Endobronchial valves for severe emphysema

Cardiothoracic Medical Devices - A Pictorial Review

The rapid advancement of medical technology has introduced a plethora of innovative devices designed for use within the thoracic cavity. Familiarity with the characteristic imaging features of these devices, their purpose and desired positioning is crucial for radiologists to identify them promptly and accurately assess any associated complications. This pictorial review provides a comprehensive overview of the radiologic findings associated with various new chest devices, aiming to equip radiologists with the knowledge required for effective clinical management.

First real-time imaging of bronchoscopic lung volume reduction by electrical impedance tomography

BACKGROUND

Bronchoscopic lung volume reduction (BLVR) with one-way endobronchial valves (EBV) has better outcomes when the target lobe has poor collateral ventilation, resulting in complete lobe atelectasis. High-inspired oxygen fraction (FIO2) promotes atelectasis through faster gas absorption after airway occlusion, but its application during BLVR with EBV has been poorly understood. We aimed to investigate the real-time effects of FIO2 on regional lung volumes and regional ventilation/perfusion by electrical impedance tomography (EIT) during BLVR with EBV.

METHODS

Six piglets were submitted to left lower lobe occlusion by a balloon-catheter and EBV valves with FIO2 0.5 and 1.0. Regional end-expiratory lung impedances (EELI) and regional ventilation/perfusion were monitored. Local pocket pressure measurements were obtained (balloon occlusion method). One animal underwent simultaneous acquisitions of computed tomography (CT) and EIT. Regions-of-interest (ROIs) were right and left hemithoraces.

RESULTS

Following balloon occlusion, a steep decrease in left ROI-EELI with FIO2 1.0 occurred, 3-fold greater than with 0.5 (p < 0.001). Higher FIO2 also enhanced the final volume reduction (ROI-EELI) achieved by each valve (p < 0.01). CT analysis confirmed the denser atelectasis and greater volume reduction achieved by higher FIO2 (1.0) during balloon occlusion or during valve placement. CT and pocket pressure data agreed well with EIT findings, indicating greater strain redistribution with higher FIO2.

CONCLUSIONS

EIT demonstrated in real-time a faster and more complete volume reduction in the occluded lung regions under high FIO2 (1.0), as compared to 0.5. Immediate changes in the ventilation and perfusion of ipsilateral non-target lung regions were also detected, providing better estimates of the full impact of each valve in place.

TRIAL REGISTRATION

Not applicable.

Lung Hyperinflation as Treatable Trait in Chronic Obstructive Pulmonary Disease: A Narrative Review

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.

Body Composition after Endoscopic Lung Volume Reduction with Endobronchial Valves: A Prospective Study

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) and emphysema experience malnutrition and pulmonary cachexia. Endoscopic lung volume reduction (ELVR) with endobronchial valves has not only improved lung function, exercise capacity, and quality of life but also influenced body weight. Only a few data are available on body composition changes after ELVR.

METHODS

This single-center prospective study of patients with advanced COPD investigates body composition before and after endoscopic valve treatment using multifrequency bioelectrical impedance analysis (BIA). The following parameters were evaluated in addition to clinical data and routine tests: body weight, body mass index (BMI), basal metabolic rate, total body water, body fat, cell percentage, phase angle, intracellular water (ICW), extracellular water (ECW), extracellular mass (ECM), body cell mass (BCM), lean body mass (ECM + BCM), and fat-free mass index.

RESULTS

A total of 23 patients (mean emphysema index 37.2 ± 7.5%, BMI 23.4 ± 4.3 kg/m2) experienced improvements in lung function and exercise capacity with ELVR. Complete lobar atelectasis was achieved in 39.1% of participants. A non-statistically significant increase in body weight and BMI was observed after ELVR (p = 0.111 and p = 0.102). BIA measurement revealed a worsening of phase angle, cell percentage and ECM/BCM and thus of body composition, but without statistical significance. This is mainly due to a statistically significant increase in ECM, ECW, and ICW (all p < 0.001).

CONCLUSION

ELVR demonstrated no beneficial changes in body composition, although patients tend to gain weight. A larger cohort is warranted to confirm these findings.

Lung volume reduction surgery: a micro-costing analysis from a national tertiary referral centre

OBJECTIVES

Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease. LVRS has recently been commissioned by the NHS England. In this study, a costing model was developed to analyse cost and resource implications of different LVRS procedures.

METHODS

Three pathways were defined by their surgical procedures: bronchoscopic endobronchial valve insertion (EBV-LVRS), video-assisted thoracic surgery LVRS and robotic-assisted thoracic surgery LVRS. The costing model considered use of hospital resources from the LVRS decision until 90 days after hospital admission. The model was calibrated with data obtained from an observational study, electronic health records and expert opinion. Unit costs were obtained from the hospital finance department and reported in 2021 Euros.

RESULTS

Video-assisted thoracic surgery LVRS was associated with the lowest cost at €12 896 per patient. This compares to the costs of EBV-LVRS at €15 598 per patient and €13 305 per patient for robotic-assisted thoracic surgery LVRS. A large component of EBV-LVRS costs were accrued secondary to complications, including revision EBV-LVRS.

CONCLUSIONS

This study presents a comprehensive model framework for the analysis of hospital-related resource use and costs for the 3 surgical modalities. In the future, service commissioning agencies, hospital management and clinicians can use this framework to determine their modifiable resource use (composition of surgical teams, use of staff and consumables, planned length of stay and revision rates for EBV-LVRS) and to assess the potential cost implications of changes in these parameters.

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.

Endobronchial valves for emphysema and persistent air-leak: 10-year experience in an Asian country

BACKGROUND

Endobronchial valve (EBV) therapy, a validated method for bronchoscopic lung volume reduction (BLVR) in severe emphysema, has been explored for persistent air-leak (PAL) management. However, its effectiveness and safety in the Asian population require further real-world evaluation. In this study, we assessed the outcomes of treatment with EBV within this demographic.

METHODS

We conducted a retrospective analysis of medical records from 11 Korean centers. For the emphysema cohort, inclusion criteria were patients diagnosed with emphysema who underwent bronchoscopy intended for BLVR. We assessed these patients for clinical outcomes of chronic obstructive pulmonary disease. All patients with PAL who underwent treatment with EBV were included. We identified the underlying causes of PAL and evaluated clinical outcomes after the procedure.

RESULTS

The severe emphysema cohort comprised 192 patients with an average age of 70.3 years, and 95.8% of them were men. Ultimately, 137 underwent treatment with EBV. Three months after the procedure, the BLVR group demonstrated a significant improvement in forced expiratory volume in 1 s (+160 mL vs. +30 mL; P = 0.009). Radiographic evidence of lung volume reduction 6 months after BLVR was significantly associated with improved survival (adjusted hazard ratio 0.020; 95% confidence interval 0.038-0.650; P = 0.010). Although pneumothorax was more common in the BLVR group (18.9% vs. 3.8%; P = 0.018), death was higher in the no-BLVR group (38.5% vs. 54.5%, P = 0.001), whereas other adverse events were comparable between the groups. Within the subset of 18 patients with PAL, the predominant causes of air-leak included spontaneous secondary pneumothorax (44.0%), parapneumonic effusion/empyema (22.2%), and post-lung resection surgery (16.7%). Following the treatment, the majority (77.8%) successfully had their chest tubes removed. Post-procedural complications were minimal, with two incidences of hemoptysis and one of empyema, all of which were effectively managed.

CONCLUSIONS

Treatment with EBV provides substantial clinical benefits in the management of emphysema and PAL in the Asian population, suggesting a favorable outcome for this therapeutic approach.

Survival following lung volume reduction procedures: results from the UK Lung Volume Reduction (UKLVR) registry

INTRODUCTION

Lung volume reduction surgery (LVRS) and endobronchial valve (EBV) placement can produce substantial benefits in appropriately selected people with emphysema. The UK Lung Volume Reduction (UKLVR) registry is a national multicentre observational study set up to support quality standards and assess outcomes from LVR procedures at specialist centres across the UK.

METHODS

Data were analysed for all patients undergoing an LVR procedure (LVRS/EBV) who were recruited into the study at participating centres between January 2017 and June 2022, including; disease severity and risk assessment, compliance with guidelines for selection, procedural complications and survival to February 2023.

RESULTS

Data on 541 patients from 14 participating centres were analysed. Baseline disease severity was similar in patients who had surgery n=244 (44.9%), or EBV placement n=219 (40.9%), for example, forced expiratory volume in 1 s (FEV1) 32.1 (12.1)% vs 31.2 (11.6)%. 89% of cases had discussion at a multidisciplinary meeting recorded. Median (IQR) length of stay postprocedure for LVRS and EBVs was 12 (13) vs 4 (4) days(p=0.01). Increasing age, male gender and lower FEV1%predicted were associated with mortality risk, but survival did not differ between the two procedures, with 50 (10.8%) deaths during follow-up in the LVRS group vs 45 (9.7%) following EBVs (adjusted HR 1.10 (95% CI 0.72 to 1.67) p=0.661) CONCLUSION: Based on data entered in the UKLVR registry, LVRS and EBV procedures for emphysema are being performed in people with similar disease severity and long-term survival is similar in both groups.

Impact of Endobronchial Valve Treatment on Lung Function Decline

INTRODUCTION

Endobronchial valve (EBV) treatment has been shown to be beneficial for patients with severe emphysema. The forced expiratory volume in 1 s (FEV1) was found to be significantly higher compared to baseline for up to 3 years after treatment although the magnitude of improvement gradually decreases over time. So far, it has not been investigated whether this treatment decelerates the decline in lung function. Therefore, our aim was to investigate the lung function decline before and after EBV treatment.

METHODS

We included patients who were treated with EBVs in our hospital, of whom pre-treatment spirometry results were available (at least 4 measurements within at least 2 years before treatment) and who had an annual FEV1 measurement up to 3 years after treatment.

RESULTS

In total, 45 patients were included (73% female, FEV1: 28 ± 7% of predicted, residual volume: 232 ± 32% of predicted) who had a mean pre-treatment FEV1 decline of -64 mL/year. Mean FEV1 "decline" after treatment was +13 mL/year, since FEV1 was still above the baseline level at 3-year follow-up. However, the FEV1 decline between 1 and 3 years of follow-up was not significantly different compared to the pre-treatment decline (-73 mL/year, p = 0.179).

CONCLUSIONS

Our results show that the EBV treatment does not influence the progression of disease in terms of lung function decline. However, the treatment does improve the FEV1 up to a level that is still comparable 3 years after treatment with the baseline level.

Bronchoscopic Lung Volume Reduction: A Clinical Review

Bronchoscopic lung volume reduction (BLVR) for the treatment of emphysema was originally developed in the early 2000s as a minimally invasive alternative to lung volume reduction surgery. Endobronchial valves for BLVR are an advancing "guideline treatment" in the treatment of advanced emphysema. Placement of small, one-way valves into segmental or subsegmental airways can induce lobar atelectasis for portions of diseased lung. This results in the reduction of hyperinflation along with improvements in diaphragmatic curvature and excursion.

Response to endobronchial valve treatment: it's all about the target lobe

Background

Bronchoscopic lung volume reduction using endobronchial valves (EBV) has been shown to be beneficial for severe emphysema patients. The most important predictor of treatment response is absence of collateral ventilation between the treatment target and ipsilateral lobe. However, there are still a substantial number of nonresponders and it would be useful to improve the pre-treatment identification of responders. Presumably, predictors of response will be multifactorial, and therefore our aim was to explore whether we can identify response groups using a cluster analysis.

Methods

At baseline and 1 year follow-up, pulmonary function, exercise capacity and quality of life were measured. A quantitative chest computed tomography scan analysis was performed at baseline and 2-6 months follow-up. The cluster analysis was performed using a hierarchical agglomerative method.

Results

In total, 428 patients (69% female, mean±sd age 61±8 years, forced expiratory volume in 1 s 27±8% predicted, residual volume 254±50% pred) were included in our analysis. Three clusters were generated: one nonresponder cluster and two responder clusters. Despite solid technical procedures, the nonresponder cluster had significantly less clinical response after treatment compared to the other clusters. The nonresponder cluster was characterised by significantly less emphysematous destruction, less air trapping and a higher perfusion of the target lobe, and a more homogeneous distribution of emphysema and perfusion between the target and ipsilateral lobe.

Conclusions

We found that target lobe characteristics are the discriminators between responders and nonresponders, which underlines the importance of visual and quantitative assessment of the potential treatment target lobe when selecting patients for EBV treatment.

Pulmonary rehabilitation and physical interventions

Pulmonary rehabilitation has established a status of evidence-based therapy for patients with symptomatic COPD in the stable phase and after acute exacerbations. Rehabilitation should have the possibility of including different disciplines and be offered in several formats and lines of healthcare. This review focusses on the cornerstone intervention, exercise training, and how training interventions can be adapted to the limitations of patients. These adaptations may lead to altered cardiovascular or muscular training effects and/or may improve movement efficiency. Optimising pharmacotherapy (not the focus of this review) and oxygen supplements, whole-body low- and high-intensity training or interval training, and resistance (or neuromuscular electrical stimulation) training are important training modalities for these patients in order to accommodate cardiovascular and ventilatory impairments. Inspiratory muscle training and whole-body vibration may also be worthwhile interventions in selected patients. Patients with stable but symptomatic COPD, those who have suffered exacerbations and patients waiting for or who have received lung volume reduction or lung transplantation are good candidates. The future surely holds promise to further personalise exercise training interventions and to tailor the format of rehabilitation to the individual patient's needs and preferences.

Current and future developments in the pharmacology of asthma and COPD: ERS seminar, Naples 2022

Pharmacological management of airway obstructive diseases is a fast-evolving field. Several advances in unravelling disease mechanisms as well as intracellular and molecular pathways of drug action have been accomplished. While the clinical translation and implementation of in vitro results to the bedside remains challenging, advances in comprehending the mechanisms of respiratory medication are expected to assist clinicians and scientists in identifying meaningful read-outs and designing clinical studies. This European Respiratory Society Research Seminar, held in Naples, Italy, 5-6 May 2022, focused on current and future developments of the drugs used to treat asthma and COPD; on mechanisms of drug action, steroid resistance, comorbidities and drug interactions; on prognostic and therapeutic biomarkers; on developing novel drug targets based on tissue remodelling and regeneration; and on pharmacogenomics and emerging biosimilars. Related European Medicines Agency regulations are also discussed, as well as the seminar's position on the above aspects.

Endobronchial Valve Replacements in Patients with Advanced Emphysema After Endoscopic Lung Volume Reduction

Purpose

Up to 41% of patients with endobronchial valve implantation need revision bronchoscopies and valve replacements most likely due to valve dysfunction or lack of benefit. So far, no data is available whether valve replacements lead to the desired lobar volume reduction and therapy benefit.

Patients and Methods

We conducted a single-center retrospective analysis of patients with endobronchial valve implantation and at least one valve replacement. Indications and number of revision bronchoscopies and valve replacements were evaluated. Therapy benefit regarding lung function and exercise capacity as well as development of complete lobar atelectasis was investigated and possible predictors identified.

Results

We identified 73 patients with 1-12 revision bronchoscopies and 1-5 valve replacements. The main indication for revision bronchoscopy in this group was lack of therapy benefit (44.2%). Lung function and exercise capacity showed improvements in about one-third of patients even years after the initial implantation. A total of 26% of all patients showed a complete lobar atelectasis at the end of the observation period, 56.2% had developed lung volume reduction. The logistic regression revealed the development of a previous complete lobar atelectasis as predictor for a complete lobar atelectasis at final follow-up. Oral cortisone long-term therapy was also shown as predictive factor. The probability for a final complete lobar atelectasis was 69.2% if a lobar atelectasis had developed before.

Conclusion

Valve replacements are more likely to be beneficial in patients who develop a re-aeration of a previous lobar atelectasis following valve implantation. Every decision for revision bronchoscopy must be taken carefully.

Endobronchial Valve Treatment Does Not Cause Significant Nickel Deposition in Lung Tissue

Bronchoscopic lung volume reduction using endobronchial valves (EBVs) is a treatment option for patients with severe emphysema. These EBVs are made out of a nitinol mesh covered by a silicone layer. Nitinol is an alloy of nickel and titanium and is commonly used in implantable medical devices because of its biocompatibility and memory-shape properties. However, there are some concerns that nickel ions can be released from nitinol-containing devices which might cause adverse health effects, especially in patients with a known nickel hypersensitivity. In vitro, it was found that EBV release significant amounts of nickel in the first hours. Our aim was to assess the nickel concentration in lung tissue from a patient who previously underwent EBV treatment but, due to treatment failure, underwent lung volume reduction surgery and to compare this to a reference sample. We found no significant difference in the median nickel concentration between the EBV-treated patient and the non-EBV-treated patient (0.270 vs. 0.328 μg/g, respectively, p = 0.693) and these concentrations were also comparable to previously published nickel concentrations in human lung tissue samples not having any medically implanted devices in the lung. Our results suggest that there is no significant long-term nickel deposition in lung tissue after EBV treatment.

[Treatment of chronic obstructive pulmonary disease and emphysema]

We summarized the available data on therapeutic, surgical and endoscopic treatment of chronic obstructive pulmonary disease and emphysema that may be used like a bridge to lung transplantation. Treatment of chronic obstructive pulmonary disease and emphysema is expensive. Certain limitations in lung transplantation make to create new methods of treatment of severe emphysema. However, one should be ready for possible complications and carefully select patients for certain treatment to avoid false negative results. Reducing costs or developing cheaper treatments is important for the future and availability of care. The risks and complications associated with surgical treatment of emphysema can make endoscopic surgery preferable for these patients, and this undoubtedly requires further research.

Isolated Elevation in Lung Residual Volume Is Associated With Airway Diseases

BACKGROUND

Residual volume (RV) is a derived lung compartment that correlates with air trapping in the context of air flow obstruction on spirometry. The significance of an isolated elevation in RV in the absence of other pulmonary function test (PFT) abnormalities is not well defined. We sought to assess the clinical and radiologic findings associated with isolated elevation in RV.

METHODS

We searched our out-patient PFT database at Mayo Clinic (Rochester, Minnesota) from 2016-2018 for adult patients with isolated elevation in RV. We defined isolated elevation in RV as RV ≥ upper limit of normal or ≥ 130% predicted with normal total lung capacity (TLC), spirometry, and diffusion capacity of the lung for carbon monoxide (D_LCO). We then matched this high-RV group by age and sex to an equal number of individuals with normal RV, TLC, spirometry, and D_LCO (normal-RV group).

RESULTS

We identified 169 subjects with isolated elevation in RV on PFTs, with a median age of 73 y; 55.6% were female, and median body mass index was 26.8 (vs 29.8 in the normal-RV group). The median RV was 3.08 L (134% predicted, interquartile range [IQR] 130-141) in the high-RV group and 2.26 L (99% predicted, IQR 90-109) in the normal-RV group (P < .001). Subjects with high RV were more likely to have smoked (54% vs 40%, P = .01) and almost twice as likely to have a maximum voluntary ventilation < 30 times the FEV₁ (21% vs 12%, P = .02). Clinically, asthma (21% vs 11%, P = .01) and non-tuberculous mycobacterial lung infections (12% vs 2%, P = .001) were more prevalent in the high-RV group. On chest computed tomography, bronchiectasis (31% vs 15%, P = .008), bronchial thickening or mucus plugging (46% vs 22%, P < .001), and emphysema (13% vs 5%, P = .046) were more common in the high-RV group.

CONCLUSIONS

Isolated elevation in RV on PFTs is a clinically relevant abnormality associated with airway-centered diseases.

Reduction of Lung Hyperinflation Improves Cardiac Preload, Contractility, and Output in Emphysema: A Prospective Cardiac Magnetic Resonance Study in Patients Who Received Endobronchial Valves

RATIONALE

Pulmonary hyperinflation in patients with Chronic Obstructive Pulmonary Disease (COPD) has been related to smaller cardiac chamber sizes and impaired cardiac function. Nowadays, bronchoscopic lung volume reduction (BLVR) with endobronchial valves is a treatment option to reduce pulmonary hyperinflation in patients with severe emphysema.

OBJECTIVES

We hypothesized that reduction of hyperinflation would improve cardiac preload in this patient group. In addition, we investigated whether the treatment would result in elevated pulmonary artery pressures due to pulmonary vascular bed reduction.

METHODS

We included patients with emphysema and severe hyperinflation (defined by a baseline residual volume >175% of predicted) who were eligible for BLVR with endobronchial valves. Cardiac magnetic resonance imaging was obtained one day prior to treatment and at eight week follow-up. Primary endpoint was cardiac preload, as measured by the right ventricle end-diastolic volume index (RVEDVI). As secondary endpoints, we measured indexed end-diastolic and end-systolic volumes of the right ventricle, left atrium, and left ventricle, pulmonary artery pressures, cardiac output, ejection fraction, and strain.

MEASUREMENTS AND MAIN RESULTS

Twenty-four patients were included. At eight week follow-up, RVEDVI was significantly improved (+7.9 ml/m2, SD 10.0, p=0.001). In addition to increased stroke volumes, we found significantly higher ejection fractions and strain measurements. Although cardiac output was significantly increased (+0.9L/min, SD 1.5, p=0.007), there were no changes in pulmonary artery pressures.

CONCLUSIONS

We found that reduction of hyperinflation using BLVR with endobronchial valves significantly improved cardiac preload, myocardial contractility, and cardiac output, without changes in pulmonary artery pressures. Clinical trial registered with ClinicalTrials.gov (NCT03474471).

Endobronchial treatment of severe asthma and severe emphysema with hyperinflation

PURPOSE OF REVIEW

The field of interventional pulmonology has ushered in a wave of innovations for individuals with obstructive airways disease in whom established medical therapies have failed. Leading the charge are bronchial thermoplasty for severe refractory asthma and uni-directional valves for severe emphysema with hyperinflation: both have received regulatory approvals in the United Kingdom and United States. With the commissioning of these novel treatments comes new challenges relating to implementation, positioning within therapeutic algorithms, honing of patient selection, and establishing long-term safety and benefits beyond 5 years.

RECENT FINDINGS

This review summarises the evidence for their safety and efficacy, predictors of therapeutic response, mechanism(s) of action and emerging data supporting the durability of outcomes out to at least ten years.

SUMMARY

It is anticipated the experience of treating increasing numbers of patients, the adoption of international registries, and ongoing research evaluations will serve to optimise these therapies for future generations of patients.

Impact of Ventilation Modes on Bronchoscopic Chartis Assessment Outcome in Candidates for Endobronchial Valve Treatment

BACKGROUND

Endobronchial valve therapy has proven to reduce lung hyperinflation and decrease disease burden in patients with severe lung emphysema. Exclusion of collateral ventilation (CV) of the targeted lobe by using an endobronchial assessment system (Chartis; PulmonX, Drive Redwood City, CA, USA) in combination with software-based fissure integrity analysis (FCS [fissure completeness score]) of computed tomography scans of the lung are established tools to select appropriate patients for endobronchial valve treatment. So far, there is no conclusive evidence if the ventilation mode during bronchoscopy impacts the outcome of Chartis assessments.

METHODS

Patients with Chartis assessments and software-based quantification of FCS (StratX; PulmonX, Drive Redwood City, CA, USA) were enrolled in this retrospective study. During bronchoscopy, pulmonary fissure integrity was evaluated with the Chartis assessment system in each patient first under spontaneous breathing and subsequently under high-frequency (HF) jet ventilation.

RESULTS

In total, 102 patients were analyzed. Four Chartis phenotypes CV positive (CV+), CV negative (CV-), low flow, and low plateau in spontaneous breathing and HF jet ventilation were identified. The frequency of each Chartis phenotype per lobe was similar in both settings. When comparing Chartis assessments in spontaneous breathing and HF jet ventilation, there was an overall good concordance rate for all analyzed fissures. In agreement, receiver operating characteristic analysis of the FCS showed an almost similar prediction for CV+ and CV- status independent of the ventilation modes.

CONCLUSION

Chartis assessment in spontaneous breathing and HF jet ventilation had similar rates in detecting CV in lung emphysema. Our results suggest that both modes are equivalent for the assessment of CV.

Dual-Energy Computed Tomography Compared to Lung Perfusion Scintigraphy to Assess Pulmonary Perfusion in Patients Screened for Endoscopic Lung Volume Reduction

BACKGROUND

Endoscopic lung volume reduction (ELVR) using one-way endobronchial valves is a technique to reduce hyperinflation in patients with severe emphysema by inducing collapse of a severely destroyed pulmonary lobe. Patient selection is mainly based on evaluation of emphysema severity on high-resolution computed tomography and evaluation of lung perfusion with perfusion scintigraphy. Dual-energy contrast-enhanced CT scans may be useful for perfusion assessment in emphysema but has not been compared against perfusion scintigraphy.

AIMS

The aim of the study was to compare perfusion distribution assessed with dual-energy contrast-enhanced computed tomography and perfusion scintigraphy.

MATERIAL AND METHODS

Forty consecutive patients with severe emphysema, who were screened for ELVR, were included. Perfusion was assessed with 99mTc perfusion scintigraphy and using the iodine map calculated from the dual-energy contrast-enhanced CT scans. Perfusion distribution was calculated as usually for the upper, middle, and lower thirds of both lungs with the planar technique and the iodine overlay.

RESULTS

Perfusion distribution between the right and left lung showed good correlation (r = 0.8). The limits of agreement of the mean absolute difference in percentage perfusion per region of interest were 0.75-5.6%. The upper lobes showed more severe perfusion reduction than the lower lobes. Mean difference in measured pulmonary perfusion ranged from -2.8% to 2.3%. Lower limit of agreement ranged from -8.9% to 4.6% and upper limit was 3.3-10.0%.

CONCLUSION

Quantification of perfusion distribution using planar 99mTc perfusion scintigraphy and iodine overlays calculated from dual-energy contrast-enhanced CTs correlates well with acceptable variability.

Patient Satisfaction and Attainment of Patient-Specific Goals after Endobronchial Valve Treatment

Rationale: Bronchoscopic lung volume reduction with endobronchial valves (EBVs) significantly improves clinical outcomes in patients with severe emphysema. However, patient-reported outcomes like patient satisfaction and patient-specific treatment goals were never investigated.Objectives: To investigate the patient-satisfaction level 1 year after treatment and patient-specific goals before and 1 year after EBV treatment. Furthermore, the study aimed to investigate whether the level of patient satisfaction or change in goals was associated with change in the clinical outcome.Methods: We prospectively included patients who underwent EBV treatment as part of regular care in our hospital and asked patients to report and score their personal treatment goals on the patient-specific complaint (PSC) questionnaire at baseline and after 1 year of follow-up and to complete a patient-satisfaction questionnaire at 1 year of follow-up.Results: Of the 134 patients who were treated with EBV, 109 filled out the patient-satisfaction questionnaire and 88 filled out the PSC questionnaire at baseline and 1 year after treatment. When adjusting for the patients who were lost to follow-up, 91% of the patients in total would recommend the EBV treatment to other patients. Seventy-five percent of the patients were (very) satisfied with the treatment and 11% were (very) unsatisfied. The three most frequently reported patient-specific goals to improve were walking (reported by 77% of the patients), taking a shower/washing/getting dressed (35%), and completing household chores (32%). Both the total PSC questionnaire sum score (mean change, -6.01 ± 6.0) and all individual reported goals significantly improved 1 year after treatment (P < 0.001). Furthermore, a higher patient-satisfaction level and larger improvement in goals was significantly associated with an improvement in forced expiratory volume in 1 second, residual volume, dyspnea severity, and quality of life.Conclusions: We found that the patient-satisfaction level is high and patient-specific goals significantly improve 1 year after EBV treatment. We believe that the individual patient's goals are important in the process of shared decision-making before treatment, as they can be used to identify unrealistic expectations beforehand and prevent disappointment afterward.Clinical trial registered at clinicaltrials.gov (NCT02815683).

Measuring pulmonary function in COPD using quantitative chest computed tomography analysis

COPD is diagnosed and evaluated by pulmonary function testing (PFT). Chest computed tomography (CT) primarily serves a descriptive role for diagnosis and severity evaluation. CT densitometry-based emphysema quantification and lobar fissure integrity assessment are most commonly used, mainly for lung volume reduction purposes and scientific efforts.

A shift towards a more quantitative role for CT to assess pulmonary function is a logical next step, since more, currently underutilised, information is present in CT images. For instance, lung volumes such as residual volume and total lung capacity can be extracted from CT; these are strongly correlated to lung volumes measured by PFT.

This review assesses the current evidence for use of quantitative CT as a proxy for PFT in COPD and discusses challenges in the movement towards CT as a more quantitative modality in COPD diagnosis and evaluation. To better understand the relevance of the traditional PFT measurements and the role CT might play in the replacement of these parameters, COPD pathology and traditional PFT measurements are discussed.

CT may be used as a proxy for lung function in COPD diagnosis and evaluation, particularly for the hyperinflation markershttps://bit.ly/2RrGAZf

Lung volume reduction in real clinical practice

Pragmatic studies and capturing routine care clinical data in registration databases are important to further guide and optimise treatments in the future https://bit.ly/3el1lh7.

Expert Statement: Pneumothorax Associated with One-Way Valve Therapy for Emphysema: 2020 Update

For selected patients with advanced emphysema, bronchoscopic lung volume reduction with one-way valves can lead to clinically relevant improvements of airflow obstruction, hyperinflation, exercise capacity, and quality of life. The most common complication of this procedure is pneumothorax with a prevalence of up to ±34% of the treated patients. Patients who develop a pneumothorax also experience meaningful clinical benefits once the pneumothorax is resolved. Timely resolution of a post-valve treatment pneumothorax requires skilled and adequate pneumothorax management. This expert panel statement is an updated recommendation of the 2014 statement developed to help guide pneumothorax management after valve placement. Additionally, mechanisms for pneumothorax development, risk assessment, prevention of pneumothorax, and outcomes after pneumothorax are addressed. This recommendation is based on a combination of the current scientific literature and expert opinion, which was obtained through a modified Delphi method.

Thermal Volume Reduction Surgery for Surgical Treatment of Pulmonary Bullae: A Single-Center Treatment Experience of 276 Cases Accompany With Primary Lung Cancer

Objective: Lung volume reduction surgery (LVRS) has been regarded as an effective surgical procedure for severe emphysema (including pulmonary bullae). However, there still remain controversial that its applications limited that only patients with a specific clinical situation may benefit from LVRS, and so did other non-surgical treatments. The current study aims to introduce some initial experience of new technique for treating pulmonary bullae, including using thermal surgical instruments to reduce enlargement of lung tissue in a specific group that diagnosed with lung cancer accompany with pulmonary bullae. Methods: This retrospective study included 276 patients undergoing emphysema reducing surgery between 2010 and 2020. All procedure were performed by thermal volume reduction surgery of using thermal surgical instruments to reduce pulmonary bullae. Results: The average time required for operating single pulmonary bullae was <10 min. Median operative time was 106 min (range 85 to 191 min). No intraoperative air leak, massive blood loss, or other severe complications occurred. The estimated blood loss for TVRS was about 40 ml (range 15 to 120 ml). Postoperative complications included atelectasis (n = 8), pulmonary infection (n = 17), bleeding (n = 5), delayed air leak (n = 7) among the cohort. The postoperative lung function at 1-year post surgery in TVRS group recovered faster with a better recovery that achieving an FEV1 of 1.95 ± 0.46 L, TLC of 6.36 ± 0.79 L, RV of 3.56 ± 0.81 L, PO₂ of 60 ± 8 mmHg, PCO₂ of 37 ± 6 mmHg, and 6 MWD (6-min walk distant) of 305 ± 22 m. The 1-year QOL score was elevated comparing with preoperative period. Conclusion: This single-center study reported a new thermal-based surgical approach to treat pulmonary bullae by reducing abnormally enlarged lung tissue in specific patients diagnosed with lung cancer accompany with pulmonary bullae.

Revision Bronchoscopy After Endobronchial Valve Treatment for Emphysema: Indications, Findings and Outcomes

Background

Endobronchial valve (EBV) treatment is an effective treatment for patients with severe emphysema. Revision bronchoscopies after endobronchial valve treatment can be essential to prolong the effect of treatment or address long-term complications.

Purpose

To evaluate the indications, endoscopic findings and outcomes of revision bronchoscopies and investigate if any predictors for granulation tissue formation, after EBV treatment, can be identified.

Patients and Methods

Patients who underwent EBV treatment between 2016 and 2019 in our hospital, as routine care, were included. If a patient underwent a revision bronchoscopy, data regarding revision bronchoscopies, including indication, finding, intervention and pulmonary function testing (PFT) after revision bronchoscopy were analysed.

Results

One hundred seventy-nine patients were included of which 41% required at least one revision bronchoscopy. In 43% of the revision bronchoscopy patients, the indication was loss of initial treatment effect. In 53% of the revision bronchoscopy patients, granulation tissue was found to be the underlying cause. Valve replacement(s) were performed in 51% of the revision bronchoscopy cases. Permanent valve removal was required in 13% of all patients. Overall, revision bronchoscopies led to improvements in PFT outcomes for patients experiencing no or a loss of initial treatment effect. No clinically relevant predictors for granulation tissue formation were identified.

Conclusion

Performing a revision bronchoscopy after EBV treatment is a useful procedure leading to an improved treatment effect in most patients. Granulation tissue formation, causing valve dysfunction, is the most common cause of longer term problems.

Endoscopic lung volume reduction with endobronchial valves in very low D LCO patients: results from the German Registry - Lungenemphysemregister e.V

Background

Endoscopic lung volume reduction (ELVR) with valves has been suggested to be the key strategy for patients with severe emphysema and concomitant low diffusing capacity of the lung for carbon monoxide (D_LCO). However, robust evidence is still missing. We therefore aim to compare clinical outcomes in relation to D_LCO for patients treated with ELVR.

Methods

We assessed D_LCO at baseline and 3 months follow-up and compared pre- and postprocedural pulmonary function test, quality of life, exercise capacity and adverse events. This is a retrospective subanalysis of prospectively collected data from the German Lung Emphysema Registry.

Results

In total, 121 patients treated with ELVR were analysed. Thirty-four patients with a D_LCO ≤20% and 87 patients with a D_LCO >20% showed similar baseline characteristics. After ELVR, there was a decrease of residual volume (both p<0.001 to baseline) in both groups, and both demonstrated better quality of life (p<0.01 to baseline). Forced expiratory volume in 1 s (FEV₁) improved significantly only in patients with a D_LCO >20% (p<0.001 to baseline). Exercise capacity remained almost unchanged in both groups (p=0.3). The most frequent complication for both groups was a pneumothorax (D_LCO ≤20%: 17.6% versus D_LCO >20%: 16.1%; p=0.728). However, there were no significant differences in other adverse events between both groups.

Conclusions

ELVR improves lung function as well as quality of life in patients with D_LCO >20% and D_LCO ≤20%. Adverse events did not differ between groups. Therefore, ELVR should be considered as a treatment option, even in patients with a very low D_LCO.

Endoscopic lung volume reduction with endobronchial valves can be safely performed in patients with a very low diffusing capacity of the lung (D_LCO). Clinical effectiveness is comparable to patients with higher D_LCO.https://bit.ly/3cOgDK1

Endobronchial Valves for the Treatment of Advanced Emphysema

Bronchoscopic lung volume reduction with one-way endobronchial valves is a guideline treatment option for patients with advanced emphysema that is supported by extensive scientific data. Patients limited by severe hyperinflation, with a suitable emphysema treatment target lobe and with absence of collateral ventilation, are the responders to this treatment. Detailed patient selection, a professional treatment performance, and dedicated follow up of the valve treatment, including management of complications, are key ingredients to success. This treatment does not stand alone; it especially requires extensive knowledge of COPD for which the most appropriate treatment is discussed in a multidisciplinary approach. We discuss the endobronchial valve treatment for emphysema and provide a guideline for patient selection, treatment guidance, and practice tools, based on our own experience and literature.

Developments in lung transplantation over the past decade

With an improved median survival of 6.2 years, lung transplantation has become an increasingly acceptable treatment option for end-stage lung disease. Besides survival benefit, improvement of quality of life is achieved in the vast majority of patients. Many developments have taken place in the field of lung transplantation over the past decade. Broadened indication criteria and bridging techniques for patients awaiting lung transplantation have led to increased waiting lists and changes in allocation schemes worldwide. Moreover, the use of previously unacceptable donor lungs for lung transplantation has increased, with donations from donors after cardiac death, donors with increasing age and donors with positive smoking status extending the donor pool substantially. Use of ex vivo lung perfusion further increased the number of lungs suitable for lung transplantation. Nonetheless, the use of these previously unacceptable lungs did not have detrimental effects on survival and long-term graft outcomes, and has decreased waiting list mortality. To further improve long-term outcomes, strategies have been proposed to modify chronic lung allograft dysfunction progression and minimise toxic immunosuppressive effects. This review summarises the developments in clinical lung transplantation over the past decade.

The top 100 most cited articles on bronchoscopy: a bibliometric analysis

Background

Bronchoscopy is applied broadly in the diagnosis and treatment of pulmonary diseases. Over the past few decades, an increasing number of studies about bronchoscopy have been published. However, little is known about their qualities and characteristics.

Methods

All of the databases in Web of Science (including the Web of Science Core Collection, BIOSIS Citation Index, KCI-Korean Journal Database, MEDLINE, Russian Science Citation Index, and SciELO Citation Index) were utilized to identify articles published from 1990 to 2020. The top 100 most cited articles about bronchoscopy were selected for degree centrality analysis and analyses regarding publication time, total citation number, the citation density, time-related flux, first author, published journal, geographic origin, and research theme.

Results

The selected articles were published mainly in the 2000s and 1990s. Citations per article ranged from 731 to 196. The leading country was the USA, followed by the United Kingdom. The most frequently studied themes were bronchoalveolar lavage (BAL) fluid and biopsy. The degree centrality analysis connoted that “BAL, inflammation, diagnosis” had a high degree of centrality in the 1990s, while “diagnosis, BAL, biopsy, prospective” took centre stage in the 2000s.

Conclusions

The time, area, and theme distribution of the 100 most cited articles on bronchoscopy have been thoroughly analyzed. It is noticeable that researches based on BAL and endobronchial or transbronchial biopsies currently plays a major role.

Lung Volume Reduction in Pulmonary Emphysema

Severe 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.

Bronchoscopic interventions for severe emphysema: Where are we now?

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

The STELVIO trial, a game changer for bronchoscopic lung volume reduction in patients with severe emphysema

Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and airflow limitation, which is caused by small airway disease (bronchiolitis) and alveolar destruction (emphysema) [1]. Patients primarily suffering from severe emphysema are often limited in exercise capacity due to the consequences of hyperinflation [2].

The STELVIO trial was crucial to ensure that bronchoscopic lung volume reduction using one-way valves has evolved from an experimental intervention into a state-of-the-art treatment option for specific patients with advanced emphysemahttp://bit.ly/2IgMrsp