Identifying Responders and Exploring Mechanisms of Action of the Endobronchial Coil Treatment for Emphysema

Lung Tensioning Device Coil Treatment in Patients with Severe Emphysema: A Prospective Safety and Feasibility Trial (EFFORT)

INTRODUCTION

Currently, there is a lack of bronchoscopic lung volume reduction options that do not depend on fissure integrity. Endobronchial coils have been extensively studied to address this need but exhibited variable patient response and have been discontinued. Lung tension device (LTD) coils represent the next-generation coil treatment. This study aimed to evaluate safety, feasibility, and efficacy of LTD-coil treatment.

METHODS

Patients with advanced emphysema and hyperinflation were enrolled at two European sites. LTD-coils (Free Flow Medical, Fremont, CA, USA) were implanted in the two most destructed lobes, as determined by quantitative CT analysis, in two separate procedures. The primary endpoint was 3-month follow-up after the last treatment.

RESULTS

Fourteen patients (50% male, median age 64 years, FEV1 23%predicted, RV 249%predicted) received LTD-coil treatment: 12 received bilateral and 2 unilateral treatment. Six serious respiratory adverse events occurred within the initial 3 months posttreatment, including one device-associated death. Treatment significantly reduced in- and expiratory volume of the treated lobes (-410 [-710, -340], p = 0.004 and -650 [-730, -190] mL, p < 0.001, respectively) and improved quality of life (SGRQ total score -4.6 [-21.0, -2.6], p < 0.001). However, at a group level, no significant improvements in pulmonary function or 6-min walk distance were observed. Responder rates ranged from 18% to 54% for the different endpoints.

CONCLUSION

This first-in-human study shows that the new LTD-coil procedure is feasible with a safety profile comparable to the previous coil treatment. While the treatment effectively reduced lobar volume and modestly improved quality of life up to 3 months' follow-up, at a group level it did not significantly enhance pulmonary function or exercise capacity.

[First experience in endoscopic lung volume reduction with the FreeFlow Coil #4: A case series with three patients]

Lung volume reduction therapy is an established treatment for patients with severe emphysema of the lung. In Germany, the treatment with nitinol coils is the only method for endoscopic lung volume reduction in patients with positive collateral ventilation approved by the Gemeinsamer Bundesausschuss. Therefore this procedure can be performed as standard-of-care and has assured reimbursement. After the production of the initial coils was stopped for years, when the only manufacturer had been bought by a large corporation, by the end of 2022 there was a new nitinol-coil, the so called Coil #4, becme available in the European market. The new Coil #4 has a different shape, different application catheter and the implantation procedure differs from that of the original product. We report our experience in endoscopic lung volume reduction with the new Coil #4 in three patients with emphysema. The procedure was performed without complications. All three of them showed improvement in lung function parameters meeting minimal clinically important differences. In two of three patients, we also saw clinically relevant improvement in the 6MWT distance und improvements in SGRQ und CAT-Score. In our opinion, this case series is just a prospect of the possibilities that come with the Coil #4. With due caution, we will continue to offer the Coil #4 as a treatment for selected patients under constant evaluation of the outcome until more data is available.

Lung volume reduction surgery is safe and feasible after initial endobronchial valve treatment for emphysema patients

OBJECTIVES

Bronchoscopic lung volume reduction with endobronchial valves is a guideline treatment leading to improved pulmonary function, exercise tolerance and quality of life, in patients with advanced emphysema, severe hyperinflation and no collateral ventilation. After valve treatment, loss of the initial lung volume reduction effect can occur, as well as local valve-induced complications such as persistent haemoptysis. In these cases, a surgical lobectomy can be considered to achieve similar efficacy outcomes. We evaluated the safety and feasibility of a video-assisted thoracoscopic surgery lobectomy after valve treatment.

METHODS

This single-centre retrospective study included patients who underwent an elective lobectomy after previous valve treatment. Data were evaluated for safety and efficacy for the additional surgical procedure.

RESULTS

Twenty-one patients [73% female, median age 67 (7) years, forced expiratory volume in 1 s 29 (7) %pred, and residual volume 223 (58) %pred] were included. There was no 90-day mortality and there were no postoperative intensive care admissions. Pulmonary infections (14%) and prolonged air leak (14%) were the most common complications. In patients who underwent surgery due to loss or lack of effect of valve treatment, a lobectomy led to a significant improvement in pulmonary function; median forced expiratory volume in 1 s +75 (193) ml (P < 0.013), forced vital capacity +450 (572) ml (P = 0.001), residual volume -665 (715) ml (P = 0.005). In patients who underwent a lobectomy because of complications of valve treatment, all complications were resolved after surgery.

CONCLUSIONS

We demonstrate that an elective lobectomy after an initial valve treatment is safe and feasible and restores the lung volume reduction effect.

Surgical and bronchoscopic pulmonary function-improving procedures in lung emphysema

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

Endoscopic Options for Moderate COPD, Chronic Bronchitis, and Uncontrolled Asthma

Until now, interventional therapies for patients with chronic obstructive pulmonary disease have been available in the form of lung volume reduction procedures as end-stage options. Currently, the range of indications is expanding to include earlier stages of the diseases. Lung denervation is available for moderate COPD, and patients with chronic bronchitis are being evaluated for endoscopic goblet cell ablation. Rheoplasty, metered spray cryo technique, and Karakoca resector balloon are used for this indication. But also, for patients with severe uncontrolled asthma, several techniques are available today. In addition to thermoplasty as a long-proven procedure, new and currently under investigation is the targeted lung denervation.Most of these techniques are currently being tested in large pivotal trials and it will soon become clear in which phenotype which technique will be used in the different forms and stages of obstructive diseases. The current paper presents the techniques and the currently available literature.