Efficacy and safety of simultaneous combined Zephyr and Spiration valve therapy in patients with advanced pulmonary emphysema

BACKGROUND

Endoscopic lung volume reduction with valves is a minimally invasive treatment strategy for patients with severe pulmonary emphysema. Two valve systems are currently available: Zephyr and Spiration valves. As these can be implanted simultaneously in the same procedure, the question arose as to the effect on lung function, exercise capacity and subjective disease perception after combined valve treatment.

METHODS

We conducted a retrospective analysis of 108 patients with combined, simultaneous treatment of Zephyr and Spiration valves. The decision on which and how many valves to implant was based on the individual patient anatomy. Effects on lung function, exercise capacity and atelectasis formation as well as complications were evaluated 90- and 180-days post-treatment (90d-FU and 180d-FU).

RESULTS

At 90d-FU (n = 90), the mean change was 86.7 ± 183.7 mL for FEV1 and -645.3 ± 1276.5 mL for RV, with responder rates of 39.8 % and 46.5 %, respectively. Complete atelectasis occurred in 16.7 % and partial atelectasis in 25.5 % of patients. Six-minute walking distance increased by 27.00 m [-1.50 - 68.50m]. The rates of pneumothorax (10.2 %) 6 months after treatment were not higher than in randomized controlled trials (RCTs). Likely due to the inclusion of high-risk patients, there was a higher incidence of severe COPD exacerbation (21.3 %) and pneumonia (12.0 %) compared to RCTs.

CONCLUSIONS

The combined implantation of Zephyr and Spiration valves resulted in significant clinical and functional improvements with an acceptable risk profile. Therefore, the ability to combine both valve types in severe emphysema could be a promising option in endoscopic lung volume reduction.

Efficacy and safety of bronchoscopic lung volume reduction for chronic obstructive pulmonary disease: a systematic review and network meta-analysis

BACKGROUND

Various bronchoscopic lung volume reduction (BLVR) methods have been developed to treat chronic obstructive pulmonary disease (COPD). The efficacy and safety of these interventions remain unclear. This study assessed the efficacy and safety of various BLVR interventions in COPD patients.

METHODS

PubMed and Embase were searched from inception to 21 October 2023. The primary outcomes assessed included the 6-min walking distance (6MWD), St. George Respiratory Questionnaire (SGRQ) score, lung function, and adverse events (AE). A frequentist approach with a random-effects model was used for a network meta-analysis.

RESULTS

Twelve randomized controlled trials (RCTs) with 1646 patients were included in this meta-analysis. Patients treated with an endobronchial valve (EBV) achieved a minimum clinically important difference (MCID) in 6MWD and SGRQ at 6 months. Patients treated with coils achieved MCID in the SGRQ score at 12 months. Patients with aspiration valve system and bronchoscopic thermal vapor ablation (BTVA) achieved MCID in the SGRQ score at 6 months.

CONCLUSIONS

In COPD patients, EBV should be considered first, while being wary of pneumothorax. Coil and BTVA are potential therapeutic alternatives. Although BTVA demonstrates a safer procedural profile than coils, additional studies are imperative to clarify its efficacy.

Impact of Bronchoscopic Lung Volume Reduction with Valves on the Pulmonary Gas Exchange

Introduction: Bronchoscopic lung volume reduction (BLVR) with endobronchial valves has been shown to be a safe and effective treatment for patients with severe lung emphysema. Previous studies have reported a benefit in pulmonary function, exercise capacity, and quality of life after BLVR-treatment. The effect of BLVR with valves on the pulmonary gas exchange and its association with clinical outcomes has not been analyzed to date. The primary goal of this study was to investigate the impact of BLVR on the pulmonary gas exchange and the impact of the target lobe selection in patients with discordant target lobes in high-resolution computed tomography (HRCT) scan and perfusion scan on the pulmonary gas exchange and clinical outcomes. Methods: In this single-center study, we retrospectively analyzed pulmonary function tests, 6-min-walk-tests, HRCT scans, perfusion scans, and blood gas analyses in 77 patients over the course of 6 months following BLVR treatment. Results: We observed that complete lobar occlusion with bronchoscopic valves leads to a transient impairment of pulmonary gas exchange. Despite this, an overall positive clinical outcome could be shown in patients treated with endobronchial valves. If the target lobe selection based on HRCT and perfusion scans is discrepant, a selection based on the HRCT scan tends to be associated with a better outcome than a selection based on the perfusion scan. Conclusions: Complete lobar occlusion with bronchoscopic valves leads to a transient impairment of pulmonary gas exchange but nevertheless results in an overall positive clinical outcome.

Endobronchial treatment of severe asthma and severe emphysema with hyperinflation

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

[Interventional bronchoscopy-an overview]

Die Bronchoskopie stellt neben der Lungenfunktion und der radiologischen Bildgebung das wichtigste Diagnostikum bei Patienten mit Atemwegs- und Lungenerkrankungen dar. Aufgrund des kombinierten Einsatzes flexibler und starrer Bronchoskope kommt sie heutzutage aber auch zunehmend als endoskopisches Therapieverfahren bei pulmonalen Erkrankungen in Frage. Bei thorakalen Tumoren kann die interventionelle Bronchoskopie sowohl in palliativer als auch kurativer Intention zum Einsatz kommen. Neben der bronchoskopischen Tumorbehandlung rückten in den letzten Jahren zunehmend die Techniken der endoskopischen Lungenvolumenreduktion in den Fokus. Darüber hinaus bieten sich Therapiemöglichkeiten für Asthma und chronische Bronchitis sowie bei Atemwegsstenosen und -fisteln.

Bronchoscopic Valve Treatment of End-Stage Chronic Obstructive Pulmonary Disease

Endobronchial valve therapy has evolved over the past decade, with demonstration of significant improvements in pulmonary function, 6-minute walk distance, and quality of life in patients with end-stage chronic obstructive lung disease. Appropriate patient selection is crucial, with identification of the most diseased lobe and of a target lobe with minimal to no collateral ventilation. Endobronchial valve therapy typically is utilized in patients with heterogeneous disease but may be indicated in select patients with homogeneous disease. Morbidity and mortality have been lower than historically reported with lung volume reduction surgery, but complications related to pneumothoraces remain a challenge.

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

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

New bronchoscopic treatment modalities for patients with chronic bronchitis

Chronic bronchitis is a chronic, progressive disease that is difficult to treat. Despite much effort, patients remain highly symptomatic. Currently, a number of innovative bronchoscopic treatments for this disease are under investigation. Liquid nitrogen metered cryospray, bronchial rheoplasty and balloon desobstruction all aim to destroy the hyperplastic goblet cells and excess submucous glands using different strategies. These therapies are in an early phase of clinical research and larger randomised controlled trials are needed to confirm the pilot data available and to evaluate the treatment durability. The fourth technique, targeted lung denervation (TLD), aims to decrease the release of acetylcholine, which regulates smooth muscle tone and mucus production by ablating the parasympathetic nerves running alongside the main bronchi. Evaluation of this treatment is at a more advanced stage and promising effects on exacerbation frequency have been shown. However, confirmation of the benefit in improvement in chronic bronchitis symptoms is still needed.

We provide an overview of four innovative bronchoscopic treatments for chronic bronchitis. These treatments show promising results, but future work should focus specifically on chronic bronchitis symptoms and the sustainability of the treatment effect.https://bit.ly/34DNBce

Bronchoscopic lung volume reduction: status quo

Emphysema is associated with irreversible loss of lung compliance leading to gas trapping and hyperinflation. Surgical lung volume reduction has proven to improve lung function, exercise capacity, cardiac health and survival in patients with advanced emphysema; however, this procedure is associated with significant morbidity and mortality. Bronchoscopic lung volume reduction (BLVR) has emerged as an alternative approach for these patients. In this article, we review the different techniques used for the purpose of this procedure, its advantages and disadvantages. In addition, we discuss in length valve therapy and the studies that led to its recent FDA approval. Finally, we provide thought-provoking challenges that may be topics for further future investigation to enhance the efficacy and benefit of this technique.

Interventional Bronchoscopy

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Interventional Bronchoscopic Therapies for Chronic Obstructive Pulmonary Disease

Patients with severe chronic obstructive pulmonary disease who fail maximal medical therapy have bronchoscopic options that can improve lung function, quality of life, and exercise performance. Those with upper lobe predominant emphysema can consider bronchoscopic lung volume reduction with endobronchial valves. Select patients with diffuse emphysema and severe hyperinflation can also be considered for endobronchial valves. Bronchoscopic techniques targeting cholinergic pathways and mucus hypersecretion are under development. Ultimately, patients with advanced chronic obstructive pulmonary disease who are not eligible for or have failed bronchoscopic interventions can consider lung volume reduction surgery or even lung transplantation, if free from major comorbidities.

Bronchoscopic interventions for severe emphysema: Where are we now?

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

Improving Lung Function in Severe Heterogenous Emphysema with the Spiration Valve System (EMPROVE). A Multicenter, Open-Label Randomized Controlled Clinical Trial

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema.

Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management.

Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control).

Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV₁ from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV₁ responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV₁ showed statistically significant improvements between the treatment and control groups—between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060–0.141) and 0.099 L (95% BCI, 0.048–0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax.

Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile.

Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

The REACH Trial: A Randomized Controlled Trial Assessing the Safety and Effectiveness of the Spiration® Valve System in the Treatment of Severe Emphysema

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has become a leading cause of morbidity and mortality in China, with tobacco smoke, air pollution, and occupational biohazards being the major risk factors.

OBJECTIVES

The REACH trial is a multicenter, prospective, randomized controlled trial undertaken in China to assess the safety and effectiveness of the Spiration® Valve System (SVS) compared to standard medical care in COPD patients with severe emphysema.

METHODS

Patients with severe airflow obstruction, hyperinflation, and severe dyspnea with interlobar fissure integrity were evaluated for enrollment. A total of 107 subjects were randomized in a 2: 1 allocation ratio to either the treatment group (SVS valves and medical management) or the control group (medical management alone).

RESULTS

The 3-month primary endpoint showed statistically significant improvement in forced expiratory volume in 1 s in the treatment group compared to the control group (0.104 ± 0.18 vs. 0.003 ± 0.15 L, p = 0.001), with the difference being durable through 6 months. Statistically significant target lobe volume reduction was achieved at 3 months (mean change 684.4 ± 686.7 mL) and through 6 months (757.0 ± 665.3 mL). Exercise function and quality of life measures improved in the treatment group, but showed a deterioration in the control group. The serious adverse event (SAE) rate was 33% in the treatment group and 24.2% in the control group. The predominance of SAEs were acute exacerbations of COPD in both groups. There was 1 death in the control group and no deaths in the treatment group.

CONCLUSION

The SVS represents a novel approach for the treatment of severe emphysema with a clinically acceptable risk-benefit profile.

History of lung volume reduction procedures

Lung volume reduction (LVR) procedures for emphysematous patients were firstly introduced in the second half of the twentieth century. Over time, from the first invasive surgical procedures, new less invasive techniques have been conceived. In regards to the surgical approach, the adoption of VATS and the execution, in selected centers, of a non-resectional approach, with folding of less functional lung tissue, reduced mortality and adverse events risks. As regards to the bronchoscopic approach, endobronchial valves (EBV) and intrabronchial valves (IBV) were initially proposed in the early 2000s to obtain segmental or lobar atelectasis of the more compromised lung parenchyma. Despite showing promising results with respect to improvement of pulmonary function tests, particularly forced expiratory volume in 1st second (FEV₁), and quality of life, and a good safety profile, valves showed disappointing results in presence of collateral ventilation, such as in cases of incomplete fissures. To overcome this technical issue, in the last 10 years, endobronchial coils have been designed and used. Having a compressive effect on the lung parenchyma where they are located, they are not affected by collateral ventilation. Randomized control trials (RCTs) on endobronchial coils showed a significant improvement in FEV₁ and quality of life, however this technique was not immune to side effects, particularly low respiratory tract infections and pneumothoraces. Besides bronchial valves (BV) and coils, airway by-pass stents have also been evaluated in a RCT but without reaching the desired endpoints. Other innovative procedures recently considered and delivered through bronchoscopy regards thermal energy, with vapour therapy, to achieve a scarring reaction of the emphysematous lung parenchyma, and polymeric foams used as lung sealants to achieve absorptive atelectasis. In conclusion, LVR procedures may be considered in carefully selected patients with symptomatic emphysema and severe lung hyperinflation, and might be personalized according to the anatomical characteristics of emphysematous area.

Chartis Measurement of Collateral Ventilation: Conscious Sedation versus General Anesthesia - A Retrospective Comparison

BACKGROUND

Absence of interlobar collateral ventilation using the Chartis measurement is the key predictor for successful endobronchial valve treatment in severe emphysema. Chartis was originally validated in spontaneous breathing patients under conscious sedation (CS); however, this can be challenging due to cough, mucus secretion, mucosal swelling, and bronchoconstriction. Performing Chartis under general anesthesia (GA) avoids these problems and may result in an easier procedure with a higher success rate. However, using Chartis under GA with positive pressure ventilation has not been validated.

OBJECTIVES

In this study we investigated the impact of anesthesia technique, CS versus GA, on the feasibility and outcomes of Chartis measurement.

METHODS

We retrospectively analyzed all Chartis measurements performed at our hospital from October 2010 until December 2017.

RESULTS

We analyzed 250 emphysema patients (median forced expiratory volume in 1 s 26%, range 12-52% predicted). In 121 patients (48%) the measurement was performed using CS, in 124 (50%) using GA, and in 5 (2%) both anesthesia techniques were used. In total, 746 Chartis readings were analyzed (432 CS, 277 GA, and 37 combination). Testing under CS took significantly longer than GA (median 19 min [range 5-65] vs. 11 min [3-35], p < 0.001) and required more measurements (3 [1-13] vs. 2 [1-6], p < 0.001). There was no significant difference in target lobe volume reduction after treatment (-1,123 mL [-3,604 to 332] in CS vs. -1,251 mL [-3,333 to -1] in GA, p = 0.35).

CONCLUSIONS

In conclusion, Chartis measurement under CS took significantly longer and required more measurements than under GA, without a difference in treatment outcome. We recommend a prospective trial comparing both techniques within the same patients to validate this approach.

Valve therapy in patients with emphysematous type of chronic obstructive pulmonary disease (COPD): from randomized trials to patient selection in clinical practice

In recent years a number of endoscopic methods have emerged to treat patients with severe emphysematous type of chronic obstructive pulmonary disease (COPD), who are primarily symptomatic due to hyperinflation despite optimal medical management. Of these techniques, implantation of endobronchial one-way valves into targeted airways of isolated emphysematous lobes appears to be one of the most promising innovations. Results from randomized controlled trials of valve therapy for emphysema show consistent benefits in terms of lung function, exercise capacity, symptoms, and quality of life. This review aims to provide a comprehensive summary of the currently available scientific data, discussion of typical treatment related side effects, and recommendations for patient selection in clinical practice.

Endoscopic approaches for treating emphysema

INTRODUCTION

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

Interventional pulmonology in chronic obstructive pulmonary disease

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Bronchoscopic lung volume reduction: recent updates

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.

Endobronchial Valve Therapy in Patients with Homogeneous Emphysema. Results from the IMPACT Study

RATIONALE

Endobronchial valves (EBVs) have been successfully used in patients with severe heterogeneous emphysema to improve lung physiology. Limited available data suggest that EBVs are also effective in homogeneous emphysema.

OBJECTIVES

To evaluate the efficacy and safety of EBVs in patients with homogeneous emphysema with absence of collateral ventilation assessed with the Chartis system.

METHODS

Prospective, multicenter, 1:1 randomized controlled trial of EBV plus standard of care (SoC) or SoC alone. Primary outcome was the percentage change in FEV₁ (liters) at 3 months relative to baseline in the EBV group versus the SoC group. Secondary outcomes included changes in FEV₁, St. George's Respiratory Questionnaire (SGRQ), 6-minute-walk distance (6MWD), and target lobe volume reduction.

MEASUREMENTS AND MAIN RESULTS

Ninety-three subjects (age, 63.7 ± 6.1 yr [mean ± SD]; FEV₁, % predicted, 29.3 ± 6.5; residual volume, % predicted, 275.4 ± 59.4) were allocated to either the EBV group (n = 43) or the SoC group (n = 50). In the intention-to-treat population, at 3 months postprocedure, improvement in FEV₁ from baseline was 13.7 ± 28.2% in the EBV group and -3.2 ± 13.0% in the SoC group (mean between-group difference, 17.0%; P = 0.0002). Other variables demonstrated statistically and clinically significant changes from baseline to 3 months (EBV vs. SoC, respectively: SGRQ, -8.63 ± 11.25 vs. 1.01 ± 9.36; and 6MWD, 22.63 ± 66.63 m vs. -17.34 ± 52.8 m). Target lobe volume reduction at 3 months was -1,195 ± 683 ml (P < 0.0001). Of the EBV subjects, 97.2% achieved volume reduction in the target lobe (P < 0.0001). Procedure-related pneumothoraces occurred in 11 subjects (25.6%). Five subjects required removal/replacement of one or more valves. One subject experienced two valve migration events requiring removal/replacement of valves.

CONCLUSIONS

EBV in patients with homogeneous emphysema without collateral ventilation results in clinically meaningful benefits of improved lung function, exercise tolerance, and quality of life.

Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease

BACKGROUND

In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique.

SEARCH METHODS

Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software.

MAIN RESULTS

AeriSealOne RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV₁) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate. Airway bypass stentsTreatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV₁ (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high. Endobronchial coilsThree studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV₁ (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high. Endobronchial valvesFive studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV₁ (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high. Intrabronchial valvesIn the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV₁ (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV₁ and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high. Vapour ablationOne study of 69 participants found significant mean between-group differences in FEV₁ (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate.

AUTHORS' CONCLUSIONS

Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.

Novel Technologies in Endoscopic Lung Volume Reduction

Endoscopic lung volume reduction (ELVR) presents an effective therapy in patients with advanced emphysema. Different ELVR techniques are available differing in mechanism of action, degree of reversibility and safety. Precise patient selection with respect to pulmonary function test, emphysema distribution, and collateral ventilation are prerequisites for a successful use of the various ELVR techniques. To date, there are only a few randomized controlled trials for bronchoscopic therapy in patients with chronic obstructive pulmonary disease, so the various techniques should be performed within clinical trials or registry studies.

Clinical and radiological outcome following pneumothorax after endoscopic lung volume reduction with valves

INTRODUCTION

Valve implantation has evolved as a therapy for patients with advanced emphysema. Although it is a minimally invasive treatment, it is associated with complications, the most common being pneumothorax. Pneumothorax occurs due to the rapid target lobe volume reduction and may be a predictor of clinical benefit despite this complication.

OBJECTIVE

The objective of this study was to conduct an exploratory data analysis of patients who developed a pneumothorax following endoscopic valve therapy for emphysema.

MATERIALS AND METHODS

This study performed a retrospective evaluation of pneumothorax management and the impact of pneumothorax on clinical outcomes in 70 patients following valve therapy in 381 consecutive patients.

RESULTS

Pneumothorax rate following valve therapy was 18%. Pneumothorax management consisted of chest tube insertion, valve removal, and surgical intervention in 87% (61/70), 44% (31/70), and 19% (13/70) of the patients, respectively. Despite pneumothorax, patients experienced modest but significant improvements in lung function parameters (forced expiratory volume in 1 second: 55±148 mL, residual volume: -390±964 mL, total lung capacity: -348±876; all P<0.05). Persistent lobar atelectasis 3 months after recovering from pneumothorax, which was associated with relevant clinical improvement, was observed in only 21% (15/70) of the patients.

CONCLUSION

Pneumothorax is a frequent severe complication following valve therapy that requires further intervention. Nevertheless, the pneumothorax does not impair the clinical status in the majority of patients. Patients with lobar atelectasis benefit after recovering from pneumothorax in terms of lung function parameters.

Lung volume reduction for emphysema

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.

Status of and prospects for bronchoscopic lung volume reduction for patients with severe emphysema

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.

Lung perfusion and emphysema distribution affect the outcome of endobronchial valve therapy

The exclusion of collateral ventilation (CV) and other factors affect the clinical success of endoscopic lung volume reduction (ELVR). However, despite its benefits, the outcome of ELVR remains difficult to predict. We investigated whether clinical success could be predicted by emphysema distribution assessed by computed tomography scan and baseline perfusion assessed by perfusion scintigraphy. Data from 57 patients with no CV in the target lobe (TL) were retrospectively analyzed after ELVR with valves. Pulmonary function tests (PFT), St George's Respiratory Questionnaire (SGRQ), and 6-minute walk tests (6MWT) were performed on patients at baseline. The sample was grouped into high and low levels at the median of TL perfusion, ipsilateral nontarget lobe (INL) perfusion, and heterogeneity index (HI). These groups were analyzed for association with changes in outcome parameters from baseline to 3 months follow-up. Compared to baseline, patients showed significant improvements in PFT, SGRQ, and 6MWT (all P≤0.001). TL perfusion was not associated with changes in the outcome. High INL perfusion was significantly associated with increases in 6MWT (P=0.014), and high HI was associated with increases in forced expiratory volume in 1 second (FEV1), (P=0.012). Likewise, there were significant correlations for INL perfusion and improvement of 6MWT (r=0.35, P=0.03) and for HI and improvement in FEV1 (r=0.45, P=0.001). This study reveals new attributes that associate with positive outcomes for patient selection prior to ELVR. Patients with high perfusions in INL demonstrated greater improvements in 6MWT, while patients with high HI were more likely to respond in FEV1.

Sequential Bilateral Bronchoscopic Lung Volume Reduction With One-Way Valves for Heterogeneous Emphysema

BACKGROUND

Clinical benefits of bronchoscopic lung volume reduction with one-way endobronchial valves have been reported for heterogeneous emphysema after unilateral treatment. We assessed the potential role of contralateral treatment to prolong the benefits obtained with the first procedure.

METHODS

This was a retrospective multicenter study including consecutive patients with heterogeneous emphysema undergoing bronchoscopic valves deployment during the last 4 years. Patients were split into two groups depending on the procedure (unilateral versus bilateral). The intergroup differences were evaluated to assess the viability, effectiveness, and safety of the bilateral procedure.

RESULTS

Forty-nine patients were enrolled. Of these, 14 (28%) had a sequential bilateral procedure mainly due to loss of the clinical benefits obtained with the first treatment. A significant improvement of forced expiratory volume in 1 second (p < 0.05), forced vital capacity (p < 0.05), residual volume (p < 0.05), 6-minute walking test (p < 0.05), and St. George respiratory questionnaire (p < 0.02) was achieved after the second procedure. These results were maintained during follow-up. There was no significant difference regarding the changes of forced expiratory volume in 1 second (p = 0.4), forced vital capacity (p = 0.08), residual volume (p = 0.9), 6-minute walking test (p = 0.3), and St. George respiratory questionnaire (p = 0.1) between the bilateral and unilateral groups.

CONCLUSIONS

A sequential bilateral approach seems to be a valid strategy to improve respiratory function in patients with bilateral heterogeneous emphysema who have lost the benefits obtained with the first procedure.

Update on Nonsurgical Lung Volume Reduction Procedures

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.

The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema

In patients with severe emphysema, bronchoscopic lung volume reduction using one-way valves is a promising therapeutic option to improve lung function and quality of life. The goal of this treatment is to achieve a complete lobar atelectasis. In a significant proportion of patients, this atelectasis cannot be achieved due to interlobar collateral ventilation. This collateral ventilation is generated through incomplete lobar fissures. Therefore, only patients with complete fissures and no collateral ventilation can be selected for endobronchial therapy with one-way valves.

Incomplete fissures are very common and exhibit a great variation in anatomy. The reported prevalence is 17%–85% for the right major fissure, 19%–74% for the left major fissure, and 20%–90% for the minor fissure. There are several methods of measuring or predicting the presence of collateral ventilation, with computed tomography (CT)-fissure analysis and the Chartis measurement being the most important. CT-fissure analysis is an indirect method to measure the completeness of fissures as a surrogate for collateral ventilation. The Chartis system is an endobronchial method to directly measure the presence of collateral ventilation. Both methods have unique value, and the combination of both can accurately predict the treatment response to the bronchoscopic placement of endobronchial valves. This review provides an in-depth view of lung fissure and collateral ventilation to help understand its importance in selecting the appropriate patients for new emphysema treatments and thus avoid useless treatment in unsuitable patients.

Bronchoscopic lung volume reduction in chronic obstructive pulmonary disease: History and progress

Emphysema is one of the pathological manifestations of chronic obstructive pulmonary disease (COPD), which leads to lung hyperinflation, decreased activity of the diaphragm, decreased compliance of the lung, and difficulties in gas exchange. The clinical effect of pharmacological treatment for patients with severe emphysema is limited. In recent years, the emergence of bronchoscopic lung volume reduction (BLVR) has opened up the possibility for the management of COPD with severe emphysema. The article aims to summarize the development, procedure, and methodology of BLVR as well as its clinical efficacy.

Bilateral endoscopic volume reduction in a woman with severe emphysema

In selected patients with severe heterogenous emphysema lung volume reduction can be performed by using endobronchial valves. So far, only unilateral procedures have been published. Here is described a patient where a right-sided closure of the right upper lobe resulted in an increase of FEV1sec of more than 50%, and some years later the procedure was repeated on the left side with further considerable improvement. A tracheal bronchus to the apical segment of the right upper lobe made measuring the collateral flow at bronchoscopy impossible, but clearly visible fissures were used as a substitute. In conclusion, valve treatment in suitable patients can give substantial improvement in lung function and quality of life and can be repeated on the other side if warranted some years later.

Endoscopic bronchial valve treatment: patient selection and special considerations

As well as lung volume reduction surgery, different minimally invasive endoscopic techniques are available to achieve lung volume reduction in patients with severe emphysema and significant hyperinflation. Lung function parameters and comorbidities of the patient, as well as the extent and distribution of the emphysema are factors to be considered when choosing the patient and the intervention. Endoscopic bronchial valve placement with complete occlusion of one lobe in patients with heterogeneous emphysema is the preferred technique because of its reversibility. The presence of high interlobar collateral ventilation will hinder successful treatment; therefore, endoscopic coil placement, polymeric lung volume reduction, or bronchoscopic thermal vapor ablation as well as lung volume reduction surgery can be used for treating patients with incomplete fissures. The effect of endoscopic lung volume reduction in patients with a homogeneous distribution of emphysema is still unclear and this subgroup should be treated only in clinical trials. Precise patient selection is necessary for interventions and to improve the outcome and reduce the risk and possible complications. Therefore, the patients should be discussed in a multidisciplinary approach prior to determining the most appropriate treatment for lung volume reduction.

Time for the Global Rollout of Endoscopic Lung Volume Reduction

Chronic obstructive pulmonary disease remains one of the most common causes of morbidity and mortality globally. The disease is generally managed with pharmacotherapy, as well as guidance about smoking cessation and pulmonary rehabilitation. Endoscopic lung volume reduction (ELVR) has been proposed for the treatment of advanced emphysema, with the aim of obtaining the same clinical and functional advantages of surgical lung volume reduction whilst potentially reducing risks and costs. There is a growing body of evidence that certain well-defined sub-groups of patients with advanced emphysema may benefit from ELVR, provided the selection criteria are met and a systematic approach is followed. ELVR devices, particularly unidirectional valves and coils, are currently being rolled out to many countries outside of the U.S.A. and Europe, although very few centres currently have the capacity to correctly evaluate and provide ELVR to prospective candidates. The high cost of these interventions underpins the need for careful patient selection to best identify those who may or may not benefit from ELVR-related procedures. The aim of this review is to provide the practicing pulmonologist with an overview of the practical aspects and current evidence for the use of the various techniques available, and to suggest an evidence-based approach for the appropriate use of these devices, particularly in emerging markets, where there should be a drive to develop and equip key specialised ELVR units.

Endoscopic volume reduction in COPD- a critical review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is common in Germany, with a prevalence of 13.2%. The available treatments are exclusively symptomatic, except for lung transplantation, from which no more than a few patients can benefit. Over the past decade, endoscopic lung volume reduction (ELVR) has broadened the therapeutic spectrum for patients with advanced pulmonary emphysema.

METHODS

We review pertinent publications that were retrieved from Pubmed using the search terms "endoscopic lung volume reduction," "endobronchial valves," "endobronchial coil," and "bronchoscopic thermal vapor ablation," along with current data from the annual meeting of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie).

RESULTS

ELVR is now performed with three different techniques. Endoscopic valve implantation has been studied in three randomized controlled trials (RCTs) and several noncontrolled trials, which have shown a benefit from valve therapy particularly for patients who have only a small amount of interlobar collateral ventilation or none at all. A reduction of lobar lung volume by 56-80% was found, in association with a significant improvement of lung function (a 16-26% increase of forced expiratory volume in one second [FEV1]). The main complication of valve therapy is pneumothorax, which arises in up to 23% of cases. Coil implantation has been studied to date in only a single RCT, which revealed a significant improvement in quality of life as the primary endpoint (St. George´s Respiratory Questionnaire [SGRQ]: -8 points). Bronchoscopic thermoablation has been studied only in noncontrolled intervention trials; in patients with emphysema mainly affecting the upper lobes, it has been found to reduce lobar volume by an average of 48%.

CONCLUSION

Endoscopic lung volume reduction has broadened the therapeutic spectrum for selected patients with advanced pulmonary emphysema. Further prospective trials are needed to evaluate the benefits, risks, and long-term effects of the available techniques for ELVR.

Comparing Clinical Outcomes in Upper versus Lower Lobe Endobronchial Valve Treatment in Severe Emphysema

BACKGROUND

Lung volume reduction surgery has been recommended for patients with upper lobe predominant emphysema and was associated with less favorable outcomes in patients with non-upper lobe predominant emphysema. The value of endobronchial valve (EBV) treatment in lower lobe predominant emphysema has not been studied.

OBJECTIVES

To confirm the equivalence of upper and lower lobe valve treatments in patients with heterogeneous emphysema.

METHODS

A retrospective analysis from the Endobronchial Valve for Emphysema Palliation Trial (VENT), where patients with heterogeneous emphysema received Zephyr® EBV (Pulmonx Corp., Redwood City, Calif., USA) or medical treatment, was performed. Patients with low interlobar collateral ventilation and accurate placement of valves in the target lobes were identified. Safety and efficacy were compared between patients who underwent upper versus lower lobe treatment.

RESULTS

Of the 331 patients, 60 had low interlobar collateral ventilation and successful lobar exclusion (45 patients with upper lobe treatment and 15 patients with lower lobe treatment). There was no difference in baseline characteristics between the groups except for a higher destruction score (70.3 vs. 60.7%; p = 0.0010) and a higher heterogeneity index (24 vs. 13%; p = 0.0005) for the upper lobe cohort. At 180 days, both groups had improved clinically. There were no significant differences in mean changes or responder rates of forced expiratory volume in 1 s (+23.8 vs. +22.9%), the St. Georges Respiratory Questionnaire (-6.50 vs. -7.53 points), the 6-min walk test (+24.1 vs. +44.0 m), target lobe volume reduction (-1,199 vs. -1,042 ml), or in the adverse event rate between both cohorts.

CONCLUSION

Patients with lower and upper lobe predominant emphysema benefit equally from EBV therapy when interlobar collateral ventilation is low and lobar exclusion is achieved. Patients with lower lobe disease did not have increased adverse events compared to patients with upper lobe emphysema.

Efficacy and safety of endobronchial valves for advanced emphysema: a meta analysis

OBJECTIVE

A meta-analysis was undertaken to evaluate the efficacy and safety of bronchoscopic lung volume reduction with endobronchial valves (EBV) for advanced emphysema.

METHODS

A systematic search was performed from PubMed, EMBASE, CNKI, Cochrane Library database. Randomized control clinical trials on treatment of emphysema for 3-12 months with the EBV compared with standard medications and sham EBV were reviewed. Inclusion criteria were applied to select patients with advanced emphysema treated with EBV. The primary outcome was the percentage of the forced expiratory volume in the first second (FEV1%). Secondary outcomes included St George's Respiratory Questionnaire (SGRQ) score, the distance of the 6-minute walk (6MWD) test, the Modified Medical Research Council (MMRC) dyspnoea score, cycle ergometry workload, and the rate of the six major complications at 3 or 12 months. Fixed- or random-effects models were used and weighted mean differences (WMD), relative risks (RR) and 95% confidence intervals (CI) were calculated.

RESULTS

Three trials (565 patients) were considered in the meta-analysis. EBV patients yielded greater increases in FEV1% than standard medications (WMD =6.71; 95% CI, 3.31 to 10.10; P=0.0001), EBV patients also demonstrated a significant change for SGRQ score (WMD =-3.64; 95% CI, -5.93 to -1.34; P=0.002), MMRC dyspnoea score (WMD =-0.26; 95% CI, -0.44 to -0.08; P=0.004), and cycle ergometry workload (WMD =4.18; 95% CI, 2.14 to 6.22; P<0.0001). A similar level was evident for 6MWD (WMD =11.66; 95% CI, -3.31 to 26.64; P=0.13). EBV may increase the rate of hemoptysis (RR =5.15; 95% CI, 1.16 to 22.86; P=0.03), but didn't increase the adverse events including mortality, respiratory failure, empyema, pneumonia, pneumothrax. The overall rates for complications compared EBV with standard medications and sham EBV was not significant (RR =2.03; 95% CI, 0.98 to 4.21; P=0.06).

CONCLUSIONS

EBV lung volume reduction for advanced emphysema showed superior efficacy and a good safety and tolerability compared with standard medications and sham EBV, further more randomized controlled trial (RCT) studies are needed to pay more attention to the long-term efficacy and safety of bronchoscopic lung volume reduction with EBV in advanced emphysema.

Bronchoscopic interventions for severe COPD

Chronic obstructive pulmonary disease (COPD) causes severe handicap among smokers. Most patients have to remain under continuous oxygen therapy at home. Moreover, respiratory infections are very common among these patients and vaccination is obligatory against influenza. Emphysema and bronchiectasis are observed with computed tomography (CT) and in several situations these parenchymal damages are responsible for pneumothorax in one case and pseudomonas aeroginosa infection. Novel mini-invasive techniques are used currently for emphysema treatments which are described extensively throughout our current work.