of symptoms, and presence of comorbidities are critical in selecting appropriate candidates. SUMMARY Recent advances in minimally invasive approaches to lung volume reduction have offered alternatives to surgical approaches. Two endobronchial valve devices are Food and Drug Administration approved for clinical use, and investigations into alternative bronchoscopic therapies to treat both emphysema and chronic bronchitis have been performed or are currently underway. Notably, each of these treatments requires unique selection criteria and thus a personalized approach to treatment.
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Endobronchial Valves Therapy for Advanced Emphysema: A Meta-Analysis of Randomized Trials. J Bronchology Interv Pulmonol 2019; 26:81-89. [PMID: 29901536 DOI: 10.1097/lbr.0000000000000527] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trials suggest that bronchoscopic lung volume reduction (BLVR) with endobronchial valve (EBV) implantation may produce similar effects as lung volume reduction surgery, by inducing atelectasis and reducing hyperinflation through a minimally invasive procedure. This study sought to investigate the efficacy and safety of BLVR with EBV for advanced emphysema. METHODS We searched PubMed, EMBASE, Web of Science, CINAHL, ClinicalTrials.gov, and Cochrane Library databases for randomized controlled trials comparing EBV implantation versus standard medical treatment or sham bronchoscopy. The main outcome of interest was the percentage change of forced expiratory volume in 1 second. RESULTS Data analyzed from 5 randomized controlled trials with 703 patients revealed improvement in percentage change of forced expiratory volume in 1 second in EBV group compared with control group [weighted mean difference (WMD)=11.43; 95% confidence interval (CI), 6.05-16.80; P<0.0001] and improvement in the St. George's Respiratory Questionnaire score (WMD=-5.69; 95% CI, -8.67 to -2.70; P=0.0002). There is no difference shown in the 6-minute walking test (WMD=14.12; 95% CI, -4.71 to 32.95; P=0.14). The overall complication rate of EBV was not significantly different except for an increased rate of pneumothorax [relative risk (RR)=8.16; 95% CI, 2.21-30.11; P=0.002), any hemoptysis (RR=5.01; 95% CI, 1.12-22.49; P=0.04)] and valve migration (RR=8.64; 95% CI, 2.01-37.13; P=0.004). CONCLUSION BLVR using EBV shows short-term improvement in lung function and quality of life, but with increased risk of minor hemoptysis, pneumothorax, and valve migration. Follow-up data on the studies are needed to determine its long-term efficacy.
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20
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Seadler B, Thuppal S, Rizvi N, Markwell S, Sawyer J, McCullough K, Crabtree T, Hazelrigg S. Clinical and Quality of Life Outcomes After Lung Volume Reduction Surgery. Ann Thorac Surg 2019; 108:866-872. [DOI: 10.1016/j.athoracsur.2019.03.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 02/26/2019] [Accepted: 03/26/2019] [Indexed: 11/26/2022]
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Long-Term Results After Lung Volume Reduction Surgery: A Single Institution’s Experience. Ann Thorac Surg 2019; 107:1068-1073. [DOI: 10.1016/j.athoracsur.2018.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/07/2018] [Accepted: 10/01/2018] [Indexed: 11/23/2022]
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Li S, Wang G, Wang C, Gao X, Jin F, Yang H, Han B, Zhou R, Chen C, Chen L, Bai C, Shen H, Herth FJF, Zhong N. The REACH Trial: A Randomized Controlled Trial Assessing the Safety and Effectiveness of the Spiration® Valve System in the Treatment of Severe Emphysema. Respiration 2018; 97:416-427. [PMID: 30554211 PMCID: PMC6549456 DOI: 10.1159/000494327] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/05/2018] [Accepted: 10/05/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) has become a leading cause of morbidity and mortality in China, with tobacco smoke, air pollution, and occupational biohazards being the major risk factors. OBJECTIVES The REACH trial is a multicenter, prospective, randomized controlled trial undertaken in China to assess the safety and effectiveness of the Spiration® Valve System (SVS) compared to standard medical care in COPD patients with severe emphysema. METHODS Patients with severe airflow obstruction, hyperinflation, and severe dyspnea with interlobar fissure integrity were evaluated for enrollment. A total of 107 subjects were randomized in a 2: 1 allocation ratio to either the treatment group (SVS valves and medical management) or the control group (medical management alone). RESULTS The 3-month primary endpoint showed statistically significant improvement in forced expiratory volume in 1 s in the treatment group compared to the control group (0.104 ± 0.18 vs. 0.003 ± 0.15 L, p = 0.001), with the difference being durable through 6 months. Statistically significant target lobe volume reduction was achieved at 3 months (mean change 684.4 ± 686.7 mL) and through 6 months (757.0 ± 665.3 mL). Exercise function and quality of life measures improved in the treatment group, but showed a deterioration in the control group. The serious adverse event (SAE) rate was 33% in the treatment group and 24.2% in the control group. The predominance of SAEs were acute exacerbations of COPD in both groups. There was 1 death in the control group and no deaths in the treatment group. CONCLUSION The SVS represents a novel approach for the treatment of severe emphysema with a clinically acceptable risk-benefit profile.
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Affiliation(s)
- Shiyue Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guangfa Wang
- Peking University First Hospital, Beijing, China
| | | | - Xinglin Gao
- Guangdong General Hospital, Guangzhou, China
| | - Faguang Jin
- Tangdu Hospital, The Second Teaching Hospital of The Fourth Military Medical University, Xi'an, China
| | - Huaping Yang
- Xiangya Hospital of Central South University, Changsha, China
| | - Baohui Han
- Shanghai Chest Hospital affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Rui Zhou
- The Second Xiangya Hospital of Central South University, Changsha, China
| | - Chengshui Chen
- The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
| | - Liangan Chen
- The General Hospital of the Chinese People's Liberation Army (301), Beijing, China
| | - Chunxue Bai
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huahao Shen
- The Second Affiliated Hospital, ZheJiang University School of Medicine, Hangzhou, China
| | - Felix J F Herth
- Thoraxklinik and Translational Lung Research Center, University of Heidelberg, Heidelberg, Germany
| | - Nanshan Zhong
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,
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Van Der Molen MC, Klooster K, Hartman JE, Slebos DJ. Lung volume reduction with endobronchial valves in patients with emphysema. Expert Rev Med Devices 2018; 15:847-857. [DOI: 10.1080/17434440.2018.1538780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Marieke C. Van Der Molen
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jorine E. Hartman
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Slama A, Taube C, Kamler M, Aigner C. Lung volume reduction followed by lung transplantation-considerations on selection criteria and outcome. J Thorac Dis 2018; 10:S3366-S3375. [PMID: 30450243 DOI: 10.21037/jtd.2018.06.164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Lung transplantation (LuTX) and lung volume reduction (LVR), either surgical (LVRS: lung volume reduction surgery) or endoscopic (ELVR: endoscopic lung volume reduction), are established therapies in the treatment of end-stage chronic obstructive pulmonary disease (COPD) patients. Careful patient selection is crucial for each intervention. If these techniques are sequentially applied there is a paucity of available data and individual center experiences vary depending on details in selection criteria and operative technique. This review aims to summarize the published data with a focus on LuTX after LVRS. This review covers patient selection for LuTX and LVR, technical considerations, limitations and outcomes. Published literature was identified by systematic search on Medline and appropriate papers were reviewed. Seven case reports/series, 7 comparative observational studies and one multicenter database analysis incorporating a total of 284 patients with LuTX and LVR were evaluated. Prior LVR can significantly affect intraoperative and postoperative risks after subsequent LuTX. Careful patient selection and timing and the choice of appropriate techniques such as minimal invasive LVRS and using ECMO as extracorporeal support during LuTX if required can minimize those risks, ultimately leading to very good postoperative outcomes in terms of lung function and survival. LVRS has the potential to delay listing and to bridge patients to LuTX by improving their physical condition while on the waiting list. After single lung transplantation (SLuTX) contralateral LVRS can counteract the deleterious effects of native lung hyperinflation (NLH). LVR and LuTX are adjunct therapies in the treatment of end-stage COPD. The combination of both can safely be considered in selected patients.
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Affiliation(s)
- Alexis Slama
- Department of Thoracic Surgery, West German Center for Lung Transplantation, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Christian Taube
- Department of Pneumology, West German Center for Lung Transplantation, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Markus Kamler
- Department of Thoracic Transplantation, West German Center for Lung Transplantation, University Medicine Essen - University Clinic, Essen, Germany
| | - Clemens Aigner
- Department of Thoracic Surgery, West German Center for Lung Transplantation, University Medicine Essen - Ruhrlandklinik, Essen, Germany
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Pompeo E, Rogliani P, Cristino B, Fabbi E, Dauri M, Sergiacomi G. Staged unilateral lung volume reduction surgery: from mini-invasive to minimalist treatment strategies. J Thorac Dis 2018; 10:S2754-S2762. [PMID: 30210829 DOI: 10.21037/jtd.2018.05.171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection of severely damaged emphysematous tissue carried out by thoracoscopic or open surgical approaches, under general anesthesia with single-lung ventilation, has resulted in significant and long-lasting clinical and functional benefit. Unfortunately, the morbidity rates reported by simultaneous bilateral resectional LVRS has led to raise criticism regarding its cost-effectiveness and has stimulated in recent years the development of less invasive bronchoscopic and surgical non-resectional methods of treatment that are preferentially performed in a staged unilateral fashion. We had previously proposed an innovative LVRS modality, which did not entail any resection of lung tissue and was electively carried out according to a staged unilateral strategy by a multiport thoracoscopic access, through thoracic epidural anesthesia in conscious, spontaneously ventilating patients (awake LVRS). The awake LVRS resulted in significant clinical benefit paralleling that achieved by the resectional method with lower morbidity rates and shorter hospital stay. Moreover, the awake LVRS proved also suitable to be employed in stringently selected patients to perform redo procedures following previous successful bilateral LVRS. More recently, in order to minimize the global surgery- and anesthesia-related traumas, we have modified our original non-resectional method by adopting a single thoracoscopic access as well as an anesthesia protocol entailing use of a simple intercostal block with target control sedation, to realize an ultra-minimally invasive or minimalist LVRS. Hence, a deeper investigation of the pros and cons of staged unilateral LVRS strategies as well as of the novel surgical non-resectional and redo LVRS is warranted in order to verify, the optimal strategies of treatment, which will prove to reduce the typical LVRS-related morbidity while assuring the most durable benefit in patients with advanced emphysema.
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Affiliation(s)
- Eugenio Pompeo
- Department of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy
| | - Paola Rogliani
- Department of Respiratory Medicine, Policlinico Tor Vergata University, Rome, Italy
| | - Benedetto Cristino
- Department of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy
| | - Eleonora Fabbi
- Department of Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Mario Dauri
- Department of Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
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Caviezel C, Schaffter N, Schneiter D, Franzen D, Inci I, Opitz I, Weder W. Outcome After Lung Volume Reduction Surgery in Patients With Severely Impaired Diffusion Capacity. Ann Thorac Surg 2018; 105:379-385. [DOI: 10.1016/j.athoracsur.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 08/09/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
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Ginsburg ME, Thomashow BM, Bulman WA, Jellen PA, Whippo BA, Chiuzan C, Lee S, Bai D, Sonett J. The safety, efficacy, and durability of lung-volume reduction surgery: A 10-year experience. J Thorac Cardiovasc Surg 2016; 151:717-724.e1. [DOI: 10.1016/j.jtcvs.2015.10.095] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 10/16/2015] [Accepted: 10/22/2015] [Indexed: 11/29/2022]
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Quezada W, Make B. Interventional Options for COPD- LVRS, Bronchoscopic Therapies and the Future. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2016; 3:446-453. [PMID: 28848865 PMCID: PMC5559125 DOI: 10.15326/jcopdf.3.1.2015.0171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article serves as aCME available, enduring material summary of the following COPD9USA presentations: "Lung Volume Reduction Surgery" Presenter: William A. Bulman, MD "Bronchoscopic Approaches to Lung Volume Reduction" Presenter: Frank Sciurba, MD "Stem Cell Therapies for Advanced Emphysema" Presenter: Edward P. Ingenito, MD, PhD "Lung Transplantation for COPD" Presenter: Daniel Dilling, MD, FACP, FCCP.
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Affiliation(s)
- William Quezada
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Barry Make
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
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Cerfolio RJ. Hey, pulmonologists and family doctors, please read me and see the data--It is a brave new world. J Thorac Cardiovasc Surg 2015; 151:725. [PMID: 26651961 DOI: 10.1016/j.jtcvs.2015.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Robert James Cerfolio
- Department of Cardiothoracic Surgery, University of Alabama at Birmingham College of Arts and Sciences, Birmingham, Ala.
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Pompeo E, Rogliani P, Palombi L, Orlandi A, Cristino B, Dauri M. The complex care of severe emphysema: role of awake lung volume reduction surgery. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:108. [PMID: 26046049 DOI: 10.3978/j.issn.2305-5839.2015.04.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/16/2015] [Indexed: 11/14/2022]
Abstract
The resectional lung volume reduction surgery (LVRS) procedure entailing nonanatomic resection of destroyed lung regions through general anesthesia with single-lung ventilation has shown to offer significant and long-lasting improvements in respiratory function, exercise capacity, quality of life and survival, particularly in patients with upper-lobe predominant emphysema and low exercise capacity. However mortality and morbidity rates as high as 5% and 59%, respectively, have led to a progressive underuse and have stimulated investigation towards less invasive surgical and bronchoscopic nonresectional methods that could assure equivalent clinical results with less morbidity. We have developed an original nonresectional LVRS method, which entails plication of the most severely emphysematous target areas performed in awake patients through thoracic epidural anesthesia (TEA). Clinical results of this ultra-minimally invasive procedure have been highly encouraging and in a uni-center randomized study, intermediate-term outcomes paralleled those of resectional LVRS with shorter hospital stay and fewer side-effects. In this review article we analyze indications, technical details and results of awake LVRS taking into consideration the available data from the literature.
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Affiliation(s)
- Eugenio Pompeo
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Paola Rogliani
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Leonardo Palombi
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Augusto Orlandi
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Benedetto Cristino
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Mario Dauri
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
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About lemons and lemonade. J Thorac Cardiovasc Surg 2015; 149:1224-6. [PMID: 25906734 DOI: 10.1016/j.jtcvs.2015.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 01/02/2015] [Indexed: 11/22/2022]
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Xiao Y, Zhao S, Hu Y, Shi X, Tan L. Advances and applications of bronchoscopic lung volume reduction. Int J Clin Exp Med 2015; 8:52-57. [PMID: 25784974 PMCID: PMC4358429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/29/2014] [Indexed: 06/04/2023]
Abstract
Lung volume reduction surgery usually gives rise to high postoperative morbidity and impedes its further application. Recently, a plethora of bronchoscopic lung volume reduction techniques such as one-way endobronchial valves, biological sealants, thermal vapor ablation, airway bypass stents and lung volume reduction coils have been extensively used in emphysema treatment. The current data for bronchoscopic lung volume reduction although not conclusive enough do present multiple safer ways compared with conventional surgery with few serious complications, lower cost and shortened hospital care. The bronchoscopic lung volume reduction will undergo continuous development as constant randomized trials are performed to prove its full efficacy.
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Affiliation(s)
- Yang Xiao
- Department of Respiratory, Central Hospital of Wuhan Wuhan 430014, Hubei, China
| | - Su Zhao
- Department of Respiratory, Central Hospital of Wuhan Wuhan 430014, Hubei, China
| | - Yi Hu
- Department of Respiratory, Central Hospital of Wuhan Wuhan 430014, Hubei, China
| | - Xiaowu Shi
- Department of Respiratory, Central Hospital of Wuhan Wuhan 430014, Hubei, China
| | - Li Tan
- Department of Respiratory, Central Hospital of Wuhan Wuhan 430014, Hubei, China
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Kostron A, Horn-Tutic M, Franzen D, Kestenholz P, Schneiter D, Opitz I, Kohler M, Weder W. Repeated lung volume reduction surgery is successful in selected patients. Eur J Cardiothorac Surg 2014; 48:710-5. [PMID: 25548131 DOI: 10.1093/ejcts/ezu498] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 11/18/2014] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Lung volume reduction surgery (LVRS) improves dyspnoea, quality of life and may even prolong survival in carefully selected patients with end-stage emphysema. The benefit may be sustained for several years and vanishes with the natural progression of the disease. Data on repeated surgical treatment of emphysema are scarce. The aim of this study was to evaluate the safety, effects and outcomes of repeated LVRS (Re-LVRS) in patients no longer benefiting from their initial LVRS. METHODS Between June 2002 and December 2013, 22 patients (9 females) with advanced emphysema underwent Re-LVRS at a median of 60 months (25-196) after their initial LVRS. While initial LVRS was performed thoracoscopically as a bilateral procedure, Re-LVRS was performed unilaterally by a video-assisted thoracoscopic technique in 19 patients and, due to adhesions, by thoracotomy in 3 patients. Pulmonary function test (PFT) was performed at 3 and 12 months postoperatively. RESULTS Lung function at Re-LVRS was similar to that prior to the first LVRS. The 90-day mortality rate was 0%. The first patient died 15 months postoperatively. The median hospitalization time after Re-LVRS was significantly longer compared with the initial LVRS [14 days, interquartile range (IQR): 11-19, vs 9 days, IQR: 8-14; P = 0.017]. The most frequent complication was prolonged air leak with a median drainage time of 11 days (IQR: 6-13); reoperations due to persistent air leak were necessary in 7 patients (32%). Five patients (23%) had no complications. Lung function and Medical Research Council (MRC) score improved significantly for up to 12 months after Re-LVRS, with results similar to those after initial bilateral LVRS. The average increase in the forced expiratory volume in 1 s (FEV1) was 25% (a 7% increase over the predicted value or 0.18 l) at 3 months, and the mean reduction in hyperinflation, assessed by relative decrease in RV/TLC (residual volume/total lung capacity), was 12% at 3 months (a decrease of 8% in absolute ratios). The mean MRC breathlessness score decreased significantly after 3 months (from 3.7 to 2.2). CONCLUSIONS Re-LVRS can be performed successfully in carefully selected patients as a palliative treatment. It may be performed as a bridge to transplantation or in patients with newly diagnosed intrapulmonary nodules or during elective cardiac surgery. Morbidity is acceptable and outcomes may be satisfactory with significantly improved lung function and reduced dyspnoea for at least 12 months postoperatively.
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Affiliation(s)
- Arthur Kostron
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Michaela Horn-Tutic
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Daniel Franzen
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Peter Kestenholz
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
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Cooper JD. Apples, oranges, and lemons: making sense of lung volume reduction surgery. J Thorac Cardiovasc Surg 2014; 148:2470-1. [PMID: 25433867 DOI: 10.1016/j.jtcvs.2014.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 10/08/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Joel D Cooper
- University of Pennsylvania Health System, Philadelphia, Pa.
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