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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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2
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Li A, Lee P. Which Endoscopic Procedure to Use and in What Patient? Valves, Coils, Foam, and Heat in COPD and Asthma. Pulm Ther 2022; 9:49-69. [PMID: 36534323 PMCID: PMC9931990 DOI: 10.1007/s41030-022-00208-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022] Open
Abstract
Despite the latest developments in therapeutic agents targeting airway endotypes, a significant proportion of patients with asthma and chronic obstructive pulmonary disease (COPD) remain symptomatic. Endoscopic therapies have a complementary role in the management of these airway diseases. The sustained efficacy of bronchial thermoplasty (BT) among patients with asthma over 10 years has been encouraging, as it has been shown to improve symptom control and reduce hospital admissions and exacerbations. Studies suggest that BT helps ameliorate airway inflammation and reduce airway smooth muscle thickness. While studies suggest that it is as effective as biologic agents, its role in the management of severe asthma has yet to be clearly defined and GINA 2022 still suggests limiting its use to patients with characteristics of the various populations studied. Conversely, bronchoscopic lung volume reduction has shown promise among patients with advanced COPD. Rigorous patient selection is important. Patients with minimal collateral ventilation (CV) and higher heterogeneity index have shown to benefit the most from endobronchial valve (EBV) therapy. For those with ongoing CV, endobronchial coils would be more appropriate. Both therapeutic modalities have demonstrated improved quality of life, effort tolerance, and lung function indices among appropriately selected patients. The emerging evidence suggests that endoscopic procedures among airway disease still have a substantial role to play despite the development of new therapeutic options.
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Affiliation(s)
- Andrew Li
- Respiratory and Critical Care Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Respiratory Service, Department of Medicine, Woodlands Health, Singapore, Singapore.
| | - Pyng Lee
- Respiratory and Critical Care Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228 Singapore ,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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3
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Garner JL, Shah PL. Endobronchial treatment of severe asthma and severe emphysema with hyperinflation. Curr Opin Pulm Med 2022; 28:52-61. [PMID: 34720098 DOI: 10.1097/mcp.0000000000000840] [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: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Justin L Garner
- Royal Brompton Hospital
- Chelsea & Westminster Hospital
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Pallav L Shah
- Royal Brompton Hospital
- Chelsea & Westminster Hospital
- National Heart and Lung Institute, Imperial College London, London, UK
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4
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Pertzov B, Soliman M, Shostak Y, Heching M, Rosengarten D, Izbicki G, Kramer MR. Effect of Endobronchial Coils on Exercise Tolerance and Lung Functions in Patients with Severe Emphysema - A Retrospective Cohort Study of 48 Patients. Int J Chron Obstruct Pulmon Dis 2021; 16:2809-2815. [PMID: 34675505 PMCID: PMC8517418 DOI: 10.2147/copd.s327048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Lung volume reduction with endobronchial coils treatment (ECT), for patients with severe emphysema, has shown modest improvement in exercise capacity and lung functions in clinical trials, yet the benefit of this procedure is still unclear. Methods We conducted a multicenter retrospective cohort study including all patients who underwent ECT in Israel and a propensity score matched control group of patients with chronic obstructive pulmonary disease (COPD) that were treated with usual care. The primary outcome was six-minute walk test distance (6MWTD), secondary outcomes were lung function tests and patient survival. Results Overall, 46 patients were included in the ECT group. Their mean 6MWTD at baseline and at 6 and at 24 months post procedure was 331.0±101.4, 372.9±76.8 and 338.8±104.8, respectively (overall P=0.04, pairwise comparison: baseline to 6 months (P=0.1), baseline to 24 months (P=1.0)). Mean FEV1 values at baseline and at 6 and at 24 months post procedure were 0.86±0.38, 0.92±0.37 and 0.82±0.36 liters, respectively (overall P=0.003, pairwise comparison: baseline to 6 months (P=0.04), baseline to 24 months (P=0.75)). The median 6MWTD for the ECT and control groups at 24 months were 333.0 (262.5–390) and 280 (210–405), respectively (P=0.16). There was no difference in overall survival (P=0.84). Heterogenous emphysema was a significant predictor of treatment success in univariate analysis (p=0.004). Conclusion Lung volume reduction with endobronchial coils may improve the exercise capacity and FEV1 of COPD patients. However, the majority of the effect was diminished after 24 months. The current state of evidence does not support regulatory approval of ECT and warrant its use only after consideration of the benefit-harm ratio in a highly selected patient population.
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Affiliation(s)
- Barak Pertzov
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maysaa Soliman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Shostak
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Heching
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Rosengarten
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Izbicki
- Pulmonary Institute, Shaare Zedek Medical Center, Jerusalem, Israel.,Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Mordechai Reuven Kramer
- Pulmonary Division, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ashraf O, Disilvio B, Young M, Ghosh S, Cheema T. Surgical Interventions for COPD. Crit Care Nurs Q 2021; 44:49-60. [PMID: 33234859 DOI: 10.1097/cnq.0000000000000339] [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: 11/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) treatment is aimed at managing the disease rather than cure, with a focus on improving quality of life and decreasing exacerbations. Interventional therapies, including lung volume reduction surgery, bullectomy, lung transplantation, and bronchoscopic lung volume reduction treatment using endobronchial valves, are treatment options for patients with COPD who are symptomatic due to hyperinflation despite optimal medical management. We will review the current literature to provide a comprehensive summary of the currently available scientific data, discuss typical treatment-related side effects, and evidence-based management approach and recommendations for patient selection in clinical practice.
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Affiliation(s)
- Obaid Ashraf
- Division of Pulmonary Critical Care Medicine, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania
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6
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Roodenburg SA, Pouwels SD, Slebos DJ. Airway granulation response to lung-implantable medical devices: a concise overview. Eur Respir Rev 2021; 30:30/161/210066. [PMID: 34348981 PMCID: PMC9488845 DOI: 10.1183/16000617.0066-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/26/2021] [Indexed: 12/02/2022] Open
Abstract
Increasing numbers of endoscopically implantable devices are implanted in the airways, such as airway stents, one-way valves and coils, to treat both malignant and benign diseases. They significantly improve patient outcomes, but their long-term effectiveness and sustainability is hampered by the reaction of the formation of granulation tissue. Factors including procedural-related tissue injury; micro-organism presence; device-related factors, such as the material, design and sizing in relation to the airway; and patient-related factors, including genetic susceptibility, comorbidities and medication use, might all effect the severity of the tissue response and the subsequent degree of granulation tissue formation. However, research into the underlying mechanism and risk factors is scarce and therefore our knowledge is limited. Joint efforts from the scientific community, both pre-clinical and clinical, are needed to gain a deeper understanding and eventually improve the long-term treatment effectiveness of lung-implantable devices. Medical implantable devices are increasingly used in pulmonary medicine. Complications related to the tissue–device interaction are often present, but our knowledge of the underlying processes is limited.https://bit.ly/2RdWVkG
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Affiliation(s)
- Sharyn A Roodenburg
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands .,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Simon D Pouwels
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Dept of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Dept of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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7
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Hartman JE, Klooster K, Augustijn SWS, van Geffen WH, Garner JL, Shah PL, Ten Hacken NHT, Slebos DJ. Identifying Responders and Exploring Mechanisms of Action of the Endobronchial Coil Treatment for Emphysema. Respiration 2021; 100:443-451. [PMID: 33744899 PMCID: PMC8220926 DOI: 10.1159/000514319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/28/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND So far, 3 randomized controlled trials have shown that the endobronchial treatment using coils is safe and effective. However, the more exact underlying mechanism of the treatment and best predictors of response are unknown. OBJECTIVES The aim of the study was to gain more knowledge about the underlying physiological mechanism of the lung volume reduction coil treatment and to identify potential predictors of response to this treatment. METHODS This was a prospective nonrandomized single-center study which included patients who were bilaterally treated with coils. Patients underwent an extensive number of physical tests at baseline and 3 months after treatment. RESULTS Twenty-four patients (29% male, mean age 62 years, forced expiratory volume in 1 s [FEV1] 26% pred, residual volume (RV) 231% pred) were included. Three months after treatment, significant improvements were found in spirometry, static hyperinflation, air trapping, airway resistance, treated lobe RV and treated lobes air trapping measured on CT scan, exercise capacity, and quality of life. The change in RV and airway resistance was significantly associated with a change in FEV1, forced vital capacity, air trapping, maximal expiratory pressure, dynamic compliance, and dynamic hyperinflation. Predictors of treatment response at baseline were a higher RV, larger air trapping, higher emphysema score in the treated lobes, and a lower physical activity level. CONCLUSIONS Our results confirm that emphysema patients benefit from endobronchial coil treatment. The primary mechanism of action is decreasing static hyperinflation with improvement of airway resistance which consequently changes dynamic lung mechanics. However, the right patient population needs to be selected for the treatment to be beneficial which should include patients with severe lung hyperinflation, severe air trapping, and significant emphysema in target lobes.
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Affiliation(s)
- Jorine E Hartman
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands,
| | - Karin Klooster
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sonja W S Augustijn
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wouter H van Geffen
- Department of Pulmonary diseases, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Justin L Garner
- Royal Brompton Hospital, London, United Kingdom
- National Heart & Lung Institute, Imperial College, London, United Kingdom
- Chelsea & Westminster Hospital, London, United Kingdom
| | - Pallav L Shah
- Royal Brompton Hospital, London, United Kingdom
- National Heart & Lung Institute, Imperial College, London, United Kingdom
- Chelsea & Westminster Hospital, London, United Kingdom
| | - Nick H T Ten Hacken
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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8
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Wang R, Paul S, Truong V, Munavvar M. Bronchoscopic interventions for emphysema: Current status. Lung India 2020; 37:518-529. [PMID: 33154215 PMCID: PMC7879872 DOI: 10.4103/lungindia.lungindia_8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/02/2020] [Indexed: 11/04/2022] Open
Abstract
Chronic obstructive pulmonary disease is a prevalent and progressive disease. The recently developed bronchoscopic lung volume reduction (BLVR) techniques offer personalized therapeutic options in subgroups of patients with severe emphysema. Endobronchial and intrabronchial valves (EBV/IBV) achieve lung volume reduction by lobar atelectasis. The lung volume reduction coils (LVRCs) and bronchoscopic thermal vapor ablation (BTVA) induce tissue compression, either mechanically or through inflammatory processes. While the effects of EBV/IBV are reversible by removing the implants, the effects of LVRC are partially reversible and that of BTVA is irreversible. The presence of interlobar collateral ventilation (CV) impacts on EBV/IBV treatment outcome due to its mechanism of action. Therefore, using radiological and endoscopic techniques to assess CV has a vital importance. Current evidence of BLVR demonstrates acceptable safety and short-term clinical efficacy. However, head-to-head trials are lacking, and further research is needed to establish long-term clinical benefit, durability, and cost-effectiveness of these techniques.
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Affiliation(s)
- Ran Wang
- School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Suman Paul
- Department of Respiratory, Lancashire Teaching Hospital NHS Foundation Trust, Preston, United Kingdom
| | - Vi Truong
- School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Mohammed Munavvar
- School of Biological Sciences, The University of Manchester, Manchester; Department of Respiratory, Lancashire Teaching Hospital NHS Foundation Trust, Preston, United Kingdom
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9
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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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10
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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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11
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Yildiz F. The Efficacy of Lung Volume Reduction Coil Treatment in Patients with Severe Chronic Obstructive Pulmonary Disease (COPD) Type II Respiratory Failure. Int J Chron Obstruct Pulmon Dis 2020; 15:479-486. [PMID: 32184585 PMCID: PMC7060769 DOI: 10.2147/copd.s218785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 01/28/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Emphysema is a progressive and irreversible disease, proceeding with the decrease in elastic recoil which is connected to tissue damage caused by chronic inflammation. Lung volume reduction coil (LVRC) method in patients with an advanced level of emphysema and irresponsive to medical treatment is shown to provide increase in lung volumes and exercise capacity, decrease in dyspnea, and increase in quality of life. The purpose of this study is to reveal that LVRC treatment is also efficient in severe COPD patients with hypercapnic respiratory failure. Patients and Methods Eleven cases with severe COPD and emphysema were included in the study. LVRC treatment method was applied in upper lobes of both lungs in patients with severe COPD (FEV1 < %45) and Type-2 respiratory insufficiency (PCO2 55-80 mmHg) who were having medical treatment and CPAP treatment. The patients were followed up for a period of twelve months using arterial blood gas analysis. Results Beginning with the first month of the LVRC treatment, PCO2 levels were found to be significantly decreased in all patients using arterial blood gas analysis. Conclusion LVRC method can provide physiological and functional recovery and progress in quality of life in severe COPD cases. It is demonstrated that LVRC treatment caused significant decreases in carbon dioxide levels as well as causing improvement in life quality and respiratory function tests in the patients with hypercapnic respiratory failure.
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Affiliation(s)
- Fidan Yildiz
- Okan University, Okan University Chest Diseases, İçmeler, Turkey
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12
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Garner J, Kemp S, Srikanthan K, Caneja C, Zoumot Z, Roberts C, Banya W, Chaudhuri R, Bicknell S, Ross E, LaPrad A, Shah P. 5-Year Survival after Endobronchial Coil Implantation: Secondary Analysis of the First Randomised Controlled Trial, RESET. Respiration 2020; 99:154-162. [DOI: 10.1159/000505274] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/06/2019] [Indexed: 11/19/2022] Open
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13
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Hu Y, Cheng Y, Zhang H, Li A, Li S, Wang G. A New-Designed Lung-Bending Device for Bronchoscopic Lung Volume Reduction of Severe Emphysema: A Feasibility Study in Pigs. Respiration 2019; 97:444-450. [PMID: 30947231 DOI: 10.1159/000495142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 11/05/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bronchoscopic therapies are less invasive alternatives of surgical lung volume reduction for severe emphysema. Bending of lung tissue by implanting metallic coils into bronchi is one of the procedures. A new-designed device with a similar rationale, Reverser, has been developed with some improvements. OBJECTIVES The aim of the study was to evaluate the safety and feasibility of the Reversers. METHODS Twelve healthy pigs were randomly divided into 3 groups (groups A, B, and C). The Reversers were implanted bronchoscopically into the selected airways using a proprietary delivery system. Physical examination, chest fluoroscopy, computed tomography (CT) scans, and bronchoscopic observations were performed before implantation and during the follow-up period. Necropsy was performed respectively at 1 month (group A), 3 months (group B), and 6 months (group C) after implantation. RESULTS A total of 47 Reversers were implanted successfully. The procedure was feasible and well tolerated by all pigs. No severe complications, such as pneumothorax, abscesses, and airway hemorrhage, were found. No unintended injuries or death occurred. Mild granulation and inflammation were observed in the airway wall. Opacities around Reversers were shown on CT scans in some pigs. In the pigs with opacities, histological evaluation revealed widened alveolar septa due to inflammatory cell infiltration in the vicinity of the Reversers. On the analysis of CT data, there was a trend for volume reduction of the treated lung at 1 and 3 months after treatment compared with baseline. CONCLUSIONS This study showed that Reversers were safe and feasible for bronchoscopic lung volume reduction in pigs.
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Affiliation(s)
- Yan Hu
- Department of Respiratory and Critical Care Medicine of Peking University First Hospital, Beijing, China
| | - Yuan Cheng
- Department of Respiratory and Critical Care Medicine of Peking University First Hospital, Beijing, China
| | - Hong Zhang
- Department of Respiratory and Critical Care Medicine of Peking University First Hospital, Beijing, China
| | - Anning Li
- Lifetech Scientific Corp., Shenzhen, China
| | - Siyi Li
- Lifetech Scientific Corp., Shenzhen, China
| | - Guangfa Wang
- Department of Respiratory and Critical Care Medicine of Peking University First Hospital, Beijing, China,
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14
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Kloth C, Thaiss WM, Fritz J, Nikolaou K, Beer M, Hetzel J, Ioanoviciu SD, Horger M. Prediction of response to endobronchial coiling based on morphologic emphysema characterization of the lung lobe to be treated and the ipsilateral non-treated lobe as well as on functional computed tomography-data: correlation with clinical and pulmonary function. J Thorac Dis 2019; 11:93-102. [PMID: 30863577 DOI: 10.21037/jtd.2018.12.64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To test if the emphysema type of the targeted lobe, ipsilateral non-targeted lobe, and lobes of the contralateral lung impact outcome of endobronchial lung volume reduction (ELVR) treatment, and to document lobar volume changes in treated and non-treated lung lobes. Methods Thirty patients (16 men, 14 women; median age, 66±6 years; range, 48-78 years) underwent chest-computed tomography (CT) before and after endobronchial coiling for lung volume reduction (LVR) at our institution between December 2011 and March 2016. Forty-five pulmonary lobes were coiled. We classified the treated lobes into homogenous or heterogeneous emphysema phenotype based on the distribution of voxels showing tissue attenuation of less than -950 HU. Clinical response was defined as an increase or consistency in the walking distance (6MWT) 6 months after LVR-therapy. Lung volume changes were compared for treated, ipsilateral, and contralateral lobes. Additionally, pulmonary function tests (PFT), chronic obstructive pulmonary disease (COPD) assessment test (CAT), and blood gas analysis were performed. Results Responder (19/30, 63.3%) showed a significant improvement of 6 MWT from 281.05 to 335.26 (P=0.001). Non-responder (11/30, 36.7%) showed a decrease in 6MWT from 308.18 to 255.45 (P=0.001). Responders showed a significant reduction in CAT test from 23.23 to 20.73 points (P=0.038) and pCO2 from 42.94 to 40.31 (P=0.001), whereas non-responders showed an increase in pCO2 (P=0.003; from 44.27 to 47.45). There were no significant changes in PFT-parameters. In responders, there was a significant volume reduction in treated lobes from 1,627.68 to 1,519.21 mL (P=0.009). In responders, treated lobes/non-treated ipsilateral lobes were homogenous (n=11/5) and heterogeneous (n=10/28). In non-responders, treated lobes/non-treated ipsilateral were homogenous (n=5/4) and heterogeneous (n=7/16). In responders and non-responders, the emphysema phenotype in treated, ipsilateral non-treated and even contralateral lobes (P=0.250) did not differ and or change significantly before and after therapy. Only the volume of treated lobes in responders changed significantly after coiling. Conclusions The emphysema-phenotype in the targeted and non-targeted ipsilateral lobe has no impact on the outcome of endobronchial coiling for LVR and also does not change significantly after treatment, whereas the volume of the treated lobe significantly decreases in responders.
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Affiliation(s)
- Christopher Kloth
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | | | - Jan Fritz
- Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiological Science, Baltimore, MD, USA
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Tübingen, Germany
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Jürgen Hetzel
- Department of Internal Medicine II, Eberhard-Karls-University, Tübingen, Germany
| | | | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Tübingen, Germany
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15
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Slebos DJ, Cicenia J, Sciurba FC, Criner GJ, Hartman JE, Garner J, Deslée G, Delage A, Jantz M, Marquette CH, Strange C, Hatipoglu U, Mehta AC, LaPrad AS, Schmid-Bindert G, Herth FJF, Shah PL. Predictors of Response to Endobronchial Coil Therapy in Patients With Advanced Emphysema. Chest 2019; 155:928-937. [PMID: 30797746 DOI: 10.1016/j.chest.2019.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/16/2019] [Accepted: 02/01/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Lung Volume Reduction Coil Treatment in Patients With Emphysema (RENEW) trial reported improvements in quality of life, pulmonary function, and exercise performance following endobronchial coil treatment. OBJECTIVES The purpose of this post hoc analysis was to identify baseline predictors, including quantitative CT measures, that identify patients most likely to significantly benefit from endobronchial coil therapy. METHODS Quantitative CT analysis by an independent radiology laboratory and a qualitative evaluation by five blinded experts of the baseline thoracic CT imaging were performed. Univariate and multivariate logistic regression analyses were performed to elucidate characteristics associated with clinical response. RESULTS In total, 125 patients underwent coil treatment and had evaluable 12-month follow-up results. Of these, 78 patients received treatment of lobes with the highest emphysematous destruction determined by quantitative CT analysis (quantitative visual match [QVM]+), and 47 received treatment in at least one lobe that was not the most destroyed (QVM-). From the 78 patients with QVM+ treatment, a subgroup of 50 patients (64%) was identified with baseline residual volume > 200% predicted, emphysema score > 20% low attenuation area, and absence of airway disease. In this subgroup, greater lobar residual volume reduction in the treated lobes was achieved, which was associated with significant mean ± SE improvement in FEV1 (15.2 ± 3.1%), St. George's Respiratory Questionnaire (-12 ± 2 points), and residual volume (-0.57 ± 0.13 L). DISCUSSION This post hoc analysis found that both significant hyperinflation (residual volume ≥ 200% predicted) and CT analysis are critical for patient selection and treatment planning for endobronchial coil therapy. Quantitative CT analysis is important to identify optimal lobar treatment and to exclude patients with insufficient emphysema (< 20% low attenuation area), whereas visual assessment identifies patients with signs of airway disease associated with worse outcomes. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01608490; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | | | | | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Jorine E Hartman
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Justin Garner
- Royal Brompton Hospital and Chelsea and Westminster Hospital, London, UK
| | - Gaëtan Deslée
- University Hospital of Reims, INSERM U1250, Reims, France
| | - Antoine Delage
- Quebec Heart and Lung Institute, Quebec City, QC, Canada
| | | | | | | | | | | | - Adam S LaPrad
- PneumRx, Inc., a BTG International group company, Santa Clara, CA
| | - Gerald Schmid-Bindert
- PneumRx GmbH, a BTG International group company, Düsseldorf, Germany; Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Felix J F Herth
- Thoraxklinik and Translational Lung Research Center, University of Heidelberg, Heidelberg, Germany
| | - Pallav L Shah
- Royal Brompton Hospital and Chelsea and Westminster Hospital, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
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16
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Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2019; 7:313-324. [PMID: 30744937 DOI: 10.1016/s2213-2600(18)30431-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Severe emphysema is a debilitating condition with few treatment options. Lung volume reduction procedures in the treatment of severe emphysema have shown excellent results in selected patients but their exact role remains unclear with studies reporting a wide variation in outcomes. We therefore aimed to evaluate the effects of volume reduction. METHODS We did a systematic review and meta-analysis. We searched MEDLINE on Sept 29, 2016, for trials of lung volume reduction in patients with emphysema, and we did an updated search on Embase and PubMed on June 18, 2018. We only included randomised controlled studies published in English evaluating the intervention with either sham or standard of care. Inclusion was limited to trials of techniques in which there was sustainable volume reduction. Primary outcomes were residual volume, FEV1, St George's Respiratory Questionnaire (SGRQ), and 6-min walk distance (6MWT). Secondary outcomes were severe adverse events (including mortality), short-term mortality, and overall mortality. We extracted summary level data from the trial publications and where necessary we obtained unpublished data. A random-effects model with the I2 statistic was used to determine heterogeneity and trial weight in each analysis. The study is registered with the PROSPERO database, number CRD42016045705. FINDINGS We identified 4747 references in the search, and included 20 randomised controlled trials of lung volume reduction involving 2794 participants with emphysema. Following lung volume reduction from any of the interventions in pooled analyses (ie, surgery, endobronchial valve, endobronchial coil, or sclerosing agents), the mean differences compared with the control were reduction in residual volume of 0·58 L (95% CI -0·80 to -0·37), increase in FEV1 of 15·87% (95% CI 12·27 to 19·47), improvement in 6MWT of 43·28 m (31·36 to 55·21), and reduction in the SGRQ of 9·39 points (-10·92 to -7·86). The odds ratio for a severe adverse event, which included mortality, was 6·21 (95% CI 4·02 to 9·58) following intervention. Regression analysis showed improvements relative to the degree of volume reduction: FEV1 (r2=0·86; p<0·0001), 6MWT (r2=0·77; p<0·0001), and SGRQ (r2=0·70; p<0·0001). Most studies were at high risk of bias for lack of blinding, and heterogeneity was high for some outcomes when pooled across all interventions, but was generally lower in the subgroups by intervention type. INTERPRETATION Despite limitations of high risk of bias and heterogeneity for some analyses, our results provide support that lung volume reduction in patients with severe emphysema on maximal medical treatment has clinically meaningful benefits. These benefits should be considered alongside potential adverse events. FUNDING None.
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17
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Rustagi N, Singh S, Dutt N, Kuwal A, Chaudhry K, Shekhar S, Kirubakaran R. Efficacy and Safety of Stent, Valves, Vapour ablation, Coils and Sealant Therapies in Advanced Emphysema: A Meta-Analysis. Turk Thorac J 2019; 20:43-60. [PMID: 30664426 DOI: 10.5152/turkthoracj.2018.18062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/17/2018] [Indexed: 11/22/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) methods have emerged as a new treatment option for patients with severe emphysema. Endobronchial valves and coils have been extensively studied. This review assesses efficacy, safety, and cost effectiveness of the BLVR procedures (stent, valves, vapor ablation, endobronchial coils, lung sealant) in patients with severe emphysema. Databases were searched until October 2016, and randomized controlled trials (RCTs) comparing available BLVR procedures to standard medical care or sham bronchoscopy were included. Random effect model and generic inverse variance approach were used for meta-analysis. Out of 381 identified records, 16 RCTs were included. As compared to recommended medical care or sham bronchoscopy, the BLVR procedures are more effective in improving quality of life [SGRQ score (WMD=-6.38; -9.12 to -3.65)] and 6MWT (WMD=24.21; 9.68-38.74) and percentage FEV1 (WMD=10.48; 7.07-13.89). Increased risk of serious adverse events (RR=2.18; 1.63-2.93), specifically for chronic pulmonary obstructive disease exacerbations and lower respiratory tract infection combined (RR=1.37; 1.07-1.75), were observed with bronchoscopic interventions, while there was no difference in number of deaths (RR=1.25; 0.79-1.99) and respiratory failure (RR=1.13; 0.57-2.21). The BLVR procedures, especially endobronchial coils, were found to be effective in the management of patients with severe emphysema irrespective of collateral ventilation. However, characterization of patients who would be most benefited from these procedures is required, and effectiveness of these procedures in long run needs to be established.
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Affiliation(s)
- Neeti Rustagi
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences Jodhpur, Rajasthan, India
| | - Naveen Dutt
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ashok Kuwal
- Department of Pulmonary Medicine, Pacific Institute of Medical Sciences, Gyan Nagar, Near Gyan Mandir School, Sector-4, Hiran Magri, Udaipur, Rajasthan, India
| | - Kirti Chaudhry
- Department of Dentistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shashank Shekhar
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Richard Kirubakaran
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
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18
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Gulsen A. Importance of bronchoscopic lung volume reduction coil therapy in potential candidates for lung transplantation. Biosci Trends 2018; 12:395-402. [PMID: 30158333 DOI: 10.5582/bst.2018.01134] [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: 11/05/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) coil treatment is a alternative and promising treatment modality for selected severe emphysema patients. The main indication of this treatment modality is a forced expiration volume in one second (FEV1) of 15-45% and a residual volume (RV) > 175%. The aim of this study was to investigate the efficacy of BLVR coil therapy in patients with end-stage emphysema who were potential candidates for lung transplantation and had FEV1 values less than 25%. Twenty-one patients who underwent bilateral BLVR coil therapy between September 2013 and May 2015 were retrospectively reviewed. We compared the changes in clinical and laboratory parameters at the baseline and 12 months after the treatment. Twelve months after the bilateral BLVR coil treatment, we observed an average increase in FEV1 (110 mL and 4.6%), a decrease in residual volume (660 mL and 33%), and an increase in 6-minute walk tests (67 m). The most common complications were chronic obstructive pulmonary disease exacerbation (47.6%) and pneumonia (23.8%). All patients tolerated the general anesthesia and procedure very well. BLVR coil therapy is safe and effective in patients with end-stage emphysema, who are potential candidates for lung transplantation within a short to medium period. The complication rates of this treatment were not different from those of the other coil treatments, and the improvements in the clinical parameters after the treatment resulted in gaining time for lung transplantation. Future research for evaluating the long-term efficacy of BLVR coil therapy in these patients is essential.
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Affiliation(s)
- Askin Gulsen
- Department of Pneumology, School of Medicine, Sifa University.,Division of Clinical and Molecular Allergology, Research Center Borstel, Airway Research, Center North (ARCN), Member of the German Center for Lung Research
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19
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Slebos DJ, Ten Hacken NH, Hetzel M, Herth FJF, Shah PL. Endobronchial Coils for Endoscopic Lung Volume Reduction: Best Practice Recommendations from an Expert Panel. Respiration 2018; 96:1-11. [PMID: 29991060 DOI: 10.1159/000490193] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/30/2022] Open
Abstract
Endobronchial coils are an additional treatment option for lung volume reduction in patients with severe emphysema. Patient selection should be focused on patients with severe emphysema on optimal medical therapy and with evidence of severe hyperinflation. The technique is suitable in a broad range of patients with emphysema; however, patients with paraseptal emphysema, large focal (giant) bullae, significant co-morbidity and airway-predominant disease should be avoided. Treatment involves placing between 10 and 14 coils by bronchoscopy in the selected treatment lobe, with 2 lobes being treated sequentially. Lobe selection for treatment should be based on quantitative computed tomography, and the lobes with the greatest destruction should be targeted (excluding the right middle lobe). The treatment results in an improvement in pulmonary function, exercise performance and quality of life, particularly in patients with severe hyperinflation (residual volume > 200% predicted) and upper-lobe heterogeneous emphysema, but will also be of benefit in lower-lobe predominant and homogeneous emphysema. Finally, it has an acceptable safety profile, although special attention has to be paid to coil-associated opacity which is an inflammatory response that occurs in some patients treated with endobronchial coils.
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Affiliation(s)
- Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
| | - Nick H Ten Hacken
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
| | | | - Felix J F Herth
- Thoraxklinik and Translational Lung Research Center (TLRC), University of Heidelberg, Heidelberg, Germany
| | - Pallav L Shah
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.,Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom.,National Heart and Lung Institute, Imperial College, London, United Kingdom
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20
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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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21
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Abstract
Emphysema causes significant morbidity and mortality, incurring both financial and psychosocial costs. Alternatives to medical therapy and surgical lung volume reduction surgery (LVRS) have increased interest in bronchoscopic techniques. Bronchoscopic lung volume reduction (BLVR) is still in its infancy and additional trials and follow-up are critical. However, several new randomized clinical trials (RCTs) have demonstrated improvement in lung function, quality of life and exercise capacity in select patients receiving endobronchial valves and coil therapy. This article highlights recent data regarding bronchoscopic treatment of emphysema.
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Affiliation(s)
- Anuradha Ramaswamy
- Section of Pulmonary, Critical Care and Sleep, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan Puchalski
- Section of Pulmonary, Critical Care and Sleep, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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22
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Deslée G, Leroy S, Perotin JM, Mal H, Dutau H, Bourdin A, Vergnon J, Pison C, Kessler R, Jounieaux V, Salaün M, Marceau A, Dury S, Benzaquen J, Bonnaire M, Dukic S, Barbe C, Marquette CH. Two-year follow-up after endobronchial coil treatment in emphysema: results from the REVOLENS study. Eur Respir J 2017; 50:50/6/1701740. [DOI: 10.1183/13993003.01740-2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/19/2017] [Indexed: 11/05/2022]
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23
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Palamidas AF, Kemp SV, Shen M, McNulty W, Zoumot Z, Hopkinson NS, Yang GZ, Shah PL. Putative Mechanisms of Action of Endobronchial Coils. Am J Respir Crit Care Med 2017; 196:109-115. [PMID: 28665200 DOI: 10.1164/rccm.201606-1123le] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anastasios F Palamidas
- 1 Royal Brompton & Harefield NHS Foundation Trust London, United Kingdom.,2 Imperial College London London, United Kingdom.,3 Chelsea and Westminster Hospital NHS Foundation Trust London, United Kingdom and
| | - Samuel V Kemp
- 1 Royal Brompton & Harefield NHS Foundation Trust London, United Kingdom.,2 Imperial College London London, United Kingdom
| | - Mali Shen
- 2 Imperial College London London, United Kingdom
| | - Will McNulty
- 1 Royal Brompton & Harefield NHS Foundation Trust London, United Kingdom.,2 Imperial College London London, United Kingdom.,3 Chelsea and Westminster Hospital NHS Foundation Trust London, United Kingdom and
| | - Zaid Zoumot
- 4 Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates
| | - Nicholas S Hopkinson
- 1 Royal Brompton & Harefield NHS Foundation Trust London, United Kingdom.,2 Imperial College London London, United Kingdom
| | | | - Pallav L Shah
- 1 Royal Brompton & Harefield NHS Foundation Trust London, United Kingdom.,2 Imperial College London London, United Kingdom.,3 Chelsea and Westminster Hospital NHS Foundation Trust London, United Kingdom and
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24
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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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25
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Makris D, Leroy S, Pradelli J, Benzaquen J, Guenard H, Perotin JM, Zakynthinos S, Zakynthinos E, Deslee G, Marquette CH. Changes in dynamic lung mechanics after lung volume reduction coil treatment of severe emphysema. Thorax 2017; 73:584-586. [PMID: 28893857 DOI: 10.1136/thoraxjnl-2017-210118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 07/03/2017] [Accepted: 07/31/2017] [Indexed: 11/03/2022]
Abstract
We assessed the relationships between changes in lung compliance, lung volumes and dynamic hyperinflation in patients with emphysema who underwent bronchoscopic treatment with nitinol coils (coil treatment) (n=11) or received usual care (UC) (n=11). Compared with UC, coil treatment resulted in decreased dynamic lung compliance (CLdyn) (p=0.03) and increased endurance time (p=0.010). The change in CLdyn was associated with significant improvement in FEV1 and FVC, with reduction in residual volume and intrinsic positive end-expiratory pressure, and with increased inspiratory capacity at rest/and at exercise. The increase in end-expiratory lung volume (EELV) during exercise (EELVdyn-ch=EELVisotime EELVrest) demonstrated significant attenuation after coil treatment (p=0.02).
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Affiliation(s)
- Demosthenes Makris
- ICU, University Hospital Larissa, University of Thessaly, Biopolis Larissa, Greece
- Université Côte d'Azur, CHU de Nice, FHU Oncoage, Service de Pneumologie, Nice, France
| | - Sylvie Leroy
- Université Côte d'Azur, CHU de Nice, FHU Oncoage, Service de Pneumologie, Nice, France
| | - Johana Pradelli
- Université Côte d'Azur, CHU de Nice, FHU Oncoage, Service de Pneumologie, Nice, France
| | - Jonathan Benzaquen
- Université Côte d'Azur, CHU de Nice, FHU Oncoage, Service de Pneumologie, Nice, France
| | - Hervé Guenard
- Service d'Exploration Fonctionnelle, CHU Victor Segalen, Bordeaux II, Bordeaux, France
| | - Jeanne-Marie Perotin
- Service de Pneumologie, INSERM U903, Hôpital Universitaire de Reims, Reims, France
| | - Spyros Zakynthinos
- ICU, Evaggelismos University Hospital, Athens University, Athens, Greece
| | | | - Gaëtan Deslee
- Service de Pneumologie, INSERM U903, Hôpital Universitaire de Reims, Reims, France
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26
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Dutau H, Bourru D, Guinde J, Laroumagne S, Deslée G, Astoul P. Successful Late Removal of Endobronchial Coils. Chest 2017; 150:e143-e145. [PMID: 27938769 DOI: 10.1016/j.chest.2016.03.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/07/2016] [Accepted: 03/18/2016] [Indexed: 11/16/2022] Open
Abstract
Although endobronchial coils for the treatment of severe emphysema are associated with an acceptable safety profile, adverse events such as pneumothorax and thoracic pain may occur. The coils are indicated as a permanent implant and are deemed very difficult to remove. We describe the first successful removal of two coils 10 months after placement in a patient who experienced persistent thoracic pain. This case report highlights that very distal (subpleural) coil placement may induce pneumothorax and subsequent thoracic pain and that nonsurgical removal of coils up to 10 months after implantation is feasible.
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Affiliation(s)
- Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France.
| | - David Bourru
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Julien Guinde
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Sophie Laroumagne
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Gaëtan Deslée
- Department of Respiratory Diseases, INSERM U903, University Hospital, Reims, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North University Hospital, Marseille, France
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27
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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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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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Lador F, Hachulla AL, Hohn O, Plojoux J, Ronot M, Montet X, Soccal PM. Pulmonary Perfusion Changes as Assessed by Contrast-Enhanced Dual-Energy Computed Tomography after Endoscopic Lung Volume Reduction by Coils. Respiration 2016; 92:404-413. [PMID: 27820928 DOI: 10.1159/000452477] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 10/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endoscopic lung volume reduction by coils (LVRC) is a recent treatment approach for severe emphysema. Furthermore, dual-energy computed tomography (DECT) now offers a combined assessment of lung morphology and pulmonary perfusion. OBJECTIVES The aim of our study was to assess the impact of LVRC on pulmonary perfusion with DECT. METHODS Seventeen patients (64.8 ± 6.7 years) underwent LVRC. DECT was performed prior to and after LVRC. For each patient, lung volumes and emphysema quantification were automatically calculated. Then, 6 regions of interest (ROIs) on the iodine perfusion map were drawn in the anterior, mid, and posterior right and left lungs at 4 defined levels. The ROI values were averaged to obtain lung perfusion as assessed by the lung's iodine concentration (CLung, μg·cm-3). The CLung values were normalized using the left atrial iodine concentration (CLA) to take into account differences between successive DECT scans. RESULTS The 6-min walk distance (6MWD) improved significantly after the procedure (p = 0.0002). No lung volume changes were observed between successive DECT scans for any of the patients (p = 0.32), attesting the same suspended inspiration. After LVRC, the emphysema index was significantly reduced in the treated lung (p = 0.0014). Lung perfusion increased significantly adjacent to the treated areas (CLung/CLA from 3.4 ± 1.7 to 5.6 ± 2.2, p < 0.001) and in the ipsilateral untreated areas (from 4.1 ± 1.4 to 6.6 ± 1.7, p < 0.001), corresponding to a mean 65 and 61% increase in perfusion, respectively. No significant difference was observed in the contralateral upper and lower areas (from 4.4 ± 1.9 to 4.8 ± 2.1, p = 0.273, and from 4.9 ± 2.0 to 5.2 ± 1.7, p = 0.412, respectively). A significant correlation between increased 6MWD and increased perfusion was found (p = 0.0027, R2 = 0.3850). CONCLUSIONS Quantitative analysis based on DECT acquisition revealed that LVRC results in a significant increase in perfusion in the coil-free areas adjacent to the treated ones, as well as in the ipsilateral untreated areas. This suggests a possible role for LVRC in the improvement of the ventilation/perfusion relationship.
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Affiliation(s)
- Frédéric Lador
- Service of Pulmonary Medicine, Geneva University Hospitals, Geneva, Switzerland
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Zoumot Z, Kemp SV, Shah PL. Endobronchial Valves for Emphysema: Time to Push the Envelope? Respiration 2016; 92:359-361. [PMID: 27806368 DOI: 10.1159/000452630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Zaid Zoumot
- Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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Abstract
BACKGROUND Lung volume reduction surgery (LVRS) performed to treat patients with severe diffuse emphysema was reintroduced in the nineties. Lung volume reduction surgery aims to resect damaged emphysematous lung tissue, thereby increasing elastic properties of the lung. This treatment is hypothesised to improve long-term daily functioning and quality of life, although it may be costly and may be associated with risks of morbidity and mortality. Ten years have passed since the last version of this review was prepared, prompting us to perform an update. OBJECTIVES The objective of this review was to gather all available evidence from randomised controlled trials comparing the effectiveness of lung volume reduction surgery (LVRS) versus non-surgical standard therapy in improving health outcomes for patients with severe diffuse emphysema. Secondary objectives included determining which subgroup of patients benefit from LVRS and for which patients LVRS is contraindicated, to establish the postoperative complications of LVRS and its morbidity and mortality, to determine which surgical approaches for LVRS are most effective and to calculate the cost-effectiveness of LVRS. SEARCH METHODS We identified RCTs by using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register, in addition to the online clinical trials registers. Searches are current to April 2016. SELECTION CRITERIA We included RCTs that studied the safety and efficacy of LVRS in participants with diffuse emphysema. We excluded studies that investigated giant or bullous emphysema. DATA COLLECTION AND ANALYSIS Two independent review authors assessed trials for inclusion and extracted data. When possible, we combined data from more than one study in a meta-analysis using RevMan 5 software. MAIN RESULTS We identified two new studies (89 participants) in this updated review. A total of 11 studies (1760 participants) met the entry criteria of the review, one of which accounted for 68% of recruited participants. The quality of evidence ranged from low to moderate owing to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes. Eight of the studies compared LVRS versus standard medical care, one compared two closure techniques (stapling vs laser ablation), one looked at the effect of buttressing the staple line on the effectiveness of LVRS and one compared traditional 'resectional' LVRS with a non-resectional surgical approach. Participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced. Short-term mortality was higher for LVRS (odds ratio (OR) 6.16, 95% confidence interval (CI) 3.22 to 11.79; 1489 participants; five studies; moderate-quality evidence) than for control, but long-term mortality favoured LVRS (OR 0.76, 95% CI 0.61 to 0.95; 1280 participants; two studies; moderate-quality evidence). Participants identified post hoc as being at high risk of death from surgery were those with particularly impaired lung function, poor diffusing capacity and/or homogenous emphysema. Participants with upper lobe-predominant emphysema and low baseline exercise capacity showed the most favourable outcomes related to mortality, as investigators reported no significant differences in early mortality between participants treated with LVRS and those in the control group (OR 0.87, 95% CI 0.23 to 3.29; 290 participants; one study), as well as significantly lower mortality at the end of follow-up for LVRS compared with control (OR 0.45, 95% CI 0.26 to 0.78; 290 participants; one study). Trials in this review furthermore provided evidence of low to moderate quality showing that improvements in lung function parameters other than forced expiratory volume in one second (FEV1), quality of life and exercise capacity were more likely with LVRS than with usual follow-up. Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (e.g. pneumonia) and cardiovascular morbidity. Although LVRS leads to an increase in quality-adjusted life-years (QALYs), the procedure is relatively costly overall. AUTHORS' CONCLUSIONS Lung volume reduction surgery, an effective treatment for selected patients with severe emphysema, may lead to better health status and lung function outcomes, specifically for patients who have upper lobe-predominant emphysema with low exercise capacity, but the procedure is associated with risks of early mortality and adverse events.
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Affiliation(s)
| | | | - Leong Ung Tiong
- The Queen Elizabeth HospitalDepartment of SurgeryAdelaideAustralia
| | - Brian J Smith
- The University of AdelaideSchool of MedicineAdelaideAustralia
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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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Hartman JE, Klooster K, Slebos DJ, Ten Hacken NHT. Improvement of physical activity after endobronchial valve treatment in emphysema patients. Respir Med 2016; 117:116-21. [PMID: 27492521 DOI: 10.1016/j.rmed.2016.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/03/2016] [Accepted: 06/08/2016] [Indexed: 11/18/2022]
Abstract
RATIONALE Bronchoscopic lung volume reduction using endobronchial valves is a promising treatment for severe emphysema patients without collateral ventilation. Physical activity is an important contributing factor for the autonomy, morbidity and mortality of these patients. OBJECTIVE We investigated the impact of endobronchial valve treatment on physical activity in severe emphysema patients. METHODS Physical activity was measured for 7 days by a triaxial accelerometer at baseline and 6 months follow-up after EBV treatment, and compared with standard medical care in a randomized controlled trial. RESULTS Forty-three patients (77%female, age 59 ± 9years, FEV1 30 ± 7%pred, steps 3563 ± 2213per/day) wore the accelerometer and were included in the analysis. Nineteen patients received EBV treatment and 24 standard medical care. At baseline, physical activity level was comparable between groups. After 6 months, the endobronchial valve group significantly improved compared to the controls in steps/day (+1252vs-148) and locomotion time (+17vs-2 min/day). Change in sit duration (0vs + 27 min/day) did not significantly differ. CONCLUSIONS Physical activity significantly improved after endobronchial valve treatment in severe emphysema patients. This improvement was without any specific encouragement on physical activity. CLINICAL TRIAL NUMBER Dutch trial register: NTR2876.
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Affiliation(s)
- Jorine E Hartman
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands.
| | - Karin Klooster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Nick H T Ten Hacken
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
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Update on Nonsurgical Lung Volume Reduction Procedures. Can Respir J 2016; 2016:6462352. [PMID: 27445557 PMCID: PMC4904517 DOI: 10.1155/2016/6462352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 07/02/2015] [Indexed: 11/17/2022] Open
Abstract
There has been a surge of interest in endoscopic lung volume reduction (ELVR) strategies for advanced COPD. Valve implants, coil implants, biological LVR (BioLVR), bronchial thermal vapour ablation, and airway stents are used to induce lung deflation with the ultimate goal of improving respiratory mechanics and chronic dyspnea. Patients presenting with severe air trapping (e.g., inspiratory capacity/total lung capacity (TLC) < 25%, residual volume > 225% predicted) and thoracic hyperinflation (TLC > 150% predicted) have the greatest potential to derive benefit from ELVR procedures. Pre-LVRS or ELVR assessment should ideally include cardiological evaluation, high resolution CT scan, ventilation and perfusion scintigraphy, full pulmonary function tests, and cardiopulmonary exercise testing. ELVR procedures are currently available in selected Canadian research centers as part of ethically approved clinical trials. If a decision is made to offer an ELVR procedure, one-way valves are the first option in the presence of complete lobar exclusion and no significant collateral ventilation. When the fissure is not complete, when collateral ventilation is evident in heterogeneous emphysema or when emphysema is homogeneous, coil implants or BioLVR (in that order) are the next logical alternatives.
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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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Slebos DJ, Hartman JE, Klooster K, Blaas S, Deslee G, Gesierich W, Hetzel J, Hetzel M, McNulty W, Kemp SV, Kessler R, Leroy S, Stanzel F, Witt C, Zoumot Z, Herth FJ, Shah PL. Bronchoscopic Coil Treatment for Patients with Severe Emphysema: A Meta-Analysis. Respiration 2015; 90:136-45. [DOI: 10.1159/000431384] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/08/2015] [Indexed: 11/19/2022] Open
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Hartman JE, Klooster K, Ten Hacken NHT, Slebos DJ. Treatment of emphysema using bronchoscopic lung volume reduction coil technology: an update on efficacy and safety. Ther Adv Respir Dis 2015; 9:251-9. [PMID: 26113524 DOI: 10.1177/1753465815589904] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In the last decade several promising bronchoscopic lung volume reduction (BLVR) treatments were developed and investigated. One of these treatments is BLVR treatment with coils. The advantage of this specific treatment is that it works independently of collateral flow, and also shows promise for patients with a more homogeneous emphysema disease distribution. Seven years ago, the very first patients were treated with BLVR coil treatment and currently large randomized, controlled trials are underway. The aim of this article is to review the available literature and provide an update on the current knowledge on the efficacy and safety of BLVR treatment with coils.
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Affiliation(s)
- Jorine E Hartman
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nick H T Ten Hacken
- Department of Pulmonary Diseases and Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
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