Lung volume reduction coil treatment for patients with severe emphysema: a European multicentre trial

Bronchoscopic lung volume reduction in emphysema: a review

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) poses a substantial burden on the healthcare system and is currently considered the sixth leading cause of death in the United States. Emphysema, as evidenced by severe air-trapping in patients with COPD, leads to significant dyspnea and morbidity. Lung volume reduction via surgery or minimally invasive endobronchial interventions are currently available, which improve lung function and quality of life.

RECENT FINDINGS

Newer studies have noted a survival benefit in patients post bronchoscopic lung volume reduction vs. those subjected to standard of care. The presence of collateral ventilation is one of the most common impeding factors to placing endobronchial valves, and if placed, these patients might not achieve lobar atelectasis; however, there are newer modalities that are now available for patients with collateral ventilation which we have described.

SUMMARY

Combining standard of care treatment that includes smoking cessation, bronchodilators, preventive care including vaccinations, pulmonary rehabilitation, and endobronchial treatment using various interventions in decreasing hyperinflation improves quality of life and may improve survival and hence significantly reduce the burden of COPD on healthcare.

Surgical and bronchoscopic pulmonary function-improving procedures in lung emphysema

COPD is a highly prevalent, chronic and irreversible obstructive airway disease without curative treatment. Standard therapeutic strategies, both non-pharmacological and pharmacological, have only limited effects on lung function parameters of patients with severe disease. Despite optimal pharmacological treatment, many patients with severe COPD still have a high burden of dyspnoea and a poor quality of life. If these patients have severe lung emphysema, with hyperinflation as the driver of symptoms and exercise intolerance, lung volume reduction may be an effective treatment with a significant impact on lung function, exercise capacity and quality of life. Currently, different lung volume reduction approaches, both surgical and bronchoscopic, have shown encouraging results and have been implemented in COPD treatment recommendations. Nevertheless, choosing the optimal lung volume reduction strategy for an individual patient remains challenging. Moreover, there is still room for improving durability of effect and safety in all available procedures. Ongoing and innovative research is essential to push this field forwards. This review provides an overview of results and limitations of the current lung volume reduction options for patients with severe lung emphysema and hyperinflation.

Position statement on endoscopic lung volume reduction in South Africa: 2022 update

Chronic obstructive pulmonary disease (COPD) remains one of the most common causes of morbidity and mortality in South Africa. Endoscopic lung volume reduction (ELVR) was first proposed by the South African Thoracic Society (SATS) for the treatment of advanced emphysema in 2015. Since the original statement was published, there has been a growing body of evidence that a certain well-defined sub-group of patients with advanced emphysema may benefit from ELVR, to the point where the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines and the United Kingdom National Institute for Health and Care Excellence (NICE) advocate the use of endoscopic valves based on level A evidence. Patients aged 40 - 75 years with severe dyspnoea (COPD Assessment Test score ≥10) despite maximal medical therapy and pulmonary rehabilitation, with forced expiratory volume in one second (FEV₁) 20 - 50%, hyperinflation with residual volume (RV) >175% or RV/total lung capacity (TLC) >55% and a six-minute walking distance (6MWD) of 100 - 450 m (post-rehabilitation) should be referred for evaluation for ELVR, provided no contraindications (e.g. severe pulmonary hypertension) are present. Further evaluation should focus on the extent of parenchymal tissue destruction on high-resolution computed tomography (HRCT) of the lungs and interlobar collateral ventilation (CV) to identify a potential target lobe. Commercially available radiology software packages and/or an endobronchial catheter system can aid in this assessment. The aim of this statement is to provide the South African medical practitioner and healthcare funders with an overview of the practical aspects and current evidence for the judicious use of the valves and other ELVR modalities which may become available in the country.

Effects of Non-intubated Video-Assisted Thoracic Surgery on Patients With Pulmonary Dysfunction

Background: Non-intubated video-assisted thoracic surgery (NIVATS) can be safely performed in lung volume reduction surgery for patients with severe pulmonary dysfunction. However, there is still no cohort observation on the effects of NIVATS on patients with pulmonary dysfunction undergoing different types of thoracic procedures. This retrospective study aimed to observe the effects of NIVATS for this kind of patients.

Methods: Three hundred and twenty-eight patients with moderate to severe obstructive pulmonary dysfunction, who underwent video-assisted thoracic surgery (VATS), were retrospectively collected from June 1st, 2017 to September 30th, 2019. Patients in NIVATS were case-matched with those in intubated video-assisted thoracic surgery (IVATS) by a propensity score-matched analysis. The primary outcome was the comparison of perioperative values, the secondary outcome was the risk factors for postoperative clinical complications (PCP) which were identified by binary logistic regression analysis.

Results: After being matched, there were no differences in demographics and preoperative values of pulmonary function between NIVATS and IVATS groups. The duration of surgery and anesthesia had no difference (P = 0.091 and P = 0.467). As for the postoperative recovery, except for the mean intensive care unit (ICU) stay was longer in the IVATS group than in the NIVATS group (P = 0.015), the chest tube removal time and the postoperative hospital stay had no difference (P = 0.394 and P = 0.453), and the incidence of PCP also had no difference (P = 0.121). The binary logistic regression analysis revealed that the history of pulmonary disease, anesthesia method, and surgical location were risk factors of PCP.

Conclusion: For patients with pulmonary dysfunction when undergoing different types of thoracic procedures, the NIVATS can be performed as effectively and safely as the IVATS, and can reduce the ICU stay.

Lung Volume Reduction Surgery in Patients with Homogeneous Emphysema

Randomized controlled trials have demonstrated that lung volume reduction surgery (LVRS) improves exercise capacity, lung function, and quality of life in patients with heterogenous emphysema on computed tomographic and perfusion scan. However, most patients have a nonheterogenous type of destruction. These patients, summarized under "homogeneous emphysema," may also benefit from LVRS as long they are severely hyperinflated, and adequate function is remaining with a diffusing capacity of the lungs for carbon monoxide greater than 20% and no pulmonary hypertension. Surgical mortality is low when patients are well selected.

Bronchoscopic Lung Volume Reduction: A New Hope for Patients With Severe Emphysema and Air Trapping

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.

Endobronchial valve vs coil for lung volume reduction in emphysema: results from a tertiary care centre in Turkey

BACKGROUND

Bronchoscopic lung volume reduction (BLVR) by either the endobronchial valve (EBV) or coil (EBC) procedure is recommended for severe emphysematous patients. BLVR applications generally help healthy lung areas ventilate more comfortably by reducing the hyperinflation and improving the contraction capacity of diaphragm.

OBJECTIVES

Compare our experience with valve and coil BLVR devices.

DESIGN

Retrospective.

SETTING

Single tertiary care centre.

PATIENTS AND METHODS

Demographic data, vital signs, pulmonary function tests (PFTs), the six-minute walking test (6MWT), vital signs, arterial blood gases and complications were recorded.

MAIN OUTCOME MEASURES

Change in PFTs and completion of the 6MWT.

SAMPLE SIZE

60 Turkish men with a diagnosis of chronic pulmonary lung disease.

RESULTS

Clinical and demographic characteristics were similar in patients who underwent EBV and EBC. Thirty (96.8%) EBV patients and 27 (93.1%) of the EBC patients were able to properly complete the PFT before the procedures, but all complied after the procedures. Significant improvement in PFTs were achieved after the procedure and there were no statistically significant differences in post-procedure performance. For the 6MWT, the completion rate improved from 15 (48.4%) to 19 (61.3%) patients in the EBV patients (P=.125) and from 19 (65.5%) to 21 (72.4%) patients in the EBC patients (P=.500). There was no significant difference in completion rates for the walking test for either group (median 32 meters in EBV patients and 37 meters in EBC patients; P=.652). Vital signs and arterial blood gases were similar in the two groups. The rates of complications were similar in both groups.

CONCLUSION

Endobronchial valves and coils are safe and effective methods for BLVR for patients with severe emphysema.

LIMITATIONS

Relatively small sample, retrospective design, single-centre retrospective study.

CONFLICT OF INTEREST

None.

Spontaneous pneumothorax in a single lung transplant recipient-a blessing in disguise: A case report

BACKGROUND

End-stage chronic obstructive pulmonary disease (COPD) is one of the common lung diseases referred for lung transplantation. According to the international society of heart and lung transplantation, 30% of all lung transplantations are carried out for COPD alone. When compared to bilateral lung transplant, single-lung transplant (SLT) has similar short-term and medium-term results for COPD. For patients with severe upper lobe predominant emphysema, lung volume reduction surgery is an excellent alternative which results in improvement in functional status and long-term mortality. In 2018, endobronchial valves were approved by the Food and Drug Administration for severe upper lobe predominant emphysema as they demonstrated improvement in lung function, exercise capacity, and quality of life. However, the role of endobronchial valves in native lung emphysema in SLT patients has not been studied.

CASE SUMMARY

We describe an unusual case of severe emphysema who underwent a successful SLT 15 years ago and had gradual worsening of lung function suggestive of chronic lung allograft dysfunction. However, her lung function improved significantly after a spontaneous pneumothorax of the native lung resulting in auto-deflation of large bullae.

CONCLUSION

This case highlights the clinical significance of native lung hyperinflation in single lung transplant recipient and how spontaneous decompression due to pneumothorax led to clinical improvement in our patient.

Determining Static Hyperinflation in Patients with Severe Emphysema: Relation Between Lung Function Parameters and Patient-Related Outcomes

BACKGROUND

Bronchoscopic lung volume reduction techniques are minor invasive treatment modalities for severely hyperinflated emphysema patients. The severity of static lung hyperinflation determines eligibility and success rate for these treatments. However, it is not exactly known what parameter should be used to optimally reflect hyperinflation. Commonly used parameters are residual volume (RV) and the RV/Total lung capacity (TLC) ratio. Other parameters reflecting hyperinflation are Inspiratory Capacity/TLC and forced vital capacity.

OBJECTIVES

To define which of these function parameters is the most optimal reflection of hyperinflationin in relation to patient-related outcomes.

METHODS

In a retrospective cohort study, data from measurements during baseline visits of eight studies were pooled. Primary outcomes were RV/TLC ratio and RV as percentage of predicted (RV%pred), both measured by bodyplethysmography, compared to the patient-related outcome variables: 6-min walk distance (6MWD), the St. George's Respiratory Questionnaire (SGRQ), and the modified Medical Research Council (mMRC).

RESULTS

Two hundred seventy-four COPD patients (mean age 59 years; 66% female), FEV₁ 0.74 ± 0.28 L, RV 4.94 ± 1.06 L, 6MWD of 339 ± 95 m, were included in the analysis. Significant correlations (all p < 0.01) were found between RV%pred and 6MWD (r =  - 0.358), SGRQ (r = 0.184), and mMRC (r = 0.228). Also, there was a significant correlation between RV/TLC ratio and 6MWD (r =  - 0.563), SGRQ (r = 0.289) and mMRC (r = 0.354). Linear regression analyses showed that RV/TLC ratio was a better predictor of patient outcomes than RV%pred.

CONCLUSION

This study demonstrates that both RV/TLC ratio and RV%pred are relevant indicators of hyperinflation in patients with severe emphysema in relation to patient-related outcomes. RV/TLC ratio is more strongly related to the patient-related outcomes than RV%pred.

Bronchoscopic interventions for severe emphysema: Where are we now?

Patients with severe emphysema have limited treatment options and only derive a small benefit from optimal medical treatment. The only other therapy to have significant clinical beneficial effect in emphysema is LVRS but the perceived risk and invasiveness of surgery has fuelled bronchoscopic approaches to induce lung volume reduction. There are multiple bronchoscopic methods for achieving volume reduction in severe emphysema: EBV, airway bypass procedure, endobronchial coils, thermal (vapour) sclerosis and chemical sclerosis (sealants). Optimal patient selection is key to successful patient outcomes. This review discusses bronchoscopic approaches for emphysema treatment which has progressed through clinical trials to clinical practice.

Patient Selection for Bronchoscopic Lung Volume Reduction

Purpose

Bronchoscopic lung volume reduction (BLVR) is a valuable treatment option for carefully selected patients with severe COPD. There is limited knowledge about the characteristics and outcomes of patients referred to a specialized center for BLVR. The study objectives were to investigate the selection rate for BLVR treatment in patients referred for this treatment and to investigate the differences between patients that were selected for BLVR and patients that were not.

Patients and Methods

We performed a retrospective analysis of patients with severe COPD who were referred to our hospital to assess eligibility for BLVR treatment. Our parameters included demographics, comorbidity, chest computed tomography characteristics, reasons for rejection from BLVR treatment and patient survival.

Results

In total, 1500 patients were included (mean age 62 years, 50% female and forced expiratory volume in 1 s 33% of predicted). Out of this group, 282 (19%) patients were selected for BLVR treatment. The absence of a suitable target lobe for treatment, an unsuitable disease phenotype and insufficient lung hyperinflation were the most important factors for not being selected. Patients that were selected for any BLVR option lived significantly longer than the group of patients that were not selected for BLVR (median 3060 versus 2079 days, P<0.001).

Conclusion

We found that only a small proportion of patients that are referred for BLVR treatment is eligible for a BLVR treatment, indicating a need for both better referral tools and for the development of new therapies for this group of patients. Furthermore, our data suggest that selection for BLVR is associated with a significant survival benefit.

Endobronchial coils for emphysema: Dual mechanism of action on lobar residual volume reduction

BACKGROUND AND OBJECTIVE

The RENEW trial demonstrated that bronchoscopic lung volume reduction using endobronchial coils improves quality of life, pulmonary function and exercise performance. In this post hoc analysis of RENEW, we examine the mechanism of action of endobronchial coils that drives improvement in clinical outcomes.

METHODS

A total of 78 patients from the RENEW coil-treated group who were treated in one or both lobes that were deemed as the most destroyed were included in this retrospective analysis. Expiratory and inspiratory HRCT scans were used to assess lobar volume change from baseline to 12 months post coil treatment in treated and untreated lobes.

RESULTS

Reduction in lobar RV in treated lobes was significantly associated with favourable clinical improvement. Independent predictor of the change in RV and FEV₁ was the change in lobar RV reduction in the treated lobes and for change in 6MWD the absence of cardiac disease and the change in SGRQ, while the independent predictor of change in SGRQ was the change in 6MWD.

CONCLUSION

Our results suggest that residual lobar volume reduction in treated lobes measured by QCT is the driving mechanism of action of endobronchial coils leading to positive clinical outcomes. However, the improvement in exercise capacity and quality of life seems to be affected by the presence of cardiac disease.

Bronchoscopic device intervention in chronic obstructive pulmonary disease

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

BACKGROUND:

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

AIM:

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

METHODS:

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

RESULTS:

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

CONCLUSION:

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

Interventional Bronchoscopy in the Management of Chronic Obstructive Lung Disease

Background:

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

Computed Tomography Imaging for Novel Therapies of Chronic Obstructive Pulmonary Disease

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

A New-Designed Lung-Bending Device for Bronchoscopic Lung Volume Reduction of Severe Emphysema: A Feasibility Study in Pigs

BACKGROUND

Bronchoscopic therapies are less invasive alternatives of surgical lung volume reduction for severe emphysema. Bending of lung tissue by implanting metallic coils into bronchi is one of the procedures. A new-designed device with a similar rationale, Reverser, has been developed with some improvements.

OBJECTIVES

The aim of the study was to evaluate the safety and feasibility of the Reversers.

METHODS

Twelve healthy pigs were randomly divided into 3 groups (groups A, B, and C). The Reversers were implanted bronchoscopically into the selected airways using a proprietary delivery system. Physical examination, chest fluoroscopy, computed tomography (CT) scans, and bronchoscopic observations were performed before implantation and during the follow-up period. Necropsy was performed respectively at 1 month (group A), 3 months (group B), and 6 months (group C) after implantation.

RESULTS

A total of 47 Reversers were implanted successfully. The procedure was feasible and well tolerated by all pigs. No severe complications, such as pneumothorax, abscesses, and airway hemorrhage, were found. No unintended injuries or death occurred. Mild granulation and inflammation were observed in the airway wall. Opacities around Reversers were shown on CT scans in some pigs. In the pigs with opacities, histological evaluation revealed widened alveolar septa due to inflammatory cell infiltration in the vicinity of the Reversers. On the analysis of CT data, there was a trend for volume reduction of the treated lung at 1 and 3 months after treatment compared with baseline.

CONCLUSIONS

This study showed that Reversers were safe and feasible for bronchoscopic lung volume reduction in pigs.

Bronchoscopic Lung Volume Reduction

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

TRIAL REGISTRY

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

Endoscopic lung volume reduction coil treatment in patients with very low FEV1: an observational study

BACKGROUND

Endoscopic lung volume reduction coil (LVRC) treatment is a therapeutic option for selected patients with advanced emphysema. The effects and the safety of endoscopic lung volume reduction in patients with very low forced expired volume in one second (FEV₁) remain to be determined. This study was conducted to assess the effects and the safety of LVRC treatment in patients with very low FEV₁.

METHODS

The study was performed as a retrospective observational study in the Department of Respiratory Medicine at the University Medical Center Hamburg-Eppendorf on patients with very low FEV₁, defined as an FEV₁ ⩽ 20% of predicted at baseline in whom LVRC treatment was performed between 1 April 2012 and 28 February 2017.

RESULTS

LVRC treatment was performed in 33 patients with very low FEV₁. Of these, 45.5% were female and 54.5% were male. At baseline, mean FEV₁ was 0.46 ± 0.12 liters (15 ± 3% of predicted), mean forced vital capacity (FVC) was 1.61 ± 0.62 liters (42 ± 13% of predicted), mean residual volume (RV) was 6.03 ± 0.81 liters (275 ± 51% of predicted) and 6-minute walk distance was 229 ± 102 m. Bilateral LVRC treatment was completed in 21 of these patients (63.6%). Bilateral LVRC treatment led to significant improvements in functional parameters with an increase in mean FEV₁ from 0.44 ± 0.11 liters to 0.54 ± 0.12 liters ( p = 0.001), equivalent to a relative improvement of 24.5 ± 26.9%, an increase in mean FVC from 1.49 ± 0.54 liters to 1.84 ± 0.49 liters ( p = 0.001), a decrease in mean RV from 6.27 ± 0.83 liters to 5.83 ± 1.09 liters ( p = 0.004) and an improvement in 6-minute walk distance from 218 ± 91 m to 266 ± 96 m ( p = 0.01). There were no cases of respiratory failure requiring mechanical ventilation and no deaths.

CONCLUSIONS

LVRC treatment was effective and safe in patients with very low FEV₁.

Endobronchial coils in treatment of advanced emphysema: A single center experience

Background

This study aims to present our experience with endobronchial coils in patients who underwent endobronchial lung volume reduction due to advanced emphysema.

Methods

The study included 46 patients (45 males, 1 female; mean age 61.7±8 years; range, 43 to 80 years) who underwent endobronchial lung volume reduction with endobronchial coils for advanced emphysema. Patients" age, gender, pulmonary function tests, post-treatment morbidity, mortality, pre- and post-treatment (6 months) six-minute walking distance, modified Medical Research Council dyspnea scores, chronic obstructive pulmonary disease assessment test and Hospital Anxiety and Depression Scale scores were recorded.

Results

Patients had an average of 65 pack/year smoking history. An average of 11 (range, 9-15) coils were placed per lobe (right upper lobe=35, left upper lobe=19, right lower lobe=2, left lower lobe=4). Mean follow-up duration was 12.6 months (±5.6 months). Post-treatment forced expiratory volume in one second, residual volume and six-minute walking distance values were improved with statistical significance. Also, significant improvement was seen in quality of life, quantified by modified Medical Research Council, chronic obstructive pulmonary disease assessment test and Hospital Anxiety and Depression Scale scores. While no immediate major postoperative complications occurred, three patients developed chronic obstructive pulmonary disease exacerbation, two developed pneumonia, and one developed recurrence of previous neurologic disorder within 30 days.

Conclusion

Endobronchial coil administration provides lower morbidity and mortality compared to lung volume reduction surgery as well as significant improvement in pulmonary functions and quality of life in selected patients with advanced emphysema.

Bronchoscopic treatment of emphysema: an update

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

Importance of bronchoscopic lung volume reduction coil therapy in potential candidates for lung transplantation

Bronchoscopic lung volume reduction (BLVR) coil treatment is a alternative and promising treatment modality for selected severe emphysema patients. The main indication of this treatment modality is a forced expiration volume in one second (FEV1) of 15-45% and a residual volume (RV) > 175%. The aim of this study was to investigate the efficacy of BLVR coil therapy in patients with end-stage emphysema who were potential candidates for lung transplantation and had FEV1 values less than 25%. Twenty-one patients who underwent bilateral BLVR coil therapy between September 2013 and May 2015 were retrospectively reviewed. We compared the changes in clinical and laboratory parameters at the baseline and 12 months after the treatment. Twelve months after the bilateral BLVR coil treatment, we observed an average increase in FEV1 (110 mL and 4.6%), a decrease in residual volume (660 mL and 33%), and an increase in 6-minute walk tests (67 m). The most common complications were chronic obstructive pulmonary disease exacerbation (47.6%) and pneumonia (23.8%). All patients tolerated the general anesthesia and procedure very well. BLVR coil therapy is safe and effective in patients with end-stage emphysema, who are potential candidates for lung transplantation within a short to medium period. The complication rates of this treatment were not different from those of the other coil treatments, and the improvements in the clinical parameters after the treatment resulted in gaining time for lung transplantation. Future research for evaluating the long-term efficacy of BLVR coil therapy in these patients is essential.

Enhanced recovery for thoracic surgery in the elderly

PURPOSE OF REVIEW

Both surgical workload and the age of those patients being considered for radial pulmonary resection are increasing. Enhanced recovery programmes are now well established in most surgical disciplines and are increasingly reported in thoracic procedures. This review will discuss the relevant principles of these programmes as applied to an increasing elderly population.

RECENT FINDINGS

Elderly patients undergoing less radial surgical resections without lymphadenectomy have comparable outcomes to those undergoing classical curative treatment. Patients require careful assessment and self-reported quality of life metrics or function may be a better marker of outcome than static measures such as lung function. Hypotension, low values for bispectral index and low anaesthetic gas mean alveolar concentration values are common and independent predictors of mortality in the elderly. Paravertebral blockade is preferred to epidural anaesthesia because of a more favourable side-effect profile and comparable efficacy. As yet no robust work has examined the efficacy of an integrated enhanced recovery programme in thoracic surgery.

SUMMARY

Elderly patients are suitable for enhanced recovery programmes but these must be tailored to individual circumstance. Further work is required to comprehensively assess their value in a modern healthcare setting.

Thermic and chemical procedures for bronchoscopic lung volume reduction

In the last 14 years several endoscopic procedures have been developed to offer patients with advanced chronic obstructive pulmonary disease (COPD) and emphysema further therapeutic options, complementary to a medical treatment. In addition to the established valve implantation, new approaches have been available since 2009. These procedures include bronchoscopic thermal vapor ablation (BTVA) and polymeric lung volume reduction. Both therapies are independent of collateral ventilation (CV), are irreversible and can be used on segmental (BTVA) and sub-segmental level [polymeric lung volume reduction (PLVR)], in contrast to valve therapy. The intention is to induce a local inflammation with a following fibrosis and shrinkage and thus a volume reduction in the treated lung areas. Currently, only patients with predominant upper-lobe emphysema are treated. An improvement of lung function, exercise capacity and quality of life could be proved in RCTs for BTVA as well as for PLVR. However, the data for PLVR is very limited and has recently been available only in studies. Furthermore, the risk profile is unfavourable with a high number of adverse respiratory events. While BTVA is an established new approach, the PLVR requires re-evaluation regarding materials, predictive factors, safety profile and dosage.

Lung volume reduction with endobronchial coils for patients with emphysema

The lung volume reduction coil treatment is a minimally invasive bronchoscopic treatment option for emphysema patients who suffer from severe hyperinflation. The treatment is aimed at a large group of patients where lung volume reduction surgery and bronchoscopic lung volume reduction using endobronchial valves are no option, or alternatively, can be offered as a bridge to lung transplantation. The nitinol coil exhibits a shape memory effect and is biologically inert. The lung volume reduction coil procedure is performed in two separate treatment sessions, targeting one lobe per session, with the contralateral lobe being treated 4 to 8 weeks after the first session. In one treatment session, around 10 to 14 coils, thereby treating an entire lobe, are being placed. Selecting optimally treated, symptomatic chronic obstructive pulmonary disease (COPD) patients with emphysema and severe hyperinflation, while avoiding significant airway disease such as asthma, chronic bronchitis and bronchiectasis, is key to achieve treatment success. Three randomized clinical trials investigating lung volume reduction coil treatment have been published until now, reporting the results of 452 treated patients up to 12 months after coil treatment. Lung volume reduction coil treatment results in significant improvement of pulmonary function outcomes and quality of life in patients with severe hyperinflation. The most common complications of lung volume reduction coil treatment are: COPD exacerbations, pneumonia, Coil Associated Opacity and an increased risk of pneumothorax. The purpose of this article is to describe the coil technique and review the available literature regarding effect, safety and future perspectives of lung volume reduction with coils for emphysema patients.

Clinical and quantitative computed tomography predictors of response to endobronchial lung volume reduction therapy using coils

Objectives

Bronchoscopic lung volume reduction using coils (LVRC) is a well-known treatment option for severe emphysema. The purpose of this study was to identify quantitative computed tomography (QCT) and clinical parameters associated with positive treatment outcome.

Patients and methods

The CT scans, pulmonary function tests (PFT), and 6-minute walk test (6-MWT) data were collected from 72 patients with advanced emphysema prior to and at 3 months after LVRC treatment. The procedure involved placing 10 coils unilaterally. Various QCT parameters were derived using Apollo imaging software (VIDA). Independent predictors of clinically relevant outcome (Δ6-MWT ≥ 26 m, ΔFEV₁ ≥ 12%, ΔRV ≥ 10%) were identified through stepwise linear regression analysis.

Results

The response outcome for Δ6-MWT, for ΔFEV₁ and for ΔRV was met by 55%, 32% and 42%, respectively. For Δ6-MWT ≥ 26 m a lower baseline 6-MWT (p = 0.0003) and a larger standard deviation (SD) of low attenuation cluster (LAC) sizes in peripheral regions of treated lung (p = 0.0037) were significantly associated with positive outcome. For ΔFEV₁ ≥ 12%, lower baseline FEV₁ (p = 0.02) and larger median LAC sizes in the central regions of treated lobe (p = 0.0018) were significant predictors of good response. For ΔRV ≥ 10% a greater baseline TLC (p = 0.0014) and a larger SD of LAC sizes in peripheral regions of treated lung (p = 0.007) tended to respond better.

Conclusion

Patients with lower FEV₁ and 6-MWT, with higher TLC and specific QCT characteristics responded more positively to LVRC treatment, suggesting a more targeted CT-based approach to patient selection could lead to greater efficacy in treatment response.

Endobronchial Coils for Endoscopic Lung Volume Reduction: Best Practice Recommendations from an Expert Panel

Endobronchial coils are an additional treatment option for lung volume reduction in patients with severe emphysema. Patient selection should be focused on patients with severe emphysema on optimal medical therapy and with evidence of severe hyperinflation. The technique is suitable in a broad range of patients with emphysema; however, patients with paraseptal emphysema, large focal (giant) bullae, significant co-morbidity and airway-predominant disease should be avoided. Treatment involves placing between 10 and 14 coils by bronchoscopy in the selected treatment lobe, with 2 lobes being treated sequentially. Lobe selection for treatment should be based on quantitative computed tomography, and the lobes with the greatest destruction should be targeted (excluding the right middle lobe). The treatment results in an improvement in pulmonary function, exercise performance and quality of life, particularly in patients with severe hyperinflation (residual volume > 200% predicted) and upper-lobe heterogeneous emphysema, but will also be of benefit in lower-lobe predominant and homogeneous emphysema. Finally, it has an acceptable safety profile, although special attention has to be paid to coil-associated opacity which is an inflammatory response that occurs in some patients treated with endobronchial coils.

Endoscopic approaches for treating emphysema

INTRODUCTION

Surgical treatment of severe pulmonary emphysema has so far been associated with relatively high perioperative morbidity and mortality. In the past two decades, novel approaches to lung volume reduction and alternative minimally invasive endoscopic techniques have been developed. This review presents the different techniques (blocking and nonblocking) available until present as well as the appropriate patient selection and possible complications. Areas covered: All available randomized controlled trials (RCTs) have been evaluated. The only blocking technique is the reversible valve implantation. It results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation and its efficacy has been confirmed in various RCTs. Non-blocking techniques that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation, and the polymeric lung volume reduction both inducing inflammatory reaction. These methods have been up to date examined in a few RCTs only. Finally, the targeted lung denervation aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. Expert commentary: Future studies must address the predictors of clinical outcome as well as the reduction of complications to improve both outcome and safety.

Bronchoscopic Lung Volume Reduction: A 2018 Review and Update

Bronchoscopic lung volume reduction (BLVR) procedure has expanded the treatment spectrum of patients with end-stage emphysema. These treatments include valve, coil, thermal vapor ablation, bio-lung volume reduction, targeted lung denervation, and airway bypass stent. This short review provides an up-to-date information on BLVR treatments, their clinical benefits, and an overview of complications. BLVR treatments generally affect dyspnea by reducing hyperinflation and residual volume (RV). Benefits of treatment are associated with improvement in lung function parameters (forced expiration volume in the first second, total lung capacity, RV, and 6-minute walking test) and quality of life. Serious potential pulmonary complications, such as pneumothorax, pneumonia, respiratory failure, and chronic obstructive pulmonary disease exacerbation, may also occur after BLVR treatment. In addition to these, low-cost BLVR methods, such as autologous blood and fibrin glue, are in the developmental stage. Bronchoscopic lung volume reduction treatments are a promising method with positive results for patients with severe emphysema. The widespread use of these techniques, inadequate selection of patients, and non-critical and, therefore, unsuccessful use of BLVR in non-specialist centers lead to a false negative impression of the effectiveness of these techniques. In addition to these considerations, it is obvious that these treatments, which are quite expensive, are burdening social health systems. The reduction of costs or the development of lower-cost treatment methods is important for the future and for the availability of treatments.

Interventional pulmonology in chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) and emphysema are widespread diseases associated with progressive dyspnea because of airflow limitation and hyperinflation. Fundamental therapeutic strategies consist of pulmonary rehabilitation, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation, and surgical therapeutic approaches.

RECENT FINDINGS

In the last 14 years, endoscopic therapeutic modalities emerged as a substantial part of severe COPD and emphysema treatment. Techniques of the endoscopic lung volume reduction (ELVR) aim at reduction of hyperinflation. Thereby, the reversible valve implantation of which the efficacy was confirmed in various randomized controlled trials (RCT) results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation. Nonblocking ELVR methods that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation and polymeric lung volume reduction both inducing inflammatory reaction. The nonblocking methods have been examined in only a few RCTs. The targeted lung denervation as a novel bronchoscopic therapy for COPD patients aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves.

SUMMARY

The review summarizes the various endoscopic treatment approaches for managment of COPD and emphysema, their mechanism of action, their complications and the current available results of the most important RCTs.

Late onset of pneumothorax after bronchoscopic lung volume reduction due to migration of a nitinol coil

The use of Endobronchial coils are a relatively new brochoscopic technique for lung volume reduction. They appear to be safe and effective in improving quality of life, reducing morbidity and mortality related to the primary disease, while avoiding the many risks of morbidity and mortality associated with surgery. Nevertheless, some complications, such as pneumothorax, are relatively common in the periprocedural period. We describe a case of pneumothorax that occurred several days after brochoscopic technique for lung volume reduction due to direct perforation of the visceral pleura by a coil. The patient presented with a large pneumothorax associated with significant air leak, requiring surgical intervention. Exploration of the chest cavity showed a pleural tear caused by a coil. To our knowledge, this is an adverse event that has never been described before, suggesting the possible migration of the coil from the original position.

Endobronchial Coils Versus Lung Volume Reduction Surgery or Medical Therapy for Treatment of Advanced Homogenous Emphysema

Rationale: Bronchoscopic lung volume reduction utilizing shape-memory nitinol endobronchial coils (EBC) may be safer and more effective in severely hyperinflated homogeneous emphysema compared to medical therapy or lung volume reduction surgery (LVRS). Methods: The effect of bilateral EBC in patients with homogeneous emphysema on spirometry, lung volumes and survival was compared to patients with homogeneous emphysema randomized in the National Emphysema Treatment Trial (NETT) to LVRS or medical therapy. NETT participants were selected to match EBC participants in age, baseline spirometry, and gender. Outcomes were compared from baseline, at 6 and 12 months. Results: There were no significant baseline differences in gender in the EBC, NETT-LVRS or medical treatment patients. At baseline no differences existed between EBC and NETT-LVRS patients in forced expiratory volume in 1 second ( FEV₁) or total lung capacity (TLC) %-predicted; residual volume (RV) and diffusing capacity of the lung for carbon monoxide (DLco) %-predicted were higher in the EBC group compared to NETT-LVRS (p < 0.001). Compared to the medical treatment group, EBC produced greater improvements in FEV₁ and RV but not TLC at 6 months. FEV₁ and RV in the EBC group remained significantly improved at 12-months compared to the medical treatment group. While all 3 therapies improved quality of life, survival at 12 months with EBC or medical therapy was greater than NETT-LVRS. Conclusion: EBC may be a potential therapeutic option in patients with severe homogeneous emphysema and hyperinflation who are already receiving optimal medical treatment.

On the Potential Role of MRI Biomarkers of COPD to Guide Bronchoscopic Lung Volume Reduction

RATIONALE AND OBJECTIVES

In patients with severe emphysema and poor quality of life, bronchoscopic lung volume reduction (BLVR) may be considered and guided based on lobar emphysema severity. In particular, x-ray computed tomography (CT) emphysema measurements are used to identify the most diseased and the second-most diseased lobes as BLVR targets. Inhaled gas magnetic resonance imaging (MRI) also provides chronic obstructive pulmonary disease (COPD) biomarkers of lobar emphysema and ventilation abnormalities. Our objective was to retrospectively evaluate CT and MRI biomarkers of lobar emphysema and ventilation in patients with COPD eligible for BLVR. We hypothesized that MRI would provide complementary biomarkers of emphysema and ventilation that help determine the most appropriate lung lobar targets for BLVR in patients with COPD.

MATERIALS AND METHODS

We retrospectively evaluated 22 BLVR-eligible patients from the Thoracic Imaging Network of Canada cohort (diffusing capacity of the lung for carbon monoxide = 37 ± 12%_predicted, forced expiratory volume in 1 second = 34 ± 7%_predicted, total lung capacity = 131 ± 17%_predicted, and residual volume = 216 ± 36%_predicted). Lobar CT emphysema, measured using a relative area of <-950 Hounsfield units (RA₉₅₀) and MRI ventilation defect percent, was independently used to rank lung lobe disease severity.

RESULTS

In 7 of 22 patients, there were different CT and MRI predictions of the most diseased lobe. In some patients, there were large ventilation defects in lobes not targeted by CT, indicative of a poorly ventilated lung. CT and MRI classification of the most diseased and the second-most diseased lobes showed a fair-to-moderate intermethod reliability (Cohen κ = 0.40-0.59).

CONCLUSIONS

In this proof-of-concept retrospective analysis, quantitative MRI ventilation and CT emphysema measurements provided different BLVR targets in over 30% of the patients. The presence of large MRI ventilation defects in lobes next to CT-targeted lobes might also change the decision to proceed or to guide BLVR to a different lobar target.

[Not Available]

Zusammenfassung. Die endoskopische Lungenvolumenreduktion (ELVR) hat sich in den vergangenen Jahren in ausgewählten Patienten mit schwerem Lungenemphysem als valable Alternative zur chirurgischen Lungenvolumenreduktion etabliert. Die Wahl der ELVR-Technik richtet sich danach, ob zwischen dem zu behandelnden und dem benachbarten Lungenlappen Kollateralventilation vorhanden ist, was mittels computertomografischer und endoskopischer Techniken festgestellt werden kann. Als Vorteile der ELVR-Verfahren sind die geringe Invasivität mit entsprechend geringer Mortalität und Morbidität bei niedrigen Kosten zu nennen, zudem ist die Ventileinlage bei Bedarf reversibel. Die Wirksamkeit der ELVR-Verfahren (Ventile, Coils) wurde in mehreren prospektiven, randomisierten Studien belegt. Die Wahl des für den Patienten geeigneten Verfahrens zur Lungenvolumenreduktion sollte weiterhin in einer interdisziplinären Besprechung mit Thoraxchirurgen und spezialisierten Pneumologen erfolgen. La réduction du volume pulmonaire par endoscopie est devenue une importante alternative à la chirurgie chez les malades présentant un emphysème pulmonaire sévère. Le choix de la technique au niveau individuel dépend principalement de l’intégrité de la fissure interlobaire et de la présence d’une ventilation collatérale, cette dernière pouvant être déterminée par tomographie computérisée quantitative et des techniques endoscopiques. Les avantages de la réduction du volume pulmonaire par endoscopie consistent en son caractère minimalement invasif ( procédure utilisant un orifice naturel) et des coûts potentiellement réduits. Par ailleurs ce mode de réduction du volume pulmonaire permet de restaurer la ventilation en cas de besoin. Le choix de la technique appropriée chez un malade donné devrait être discuté de manière interdisciplinaire dans le cadre d’un groupe comportant des pneumologues interventionnels et des chirurgiens thoraciques.

Changes in dynamic lung mechanics after lung volume reduction coil treatment of severe emphysema

We assessed the relationships between changes in lung compliance, lung volumes and dynamic hyperinflation in patients with emphysema who underwent bronchoscopic treatment with nitinol coils (coil treatment) (n=11) or received usual care (UC) (n=11). Compared with UC, coil treatment resulted in decreased dynamic lung compliance (C_Ldyn) (p=0.03) and increased endurance time (p=0.010). The change in C_Ldyn was associated with significant improvement in FEV₁ and FVC, with reduction in residual volume and intrinsic positive end-expiratory pressure, and with increased inspiratory capacity at rest/and at exercise. The increase in end-expiratory lung volume (EELV) during exercise (EELV_dyn-ch=EELV_isotime EELV_rest) demonstrated significant attenuation after coil treatment (p=0.02).

Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures

There has been great progress in antithrombotic therapy over the past several years. Its use has increased with the advent of novel anticoagulants, as these medications do not require frequent blood tests for monitoring. Antithrombotic therapy is aimed at reducing the risk of thromboembolic events in patients with atrial fibrillation, coronary artery disease, deep vein thrombosis, valvular heart disease and pulmonary embolism. These patients are often critically ill and frequently undergo urgent interventions requiring discontinuation of anticoagulant or antiplatelet therapy which can increase the risk of thrombosis; however, continuing these agents can lead to increased risk of haemorrhage.

The purpose of this article is to summarise the literature surrounding the safety of using antiplatelet and anticoagulant therapies in patients undergoing interventional pulmonary procedures.

Available studies suggest some antithrombotic agents may be used in interventional pulmonary procedureshttp://ow.ly/vSF030bRqjt

Individualised risk in patients undergoing lung volume reduction surgery: the Glenfield BFG score

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 (T_LCO) <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.

The Safety and Feasibility of Re-treating Patients with Severe Emphysema with Endobronchial Coils: A Pilot Study

Severe emphysema patients who have been treated with endobronchial coils have been shown to initially benefit, but slowly decline in the years thereafter. Re-treating a patient with endobronchial coils could potentially lead to new improvements and may again reduce the rate of further decline. To our knowledge, until now, no results are published about patients who are re-treated. The primary aim of this study is to investigate the safety and feasibility of re-treating severe emphysema patients with endobronchial coils, using the PneumRx coil system. Furthermore, as secondary aim, we will evaluate the efficacy of re-treating these patients. Patients who at least 2 years ago were treated with endobronchial coils and responded clinically meaningful to this treatment were included in the study and re-treated. Safety was evaluated by the number of reported adverse events. Efficacy was evaluated 6 months after re-treatment, and measured by the change in quality of life, exercise capacity and pulmonary function testing. Eight patients were re-treated at a median of 1382 days (range 849-1545) after initial coil treatment with a median additional of 12 (10-15) coils per patient. During treatment, and until 6 months of follow-up, no unexpected adverse events occurred. Quality of life, exercise capacity and lung function did not change significantly 6 months after re-treatment. The results of this pilot study suggest that re-treating patients with endobronchial coils is feasible and safe. However, larger studies are needed to confirm these results and to investigate the efficacy and thus the clinical relevance.

Successful Late Removal of Endobronchial Coils

Although endobronchial coils for the treatment of severe emphysema are associated with an acceptable safety profile, adverse events such as pneumothorax and thoracic pain may occur. The coils are indicated as a permanent implant and are deemed very difficult to remove. We describe the first successful removal of two coils 10 months after placement in a patient who experienced persistent thoracic pain. This case report highlights that very distal (subpleural) coil placement may induce pneumothorax and subsequent thoracic pain and that nonsurgical removal of coils up to 10 months after implantation is feasible.

Changes in physical activity and sedentary behaviour following pulmonary rehabilitation in patients with COPD

A more profound investigation about the responses in activity levels following pulmonary rehabilitation (PR) in patients with COPD is needed. We aimed to describe groups of patients with COPD according to patterns of change in physical activity and sedentary behaviour following PR. 90 patients with COPD (60% male; mean age 67 ± 8; median FEV₁ 47 (32-62) %pred) completed a comprehensive PR programme. A triaxial accelerometer was used to assess the time in sedentary behaviour, light activities and moderate-to-vigorous physical activity (MVPA). Additionally, exercise capacity, quality of life, and symptoms of anxiety and depression were assessed before and after PR. Six groups with different patterns of change in physical activity and sedentary behaviour were identified. The two most prevalent patterns were represented by good responders (increase in physical activity and reduction in sedentary behaviour, 34%) and poor responders (decrease in physical activity and increase in sedentary behaviour, 30%). Good responders had greater improvements in six-minute walk distance (6MWD) and symptoms of depression than poor responders (P < 0.05 for all). Strong correlation was found between changes in sedentary behaviour and changes in light activities (r_s = -0.89; P < 0.0001). Changes in 6MWD correlated fairly with changes in sedentary behaviour (r_s = -0.26), light activities (r_s = 0.25), and MVPA (r_s = 0.24); P < 0.05 for all. Different patterns of change in activity levels following PR can be found in patients with COPD. Focusing on light physical activities might be a potential strategy to make patients less sedentary, but for this to be achieved prior (or at least parallel) improvements in functional capacity seem to be necessary.

Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease

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.

Predicting Structure-Function Relations and Survival following Surgical and Bronchoscopic Lung Volume Reduction Treatment of Emphysema

Lung volume reduction surgery (LVRS) and bronchoscopic lung volume reduction (bLVR) are palliative treatments aimed at reducing hyperinflation in advanced emphysema. Previous work has evaluated functional improvements and survival advantage for these techniques, although their effects on the micromechanical environment in the lung have yet to be determined. Here, we introduce a computational model to simulate a force-based destruction of elastic networks representing emphysema progression, which we use to track the response to lung volume reduction via LVRS and bLVR. We find that (1) LVRS efficacy can be predicted based on pre-surgical network structure; (2) macroscopic functional improvements following bLVR are related to microscopic changes in mechanical force heterogeneity; and (3) both techniques improve aspects of survival and quality of life influenced by lung compliance, albeit while accelerating disease progression. Our model predictions yield unique insights into the microscopic origins underlying emphysema progression before and after lung volume reduction.

Surgical and, more recently, bronchoscopic lung volume reduction is the only available treatments for patients with advanced stage emphysema. Several large-scale, clinical studies have outlined appropriate selection criteria based on patient outcomes; however, the underlying mechanisms determining disease progression and response to these treatments are not well-understood. To answer this question, we have developed a network model of the lung to compare immediate and long-term response to each treatment. This approach allows us to directly study macroscopic changes in function related to microscopic changes in the local structural and mechanical environment. In addition, it facilitates direct comparisons between surgical and bronchoscopic lung volume reduction given identical initial conditions, which is not feasible in a clinical study. We propose here a mechanism suggesting that lung volume reduction efficacy is intimately linked to changes in microscopic force heterogeneity within the lung. Such an understanding of the mechanisms driving emphysema has the potential to greatly improve current therapies for this condition through more rationalized, patient-specific treatment strategies.

Novel Technologies in Endoscopic Lung Volume Reduction

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.

Early Trends in Bronchoscopic Lung Volume Reduction: A Systematic Review and Meta-analysis of Efficacy Parameters

INTRODUCTION

The goal of our systematic review and meta-analysis is to examine the therapeutic effectiveness of bronchoscopic lung volume reduction (BLVR), and to compare it with medical management and lung volume reduction surgery.

METHODS

Variables of interest were absolute change in FEV1, 6MWT, and SGRQ. Meta-analysis was performed for the BLVR modalities with ≥3 trials. Of the 18 shortlisted publications, only valves (four trials; n = 159) and coils (six trials; n = 194) qualified for meta-analysis. To avoid redundant reporting for valves, only the data for intact fissure subjects were analyzed. Outcome data are presented as the mean difference from baseline with 95% confidence interval at 6-months follow-up.

RESULTS

For BLVR using valves, the pooled mean difference (PMD) for FEV1 was 0.146 L (95% CI 0.111-0.181; p < 0.001), 6MWT was 45.225 meters (95% CI 26.954-63.495; p < 0.001), and SGRQ was -8.825 points (95% CI -14.824 to -2.825; p = 0.004). All the PMDs were statistically significant and higher than their respective minimal clinically important difference (MCID). For BLVR using coils, the PMD for FEV1 was 0.080 L (95% CI 0.057-0.104; p < 0.001), 6MWT was 45.320 meters (95% CI 28.040-62.600; p < 0.001), and SGRQ was -10.570 points (95% CI -13.299 to -7.841; p < 0.001). All three variables showed statistically significant PMDs but that for FEV1 was smaller than the MCID. Data from BLVR modalities with <3 major publications are reviewed in the discussion section.

CONCLUSIONS

BLVR offers early promise in the palliation of advanced emphysema. Better characterization of patients to identify phenotypes that will derive sustained benefit is needed.

Coils for the Treatment of Advanced Emphysema: A Growing Body of Evidence and Routine Experience

Endoscopic lung volume reduction (ELVR) mainly comprises endobronchial valves (EBV) and endobronchial coil (EBC) implants. EBV aims to occlude the most diseased and/or hyperinflated lobe thus inducing complete atelectasis. EBC therapy was developed a few years ago and is applicable independently of collateral flow and in patients presenting with disease dispersed throughout the upper and lower lobes. Bronchoscopic lung volume reduction with EBC is feasible in a wider range of patients (irrespective of collateral flow or disease homo/heterogeneity) than for EBV, and provides clinical benefits in the short-term, associated to an acceptable safety profile. The growing clinical and commercial experience of ELVR with nitinol coils will be reviewed in this article.