Bronchoscopic lung volume reduction procedures for emphysema: A network meta-analysis

Efficacy and safety of bronchoscopic lung volume reduction for chronic obstructive pulmonary disease: a systematic review and network meta-analysis

BACKGROUND

Various bronchoscopic lung volume reduction (BLVR) methods have been developed to treat chronic obstructive pulmonary disease (COPD). The efficacy and safety of these interventions remain unclear. This study assessed the efficacy and safety of various BLVR interventions in COPD patients.

METHODS

PubMed and Embase were searched from inception to 21 October 2023. The primary outcomes assessed included the 6-min walking distance (6MWD), St. George Respiratory Questionnaire (SGRQ) score, lung function, and adverse events (AE). A frequentist approach with a random-effects model was used for a network meta-analysis.

RESULTS

Twelve randomized controlled trials (RCTs) with 1646 patients were included in this meta-analysis. Patients treated with an endobronchial valve (EBV) achieved a minimum clinically important difference (MCID) in 6MWD and SGRQ at 6 months. Patients treated with coils achieved MCID in the SGRQ score at 12 months. Patients with aspiration valve system and bronchoscopic thermal vapor ablation (BTVA) achieved MCID in the SGRQ score at 6 months.

CONCLUSIONS

In COPD patients, EBV should be considered first, while being wary of pneumothorax. Coil and BTVA are potential therapeutic alternatives. Although BTVA demonstrates a safer procedural profile than coils, additional studies are imperative to clarify its efficacy.

Impact of bronchoscopic thermal vapor ablation on lung volume reduction in patients with emphysema: a meta-analysis

BACKGROUND

Bronchoscopic lung volume reduction (LVR) could significantly improve pulmonary function and quality of life in patients with emphysema. We aimed to assess the efficacy and safety of bronchoscopic thermal vapor ablation (BTVA) on LVR in patients with emphysema at different stage.

METHODS

A systematic search of database including PubMed, Embase and Cochrane library was conducted to determine all the studies about bronchoscopic thermal vapor ablation published through Dec 1, 2022. Related searching terms were "lung volume reduction", "bronchoscopic thermal vapor ablation", "bronchial thermal vapor ablation" "BTVA" and "emphysema", "efficacy" and"safety". We used standardized mean difference (SMD) to analyze the summary estimates for BTVA therapy.

RESULTS

We retrieved 30 records through database search, and 4 trials were selected for meta-analysis, including 112 patients with emphysema. Meta-analysis of the pooled effect showed that levels of forced expiratory volume in 1 s (FEV1), residual volume (RV), total lung capacity (TLC), 6-min walk distance (6MWD) and St George's Respiratory Questionnaire (SGRQ) were significantly improved in patients with emphysema following BTVA treatment between 6 months vs. baseline. Additionally, no significant changes in FEV1, RV, TLC and SGRQ occurred from 3 to 6 months of follow-up except for 6MWD. The magnitude of benefit was higher at 3 months compared to 6 months. The most common complications at 6 months were treatment-related chronic obstructive pulmonary disease (COPD) exacerbations (RR: 12.49; 95% CI: 3.06 to 50.99; p < 0.001) and pneumonia (RR: 9.49; 95% CI: 2.27 to 39.69; p < 0.001).

CONCLUSIONS

Our meta-analysis provided clinically relevant information about the impact and safety of BTVA on predominantly upper lobe emphysema. Particularly, short-term significant improvement of lung function and quality of life occurred especially within the initial 3 months. Further large-scale, well-designed long-term interventional investigations are needed to clarify this issue.

Treatable traits in COPD patients

There is no justification for a therapeutic nihilism in clinical practice because current management (pharmacological and non-pharmacological) of the patients with chronic obstructive pulmonary disease according to treatable traits is effective in decreasing their respiratory symptoms, increasing their exercise tolerance and capacity, improving their quality of life, preventing (and treating) many of their exacerbations and decreasing their mortality.

Use of bronchoscopic steam thermal ablation (BTVA) in a clinically compromised patient

Background

Bronchoscopic lung volume reduction (BLVR) techniques improve lung function and increase exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) and BLVR treatment is included in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) treatment guidelines for these patients. BTVA (Intervapor Uptake Medical, Tustin, CA, USA) represents a recent therapy of this group that allows to treat sublobar areas and for this reason is used clinically compromised patients, like in this case report.

Case presentation

In this paper we describe a case report of an 85-year-old male with severe respiratory failure and a diagnosis of emphysema presented with dyspnea and clinical worsening, despite the best medical therapy practiced. For comorbidity and pathology’s features he was excluded from surgical treatment options, like lung volume reduction surgical (LVRS) and from positioning of endobronchial valves (EBV) for the presence of collateral ventilation and he was addressed to BTVA. The procedure was successful for this patient.

Conclusions

This case supports recent suggestions that BTVA can be a good alternative treatment for patients properly selected.

Vapor for lung volume reduction; pros and cons

INTRODUCTION

Bronchoscopic lung volume reduction (BLVR) is a novel approach for treatment of emphysema. Several techniques are available to accomplish BLVR including Bronchoscopic Vapor Thermal Ablation (BVTA). This technique is easy to perform and considered safe due to its gradual effect. We discuss BTVA in detail in this editorial.

AREAS COVERED

We discuss our experience with BTVA in detail including patient selection, equipment, procedure, post-procedural care and complications. We also review the literature to determine the pros and cons for its use. Other modalities such as endobronchial valves, coils and lung sealants are also briefly discussed.

EXPERT OPINION

Vapor ablation is a novel and safe approach in inducing lung volume reduction in emphysema patients. The effects are gradual, and therefore potentially making it safer than other minimally invasive modalities. Pneumonitis and infection are common side effects. Just as in other BLVR techniques, a case by case evaluation is needed to determine the right candidate for BTVA. Further larger studies are needed before BTVA becomes standard of care in treatment of patients with emphysema.