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Koopman M, Posthuma R, Vanfleteren LEGW, Simons SO, Franssen FME. Lung Hyperinflation as Treatable Trait in Chronic Obstructive Pulmonary Disease: A Narrative Review. Int J Chron Obstruct Pulmon Dis 2024; 19:1561-1578. [PMID: 38974815 PMCID: PMC11227310 DOI: 10.2147/copd.s458324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/12/2024] [Indexed: 07/09/2024] Open
Abstract
Lung hyperinflation (LH) is a common clinical feature in patients with chronic obstructive pulmonary disease (COPD). It results from a combination of reduced elastic lung recoil as a consequence of irreversible destruction of lung parenchyma and expiratory airflow limitation. LH is an important determinant of morbidity and mortality in COPD, partially independent of the degree of airflow limitation. Therefore, reducing LH has become a major target in the treatment of COPD over the last decades. Advances were made in the diagnostics of LH and several effective interventions became available. Moreover, there is increasing evidence suggesting that LH is not only an isolated feature in COPD but rather part of a distinct clinical phenotype that may require a more integrated management. This narrative review focuses on the pathophysiology and adverse consequences of LH, the assessment of LH with lung function measurements and imaging techniques and highlights LH as a treatable trait in COPD. Finally, several suggestions regarding future studies in this field are made.
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Affiliation(s)
- Maud Koopman
- Research and Development, Ciro+, Horn, the Netherlands
- NUTRIM, Institute of Nutrition and Translational Research in Metabolism, University Maastricht, Maastricht, the Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Rein Posthuma
- Research and Development, Ciro+, Horn, the Netherlands
- NUTRIM, Institute of Nutrition and Translational Research in Metabolism, University Maastricht, Maastricht, the Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Lowie E G W Vanfleteren
- COPD Center, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Sami O Simons
- NUTRIM, Institute of Nutrition and Translational Research in Metabolism, University Maastricht, Maastricht, the Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Frits M E Franssen
- Research and Development, Ciro+, Horn, the Netherlands
- NUTRIM, Institute of Nutrition and Translational Research in Metabolism, University Maastricht, Maastricht, the Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
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2
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El Gohary DAEW, Eltomey MA, Mohamed AS, Farahat AAER, Abd El Zaher AH. Bronchoscopic lung volume reduction by instillation of fibrinogen and thrombin in COPD patients with homogenous emphysema. BMC Pulm Med 2024; 24:86. [PMID: 38355502 PMCID: PMC10868100 DOI: 10.1186/s12890-024-02883-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The new endobronchial therapy called biological lung volume reduction (BioLVR) involves using a rapid polymerizing sealant to block off the most emphysematous portions of the lungs. The primary mechanism of action is resorption atelectasis, which is then followed by inflammation and remodeling of the airspace. The remodeling process will result in the formation of scars, leading to the contraction of the lung tissue. As a result, a decrease in functional lung volume is anticipated for a period of 6-8 weeks. OBJECTIVE Assessing the safety and effectiveness of bronchoscopic installation of (fibrinogen and thrombin) in COPD patients with homogeneous emphysema in terms of radiological, physiological, and quality of life outcomes. METHODS Between December 2017 and December 2019, 40 COPD patients with homogeneous emphysema were studied using a fiber optic bronchoscope while they were awake but sedated. Tanta University Hospitals' chest medicine department collaborated with the diagnostic radiology department of the Faculty of Medicine. RESULTS All the following parameters were reduced from their initial values: HRCT volumetry, RV/TLC, mMRC dyspnea scale, CAT score, 6MWT, FEV1, and the FEV1/FVC ratio at the first, third, and sixth months from the beginning (p = 0.001). One individual (0.025%) had pneumonia, whereas three individuals had COPD (0.075%). Using fibrin glue produced locally, biological lung volume reduction (Bio LVR) may be an effective treatment for advanced homogenous emphysema. CONCLUSION By using locally prepared fibrin glue the biologic lung volume reduction (Bio LVR) may be a convenient method to treat advanced homogenous emphysema.
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Affiliation(s)
| | - Mohamed Adel Eltomey
- Diagnostic Radiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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3
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Ravikumar N, Wagh A, Holden VK, Hogarth DK. Bronchoscopic lung volume reduction in emphysema: a review. Curr Opin Pulm Med 2024; 30:58-67. [PMID: 37916600 DOI: 10.1097/mcp.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- Nakul Ravikumar
- Department of Medicine, Division of Pulmonary and Critical Care, UMass Chan Medical School-Baystate, Springfield, Massachusetts
| | - Ajay Wagh
- Department of Medicine, Division of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Van K Holden
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - D Kyle Hogarth
- Department of Medicine, Division of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
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Everaerts S, Vandervelde CM, Shah P, Slebos DJ, Ceulemans LJ. Surgical and bronchoscopic pulmonary function-improving procedures in lung emphysema. Eur Respir Rev 2023; 32:230004. [PMID: 38123230 PMCID: PMC10731473 DOI: 10.1183/16000617.0004-2023] [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: 01/12/2023] [Accepted: 09/17/2023] [Indexed: 12/23/2023] Open
Abstract
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.
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Affiliation(s)
- Stephanie Everaerts
- Department of Pulmonary Diseases, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Christelle M. Vandervelde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Pallav Shah
- Department of Pulmonology, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
- Department of Pulmonology, Chelsea and Westminster Hospital, London, UK
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Both authors contributed equally
| | - Laurens J. Ceulemans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Both authors contributed equally
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5
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Egenod T, Deslee G, Degano B. [Bronchoscopic COPD treatments]. Rev Mal Respir 2023; 40:820-833. [PMID: 37684196 DOI: 10.1016/j.rmr.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/18/2023] [Indexed: 09/10/2023]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is associated with disabling respiratory symptoms including dyspnea, frequent exacerbations and chronic bronchitis. The currently available pharmacological and non-pharmacological therapies have limited efficacy, necessitating the development of interventional strategies, many of them endoscopic. STATE OF THE ART Endoscopic lung volume reduction has markedly increased over recent years, principally as regards the endobronchial valves currently used in routine care. Indeed, multiple randomized trials have demonstrated a significant clinical benefit in a selected population identifiable due to the absence of interlobar collateral ventilation. Other endoscopic volume reduction techniques (polymers, thermal vapor, spirals) shall require additional studies before being considered as options in routine care. Targeted lung denervation (TLD) has aroused interest as a means of reducing exacerbations in the early phases of relevant studies. Endobronchial techniques (bronchoscopic cryospray, bronchial rheoplasty) are still at a very early stage of development, which is aimed at reducing the symptoms of chronic bronchitis. OUTLOOK Aside from endobronchial valves, which are currently employed in routine care, all the above-mentioned endoscopic techniques require additional studies in order to determine their benefit/risk balance and to identify the population that would benefit the most. CONCLUSIONS Endoscopic treatments constitute a major avenue of research and innovation in the therapeutic management of COPD. Inclusion of patients in disease registries and clinical trials remains essential, the objective being to gauge the interest of these treatments and their future role in everyday COPD management.
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Affiliation(s)
- T Egenod
- Alpes, Inserm 1300, Grenoble, France.
| | - G Deslee
- Service de pneumologie, hôpital universitaire Dupuytren, Limoges, France
| | - B Degano
- Service de pneumologie, hôpital Maison Blanche, Inserm UMRS-1250, université Reims Champagne Ardenne, Reims, France
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6
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DeMarco B, MacRosty CR. Bronchoscopic Management of COPD and Advances in Therapy. Life (Basel) 2023; 13:life13041036. [PMID: 37109565 PMCID: PMC10147055 DOI: 10.3390/life13041036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent and morbid disease marked by irreversible structural changes in the lungs. Bronchoscopic therapies have significantly expanded the treatment armamentarium for patients with persistent symptoms by reducing the physiologic detriments of hyperinflation in a less invasive fashion than surgical lung volume reduction. The spectrum of bronchoscopic techniques to reduce hyperinflation includes endobronchial valves, coils, thermal ablation, and biologic sealants. Other therapies focus on reducing parasympathetic tone and mucus hypersecretion and include targeted lung denervation, bronchial rheoplasty, and cryospray techniques. In this article, we will review the variety of techniques for bronchoscopic lung volume reduction, both established and investigational, along with their respective benefits and complications and will briefly review other investigational therapies for COPD.
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Affiliation(s)
- Benjamin DeMarco
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Christina R MacRosty
- Section of Interventional Pulmonology and Pulmonary Oncology, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
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7
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Tonkin J, Shah PL. Sealing the gap in bronchoscopic lung volume reduction. Respirology 2022; 27:1012-1014. [PMID: 36104311 DOI: 10.1111/resp.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 12/13/2022]
Affiliation(s)
- James Tonkin
- Royal Brompton Hospital, London, UK.,Imperial College London, National Heart and Lung Institute, London, UK
| | - Pallav L Shah
- Royal Brompton Hospital, London, UK.,Imperial College London, National Heart and Lung Institute, London, UK.,Chelsea & Westminster Hospital, London, UK
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8
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Ing AJ, Jayapadman A, Kim WV, Ly C, Ho-Shon K, Lilburn P, Carew A, Ng BJH, Saghaie T, Williamson JP. Reversal of collateral ventilation using endoscopic polymer foam in COPD patients undergoing endoscopic lung volume reduction with endobronchial valves: A controlled parallel group trial. Respirology 2022; 27:1064-1072. [PMID: 35918295 DOI: 10.1111/resp.14338] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/18/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVE We have previously described reversal of collateral ventilation (CV) in a severe chronic obstructive pulmonary disease (COPD) patient with endoscopic polymer foam (EPF), prior to endoscopic lung volume reduction (ELVR) with valves. The aim of this study was to investigate the efficacy of this in a larger cohort and compare outcomes with a similar cohort with no CV. METHODS Patients with severe COPD, with the left upper lobe (LUL) targeted for ELVR, were assessed for CV with high resolution computed tomography (HRCT). If fissure completeness was >95% they were enrolled as controls for valves alone (endobronchial valve control group [EBV-CTRL]). If fissure completeness was 80%-95%, defects were mapped to the corresponding segment, where EPF was instilled following confirmation of CV with CHARTIS. EBVs were inserted 1 month afterwards. RESULTS Fourteen patients were enrolled into both arms. After 6 months, there were significant improvements in both groups in forced expiratory volume in 1 s (FEV1; +19.7% EPF vs. +27.7% EBV-CTRL, p < 0.05); residual volume (RV; -16.2% EPF vs. -20.1% EBV-CTRL, p = NS); SGRQ (-15.1 EPF vs. -16.6 EBV-CTRL p = NS) and 6 min walk (+25.8% EPF [77.2 m] vs. +28.4% [82.3 m] EBV-CTRL p = NS). Patients with fissural defects mapped to the lingula had better outcomes than those mapped to other segments (FEV1 +22.9% vs. +16.3% p < 0.05). There were no serious adverse reactions to EPF. CONCLUSION EPF successfully reverses CV in severe COPD patients with a left oblique fissure that is 80%-95% complete. Following EBV, outcomes are similar to patients with complete fissures undergoing ELVR with EBV alone. EPF therapy to reverse CV potentially increases the number of COPD patients suitable for ELVR with minimal adverse reactions.
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Affiliation(s)
- Alvin J Ing
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Anand Jayapadman
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Woo-Veen Kim
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Chelsea Ly
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Kevin Ho-Shon
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Paul Lilburn
- MQ Health, Macquarie University Hospital, North Ryde, New South Wales, Australia.,Department of Respiratory Medicine, Prince of Wales Hospital, Randwick, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Alan Carew
- Department of Thoracic Medicine, Prince Charles Hospital, Chermside, Queensland, Australia
| | - Benjamin J H Ng
- Respiratory Medicine, MQ Health, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Tajalli Saghaie
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Jonathan P Williamson
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
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9
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A multicenter, prospective, single-arm clinical investigation of a modified staged treatment algorithm using the AeriSeal system - The STAGE trial. Respir Med 2022; 203:106989. [PMID: 36166995 DOI: 10.1016/j.rmed.2022.106989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/02/2022] [Accepted: 09/11/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Treatment with AeriSeal is an alternate treatment option to achieve lung volume reduction in patients with severe COPD and emphysema who are not eligible for valve treatment. This study aimed to assess the safety and mode of action of a modified staged treatment algorithm with a staged treatment with lower dose of AeriSeal. METHODS We performed a prospective, multicenter feasibility study. AeriSeal was administered during two sequential bronchoscopies: 2 subsegments of a lobe treated with two 5 mL doses, followed by two 10 mL doses in a contralateral lobe after 6 weeks. RESULTS A total of 14 patients (36% male, mean FEV1 28.4% ± 6.7% of predicted) were enrolled. Ten patients completed both treatments, four were treated unilaterally. AeriSeal treatment resulted in significant TLVR (median 220.5 mL) at 3 months follow up. There were no significant changes from baseline at 12 months in lung function, exercise capacity and quality of life. During the 3-month post-treatment period, respiratory SAEs included 5 COPD exacerbations in 4 (28.6%) subjects, post-treatment acute inflammatory response (PAIR) in 2 (14.3%) subjects, and 1 respiratory failure event in 1 (7.1%) subject. CONCLUSION The staged and lower dosed administration of AeriSeal does not impact the overall safety profile in terms of reducing the type and frequency of respiratory SAEs previously reported for a single-stage treatment. A larger volume of AeriSeal than used in this study may be necessary to provide meaningful clinical benefits.
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10
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Koster TD, Dijk MV, Slebos DJ. Bronchoscopic Lung Volume Reduction for Emphysema: Review and Update. Semin Respir Crit Care Med 2022; 43:541-551. [PMID: 35562097 DOI: 10.1055/s-0042-1747938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In carefully selected patients with severe chronic obstructive pulmonary disease, characterized by emphysema and hyperinflation, lung volume reduction is an option to reduce lung hyperinflation, improve lung function, quality of life, and exercise capacity. Currently, there are several bronchoscopic and surgical treatment options to achieve lung volume reduction. It is important to carefully phenotype these patients, to select the optimal treatment option, with consideration of possible adverse events or contraindications, and it is highly recommended to discuss these treatment strategies in a multidisciplinary team. The treatment with one-way endobronchial valves has been investigated most extensively and more data are available regarding the treatment of more "marginal cases," or subsequent lung volume reduction surgery. Other bronchoscopic lung volume reduction options include treatment with coils, thermal vapor ablation, and sclerosant agents. In this review, we aim to summarize the current clinical evidence on the bronchoscopic lung volume reduction therapies and important aspects regarding optimal patient selection.
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Affiliation(s)
- T David Koster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marlies Van Dijk
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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11
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Joglekar MM, Slebos DJ, Leijten J, Burgess JK, Pouwels SD. Crosslink bio-adhesives for bronchoscopic lung volume reduction: current status and future direction. Eur Respir Rev 2021; 30:30/162/210142. [PMID: 34853096 DOI: 10.1183/16000617.0142-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/27/2021] [Indexed: 11/05/2022] Open
Abstract
Several bronchoscopic lung volume reduction (BLVR) treatments have been developed to reduce hyperinflation in emphysema patients. Lung bio-adhesives are among the most promising new BLVR treatment options, as they potentially provide a permanent solution for emphysematous patients after only a single application. To date, bio-adhesives have mainly been used as haemostats and tissue sealants, while their application in permanently contracting and sealing hyperinflated lung tissue has recently been identified as a novel and enticing opportunity. However, a major drawback of the current adhesive technology is the induction of severe inflammatory responses and adverse events upon administration. In our review, we distinguish between and discuss various natural, semi-synthetic and synthetic tissue haemostats and sealants that have been used for pulmonary applications such as sealing air/fluid leaks. Furthermore, we present an overview of the different materials including AeriSeal and autologous blood that have been used to achieve lung volume reduction and discuss their respective advantages and drawbacks. In conclusion, we describe the key biological (therapeutic benefit and biocompatibility) and biomechanical (degradability, adhesive strength, stiffness, viscoelasticity, tunability and self-healing capacity) characteristics that are essential for an ideal lung bio-adhesive material with the potential to overcome the concerns related to current adhesives.
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Affiliation(s)
- Mugdha M Joglekar
- University of Groningen, University Medical Center Groningen, Dept of Pathology and Medical Biology, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- University of Groningen, University Medical Center Groningen, Dept of Pulmonary Diseases, Groningen, The Netherlands
| | - Jeroen Leijten
- Dept of BioEngineering, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Janette K Burgess
- University of Groningen, University Medical Center Groningen, Dept of Pathology and Medical Biology, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Simon D Pouwels
- University of Groningen, University Medical Center Groningen, Dept of Pathology and Medical Biology, Groningen, The Netherlands .,University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Dept of Pulmonary Diseases, Groningen, The Netherlands
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12
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Carew AM, Williamson JP, Farah CS, Saghaie T, Phillips M, Ing A. Interventional bronchoscopy for chronic obstructive pulmonary disease: more than a pipe dream. Med J Aust 2021; 215:280-285. [PMID: 34382211 DOI: 10.5694/mja2.51218] [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] [Received: 01/19/2021] [Revised: 04/03/2021] [Accepted: 04/12/2021] [Indexed: 01/11/2023]
Abstract
Endoscopic lung volume reduction (ELVR) is recognised in both national and international expert guidelines as one of the few additive treatments to benefit patients with advanced chronic obstructive pulmonary disease (COPD) who are otherwise receiving optimal medical and supportive care. Despite these recommendations and a growing evidence base, these procedures are not widely offered across Australia and New Zealand, and general practitioner and physician awareness of this therapy can be improved. ELVR aims to mitigate the impact of hyperinflation and gas trapping on dyspnoea and exercise intolerance in COPD. Effective ELVR is of proven benefit in improving symptoms, quality of life, lung function and survival. Several endoscopic techniques to achieve ELVR have been developed, with endobronchial valve placement to collapse a single lobe being the most widely studied and commonly practised. This review describes the physiological rationale underpinning lung volume reduction, highlights the challenges of patient selection, and provides an overview of the evidence for current and investigational endoscopic interventions for COPD.
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Affiliation(s)
- Alan M Carew
- Macquarie Health, Sydney, NSW.,University of Queensland, Brisbane, QLD
| | - Jonathan P Williamson
- Macquarie Health, Sydney, NSW.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW
| | - Claude S Farah
- Macquarie Health, Sydney, NSW.,Concord Hospital, Sydney, NSW
| | - Tajalli Saghaie
- Macquarie Health, Sydney, NSW.,Concord Hospital, Sydney, NSW
| | | | - Alvin Ing
- Concord Hospital, Sydney, NSW.,Macquarie University, Sydney, NSW
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13
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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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Perotin JM, Dewolf M, Launois C, Dormoy V, Deslee G. Bronchoscopic management of asthma, COPD and emphysema. Eur Respir Rev 2021; 30:30/159/200029. [PMID: 33650526 DOI: 10.1183/16000617.0029-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/15/2020] [Indexed: 11/05/2022] Open
Abstract
In recent years, many bronchoscopic techniques have been developed in chronic obstructive airway inflammatory diseases, including asthma, COPD and emphysema. The main techniques with available data from randomised controlled trials are: 1) bronchial thermoplasty in asthma; 2) valves, coils and thermal vapor ablation in emphysema; and 3) targeted lung denervation in COPD. The objectives of this article are to describe the levels of evidence for efficacy and safety, long-term follow-up results beyond 1 year, and current recommendations for clinical practice from international guidelines for each technique.
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Affiliation(s)
- Jeanne Marie Perotin
- Dept of Pulmonary Medicine, University Hospital of Reims, Reims, France.,INSERM P3Cell UMR-S1250, SFR CAP-SANTE, University of Reims Champagne Ardenne, Reims, France
| | - Maxime Dewolf
- Dept of Pulmonary Medicine, University Hospital of Reims, Reims, France
| | - Claire Launois
- Dept of Pulmonary Medicine, University Hospital of Reims, Reims, France
| | - Valérian Dormoy
- INSERM P3Cell UMR-S1250, SFR CAP-SANTE, University of Reims Champagne Ardenne, Reims, France
| | - Gaëtan Deslee
- Dept of Pulmonary Medicine, University Hospital of Reims, Reims, France .,INSERM P3Cell UMR-S1250, SFR CAP-SANTE, University of Reims Champagne Ardenne, Reims, France
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15
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Endobronchial Lung Volume Reduction Therapies. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-020-00266-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Gülşen A. Endoscopic Lung Volume Reduction with Autologous Blood: What is the Evidence? Turk Thorac J 2021; 22:67-74. [PMID: 33646107 DOI: 10.5152/turkthoracj.2020.19118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 02/06/2020] [Indexed: 11/22/2022]
Abstract
Biological lung volume reduction (BioLVR) is a novel and low-cost endobronchial treatment method aimed at reducing the volume of the target lung lobe using biological agents, including fibrin-based hydrogel, fibrinogen, and autologous blood (AB) with thrombin. BioLVR induces local inflammation, resulting in acute airway obstruction, resorption atelectasis, fibrosis, and finally tissue remodeling by contraction of the target lobe and reduction in the lung volume, similar to the application of hot water vapor and foam. In addition, patients with severe impairment in lung function and quality of life may refuses to undergo surgery, resulting in limited treatment options. In such complex clinical scenarios, BioLVR with AB appears to be a good therapeutic option. These treatment modalities resulted in favorable outcomes in patients with heterogeneous and bullous emphysema, pulmonary lymphangioleiomyomatosis, and giant bullous lesions. AB applications result in functional improvement, improvement in the quality of life, decrease in dyspnea scores, and reduction in the size of bullae. Based on the available evidence, application of AB for lung volume reduction is minimally invasive and well tolerated by patients. There was no incidence of pneumothorax or mortality. This review aimed to investigate the benefits, complications, and future perspectives of AB application as BioLVR in the treatment of hyperinflated lung diseases.
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Affiliation(s)
- Aşkın Gülşen
- Interdisciplinary Allergy Outpatient Clinic, Department of Pneumology, University of Lübeck, Lübeck, Germany
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17
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Abstract
AbstractSevere emphysema with hyperinflation presents a therapeutic challenge. Inhaled medication has limited efficacy in individuals with mechanical constraints to the respiratory pump and impaired gas exchange. Lung volume reduction surgery (LVRS) reestablishes some semblance of normal physiology, resecting grossly expanded severely diseased tissue to restore the function of compromised relatively healthy lung, and has been shown to significantly improve exercise capacity, quality of life, and survival, especially in individuals with upper-lobe predominant emphysema and low-baseline exercise capacity, albeit with higher early morbidity and mortality. Bronchoscopic lung volume reduction achieved by deflating nonfunctioning parts of the lung is promoted as a less invasive and safer approach. Endobronchial valve implantation has demonstrated comparable outcomes to LVRS in selected individuals and has recently received approvals by the National Institute of Clinical Excellence in the United Kingdom and the Food and Drug Administration in the United States of America. Endobronchial coils are proving a viable treatment option in severe hyperinflation in the presence of collateral ventilation in selected cases of homogeneous disease. Modalities including vapor and sealant are delivered using a segmental strategy preserving healthier tissue within the same target lobe-efficacy and safety-data are, however, limited. This article will review the data supporting these novel technologies.
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Affiliation(s)
- Justin L. Garner
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- Department of Respiratory Medicine, Chelsea and Westminster Hospital, London, United Kingdom
- Airways Division, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Pallav L. Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- Department of Respiratory Medicine, Chelsea and Westminster Hospital, London, United Kingdom
- Airways Division, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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18
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Shah PL, Slebos DJ. Bronchoscopic interventions for severe emphysema: Where are we now? Respirology 2020; 25:972-980. [PMID: 32363706 DOI: 10.1111/resp.13835] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Chelsea and Westminster Hospital, London, UK
| | - Dirk-Jan Slebos
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
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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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20
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Bilaçeroğlu S. Interventional Bronchoscopy in the Management of Chronic Obstructive Lung Disease. CURRENT RESPIRATORY MEDICINE REVIEWS 2019. [DOI: 10.2174/1573398x15666190211155026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Semra Bilaçeroğlu
- Department of Pulmonary Medicine, Health Sciences University, Izmir Dr. Suat Seren Training and Research Hospital for Thoracic Medicine and Surgery, Izmir, Turkey
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21
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Mal H, Bunel V, Marceau A, Dombret M, Debray M, Crestani B. Réduction de volume pulmonaire endoscopique dans l’emphysème. Rev Mal Respir 2019; 36:880-888. [DOI: 10.1016/j.rmr.2019.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/28/2018] [Indexed: 01/03/2023]
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Flandes J, Soto FJ, Cordovilla R, Cases E, Alfayate J. Bronchoscopic Lung Volume Reduction. Clin Chest Med 2019; 39:169-180. [PMID: 29433712 DOI: 10.1016/j.ccm.2017.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Javier Flandes
- Bronchology and Interventional Pulmonology Unit, IIS-Fundación Jiménez Díaz, CIBERES, Avenida Reyes Catolicos No 2, Madrid 28040, Spain.
| | - Francisco J Soto
- Pulmonary and Critical Care, Department of Medicine, University of Tennessee Medical Center, 1940 Alcoa Hwy e, Knoxville, TN 37920, USA
| | - Rosa Cordovilla
- Bronchology and Interventional Pulmonology Unit, Salamanca University Hospital, Paseo de San Vicente 58, Salamanca 37007, Spain
| | - Enrique Cases
- Bronchology and Interventional Pulmonology Unit, La Fe University Hospital, Avenida Fernando Abril Martorell 106, Valencia 46026, Spain
| | - Javier Alfayate
- Bronchology and Interventional Pulmonology Unit, IIS-Fundación Jiménez Díaz, CIBERES, Avenida Reyes Catolicos No 2, Madrid 28040, Spain
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23
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Marchand E, d'Odemont JP, Dupont MV. A Patient with GOLD Stage 3 COPD « cured » by One-Way Endobronchial Valves. MEDICINA-LITHUANIA 2019; 55:medicina55030065. [PMID: 30862115 PMCID: PMC6473594 DOI: 10.3390/medicina55030065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/14/2019] [Accepted: 03/04/2019] [Indexed: 11/16/2022]
Abstract
Lung hyperinflation is a main determinant of dyspnoea in patients with chronic obstructive pulmonary disease (COPD). Surgical or bronchoscopic lung volume reduction are the most efficient therapeutic approaches for reducing hyperinflation in selected patients with emphysema. We here report the case of a 69-year old woman with COPD (GOLD stage 3-D) referred for lung volume reduction. She complained of persistent disabling dyspnoea despite appropriate therapy. Chest imaging showed marked emphysema heterogeneity as well as severe hyperinflation of the right lower lobe. She was deemed to be a good candidate for bronchoscopic treatment with one-way endobronchial valves. In the absence of interlobar collateral ventilation, 2 endobronchial valves were placed in the right lower lobe under general anaesthesia. The improvement observed 1 and 3 months after the procedure was such that the patient no longer met the pulmonary function criteria for COPD. The benefit persisted after 3 years.
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Affiliation(s)
- Eric Marchand
- CHU-UCL-Namur, site Godinne, Université catholique de Louvain, Department of Pneumology, Institut de recherche expérimentale et Clinique (IREC), Av Dr Therasse 1, Yvoir, BE 5530, Belgium.
- Laboratoire de Physiologie Respiratoire, URPhyM, NARILIS, Faculté de Médecine, UNamur. Rue de Bruxelles, 61, Namur, BE 5000, Belgium.
| | - Jean-Paul d'Odemont
- CHU-UCL-Namur, site Godinne, Université catholique de Louvain, Department of Pneumology, Av Dr Therasse 1, Yvoir - BELGIUM, BE 5530, Belgium.
| | - Michael V Dupont
- CHU-UCL-Namur, site Godinne, Department of Radiology, Av Dr Therasse 1, Yvoir , BE 5530, Belgium.
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24
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Herth F, Slebos DJ, Criner G, Valipour A, Sciurba F, Shah P. Endoscopic Lung Volume Reduction: An Expert Panel Recommendation – Update 2019. Respiration 2019; 97:548-557. [DOI: 10.1159/000496122] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
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25
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Bezzi M, Luzzi V, Novali M, Comel A, Polese G, Corbetta L. Competence in bronchoscopic treatments in emphysema. Panminerva Med 2018; 61:401-421. [PMID: 30486616 DOI: 10.23736/s0031-0808.18.03571-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) has been proven to be effective in patients with severe emphysema. These techniques are divided into two groups: non-blocking devices that are independent of collateral ventilation and blocking devices that are dependent on collateral ventilation so the choice of the target lobe with inadequate scissors is crucial for the success of the treatment. Current evidences suggest that not all classes and phenotypes of emphysema will benefit from BLVR, and that each technique appears to provide a greater benefit to specific sub-groups of patients. Careful patient selection is imperative to prevent insertion in patients unlikely to gain clinical benefits as well as wasteful expenditure. The Chartis system represents the gold standard for measuring fissure integrity and is a direct measurement method. Indirect method is instead the TC study which, thanks to the development of software for quantitative analysis, allows us to obtain reliable measurements of regional density of parenchyma, airway thickness and scissor integrity. BLVR is a highly complex procedure: a first-level competence is a pre-requisite for admission to training. The practical training must be based on discussion of clinical cases and the insertion techniques of the different devices on plastic or animal models, or on cadavers. A specific course, offering final certification, has been developed on the use of Zephyr valves.
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Affiliation(s)
| | - Valentina Luzzi
- Department of Interventional Pneumology, Careggi University Hospital, Florence, Italy -
| | | | - Andrea Comel
- Operative Unit of Pneumology, Department of Medicine, P. Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Guido Polese
- Operative Unit of Pneumology, Hospital of Villafranca, Villafranca di Verona Centro Polivalente (CUBO), Villafranca di Verona, Verona, Italy
| | - Lorenzo Corbetta
- Unit of Interventional Pneumology, University of Florence, Florence, Italy
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26
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Roetting M, Gompelmann D, Herth FJF. Thermic and chemical procedures for bronchoscopic lung volume reduction. J Thorac Dis 2018; 10:S2806-S2810. [PMID: 30210834 PMCID: PMC6129803 DOI: 10.21037/jtd.2018.05.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/14/2018] [Indexed: 11/06/2022]
Abstract
In the last 14 years several endoscopic procedures have been developed to offer patients with advanced chronic obstructive pulmonary disease (COPD) and emphysema further therapeutic options, complementary to a medical treatment. In addition to the established valve implantation, new approaches have been available since 2009. These procedures include bronchoscopic thermal vapor ablation (BTVA) and polymeric lung volume reduction. Both therapies are independent of collateral ventilation (CV), are irreversible and can be used on segmental (BTVA) and sub-segmental level [polymeric lung volume reduction (PLVR)], in contrast to valve therapy. The intention is to induce a local inflammation with a following fibrosis and shrinkage and thus a volume reduction in the treated lung areas. Currently, only patients with predominant upper-lobe emphysema are treated. An improvement of lung function, exercise capacity and quality of life could be proved in RCTs for BTVA as well as for PLVR. However, the data for PLVR is very limited and has recently been available only in studies. Furthermore, the risk profile is unfavourable with a high number of adverse respiratory events. While BTVA is an established new approach, the PLVR requires re-evaluation regarding materials, predictive factors, safety profile and dosage.
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Affiliation(s)
- Matthias Roetting
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
| | - Daniela Gompelmann
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
| | - Felix J. F. Herth
- Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany
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Abstract
INTRODUCTION Surgical treatment of severe pulmonary emphysema has so far been associated with relatively high perioperative morbidity and mortality. In the past two decades, novel approaches to lung volume reduction and alternative minimally invasive endoscopic techniques have been developed. This review presents the different techniques (blocking and nonblocking) available until present as well as the appropriate patient selection and possible complications. Areas covered: All available randomized controlled trials (RCTs) have been evaluated. The only blocking technique is the reversible valve implantation. It results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation and its efficacy has been confirmed in various RCTs. Non-blocking techniques that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation, and the polymeric lung volume reduction both inducing inflammatory reaction. These methods have been up to date examined in a few RCTs only. Finally, the targeted lung denervation aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. Expert commentary: Future studies must address the predictors of clinical outcome as well as the reduction of complications to improve both outcome and safety.
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Affiliation(s)
- Konstantina Kontogianni
- a Department of Pneumology and Critical Care Medicine , Thoraxklinik at University of Heidelberg , Heidelberg , Germany.,b Center for Lung Research , Heidelberg , Germany
| | - Ralf Eberhardt
- a Department of Pneumology and Critical Care Medicine , Thoraxklinik at University of Heidelberg , Heidelberg , Germany.,b Center for Lung Research , Heidelberg , Germany
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28
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Gülşen A. Bronchoscopic Lung Volume Reduction: A 2018 Review and Update. Turk Thorac J 2018; 19:141-149. [PMID: 30083406 PMCID: PMC6077007 DOI: 10.5152/turkthoracj.2018.18044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/11/2018] [Indexed: 11/22/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) procedure has expanded the treatment spectrum of patients with end-stage emphysema. These treatments include valve, coil, thermal vapor ablation, bio-lung volume reduction, targeted lung denervation, and airway bypass stent. This short review provides an up-to-date information on BLVR treatments, their clinical benefits, and an overview of complications. BLVR treatments generally affect dyspnea by reducing hyperinflation and residual volume (RV). Benefits of treatment are associated with improvement in lung function parameters (forced expiration volume in the first second, total lung capacity, RV, and 6-minute walking test) and quality of life. Serious potential pulmonary complications, such as pneumothorax, pneumonia, respiratory failure, and chronic obstructive pulmonary disease exacerbation, may also occur after BLVR treatment. In addition to these, low-cost BLVR methods, such as autologous blood and fibrin glue, are in the developmental stage. Bronchoscopic lung volume reduction treatments are a promising method with positive results for patients with severe emphysema. The widespread use of these techniques, inadequate selection of patients, and non-critical and, therefore, unsuccessful use of BLVR in non-specialist centers lead to a false negative impression of the effectiveness of these techniques. In addition to these considerations, it is obvious that these treatments, which are quite expensive, are burdening social health systems. The reduction of costs or the development of lower-cost treatment methods is important for the future and for the availability of treatments.
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Affiliation(s)
- Aşkın Gülşen
- Division of Clinical and Molecular Allergology, Research Center Borstel, Airway Research, Center North (ARCN), Member of the German Center for Lung Research, Borstel, Germany
- Interdisciplinary Allergy Outpatient Clinic, Department of Pneumology, University of Lübeck, Germany
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29
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Milenkovic B, Janjic SD, Popevic S. Review of lung sealant technologies for lung volume reduction in pulmonary disease. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2018; 11:225-231. [PMID: 29983599 PMCID: PMC6027678 DOI: 10.2147/mder.s127136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Emphysema is an incurable and underdiagnosed disease with obstructive ventilatory impairment of lung function. Despite decades of research, medical treatments available so far did not significantly improve the survival benefits. Different bronchoscopic methods for lung volume reduction (LVR) in emphysema were used in the past 2 decades aiming to close the airways serving the hyperinflated lung regions and to allow the gas in the more distal bullas to be absorbed. Sealants and adhesives can be natural/biological, synthetic and semisynthetic. In lung surgery, lung sealants are used to treat prolonged air leak, which is the most common complication. Sealants can also be applied in bronchoscopic lung volume reduction (BLVR) as they administer into the peripheral airways where they polymerize and act as tissue glue on the surface of the lung to seal the target area to cause durable permanent absorption atelectasis. Initial studies analyzed the efficacy of bronchoscopic instillation of a fibrinogen-thrombin complex solution in advanced emphysema. Future studies will analyze the effects of adding chondroitin sulfate and poly-L-lysine to thrombin-fibrinogen complex thus promoting fibroblast attachment, proliferation and scarring, causing bronchial fibrostenosis and preventing ventilation of the affected part of the lung. Modifications of these methods were later developed, and the efficacy of BLVR with other sealants was analyzed in clinical studies. Results from current studies using this treatment method are promising showing that it is effective in improving exercise tolerance and quality of life in patients with advanced emphysema. It seems that subjective benefits in dyspnea scores and quality of life are more marked than improvements in lung function tests. The safety profile of sealant techniques in BLVR was mostly acceptable in clinical studies. The definite conclusions about the effectiveness of sealant in BLVR could be difficult because only a small population was involved in the current studies. More randomized large controlled studies are needed in establishing the definite role of biological BLVR in the bronchoscopic treatment of emphysema.
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Affiliation(s)
- Branislava Milenkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia, .,Clinic for Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia,
| | - Sanja Dimic Janjic
- Clinic for Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia,
| | - Spasoje Popevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia, .,Clinic for Pulmonary Diseases, Clinical Center of Serbia, Belgrade, Serbia,
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30
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Straub G, Franzen D. [Not Available]. PRAXIS 2018; 107:379-386. [PMID: 29587594 DOI: 10.1024/1661-8157/a002937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Zusammenfassung. Die endoskopische Lungenvolumenreduktion (ELVR) hat sich in den vergangenen Jahren in ausgewählten Patienten mit schwerem Lungenemphysem als valable Alternative zur chirurgischen Lungenvolumenreduktion etabliert. Die Wahl der ELVR-Technik richtet sich danach, ob zwischen dem zu behandelnden und dem benachbarten Lungenlappen Kollateralventilation vorhanden ist, was mittels computertomografischer und endoskopischer Techniken festgestellt werden kann. Als Vorteile der ELVR-Verfahren sind die geringe Invasivität mit entsprechend geringer Mortalität und Morbidität bei niedrigen Kosten zu nennen, zudem ist die Ventileinlage bei Bedarf reversibel. Die Wirksamkeit der ELVR-Verfahren (Ventile, Coils) wurde in mehreren prospektiven, randomisierten Studien belegt. Die Wahl des für den Patienten geeigneten Verfahrens zur Lungenvolumenreduktion sollte weiterhin in einer interdisziplinären Besprechung mit Thoraxchirurgen und spezialisierten Pneumologen erfolgen. La réduction du volume pulmonaire par endoscopie est devenue une importante alternative à la chirurgie chez les malades présentant un emphysème pulmonaire sévère. Le choix de la technique au niveau individuel dépend principalement de l’intégrité de la fissure interlobaire et de la présence d’une ventilation collatérale, cette dernière pouvant être déterminée par tomographie computérisée quantitative et des techniques endoscopiques. Les avantages de la réduction du volume pulmonaire par endoscopie consistent en son caractère minimalement invasif ( procédure utilisant un orifice naturel) et des coûts potentiellement réduits. Par ailleurs ce mode de réduction du volume pulmonaire permet de restaurer la ventilation en cas de besoin. Le choix de la technique appropriée chez un malade donné devrait être discuté de manière interdisciplinaire dans le cadre d’un groupe comportant des pneumologues interventionnels et des chirurgiens thoraciques.
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Affiliation(s)
- Gilles Straub
- 1 Interventionelles Lungenzentrum, Klinik für Pneumologie, Universitätsspital Zürich
| | - Daniel Franzen
- 1 Interventionelles Lungenzentrum, Klinik für Pneumologie, Universitätsspital Zürich
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31
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van Geffen WH, Kerstjens HA, Slebos DJ. Emerging bronchoscopic treatments for chronic obstructive pulmonary disease. Pharmacol Ther 2017; 179:96-101. [DOI: 10.1016/j.pharmthera.2017.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Aggelou K, Siafakas N. Medical lung volume reduction for severe emphysema: A review. Respir Med 2017; 131:141-147. [DOI: 10.1016/j.rmed.2017.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/13/2017] [Accepted: 08/07/2017] [Indexed: 12/27/2022]
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van Geffen WH, Klooster K, Hartman JE, Ten Hacken NHT, Kerstjens HAM, Wolf RFE, Slebos DJ. Pleural Adhesion Assessment as a Predictor for Pneumothorax after Endobronchial Valve Treatment. Respiration 2017. [PMID: 28637047 DOI: 10.1159/000477258] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pneumothorax after bronchoscopic lung volume reduction using one-way endobronchial valves (EBVs) in patients with advanced emphysema occurs in approximately 20% of patients. It is not well known which factors predict the development of pneumothorax. OBJECTIVE To assess whether pleural adhesions on pretreatment high-resolution computed tomography (HRCT) scans are associated with pneumothorax occurrence after EBV treatment. METHODS HRCT scan analyses were performed on all patients who received EBV treatment in a randomized controlled trial. Three blinded readers scored adhesions by number and by measuring the longest axis of each pleural adhesion in the treated lung. The Pleural Adhesion Score (PAS) was calculated by adding 1 point for each small pleural lesion (<1 mm), 5 points for each medium-sized lesion (1-5 mm), and 10 points for each large lesion (>5 mm). RESULTS The HRCT scans of 64 treated patients were assessed, of whom 14 developed pneumothorax. Patients who developed pneumothorax had a higher median number of pleural adhesions, 2.7 (IQR 1.9-4) compared to 1.7 (1-2.7) adhesions in the group without pneumothorax (p < 0.01). The PAS in the group with pneumothorax was higher compared to that in the group without: 14.3 (12.4-24.1) versus 6.7 (3.7-11.2) (p < 0.01). A threshold PAS of ≥12 was associated with a higher risk of pneumothorax (OR 13.0, 95% CI 3.1-54.9). A score <12 did not rule out the occurrence of pneumothorax. CONCLUSION A higher number of pleural adhesions on HRCT with a subsequent higher PAS in the treated lung is associated with a higher occurrence of pneumothorax after EBV treatment.
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Affiliation(s)
- Wouter H van Geffen
- Department of Respiratory Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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Abstract
PURPOSE The aim of the study was to assess the pulmonary temporal changes after bronchoscopic lung volume reduction (BLVR) using sealants for treatment of emphysema. MATERIALS AND METHODS We retrospectively assessed all chest computerized tomography (CT) and F-18 fluorodeoxyglucose (FDG) positron emission tomography CT scans of patients treated at our institution with BLVR. RESULTS Eleven patients were treated with sealants: 4 with biological sealants and 7 with synthetic sealants. The first CT scan after biological sealant treatment showed no abnormalities in 8 lobes and 5 nodules, and 3 consolidations in 7 lobes. All findings resolved within 3 months, except for a nodule that decreased after 2 months and remained stable for 9 years. The first CT scan after utilizing the synthetic sealant showed abnormalities in each treated lobe: 19 nodules/masses (16 cavitary, 3 solid) and 3 consolidations. Follow-up CT scans were available for 16 nodules/masses: 1 resolved, 12 slowly decreased in size, 1 remained unchanged, and 2 grew. Of 3 consolidations 1 resolved and 2 decreased in size. FDG positron emission tomography CT scans performed in 2 patients showed FDG uptake higher than mediastinal background activity in 2 nodules in the same patient. CONCLUSIONS Pulmonary changes after BLVR are variable. After treatment with biological sealants, most findings resolve within 3 months. In contrast, after synthetic sealants, although the majority regress over time, some show waxing and waning in growth that can mimic malignancy. FDG uptake in some of these lesions is suggestive of chronic inflammation. Radiologists should be aware of the spectrum of these pulmonary changes to avoid misdiagnosis of lung cancer.
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Zhang JJ, Yin Y, Hou G. The bronchoscopic interventions for chronic obstructive pulmonary disease according to different phenotypes. J Thorac Dis 2017; 9:1361-1365. [PMID: 28616289 DOI: 10.21037/jtd.2017.05.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bronchoscopic interventions are valuable adjuncts to the pharmacologic therapy for chronic obstructive pulmonary disease (COPD). But different phenotypes of COPD patients showed different clinical responses to the same or similar therapy. The optimal selection of bronchoscopic interventions for COPD patients also needs to be based on the phenotypes. According to the different phenotypes, novel interventional pulmonology techniques which were used for COPD treatments in daily clinical practice or clinical trials have been described extensively throughout our current review.
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Affiliation(s)
| | - Yan Yin
- Department of Respiratory Medicine, First Hospital of China Medical University, Shenyang 110001, China
| | - Gang Hou
- Department of Respiratory Medicine, First Hospital of China Medical University, Shenyang 110001, China
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van Agteren JEM, Hnin K, Grosser D, Carson KV, Smith BJ. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; 2:CD012158. [PMID: 28230230 PMCID: PMC6464526 DOI: 10.1002/14651858.cd012158.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD). OBJECTIVES To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique. SEARCH METHODS Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016. SELECTION CRITERIA We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available. DATA COLLECTION AND ANALYSIS Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software. MAIN RESULTS AeriSealOne RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV1) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate. Airway bypass stentsTreatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV1 (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high. Endobronchial coilsThree studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV1 (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high. Endobronchial valvesFive studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV1 (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high. Intrabronchial valvesIn the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV1 (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV1 and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high. Vapour ablationOne study of 69 participants found significant mean between-group differences in FEV1 (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate. AUTHORS' CONCLUSIONS Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.
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Affiliation(s)
| | - Khin Hnin
- Flinders UniversityAdelaideAustralia
| | | | | | - Brian J Smith
- The University of AdelaideSchool of MedicineAdelaideAustralia
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Mondoñedo JR, Suki B. Predicting Structure-Function Relations and Survival following Surgical and Bronchoscopic Lung Volume Reduction Treatment of Emphysema. PLoS Comput Biol 2017; 13:e1005282. [PMID: 28182686 PMCID: PMC5300131 DOI: 10.1371/journal.pcbi.1005282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/06/2016] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Jarred R. Mondoñedo
- Department of Biomedical Engineering, Boston University, Boston, MA, United States of America
- School of Medicine, Boston University, Boston, MA, United States of America
| | - Béla Suki
- Department of Biomedical Engineering, Boston University, Boston, MA, United States of America
- * E-mail:
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Kumar A, Dy R, Singh K, Jeffery Mador M. Early Trends in Bronchoscopic Lung Volume Reduction: A Systematic Review and Meta-analysis of Efficacy Parameters. Lung 2016; 195:19-28. [PMID: 28005150 DOI: 10.1007/s00408-016-9969-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Abhishek Kumar
- Mercy Medical Center, Cedar Rapids, IA, USA. .,State University of New York/University at Buffalo, Buffalo, NY, USA.
| | - Rajany Dy
- State University of New York/University at Buffalo, Buffalo, NY, USA
| | | | - M Jeffery Mador
- State University of New York/University at Buffalo, Buffalo, NY, USA.,Western New York Veterans Administration Healthcare System, Buffalo, NY, USA
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Fellrath JM. Coils for the Treatment of Advanced Emphysema: A Growing Body of Evidence and Routine Experience. EUROPEAN MEDICAL JOURNAL 2016. [DOI: 10.33590/emj/10313673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
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.
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Affiliation(s)
- Jean-Marc Fellrath
- Internal Medicine Department/Service of Pneumology, Pourtalès Hospital, Neuchâtel, Switzerland
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Lung volume reduction for emphysema. THE LANCET RESPIRATORY MEDICINE 2016; 5:147-156. [PMID: 27693408 DOI: 10.1016/s2213-2600(16)30221-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 11/22/2022]
Abstract
Advanced emphysema is a lung disease in which alveolar capillary units are destroyed and supporting tissue is lost. The combined effect of reduced gas exchange and changes in airway dynamics impairs expiratory airflow and leads to progressive air trapping. Pharmacological therapies have limited effects. Surgical resection of the most destroyed sections of the lung can improve pulmonary function and exercise capacity but its benefit is tempered by significant morbidity. This issue stimulated a search for novel approaches to lung volume reduction. Alternative minimally invasive approaches using bronchoscopic techniques including valves, coils, vapour thermal ablation, and sclerosant agents have been at the forefront of these developments. Insertion of endobronchial valves in selected patients could have benefits that are comparable with lung volume reduction surgery. Endobronchial coils might have a role in the treatment of patients with emphysema with severe hyperinflation and less parenchymal destruction. Use of vapour thermal energy or a sclerosant might allow focal treatment but the unpredictability of the inflammatory response limits their current use. In this Review, we aim to summarise clinical trial evidence on lung volume reduction and provide guidance on patient selection for available therapies.
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Yu H, Wang L, Wu Z, Yang Z. Status of and prospects for bronchoscopic lung volume reduction for patients with severe emphysema. Biosci Trends 2016; 10:344-356. [PMID: 27594047 DOI: 10.5582/bst.2016.01113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) is a minimally invasive treatment for severe emphysema, providing treatment options for patients who are unable to undergo lung volume reduction surgery (LVRS) or lung transplantation. Current BLVR techniques include bronchoscopic volume reduction with valve implants, use of a lung volume reduction coil (LVRC), bronchoscopic thermal vapor ablation (BTVA), biological lung volume reduction (BioLVR), and use of airway bypass stents (ABS). To date, several randomized controlled trials of these bronchoscopic therapies have been conducted in patients with emphysema, and bronchoscopic volume reduction with valve implants remains the best approach thus far. Recent studies indicate that BLVR may be of great value in improving lung function, exercise capacity, and quality of life and that BLVR has the potential to replace conventional surgery for patients with severe emphysema. Optimal patient selection and the proper selection of the BLVR technique in accordance with patient characteristics are crucial to the success of BLVR. More multicenter, prospective, randomized controlled trials need to be conducted in the future to optimize the current selection strategy and evaluate the safety, efficiency, and long-term benefit of BLVR techniques.
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Affiliation(s)
- Hang Yu
- Department of Respiratory Medicine, Chinese PLA General Hospital
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The importance of patient selection for lung volume reduction. CURRENT PULMONOLOGY REPORTS 2016. [DOI: 10.1007/s13665-016-0153-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bakeer M, Abdelgawad TT, El-Metwaly R, El-Morsi A, El-Badrawy MK, El-Sharawy S. Low cost biological lung volume reduction therapy for advanced emphysema. Int J Chron Obstruct Pulmon Dis 2016; 11:1793-800. [PMID: 27536091 PMCID: PMC4976808 DOI: 10.2147/copd.s112009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Bronchoscopic lung volume reduction (BLVR), using biological agents, is one of the new alternatives to lung volume reduction surgery. OBJECTIVES To evaluate efficacy and safety of biological BLVR using low cost agents including autologous blood and fibrin glue. METHODS Enrolled patients were divided into two groups: group A (seven patients) in which autologous blood was used and group B (eight patients) in which fibrin glue was used. The agents were injected through a triple lumen balloon catheter via fiberoptic bronchoscope. Changes in high resolution computerized tomography (HRCT) volumetry, pulmonary function tests, symptoms, and exercise capacity were evaluated at 12 weeks postprocedure as well as for complications. RESULTS In group A, at 12 weeks postprocedure, there was significant improvement in the mean value of HRCT volumetry and residual volume/total lung capacity (% predicted) (P-value: <0.001 and 0.038, respectively). In group B, there was significant improvement in the mean value of HRCT volumetry and (residual volume/total lung capacity % predicted) (P-value: 0.005 and 0.004, respectively). All patients tolerated the procedure with no mortality. CONCLUSION BLVR using autologous blood and locally prepared fibrin glue is a promising method for therapy of advanced emphysema in term of efficacy, safety as well as cost effectiveness.
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Affiliation(s)
| | | | | | | | | | - Solafa El-Sharawy
- Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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An update on bronchoscopic treatments for chronic obstructive pulmonary disease. Curr Opin Pulm Med 2016; 22:265-70. [DOI: 10.1097/mcp.0000000000000260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Herth FJ, Slebos DJ, Rabe KF, Shah PL. Endoscopic Lung Volume Reduction: An Expert Panel Recommendation. Respiration 2016; 91:241-50. [DOI: 10.1159/000444090] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/16/2016] [Indexed: 11/19/2022] Open
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Liberator C, Shenoy K, Marchetti N, Criner G. The Role of Lobe Selection on FEV1 Response in Endobronchial Valve Therapy. COPD 2016; 13:477-82. [PMID: 26789984 DOI: 10.3109/15412555.2015.1115007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Endobronchial valve (EBV) therapy has shown improvement in symptoms and lung function despite limited understanding of ideal patient selection. The impact of lobe selection on EBV therapy is unclear. We performed a retrospective analysis to determine the role of lobe selection and identify preprocedure predictors of response to EBV therapy. A total of 492 patients from the USA and Europe were randomized to EBV or control therapy. Spirometry and functional measurements were taken at baseline and 12 months later. At 365 days patients undergoing EBV therapy showed improvement in FEV1 change compared to control regardless of treatment to upper or lower. There was no difference in FEV1 change between the upper and lower lobe treatment groups ( 5 .99, 7.04, p = 0.75). In addition lobe selection was not identified as a significant modifier of FEV1 change in multiple linear regression analysis. Complete lobe fissure was the only significant predictor of FEV1 change (OR 4.14 (2.29, 7.47)). Our results suggest that lobe selection does not play a major role in EBV therapy response. Complete fissure status preprocedure has the greatest influence on FEV1 improvement. These results have implications on patient selection for current treatment and in future EBV studies.
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Affiliation(s)
- Cole Liberator
- a Department of Internal Medicine , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Kartik Shenoy
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Nathaniel Marchetti
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Gerard Criner
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
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Eberhardt R, Gompelmann D, Herth FJF, Schuhmann M. Endoscopic bronchial valve treatment: patient selection and special considerations. Int J Chron Obstruct Pulmon Dis 2015; 10:2147-57. [PMID: 26504379 PMCID: PMC4603713 DOI: 10.2147/copd.s63473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
As well as lung volume reduction surgery, different minimally invasive endoscopic techniques are available to achieve lung volume reduction in patients with severe emphysema and significant hyperinflation. Lung function parameters and comorbidities of the patient, as well as the extent and distribution of the emphysema are factors to be considered when choosing the patient and the intervention. Endoscopic bronchial valve placement with complete occlusion of one lobe in patients with heterogeneous emphysema is the preferred technique because of its reversibility. The presence of high interlobar collateral ventilation will hinder successful treatment; therefore, endoscopic coil placement, polymeric lung volume reduction, or bronchoscopic thermal vapor ablation as well as lung volume reduction surgery can be used for treating patients with incomplete fissures. The effect of endoscopic lung volume reduction in patients with a homogeneous distribution of emphysema is still unclear and this subgroup should be treated only in clinical trials. Precise patient selection is necessary for interventions and to improve the outcome and reduce the risk and possible complications. Therefore, the patients should be discussed in a multidisciplinary approach prior to determining the most appropriate treatment for lung volume reduction.
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Affiliation(s)
- Ralf Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany ; Translational Lung Research Center, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Daniela Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany ; Translational Lung Research Center, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Felix J F Herth
- Pneumology and Critical Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany ; Translational Lung Research Center, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Maren Schuhmann
- Pneumology and Critical Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany
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Koegelenberg CFN, Slebos DJ, Shah PL, Theron J, Dheda K, Allwood BW, Herth FJF. Time for the Global Rollout of Endoscopic Lung Volume Reduction. Respiration 2015; 90:430-40. [PMID: 26393503 DOI: 10.1159/000439311] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/10/2015] [Indexed: 11/19/2022] Open
Abstract
Chronic obstructive pulmonary disease remains one of the most common causes of morbidity and mortality globally. The disease is generally managed with pharmacotherapy, as well as guidance about smoking cessation and pulmonary rehabilitation. Endoscopic lung volume reduction (ELVR) has been proposed for the treatment of advanced emphysema, with the aim of obtaining the same clinical and functional advantages of surgical lung volume reduction whilst potentially reducing risks and costs. There is a growing body of evidence that certain well-defined sub-groups of patients with advanced emphysema may benefit from ELVR, provided the selection criteria are met and a systematic approach is followed. ELVR devices, particularly unidirectional valves and coils, are currently being rolled out to many countries outside of the U.S.A. and Europe, although very few centres currently have the capacity to correctly evaluate and provide ELVR to prospective candidates. The high cost of these interventions underpins the need for careful patient selection to best identify those who may or may not benefit from ELVR-related procedures. The aim of this review is to provide the practicing pulmonologist with an overview of the practical aspects and current evidence for the use of the various techniques available, and to suggest an evidence-based approach for the appropriate use of these devices, particularly in emerging markets, where there should be a drive to develop and equip key specialised ELVR units.
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Affiliation(s)
- Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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Mizumori Y, Mochiduki Y, Nakahara Y, Kawamura T, Sasaki S, Morimoto A, Tsukamoto H. Effects of bronchoscopic lung volume reduction using transbronchial infusion of autologous blood and thrombin in patients with severe chronic obstructive pulmonary disease. J Thorac Dis 2015; 7:413-21. [PMID: 25922720 DOI: 10.3978/j.issn.2072-1439.2015.01.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 12/04/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Existing medical treatments have limitations in the management of very severe chronic obstructive pulmonary disease (COPD). METHODS We performed bronchoscopic lung volume reduction (BLVR) using transbronchial infusion of autologous blood and thrombin (BLVR with blood) in three patients with very severe COPD whose dyspnea could not be relieved by maximum medical management. Two patients underwent BLVR with blood in the left and right lungs at intervals of a half-year or a year, and one patient underwent this procedure in only the right lung. We assessed the changes in pulmonary function, exercise capacity and quality of life before and after BLVR with blood in a total of five procedures. RESULTS The subjects were 58- to 74-year-old males. Their forced expiratory volume in one second (FEV1) percent predicted ranged from 14.8% to 23.4%. BLVR with blood achieved significant improvements as follows (values before → after the procedure, mean ± standard deviation): FEV1 0.45r the L → 0.76r the L (P=0.004), inspiratory capacity 1.50cityo L → 2.05±.05c L (P=0.015), 3-minute walk test 46.8nuteo m → 89.6±34.5 m (P=0.004). Lung function peaked several months after BLVR with blood and returned to nearly the baseline level in 6 months, but exercise capacity was better than that at baseline for at least 12 months. St. George's Respiratory Questionnaire (SGRQ), measured in two patients before and 12 months after the procedure, showed remarkable improvements (-15.6 and -11.9 units). CONCLUSIONS BLVR with blood is an effective palliative treatment for very severe COPD.
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Affiliation(s)
- Yasuyuki Mizumori
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Yoshiro Mochiduki
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Shin Sasaki
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Akie Morimoto
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
| | - Hiroaki Tsukamoto
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, Japan
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Radiologic manifestations of bronchoscopic lung volume reduction in severe chronic obstructive pulmonary disease. AJR Am J Roentgenol 2015; 204:475-86. [PMID: 25714276 DOI: 10.2214/ajr.14.13185] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. Bronchoscopic lung volume reduction promises to become an effective treatment option in severe chronic obstructive pulmonary disease. Several techniques are currently being investigated, including implantation of devices into the lung and instillation of hot water vapor or polymer. This article reviews the spectrum of radiologic manifestations on chest radiography and CT that occur after the intervention. CONCLUSION. Familiarity with the intended effects and adverse events will aid the radiologist in supporting bronchoscopic lung volume reduction.
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