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Ide Bolet S, Sisti J, Cheng K, Dadparvar S. Quantitative lobar Tc99m-MAA SPECT/CT of the lung in pre-and post-procedural guidance for bronchoscopic lung volume reduction. Nucl Med Commun 2024; 45:770-778. [PMID: 38832427 DOI: 10.1097/mnm.0000000000001868] [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: 06/05/2024]
Abstract
METHODS This prospective study included 92 patients who underwent BLVR with quantitative SPECT/CT study pre- and post-procedure between November 2018 and June 2023. The mean age was 70 years (range 56-85). with 51 males and 41 females. SPECT/CT quantified perfusion for each lobe, and the lowest counts/volume ratio determined the procedural target. Postprocedure SPECT/CT assessed total atelectasis and perfusion shifts. The 6-minute walk test and pulmonary function tests were compared pre- and post-BLVR. RESULTS SPECT/CT-guided BLVR showed clinical benefits (decreased oxygen requirements) and physiological improvements in total lung capacity, forced expiratory volume, and forced vital capacity ( P < 0.05). Significant perfusion shifts were observed away from the target lobe, with unique patterns noted for ipsilateral and contralateral nontarget lobes ( P < 0.05). CONCLUSION Quantitative lobar SPECT/CT in preprocedural guidance for BLVR proved useful in identifying suitable targets in multi-lobe homogeneous emphysema, resulting in physiological and clinical improvements for this patient group. The perfusion shift information provided by SPECT/CT offers valuable insights for pulmonologists.
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Affiliation(s)
| | | | - Ke Cheng
- Lewis Katz School of Medicine,
- Center for Biostatistics and Epidemiology, Lewis Katz School of Medicine and
| | - Simin Dadparvar
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
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Jiao Y, Tian S, Liu J, Shen X, Wang Q, Li X, Zhang W, Dong Y, Li Y, Bai C, Huang H. A preclinical animal study to evaluate the operability and safety of domestic one-way endobronchial valves. Front Med (Lausanne) 2024; 11:1293940. [PMID: 38751979 PMCID: PMC11094200 DOI: 10.3389/fmed.2024.1293940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 04/09/2024] [Indexed: 05/18/2024] Open
Abstract
Purpose To evaluate the operability and safety of bronchoscopic domestic one-way endobronchial valves (EBV) on animals. Methods Nine pigs were randomly assigned (2:1) to receive domestic one-way EBV (the experimental group, n = 6) and Zephyr® EBV (the control group, n = 3). Routine blood tests, arterial blood gases, and CT scans of the lungs were performed 1 day pre-procedure in addition to 1 week and 1 month post-procedure to assess changes in blood markers and lung volumes. At 1 month post-procedure, the animals were sacrificed, followed by removal of all valves via bronchoscopy. Pathological examinations of critical organs were subsequently performed. Results A total of 15 valves were placed in the experimental group and 6 valves were placed in the control group, without serious complications. Routine blood tests and arterial blood gas examinations at 1 day pre-procedure, 1 week post-procedure, and 1 month post-procedure did not differ significantly in both groups. No EBV displacement was noted under bronchoscopy, and the valve was smoothly removable by bronchoscope at 1 month post-procedure. At 1 week post-procedure, varying degrees of target lung lobe volume reduction were observed on lung CT in both groups. Lung volume reduction was achieved at 1 month post-procedure in both groups, without significant statistical difference. Although 3 cases in the experimental group and 1 case in the control group developed varying degrees of pneumonia, the inflammatory response did not increase over time during the experimental period. Pathological examination revealed no significant abnormal changes in the critical organs for both groups. Conclusion Our results demonstrate that domestic EBV is safe and reliable for endobronchial application in general-grade laboratory white pigs. The safety of domestic EBV is similar to that of Zephyr® EBV, with good ease of use and operability. This kind of domestic EBV can meet the safety evaluation requirements for animal testing.
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Affiliation(s)
- Yang Jiao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Sen Tian
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Department of Respiratory and Critical Care Medicine, No. 906 Hospital of the Chinese People’s Liberation Army Joint Logistic Support Force, Ningbo, China
| | - Jian Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiaping Shen
- Department of Radiology, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Qin Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiang Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Department of Respiratory and Critical Care Medicine, General Hospital of Central Theater Command of Chinese People's Liberation Army, Wuhan, China
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yuchao Dong
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Yonghua Li
- Department of Respiratory and Critical Care Medicine, No. 906 Hospital of the Chinese People’s Liberation Army Joint Logistic Support Force, Ningbo, China
| | - Chong Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Haidong Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Naval Medical University, Shanghai, China
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Lund A, Soldath P, Nodin E, Hansen HJ, Perch M, Jensen K, Hornbech K, Kalhauge A, Mortensen J, Petersen RH. Predictors of reoperation after lung volume reduction surgery. Surg Endosc 2024; 38:679-687. [PMID: 38017156 PMCID: PMC10830766 DOI: 10.1007/s00464-023-10559-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/22/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES Lung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation. Our aim was to analyse reoperations after LVRS and identify potential predictors. METHODS Consecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3-5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered. RESULTS In total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11-33) vs. 5 days (3-11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02). CONCLUSIONS Our incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line.
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Affiliation(s)
- Alberte Lund
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Patrick Soldath
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Erika Nodin
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Henrik Jessen Hansen
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Jensen
- Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Kåre Hornbech
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anna Kalhauge
- Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Jann Mortensen
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - René Horsleben Petersen
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Wu W, Xu H, Chen X, He W, Shi H. Comparison of erector spinae plane block and serratus anterior plane block for postoperative analgesia in uniportal thoracoscopic lobectomy: a randomized controlled trial. BMC Anesthesiol 2023; 23:394. [PMID: 38041029 PMCID: PMC10691001 DOI: 10.1186/s12871-023-02353-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/20/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Postoperative pain remains a significant concern following uniportal thoracoscopic surgery. The analgesic efficacy of erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) in terms of postoperative opioid consumption in uniportal thoracoscopic surgery still needs further studies. METHODS A randomized controlled trial was conducted, enrolling 150 patients who underwent uniportal thoracoscopic lobectomy. The patients were randomly allocated to three groups in a 1:1:1 ratio: the ESPB group (administered 20 ml of 0.5% ropivacaine), the SAPB group (administered 20 ml of 0.5% ropivacaine), and the standard care (control) group. The primary endpoint was the consumption of sufentanil during the first 24 h following surgery. Secondary endpoints assessed the area under the curve (AUC) of pain numerical rating scale (NRS) scores, occurrence of moderate to severe pain, time to initial sufentanil request, and postoperative adverse events. RESULTS No significant difference was observed in the consumption of sufentanil during the first 24 h following surgery between the ESPB and SAPB groups (adjusted difference, 1.53 [95% CI, -5.15 to 2.08]). However, in comparison to the control group, both intervention groups demonstrated a significant decrease in sufentanil consumption, with adjusted differences of -9.97 [95% CI, -13.10 to -6.84] for the ESPB group and -12.55 [95% CI, -15.63 to -9.47] for the SAPB group. There were no significant differences in AUC of NRS scores during rest and movement between the ESPB and SAPB groups, with adjusted differences of -7.10 [95% CI, 1.33 to -15.55] for the rest condition and 5.61 [95% CI, -13.23 to 2.01] for the movement condition. At 6 h postoperatively, there were fewer patients with moderate to severe pain in the ESPB group compared with those in the SAPB group (adjusted difference, -1.37% [95% CI, -2.29% to -0.45%]. The time to first sufentanil request significantly differed among the three groups (ESPB vs Control P < 0.01, SAPB vs Control P < 0.01, ESPB vs SAPB P = 0.015). CONCLUSIONS In patients undergoing uniportal thoracoscopic lobectomy, although the differences between the two groups are not statistically significant, both the ESPB and SAPB demonstrate effective reduction in postoperative opioid consumption and the need for rescue analgesics compared to the control group. Moreover, the ESPB group experienced a significantly lower incidence of moderate to severe pain at 6 h postoperatively compared to the SAPB group. TRIAL REGISTRATION The study was registered in the Chinese Clinical Trial Registry (registration No: ChiCTR1900021695, Date of registration: March 5th, 2019).
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Affiliation(s)
- Wei Wu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China
| | - Huan Xu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China
| | - Xue Chen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China
| | - Wenxin He
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China.
| | - Hong Shi
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, 200433, China.
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Lauria M, Stiehl B, Santhanam A, O’Connell D, Naumann L, McNitt-Gray M, Raldow A, Goldin J, Barjaktarevic I, Low DA. An analysis of the regional heterogeneity in tissue elasticity in lung cancer patients with COPD. Front Med (Lausanne) 2023; 10:1151867. [PMID: 37840998 PMCID: PMC10575648 DOI: 10.3389/fmed.2023.1151867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Purpose Recent advancements in obtaining image-based biomarkers from CT images have enabled lung function characterization, which could aid in lung interventional planning. However, the regional heterogeneity in these biomarkers has not been well documented, yet it is critical to several procedures for lung cancer and COPD. The purpose of this paper is to analyze the interlobar and intralobar heterogeneity of tissue elasticity and study their relationship with COPD severity. Methods We retrospectively analyzed a set of 23 lung cancer patients for this study, 14 of whom had COPD. For each patient, we employed a 5DCT scanning protocol to obtain end-exhalation and end-inhalation images and semi-automatically segmented the lobes. We calculated tissue elasticity using a biomechanical property estimation model. To obtain a measure of lobar elasticity, we calculated the mean of the voxel-wise elasticity values within each lobe. To analyze interlobar heterogeneity, we defined an index that represented the properties of the least elastic lobe as compared to the rest of the lobes, termed the Elasticity Heterogeneity Index (EHI). An index of 0 indicated total homogeneity, and higher indices indicated higher heterogeneity. Additionally, we measured intralobar heterogeneity by calculating the coefficient of variation of elasticity within each lobe. Results The mean EHI was 0.223 ± 0.183. The mean coefficient of variation of the elasticity distributions was 51.1% ± 16.6%. For mild COPD patients, the interlobar heterogeneity was low compared to the other categories. For moderate-to-severe COPD patients, the interlobar and intralobar heterogeneities were highest, showing significant differences from the other groups. Conclusion We observed a high level of lung tissue heterogeneity to occur between and within the lobes in all COPD severity cases, especially in moderate-to-severe cases. Heterogeneity results demonstrate the value of a regional, function-guided approach like elasticity for procedures such as surgical decision making and treatment planning.
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Affiliation(s)
- Michael Lauria
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Bradley Stiehl
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Anand Santhanam
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dylan O’Connell
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Louise Naumann
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Michael McNitt-Gray
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ann Raldow
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jonathan Goldin
- Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Daniel A. Low
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, United States
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6
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Alimohammadi M, Chaovalitwongse WA, Vesselle HJ, Zhang S. Utilizing Clinical Trial Data to Assess Timing of Surgical Treatment for Emphysema Patients. Med Decis Making 2023; 43:110-124. [PMID: 36484571 DOI: 10.1177/0272989x221132256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lung volume reduction surgery (LVRS) and medical therapy are 2 available treatment options in dealing with severe emphysema, which is a chronic lung disease. However, or there are currently limited guidelines on the timing of LVRS for patients with different characteristics. OBJECTIVE The objective of this study is to assess the timing of receiving LVRS in terms of patient outcomes, taking into consideration a patient's characteristics. METHODS A finite-horizon Markov decision process model for patients with severe emphysema was developed to determine the short-term (5 y) and long-term timing of emphysema treatment. Maximizing the expected life expectancy, expected quality-adjusted life-years, and total expected cost of each treatment option were applied as the objective functions of the model. To estimate parameters in the model, the data provided by the National Emphysema Treatment Trial were used. RESULTS The results indicate that the treatment timing strategy for patients with upper-lobe predominant emphysema is to receive LVRS regardless of their specific characteristics. However, for patients with non-upper-lobe-predominant emphysema, the optimal strategy depends on the age, maximum workload level, and forced expiratory volume in 1 second level. CONCLUSION This study demonstrates the utilization of clinical trial data to gain insights into the timing of surgical treatment for patients with emphysema, considering patient age, observable health condition, and location of emphysema. HIGHLIGHTS Both short-term and long-term Markov decision process models were developed to assess the timing of receiving lung volume reduction surgery in patients with severe emphysema.How clinical trial data can be used to estimate the parameters and obtain short-term results from the Markov decision process model is demonstrated.The results provide insights into the timing of receiving lung volume reduction surgery as a function of a patient's characteristics, including age, emphysema location, maximum workload, and forced expiratory volume in 1 second level.
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Affiliation(s)
- Maryam Alimohammadi
- Department of Industrial Engineering, University of Arkansas, Fayetteville, AR, USA
| | | | | | - Shengfan Zhang
- Department of Industrial Engineering, University of Arkansas, Fayetteville, AR, USA
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Robotic-assisted Fissure Completion for Lung Volume Reduction with Endobronchial Valves. Ann Am Thorac Soc 2022; 19:2087-2090. [PMID: 36454166 DOI: 10.1513/annalsats.202204-308cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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McCarthy DP, Taylor LJ, DeCamp MM. Analysis of Recent Literature on Lung Volume Reduction Surgery. Thorac Surg Clin 2021; 31:119-128. [PMID: 33926666 DOI: 10.1016/j.thorsurg.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Publication of the National Emphysema Treatment Trial (NETT) in 2003 established lung volume reduction surgery (LVRS) as a viable treatment of select patients with moderate to severe emphysema, and the only intervention since the availability of ambulatory supplemental oxygen to improve survival. Despite these findings, surgical treatment has been underused in part because of concern for high morbidity and mortality. This article reviews recent literature generated since the original NETT publication, focusing on physiologic implications of LVRS, recent data regarding the safety and durability of LVRS, and patient selection and extension of NETT criteria to other patient populations.
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Affiliation(s)
- Daniel P McCarthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792, USA
| | - Lauren J Taylor
- Division of Cardiothoracic Surgery, University of Colorado, Anschutz Medical Campus, 12631 East 17th Avenue, Room 5401, Mail Stop C-291, Aurora, CO 80045, USA
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, H4/340, Madison, WI 53792-0001, USA.
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Lemaitre PH, Stanifer BP, Sonett JR, Ginsburg ME. Technical Aspects of Lung Volume Reduction Surgery Including Anesthetic Management and Surgical Approaches. Thorac Surg Clin 2021; 31:129-137. [PMID: 33926667 DOI: 10.1016/j.thorsurg.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
As palliative treatment, lung volume reduction surgery can be offered to a selected subset of chronic obstructive pulmonary disease patients. Careful adherence to established inclusion and exclusion criteria is critical to achieve good outcomes. The evolution of surgical techniques toward minimally invasive approaches has improved outcomes. The fully extrathoracic access combining a subxiphoid incision with subcostal port placement allowed a further decrease in perioperative pain, which favors spontaneous respiratory drive and early postoperative mobilization. Less aggressive resections and better match for size of the hemithorax have contributed to a short-term reduction in morbidity and continued improvements in cardiopulmonary function.
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Affiliation(s)
- Philippe H Lemaitre
- Department of Thoracic Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 3rd Floor, New York, NY 10032, USA
| | - Bryan Payne Stanifer
- Department of Thoracic Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 3rd Floor, New York, NY 10032, USA
| | - Joshua R Sonett
- Department of Thoracic Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 3rd Floor, New York, NY 10032, USA
| | - Mark E Ginsburg
- Department of Thoracic Surgery, NewYork-Presbyterian Columbia University Irving Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, 3rd Floor, New York, NY 10032, USA.
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Platz JJ, Naunheim KS. Critical Analysis of the National Emphysema Treatment Trial Results for Lung-Volume-Reduction Surgery. Thorac Surg Clin 2021; 31:107-118. [PMID: 33926665 DOI: 10.1016/j.thorsurg.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The National Emphysema Treatment Trial compared medical treatment of severe pulmonary emphysema with lung-volume-reduction surgery in a multiinstitutional randomized prospective fashion. Two decades later, this trial remains one of the key sources of information we have on the treatment of advanced emphysematous lung disease. The trial demonstrated the short- and long-term effectiveness of surgical intervention as well as the need for strict patient selection and preoperative workup. Despite these findings, the key failure of the trial was an inability to convince the medical community of the value of surgical resection in the treatment of advanced emphysema.
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Affiliation(s)
- Joseph J Platz
- Division of Cardiothoracic Surgery, Saint Louis University School of Medicine, 1008 South Spring Avenue, Saint Louis, MO 63110, USA.
| | - Keith S Naunheim
- Division of Cardiothoracic Surgery, Saint Louis University School of Medicine, 1008 South Spring Avenue, Saint Louis, MO 63110, USA
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11
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Krishnan A, Chidi A, Merlo CA, Shah PD, Ha J, Higgins RSD, Bush EL. Lung Volume Reduction Surgery Before Lung Transplantation: A Propensity-Matched Analysis. Ann Thorac Surg 2021; 113:491-497. [PMID: 33609545 DOI: 10.1016/j.athoracsur.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/25/2021] [Accepted: 02/08/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lung volume reduction surgery (LVRS) is treatment option for chronic obstructive pulmonary disease, the second most common indication for lung transplantation (LTx) in the United States. Lung volume reduction surgery before LTx is controversial. Single-institution studies report contradicting results, and the impact of undergoing LVRS before LTx on outcomes after LTx is unclear. METHODS We reviewed the United Network for Organ Sharing database for all adults (aged more than 18 years) who underwent first-time LTx for chronic obstructive pulmonary disease in the lung allocation score era. We used patient demographic and clinical characteristics and lung allocation score to propensity match patients who did and patients who did not undergo LVRS before LTx. The primary exposure was prior LVRS. The primary outcome was graft failure after LTx. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards models were used to assess outcomes. RESULTS A total of 4905 patients with chronic obstructive pulmonary disease underwent LTx between May 2005 and March 2017. Of them, 107 patients (2.2%) underwent LVRS before LTx. Propensity matching generated 212 matches (106 LVRS+LTx, and 106 LTx only). Median survival was significantly longer in the LTx only cohort (6.5 vs 3.4 years, P = .034). Lung volume reduction surgery before lung transplantation was associated with significantly increased risk of graft failure after lung transplant (hazard ratio 1.72; 95% confidence interval, 1.13 to 2.60; P = .01). CONCLUSIONS In this national, propensity-matched analysis of LVRS before LTx, we show that LVRS is associated with a significantly increased risk of graft failure. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed postoperatively.
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Affiliation(s)
- Aravind Krishnan
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexis Chidi
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jinny Ha
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert S D Higgins
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Finnerty DT, McMahon A, McNamara JR, Hartigan SD, Griffin M, Buggy DJ. Comparing erector spinae plane block with serratus anterior plane block for minimally invasive thoracic surgery: a randomised clinical trial. Br J Anaesth 2020; 125:802-810. [PMID: 32660716 DOI: 10.1016/j.bja.2020.06.020] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Minimally invasive thoracic surgery causes significant postoperative pain. Erector spinae plane (ESP) block and serratus anterior plane (SAP) block promise effective thoracic analgesia compared with systemically administered opioids, but have never been compared in terms of terms of quality of recovery and overall morbidity after minimally invasive thoracic surgery. METHODS Sixty adult patients undergoing minimally invasive thoracic surgery were randomly assigned to receive either single-shot ESP or SAP block before surgery using levobupivacaine 0.25%, 30 ml. The primary outcome was quality of patient recovery at 24 h, using the Quality of Recovery-15 (QoR-15) scale. Secondary outcomes included area under the curve (AUC) of pain verbal rating scale (VRS) over time, time to first opioid analgesia, postoperative 24 h opioid consumption, in-hospital comprehensive complication index (CCI) score and hospital stay. RESULTS The QoR-15 score was higher among ESP patients compared with those in the SAP group, mean (standard deviation): 114 (16) vs 102 (22) (P=0.02). Time (min) to first i.v. opioid analgesia in recovery was 32.6 (20.6) in ESP vs 12.7 (9.5) in SAP (P=0.003). AUC at rest was 92 (31) mm h-1vs 112 (35) in ESP and SAP (P=0.03), respectively, whereas AUC on deep inspiration was 107 mm h-1 (32) vs 129 (32) in ESP and SAP (P=0.01), respectively. VRS pain on movement in ESP and SAP at 24 h was, median (25-75% range): 4 (2-4) vs 5 (3-6) (P=0.04), respectively. Opioid consumption at 24 h postoperatively was 29 (31) vs 39 (34) (P=0.37). Median (25-75%) CCI in ESP and SAP was 1 (0-2) vs 4 (0-26) (P=0.03), whereas hospital stay was 3 (2-6) vs 6 (3-9) days (P=0.17), respectively. CONCLUSION Compared with SAP, ESP provides superior quality of recovery at 24 h, lower morbidity, and better analgesia after minimally invasive thoracic surgery. CLINICAL TRIAL REGISTRATION NCT03862612.
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Affiliation(s)
- Dylan T Finnerty
- Division of Anaesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland; EU COST Action 15204 Euro-Periscope, Brussels, Belgium.
| | - Aisling McMahon
- Division of Anaesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John R McNamara
- Division of Anaesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean D Hartigan
- Division of Anaesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Griffin
- Division of Anaesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Donal J Buggy
- Division of Anaesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland; EU COST Action 15204 Euro-Periscope, Brussels, Belgium; Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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13
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Emerging Interventional Pulmonary Therapies for Chronic Obstructive Pulmonary Disease. J Thorac Imaging 2020; 34:248-257. [PMID: 31145187 DOI: 10.1097/rti.0000000000000424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic obstructive pulmonary disease is a condition characterized by progressive airflow limitation caused by airway and parenchymal inflammation. Current medical therapies, including bronchodilators, corticosteroids, and anti-inflammatory medications, have been shown to variably improve pulmonary function or quality of life without providing a long-term mortality benefit. Mortality benefits to therapy have been demonstrated in only 2 therapeutic interventions to date: long-term use of daily supplemental oxygen and surgical lung volume reduction (LVRS) for upper-lobe-predominant disease in patients with a low baseline exercise capacity. Newer bronchoscopic techniques for lung volume reduction (bLVR) have attracted interest from clinicians and researchers. To achieve successful results, these advanced therapies require an interdisciplinary approach between general and interventional pulmonologists and thoracic radiologists. In this article, we aim to review the latest interventional pulmonary techniques for treatment of chronic obstructive pulmonary disease with an emphasis on bLVR. We will review the bLVR preprocedure imaging evaluation, postprocedure imaging findings, and explore the potential benefits and risks of therapy based on the most recent clinical trial evidence.
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14
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Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease is a heterogeneous syndrome associated with varying degrees of parenchymal emphysema and airway inflammation resulting in decreased expiratory flow, lung hyperinflation, and symptoms leading to decreased exercise tolerance and quality of life. Impairment in lung function and quality of life persists following guideline-based medical therapy, thus surgical and minimally invasive bronchoscopic approaches were developed to address this unmet need. We offer a narrative review of the available technologies. RECENT FINDINGS Although lung volume reduction surgery has been shown to improve survival in appropriately selected patients, it is infrequently performed. Less invasive bronchoscopic procedures have thus been explored including endobronchial valves, coils, lung sealant, thermal vapor, and other airway approaches. Selection criteria including severity of physiologic and radiographic impairment, degree of lung hyperinflation, presence of intact fissures, type of symptoms, and presence of comorbidities are critical in selecting appropriate candidates. SUMMARY Recent advances in minimally invasive approaches to lung volume reduction have offered alternatives to surgical approaches. Two endobronchial valve devices are Food and Drug Administration approved for clinical use, and investigations into alternative bronchoscopic therapies to treat both emphysema and chronic bronchitis have been performed or are currently underway. Notably, each of these treatments requires unique selection criteria and thus a personalized approach to treatment.
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15
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Giang NT, Ngoc TN, Nam NV, Nhung NV, Thang TB, Hung DK, Bac ND, Toi CD, Hung PN. Lung Volume Reduction Surgery in Patients with Heterogenous Emphysema: Selecting Perspective. Open Access Maced J Med Sci 2019; 7:4389-4392. [PMID: 32215100 PMCID: PMC7084044 DOI: 10.3889/oamjms.2019.841] [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: 09/26/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND: Lung volume reduction surgery (LVRS) was introduced to alleviate clinical conditions in selected patients with heterogenous emphysema. Clarifying the most suitable patients for LVRS remained unclear. AIM: This study was undertaken to specifically analyze the preoperative factor affecting to LVRS. METHODS: The prospective study was conducted at 103 Military Hospital between July 2014 and April 2016. Severe heterogenous emphysema patients were selected to participate in the study. The information, spirometry, and body plethysmographic pulmonary function tests in 31 patients who underwent LVRS were compared with postoperative outcomes (changing in FEV1 and CAT scale). RESULTS: Of the 31 patients, there was statistically significant difference in the outcome of functional capacity, lung function between two groups (FEV1 ≤ 50% and > 50%) (∆FEV1: 22.46 vs 18.32%; p = 0.042. ∆ CAT: 6.85 vs 5.07; p = 0.048). Changes of the FEV1 and CAT scale were no statistically significant differences in three groups residual volume. Patients with total lung capacity < 140% had more improved than others (∆FEV1: 23.81 vs 15.1%; p = 0.031). CONCLUSION: Preoperative spirometry and body plethysmographic pulmonary function tests were useful measures to selected severe heterogenous emphysema patients for LVRS. Patients with FEV1 ≤ 50%, TLC in the range of 100-140% should be selected.
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Affiliation(s)
- Nguyen Truong Giang
- Department of Cardiothoracic Surgery, Vietnam Military Medical University, Hanoi, Vietnam
| | - Trung Nguyen Ngoc
- Department of Cardiothoracic Surgery, Vietnam Military Medical University, Hanoi, Vietnam
| | - Nguyen Van Nam
- Department of Cardiothoracic Surgery, Vietnam Military Medical University, Hanoi, Vietnam
| | | | - Ta Ba Thang
- Department of Pneumology, Vietnam Military Medical University, Hanoi, Vietnam
| | - Dong Khac Hung
- Department of Pneumology, Vietnam Military Medical University, Hanoi, Vietnam
| | - Nguyen Duy Bac
- Department of Training, Vietnam Military Medical University, Hanoi, Vietnam
| | - Chu Dinh Toi
- Department of Human and Animal Physiology, Faculty of Biology, Hanoi National University of Education, Hanoi, Vietnam
| | - Pham Ngoc Hung
- Department of Training, Vietnam Military Medical University, Hanoi, Vietnam.,Department of Epidemiology, Vietnam Military Medical University, Hanoi, Vietnam
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16
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Criner GJ, Sue R, Wright S, Dransfield M, Rivas-Perez H, Wiese T, Sciurba FC, Shah PL, Wahidi MM, de Oliveira HG, Morrissey B, Cardoso PFG, Hays S, Majid A, Pastis N, Kopas L, Vollenweider M, McFadden PM, Machuzak M, Hsia DW, Sung A, Jarad N, Kornaszewska M, Hazelrigg S, Krishna G, Armstrong B, Shargill NS, Slebos DJ. A Multicenter Randomized Controlled Trial of Zephyr Endobronchial Valve Treatment in Heterogeneous Emphysema (LIBERATE). Am J Respir Crit Care Med 2019; 198:1151-1164. [PMID: 29787288 DOI: 10.1164/rccm.201803-0590oc] [Citation(s) in RCA: 232] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE This is the first multicenter randomized controlled trial to evaluate the effectiveness and safety of Zephyr Endobronchial Valve (EBV) in patients with little to no collateral ventilation out to 12 months. OBJECTIVES To evaluate the effectiveness and safety of Zephyr EBV in heterogeneous emphysema with little to no collateral ventilation in the treated lobe. METHODS Subjects were enrolled with a 2:1 randomization (EBV/standard of care [SoC]) at 24 sites. Primary outcome at 12 months was the ΔEBV-SoC of subjects with a post-bronchodilator FEV1 improvement from baseline of greater than or equal to 15%. Secondary endpoints included absolute changes in post-bronchodilator FEV1, 6-minute-walk distance, and St. George's Respiratory Questionnaire scores. MEASUREMENTS AND MAIN RESULTS A total of 190 subjects (128 EBV and 62 SoC) were randomized. At 12 months, 47.7% EBV and 16.8% SoC subjects had a ΔFEV1 greater than or equal to 15% (P < 0.001). ΔEBV-SoC at 12 months was statistically and clinically significant: for FEV1, 0.106 L (P < 0.001); 6-minute-walk distance, +39.31 m (P = 0.002); and St. George's Respiratory Questionnaire, -7.05 points (P = 0.004). Significant ΔEBV-SoC were also observed in hyperinflation (residual volume, -522 ml; P < 0.001), modified Medical Research Council Dyspnea Scale (-0.8 points; P < 0.001), and the BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index (-1.2 points). Pneumothorax was the most common serious adverse event in the treatment period (procedure to 45 d), in 34/128 (26.6%) of EBV subjects. Four deaths occurred in the EBV group during this phase, and one each in the EBV and SoC groups between 46 days and 12 months. CONCLUSIONS Zephyr EBV provides clinically meaningful benefits in lung function, exercise tolerance, dyspnea, and quality of life out to at least 12 months, with an acceptable safety profile in patients with little or no collateral ventilation in the target lobe. Clinical trial registered with www.clinicaltrials.gov (NCT 01796392).
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Affiliation(s)
- Gerard J Criner
- 1 Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Richard Sue
- 2 St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Shawn Wright
- 2 St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark Dransfield
- 3 University of Alabama at Birmingham UAB Lung Health Center, Birmingham, Alabama
| | - Hiram Rivas-Perez
- 4 Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Tanya Wiese
- 4 Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Frank C Sciurba
- 5 Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pallav L Shah
- 6 Royal Brompton Hospital and Imperial College, London, United Kingdom
| | - Momen M Wahidi
- 7 Duke University Medical Center, Duke University, Durham, North Carolina
| | | | - Brian Morrissey
- 9 Division of Pulmonary, Critical Care and Sleep Medicine, University of California, Davis, Sacramento, California
| | - Paulo F G Cardoso
- 10 Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Steven Hays
- 11 University of California, San Francisco, San Francisco, California
| | - Adnan Majid
- 12 Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicholas Pastis
- 13 Medical University of South Carolina, Charleston, South Carolina
| | - Lisa Kopas
- 14 Pulmonary Critical Care and Sleep Medicine Consultants, Houston Methodist, Houston, Texas
| | - Mark Vollenweider
- 15 Orlando Health Pulmonary and Sleep Medicine Group, Orlando Regional Medical Center, Orlando, Florida
| | - P Michael McFadden
- 16 Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael Machuzak
- 17 Center for Major Airway Diseases, Cleveland Clinic, Cleveland Clinic Foundation, Respiratory Institute, Cleveland, Ohio
| | - David W Hsia
- 18 Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles, Torrance, California
| | - Arthur Sung
- 19 Stanford Hospital and Clinics, Stanford, California
| | - Nabil Jarad
- 20 University Hospital Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Malgorzata Kornaszewska
- 21 Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Stephen Hazelrigg
- 22 Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Ganesh Krishna
- 23 Palo Alto Medical Foundation, El Camino Hospital, Mountain View, California
| | | | | | - Dirk-Jan Slebos
- 26 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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17
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Polke M, Rötting M, Sarmand N, Krisam J, Eberhardt R, Herth FJF, Gompelmann D. Interventional therapy in patients with severe emphysema: evaluation of contraindications and their incidence. Ther Adv Respir Dis 2019; 13:1753466619835494. [PMID: 30874483 PMCID: PMC6421604 DOI: 10.1177/1753466619835494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Endoscopic and surgical interventions may be beneficial for selected patients with emphysema. Rates of treatment failure decrease when the predictors for successful therapy are known. The aim of the study was to evaluate the number of patients with severe emphysema who were not eligible for any intervention, and the reasons for their exclusion. Methods: The study was a retrospective analysis of 231 consecutive patients with advanced emphysema who were considered for interventional therapy in 2016 at the Thoraxklinik, Heidelberg, Germany. The reasons for not receiving valve or coil therapy were assessed for all patients who did not receive any therapy. Results: Of the 231 patients, 50% received an interventional therapy for lung volume reduction (LVR) (82% valve therapy, 6% coil therapy, 4.3% polymeric LVR or bronchial thermal vapour ablation, 4.3% total lung denervation, and 3.4% lung volume reduction surgery [LVRS]). A total of 115 patients did not undergo LVR. Out of these, valve or coil therapy was not performed due to one or more of the following reasons: incomplete fissure in 37% and 0%; missing target lobe in 31% and 30%; personal decision in 18% and 28%; pulmonary function test results in 8% and 15%; ventilatory failure in 4% and 4%; missing optimal standard medical care and/or continued nicotine abuse in 4% and 3%; general condition too good in less than 1% and 3%; cardiovascular comorbidities in 0% and 3%; age of patient in 0% and less than 1%. Both techniques were not performed due to one or more of the following reasons: solitary pulmonary nodule(s)/consolidation in 27%; bronchopathy in 7%; neoplasia in 2%; destroyed lung in 2%; prior LVRS in less than 1%. Conclusions: The main reason for not placing valves was an incomplete fissure and for coils a missing target lobe. Numerous additional contraindications that may exclude a patient from interventional emphysema therapy should be respected.
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Affiliation(s)
- Markus Polke
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Röntgenstr. 1, 69126 Heidelberg, Germany
| | - Matthias Rötting
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany
| | - Nilab Sarmand
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Ralf Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany, and Translational Lung Research Center Heidelberg (TLRCH, German Center for Lung Research), Heidelberg, Germany
| | - Felix J F Herth
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany, and Translational Lung Research Center Heidelberg (TLRCH, German Center for Lung Research), Heidelberg, Germany
| | - Daniela Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany, and Translational Lung Research Center Heidelberg (TLRCH, German Center for Lung Research), Heidelberg, Germany
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18
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Long-Term Results After Lung Volume Reduction Surgery: A Single Institution’s Experience. Ann Thorac Surg 2019; 107:1068-1073. [DOI: 10.1016/j.athoracsur.2018.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/07/2018] [Accepted: 10/01/2018] [Indexed: 11/23/2022]
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19
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Mansfield C, Sutphin J, Shriner K, Criner GJ, Celli BR. Patient Preferences for Endobronchial Valve Treatment of Severe Emphysema. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 6:51-63. [PMID: 30775424 DOI: 10.15326/jcopdf.6.1.2018.0147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Patients with severe emphysema have limited treatment options. Little is known about patients' willingness to accept risks for new treatments that offer meaningful benefits. Methods: We determined treatment preferences of patients with severe emphysema using a web-based discrete-choice experiment survey. Respondents answered 9 questions that offered choices between 2 hypothetical interventional treatments or continuing current medical management. Variations in 5 attributes defined the 2 interventional treatments: improvement in ability to breathe and carry out day-to-day activities, frequency of hospitalized exacerbations, treatment type, risk of pneumothorax within 30 days of procedure, and risk of death within 3 months. Respondents were recruited through the COPD Foundation's COPD Patient-Powered Research Network and had a self-reported emphysema diagnosis and 2+ score on the modified Medical Research Council Dyspnea Scale. The relative importance of the attributes and the percentage of respondents who would select different treatment options was modeled using random-parameters logit. Results: Among 294 respondents, 51% always chose an interventional treatment option, while 19% always selected continued medical management. The most important change on average was moving from continued medical management (with no improvement in breathlessness) to an interventional treatment with improvement in breathlessness. The model predicted 71% of respondents would select a treatment option similar to removable endobronchial valve implants, 6% would select lung volume reduction surgery (LVRS), and 23% continued medical management. Conclusion: Patients with severe emphysema perceive that a procedure with risks and benefits similar to the Zephyr® endobronchial valve implants is desirable over continued medical management or LVRS.
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Affiliation(s)
- Carol Mansfield
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Jessie Sutphin
- RTI Health Solutions, Research Triangle Park, North Carolina
| | | | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Bartolome R Celli
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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20
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Ambrogi V, Gallina FT, Mineo TC. Early and Long-Term Outcomes After Non-Intubated, Non-Resectional Lung Volume Reduction Surgery. EUROPEAN MEDICAL JOURNAL 2018. [DOI: 10.33590/emj/10314293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Objective: In 2001, the introduction of non-resectional lung volume reduction surgery (LVRS) enabled surgery under non-intubated anaesthesia. This study compares this combined technique to a group of patients with a similar disorder who refused non-intubated anaesthesia.
Methods: Between January 2001 and October 2015, 108 patients with severe emphysema underwent non-resectional LVRS under non-intubated anaesthesia. During the same period, another 15 patients scheduled for LVRS refused non-intubated surgery and underwent the same procedure under traditional intubated modality. Respiratory and functional parameters were evaluated. Time to residual volume recurrence and overall survival were analysed with the Kaplan–Meier method.
Results: Thirteen cases (12%) required intubation due to tenacious pleuropulmonary adhesions (n=7) or intolerance (n=6). Compared with the intubated group, the non-intubated group were found to have significantly better results in post-operative partial pressure of carbon dioxide in arterial blood (PaCO2) (45±8 versus 52±8 mmHg; p=0.04), global operative time (41±24 versus 72±31 minutes; p=0.01), non-fatal complication rate (13.6% versus 33.3%; p=0.029), and especially postoperative pneumonia rate (3.1% versus 33.3%; p=0.004); patient satisfaction for anaesthesia was also improved in the non-intubated group (3.6±1.2 versus 2.8±1.7; p=0.03). Mean air leakage (5.3±3.5 versus 6.1±4.6 days), hospital stay (6.3±4.8 versus 8.0±6.1 days), and 90 days postoperative mortality rate (1.0% versus 6.6%) were lower, yet not significantly, in the non-intubated cohort. All mean respiratory and symptomatic parameters significantly improved in both groups, with no intergroup significant difference, and persisted for 4 years after surgery. Mean follow-up for the non-intubated group was 78±30 months. Analysis of time to residual volume recurrence and overall survival showed no statistically significant intergroup difference.
Conclusion: Non-intubated, non-resectional LVRS presents a 90-day postoperative non-fatal complication rate and patient satisfaction for non-intubated anaesthesia that are significantly better than intubated procedures. The long-term outcomes were similar between both groups.
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Affiliation(s)
- Vincenzo Ambrogi
- Thoracic Surgery, Official Awake Thoracic Surgery Research Group & Multidisciplinary Lung Volume Reduction Group, Policlinico Tor Vergata University, Rome, Italy; Minimally Invasive Thoracic Surgery Unit, Policlinico Tor Vergata University, Rome, Italy
| | - Filippo Tommaso Gallina
- Thoracic Surgery, Official Awake Thoracic Surgery Research Group & Multidisciplinary Lung Volume Reduction Group, Policlinico Tor Vergata University, Rome, Italy
| | - Tommaso Claudio Mineo
- Thoracic Surgery, Official Awake Thoracic Surgery Research Group & Multidisciplinary Lung Volume Reduction Group, Policlinico Tor Vergata University, Rome, Italy
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21
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Kemp SV, Slebos DJ, Kirk A, Kornaszewska M, Carron K, Ek L, Broman G, Hillerdal G, Mal H, Pison C, Briault A, Downer N, Darwiche K, Rao J, Hübner RH, Ruwwe-Glosenkamp C, Trosini-Desert V, Eberhardt R, Herth FJ, Derom E, Malfait T, Shah PL, Garner JL, Ten Hacken NH, Fallouh H, Leroy S, Marquette CH. A Multicenter Randomized Controlled Trial of Zephyr Endobronchial Valve Treatment in Heterogeneous Emphysema (TRANSFORM). Am J Respir Crit Care Med 2017; 196:1535-1543. [PMID: 28885054 DOI: 10.1164/rccm.201707-1327oc] [Citation(s) in RCA: 195] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Single-center randomized controlled trials of the Zephyr endobronchial valve (EBV) treatment have demonstrated benefit in severe heterogeneous emphysema. This is the first multicenter study evaluating this treatment approach. OBJECTIVES To evaluate the efficacy and safety of Zephyr EBVs in patients with heterogeneous emphysema and absence of collateral ventilation. METHODS This was a prospective, multicenter 2:1 randomized controlled trial of EBVs plus standard of care or standard of care alone (SoC). Primary outcome at 3 months post-procedure was the percentage of subjects with FEV1 improvement from baseline of 12% or greater. Changes in FEV1, residual volume, 6-minute-walk distance, St. George's Respiratory Questionnaire score, and modified Medical Research Council score were assessed at 3 and 6 months, and target lobe volume reduction on chest computed tomography at 3 months. MEASUREMENTS AND MAIN RESULTS Ninety seven subjects were randomized to EBV (n = 65) or SoC (n = 32). At 3 months, 55.4% of EBV and 6.5% of SoC subjects had an FEV1 improvement of 12% or more (P < 0.001). Improvements were maintained at 6 months: EBV 56.3% versus SoC 3.2% (P < 0.001), with a mean ± SD change in FEV1 at 6 months of 20.7 ± 29.6% and -8.6 ± 13.0%, respectively. A total of 89.8% of EBV subjects had target lobe volume reduction greater than or equal to 350 ml, mean 1.09 ± 0.62 L (P < 0.001). Between-group differences for changes at 6 months were statistically and clinically significant: ΔEBV-SoC for residual volume, -700 ml; 6-minute-walk distance, +78.7 m; St. George's Respiratory Questionnaire score, -6.5 points; modified Medical Research Council dyspnea score, -0.6 points; and BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index, -1.8 points (all P < 0.05). Pneumothorax was the most common adverse event, occurring in 19 of 65 (29.2%) of EBV subjects. CONCLUSIONS EBV treatment in hyperinflated patients with heterogeneous emphysema without collateral ventilation resulted in clinically meaningful benefits in lung function, dyspnea, exercise tolerance, and quality of life, with an acceptable safety profile. Clinical trial registered with www.clinicaltrials.gov (NCT02022683).
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Affiliation(s)
- Samuel V Kemp
- 1 Royal Brompton Hospital and Imperial College London, London, United Kingdom.,2 Sherwood Forest Hospitals, NHS Foundation Trust, Nottinghamshire, United Kingdom
| | - Dirk-Jan Slebos
- 3 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Alan Kirk
- 4 Department of Thoracic Surgery, West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, West Dunbartonshire, Scotland, United Kingdom
| | - Malgorzata Kornaszewska
- 5 Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Kris Carron
- 6 Department of Pulmonology, AZ Delta, Menen, Belgium
| | - Lars Ek
- 7 Department of Pulmonary Diseases, Skane University Hospital, Lund, Sweden
| | - Gustav Broman
- 8 Department of Pulmonary Diseases, Uppsala University Hospital, Uppsala, Sweden
| | - Gunnar Hillerdal
- 8 Department of Pulmonary Diseases, Uppsala University Hospital, Uppsala, Sweden
| | - Herve Mal
- 9 Service de Pneumologie A, Hôpital Bichat, Paris, France
| | - Christophe Pison
- 10 Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France
| | - Amandine Briault
- 10 Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France
| | - Nicola Downer
- 2 Sherwood Forest Hospitals, NHS Foundation Trust, Nottinghamshire, United Kingdom
| | - Kaid Darwiche
- 11 Department of Interventional Pneumology, Ruhrlandklinik, West German Lung Center, University Clinic Essen, Essen, Germany
| | - Jagan Rao
- 12 Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Ralf-Harto Hübner
- 13 Charité Universitätsmedizin Berlin, Medizinische Klinik m. Schw. Infektiologie und Pneumologie, Campus Virchow, Berlin, Germany
| | - Christof Ruwwe-Glosenkamp
- 13 Charité Universitätsmedizin Berlin, Medizinische Klinik m. Schw. Infektiologie und Pneumologie, Campus Virchow, Berlin, Germany
| | - Valéry Trosini-Desert
- 14 Service de Pneumologie et Réanimation, Unité d'Endoscopie Bronchique, Groupe Hospitalier Pitié Salpétrière, Paris, France
| | - Ralf Eberhardt
- 15 Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, Heidelberg, Germany
| | - Felix J Herth
- 15 Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg and Translational Lung Research Center Heidelberg, Heidelberg, Germany
| | - Eric Derom
- 16 Department of Pulmonary Diseases, Ghent University Hospital, Ghent, Belgium; and
| | - Thomas Malfait
- 16 Department of Pulmonary Diseases, Ghent University Hospital, Ghent, Belgium; and
| | - Pallav L Shah
- 1 Royal Brompton Hospital and Imperial College London, London, United Kingdom
| | - Justin L Garner
- 1 Royal Brompton Hospital and Imperial College London, London, United Kingdom
| | - Nick H Ten Hacken
- 3 Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hazem Fallouh
- 5 Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Sylvie Leroy
- 17 Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, FHU OncoAge, Service de Pneumologie, Nice, France
| | - Charles H Marquette
- 17 Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, FHU OncoAge, Service de Pneumologie, Nice, France
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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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De Wolf J, Bonnette P, Sage É, Hamid A. [What place for lung volume reduction surgery for emphysema?]. Rev Mal Respir 2016; 34:147-154. [PMID: 27444695 DOI: 10.1016/j.rmr.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 01/04/2016] [Indexed: 11/25/2022]
Abstract
Lung volume reduction surgery (LVRS) has been part of the management for the treatment of selected emphysematous patients for two decades. In a large randomized American trial (NETT), lung volume reduction surgery was shown to improve overall survival at 5 years as well as exercise capacity and health-related quality of life, especially in cases of upper-lobe-predominant emphysema and low exercise capacity. Inclusion criteria were pretreatment FEV1≤45 %, TLC≥100 %, RV≥150 %, room air resting PaCO2≤60mmHg and PaO2≥45mmHg. Patients with FEV1≤20 % and either a DLCO<20 % or homogeneous emphysema were at increased risk of mortality following LVRS and should not be considered for this procedure. Despite this evidence base, lung volume reduction surgery is performed infrequently, competing with lung transplantation and new endoscopic volume reduction techniques.
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Affiliation(s)
- J De Wolf
- Service de chirurgie thoracique et transplantation pulmonaire, hôpital Foch, 92150 Suresnes, France
| | - P Bonnette
- Service de chirurgie thoracique et transplantation pulmonaire, hôpital Foch, 92150 Suresnes, France.
| | - É Sage
- Service de chirurgie thoracique et transplantation pulmonaire, hôpital Foch, 92150 Suresnes, France
| | - A Hamid
- Service de pneumologie, hôpital Foch, 92150 Suresnes, France
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24
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Liu Z, Jin C, Lui R, Guo R, Yang Y, Maimaitiyiming X, Peng C. Video-Assisted Thoracoscopic Surgery for Treatment of Chronic Obstructive Pulmonary Disease. Indian J Surg 2016; 78:112-6. [PMID: 27303119 DOI: 10.1007/s12262-015-1328-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/18/2015] [Indexed: 10/23/2022] Open
Abstract
The aim of this study is to evaluate the safety and efficacy of lung volume reduction surgery (LVRS) by video-assisted thoracoscopic surgery (VATS) in the treatment of chronic obstructive pulmonary disease (COPD). A total of 90 patients with COPD from 2002 to 2012 were enrolled into our study, comprising 22 who underwent conventional thoracotomies and 68 VATS. Pulmonary function testings, arterial blood gases analysis, and quality of life between these two groups were compared. VATS was found to be superior to the conventional thoracotomy in terms of length of hospital stay, intraoperative blood loss, intubation time, volume of chest tube drainage, and postoperative pain assessment (P < 0.05). However, significant differences in pulmonary function testings, arterial blood gases analysis, 6-min walking distance (6-MWD), and postoperative quality of life between the two groups were not found (P > 0.05). LVRS by VATS is a safe and reliable surgical approach for the treatment of COPD, with less invasiveness and shorter hospital recovery time.
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Affiliation(s)
- Zhonghao Liu
- Department of Orthopedics, the Second Hospital of Shandong University, Jinan, China
| | - Chengyu Jin
- Department of Thoracic Surgery, Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Raphael Lui
- Department of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Rui Guo
- Department of Thoracic Surgery, Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Yongwei Yang
- Department of Thoracic Surgery, Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Xiaokaiti Maimaitiyiming
- Department of Thoracic Surgery, Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Chuanliang Peng
- Department of Thoracic Surgery, the Second Hospital of Shandong University, Jinan, China
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25
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Ginsburg ME, Thomashow BM, Bulman WA, Jellen PA, Whippo BA, Chiuzan C, Lee S, Bai D, Sonett J. The safety, efficacy, and durability of lung-volume reduction surgery: A 10-year experience. J Thorac Cardiovasc Surg 2016; 151:717-724.e1. [DOI: 10.1016/j.jtcvs.2015.10.095] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 10/16/2015] [Accepted: 10/22/2015] [Indexed: 11/29/2022]
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26
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Liberator C, Shenoy K, Marchetti N, Criner G. The Role of Lobe Selection on FEV1 Response in Endobronchial Valve Therapy. COPD 2016; 13:477-82. [PMID: 26789984 DOI: 10.3109/15412555.2015.1115007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Endobronchial valve (EBV) therapy has shown improvement in symptoms and lung function despite limited understanding of ideal patient selection. The impact of lobe selection on EBV therapy is unclear. We performed a retrospective analysis to determine the role of lobe selection and identify preprocedure predictors of response to EBV therapy. A total of 492 patients from the USA and Europe were randomized to EBV or control therapy. Spirometry and functional measurements were taken at baseline and 12 months later. At 365 days patients undergoing EBV therapy showed improvement in FEV1 change compared to control regardless of treatment to upper or lower. There was no difference in FEV1 change between the upper and lower lobe treatment groups ( 5 .99, 7.04, p = 0.75). In addition lobe selection was not identified as a significant modifier of FEV1 change in multiple linear regression analysis. Complete lobe fissure was the only significant predictor of FEV1 change (OR 4.14 (2.29, 7.47)). Our results suggest that lobe selection does not play a major role in EBV therapy response. Complete fissure status preprocedure has the greatest influence on FEV1 improvement. These results have implications on patient selection for current treatment and in future EBV studies.
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Affiliation(s)
- Cole Liberator
- a Department of Internal Medicine , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Kartik Shenoy
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Nathaniel Marchetti
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
| | - Gerard Criner
- b Department of Thoracic Medicine and Surgery , Lewis Katz School of Medicine at Temple University , Philadelphia , PA , USA
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Eberhardt R, Herth FJF, Radhakrishnan S, Gompelmann D. Comparing Clinical Outcomes in Upper versus Lower Lobe Endobronchial Valve Treatment in Severe Emphysema. Respiration 2015; 90:314-20. [PMID: 26340540 DOI: 10.1159/000437358] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/26/2015] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Ralf Eberhardt
- Thoraxklinik, University of Heidelberg, Heidelberg, Germany
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28
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Meena M, Dixit R, Singh M, Samaria JK, Kumar S. Surgical and bronchoscopic lung volume reduction in chronic obstructive pulmonary disease. Pulm Med 2014; 2014:757016. [PMID: 25614834 PMCID: PMC4295139 DOI: 10.1155/2014/757016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/20/2014] [Accepted: 12/01/2014] [Indexed: 11/25/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the most extensively studied and researched disease in pulmonology and a cause of significant morbidity, mortality, and financial burden on patient's family and country's economy. Its management continues to be a challenge to both the physician and the patient's family. So far, it is preventable and treatable but not curable. Emphysema, a phenotype of COPD, is the most debilitating condition associated with progressive exercise intolerance and severe dyspnea. Despite decades of research, medical treatments available so far have helped improve quality of life and slowed down the decline in respiratory function but did not significantly improve the survival benefits. Though surgical lung volume reduction (LVR) procedures have shown some promise in context to functional gains and survival but, only in a carefully selected group of patients, bronchoscopic LVR procedures are yet to explore their full potential and limitations. This paper retrospectively studied the developments so far, medical and surgical, with special emphasis on the bronchoscopic procedures of lung volume reduction, and tried to comparatively analyze the risks and benefits of each one of them through various trials and studies done to date.
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Affiliation(s)
- Manoj Meena
- Department of Respiratory Medicine, JLN Medical College, Ajmer, Rajasthan 305001, India
| | - Ramakant Dixit
- Department of Respiratory Medicine, JLN Medical College, Ajmer, Rajasthan 305001, India
| | - Mrityunjaya Singh
- Department of Tuberculosis & Respiratory Diseases, IMS, BHU, Varanasi, Uttar Pradesh 221005, India
| | - Jai Kumar Samaria
- Department of Tuberculosis & Respiratory Diseases, IMS, BHU, Varanasi, Uttar Pradesh 221005, India
| | - Surendra Kumar
- Department of Dermatology and Venereology, JLN Medical College, Ajmer, Rajasthan 305001, India
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30
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Valipour A, Kramer MR, Stanzel F, Kempa A, Asadi S, Fruchter O, Eberhardt R, Herth FJ, Ingenito EP. Physiological modeling of responses to upper versus lower lobe lung volume reduction in homogeneous emphysema. Front Physiol 2012; 3:387. [PMID: 23060811 PMCID: PMC3461642 DOI: 10.3389/fphys.2012.00387] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 09/10/2012] [Indexed: 11/18/2022] Open
Abstract
Rationale: In clinical trials, homogeneous emphysema patients have responded well to upper lobe volume reduction but not lower lobe volume reduction. Materials/Methods: To understand the physiological basis for this observation, a computer model was developed to simulate the effects of upper and lower lobe lung volume reduction on RV/TLC and lung recoil in homogeneous emphysema. Results: Patients with homogeneous emphysema received either upper or lower lobe volume reduction therapy based on findings of radionucleotide scintigraphy scanning. CT analysis of lobar volumes showed that patients undergoing upper (n = 18; −265 mL/site) and lower lobe treatment (LLT; n = 11; −217 mL/site) experienced similar reductions in lung volume. However, only upper lobe treatment (ULT) improved FEV1 (+11.1 ± 14.7 versus −4.4 ± 15.8%) and RV/TLC (−5.4 ± 8.1 versus −2.4 ± 8.6%). Model simulations provided an unexpected explanation for this response. Increases in transpulmonary pressure subsequent to volume reduction increased RV/TLC in upper lobe alveoli, while caudal shifts in airway closure decreased RV/TLC in lower lobe alveoli. ULT, which eliminates apical alveoli with high RV/TLC values, lowers the average RV/TLC of the lung. Conversely, LLT, which eliminates caudal alveoli with low RV/TLC values, has less effect. Conclusion: LLT in homogeneous emphysema is uniformly less effective than ULT.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig-Boltzmann-Institute for COPD, Otto Wagner Hospital Vienna, Austria
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31
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Mather NL, Padmakumar AD, Milton R, Lumb AB. Emphysema, lung volume reduction and anaesthesia. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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32
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Akuthota P, Litmanovich D, Zutler M, Boiselle PM, Bankier AA, Roberts DH, Celli BR, DeCamp MM, Berger RL. An evidence-based estimate on the size of the potential patient pool for lung volume reduction surgery. Ann Thorac Surg 2012; 94:205-11. [PMID: 22571881 DOI: 10.1016/j.athoracsur.2012.03.047] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 03/15/2012] [Accepted: 03/20/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Observational and randomized studies have demonstrated that lung volume reduction surgery (LVRS) improves symptoms, lung function, and survival in selected patients with emphysema. In spite of an approximately 3.8 million patient prevalence of the disease in the US, only 119 LVRS procedures were performed nationwide under Medicare during 2008. In order to obtain evidence-based estimate on the size of the patient pool potentially suitable for LVRS, we analyzed the database from our clinical practice that is representative of a substantial segment of the general emphysema population. METHODS Our pulmonary function test laboratory database between 1996 and 2006 was searched for patients with stage III and IV global initiative for chronic obstructive lung disease (GOLD) who also had lung volumes and carbon monoxide diffusing capacity data. Patients without available chest computed tomographic scans (CT) or with primary diagnoses other than emphysema were excluded. The resultant emphysema cohort was screened using clinical inclusion and exclusion criteria adopted from the National Emphysema Treatment Trial. A suitable clinical profile combined with CT scan evidence of 40% or greater involvement of the lungs and predominantly upper lobe distribution of emphysema were regarded as favorable markers for LVRS. RESULTS Pulmonary function test criteria were met by 959 patients and CT scans were available in 588 patients, but 175 patients were excluded because of primary diagnoses other than emphysema. In the remaining 413 patients, 61 or 15% exhibited favorable clinical profiles and anatomy for LVRS. CONCLUSIONS In a subset of patients that resembles a substantial segment of the general population with advanced emphysema, up to 15% appeared potential candidates for LVRS. Formation of a task force by relevant medical specialty and patient advocate organizations to address the apparent underutilization of LVRS is recommended.
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Affiliation(s)
- Praveen Akuthota
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
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Le Pimpec-Barthes F, Das Neves-Pereira JC, Cazes A, Arame A, Grima R, Hubsch JP, Zukerman C, Hernigou A, Badia A, Bagan P, Delclaux C, Dusser D, Riquet M. [Lung volume reduction surgery for emphysema and bullous pulmonary emphysema]. REVUE DE PNEUMOLOGIE CLINIQUE 2012; 68:131-145. [PMID: 22361067 DOI: 10.1016/j.pneumo.2012.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/19/2011] [Indexed: 05/31/2023]
Abstract
The improvement of respiratory symptoms for emphysematous patients by surgery is a concept that has evolved over time. Initially used for giant bullae, this surgery was then applied to patients with diffuse microbullous emphysema. The physiological and pathological concepts underlying these surgical procedures are the same in both cases: improve respiratory performance by reducing the high intrapleural pressure. The functional benefit of lung volume reduction surgery (LVRS) in the severe diffuse emphysema has been validated by the National Emphysema Treatment Trial (NETT) and the later studies which allowed to identify prognostic factors. The quality of the clinical, morphological and functional data made it possible to develop recommendations now widely used in current practice. Surgery for giant bullae occurring on little or moderately emphysematous lung is often a simpler approach but also requires specialised support to optimize its results.
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Affiliation(s)
- F Le Pimpec-Barthes
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, AP-HP, université Paris V-René Descartes, 20 rue Leblanc, Paris cedex 15, France.
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Pompeo E, Rogliani P, Tacconi F, Dauri M, Saltini C, Novelli G, Mineo TC. Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery. J Thorac Cardiovasc Surg 2011; 143:47-54, 54.e1. [PMID: 22056369 DOI: 10.1016/j.jtcvs.2011.09.050] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 08/01/2011] [Accepted: 09/23/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The study objective was to assess in a randomized controlled study (NCT00566839) the comparative results of awake nonresectional or nonawake resectional lung volume reduction surgery. METHOD Sixty-three patients were randomly assigned by computer to receive unilateral video-assisted thoracic surgery lung volume reduction surgery by a nonresectional technique performed through epidural anesthesia in 32 awake patients (awake group) or the standard resectional technique performed through general anesthesia in 31 patients (control group). Primary outcomes were hospital stay and changes in forced expiratory volume in 1 second. During follow-up, the need of contralateral treatment because of loss of postoperative benefit was considered a failure event as death. RESULTS Intergroup comparisons (awake vs control) showed no difference in gender, age, and body mass index. Hospital stay was shorter in the awake group (6 vs 7.5 days, P = .04) with 21 versus 10 patients discharged within 6 days (P = .01). At 6 months, forced expiratory volume in 1 second improved significantly in both study groups (0.28 vs 0.29 L) with no intergroup difference (P = .79). In both groups, forced expiratory volume in 1 second improvements lasted more than 24 months. At 36 months, freedom from contralateral treatment was 55% versus 50% (P = .5) and survival was 81% versus 87% (P = .5). CONCLUSIONS In this randomized study, awake nonresectional lung volume reduction surgery resulted in significantly shorter hospital stay than the nonawake procedure. There were no differences between study groups in physiologic improvements, freedom from contralateral treatment, and survival. We speculate that compared with the nonawake procedure, awake lung volume reduction surgery can offer similar clinical benefit but a faster postoperative recovery.
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Affiliation(s)
- Eugenio Pompeo
- Department of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy.
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Abstract
Emphysema is a progressive, disabling disease. Emphysematous bullae form as a result of local areas of alveolar weakness and parenchymal remodeling. They grow as a result of preferential inflation during inspiration and elastic recoil of the surrounding lung tissue. Isolated apical bullae can be a consequence of illicit drug use, as was suspected in this patient. In the case of cocaine and marijuana smoking, direct drug toxicity or drug-induced vasoconstriction presumably contributes to bullae development. LVRS is often used to treat patients with bullae and severe underlying emphysema, although these patients are difficult to assess and their disease course is hard to predict. LVRS is associated with a higher morbidity and mortality. The best candidates for surgery have enlarged, well-localized bullae and minimal underlying lung disease. Early postoperative results include relief of shortness of breath, improved lung function, increased energy level and physical mobility, and improved ability to function during daily activities. LVRS may decrease the need for supplemental oxygen as soon as a few weeks after surgery, and benefits may be sustained for years. The best results are seen in patients with large bullae that cause the greatest compression of almost normal underlying lung. However, clinical and symptomatic improvement may be greater than actual spirometric measurements.
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36
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Ernst A, Anantham D. Bronchoscopic lung volume reduction. Semin Thorac Cardiovasc Surg 2011; 22:330-7. [PMID: 21549273 DOI: 10.1053/j.semtcvs.2011.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2011] [Indexed: 11/11/2022]
Abstract
Lung volume-reduction surgery is a proven palliative procedure for emphysema, and in patients with heterogeneous upper-lobe disease as well as low baseline exercise capacity, even mortality benefits can be realized. However, its application is limited by high postoperative morbidity and stringent selection criteria that effectively exclude many patients. This has been the impetus for the development of less-invasive approaches to lung volume reduction. A range of different bronchoscopic techniques, such as endobronchial blockers, airway bypass, endobronchial valves, thermal vapor ablation, biological sealants, and airway implants have been investigated. The underlying physiological mechanisms of the various endoscopic modalities differ and both homogeneous, as well as heterogeneous, emphysema have been targeted. The currently available data on efficacy of bronchoscopic lung volume reduction are not conclusive, although subjective benefit in dyspnea scores and quality of life is a frequent finding. Improvements in objective outcomes, such as spirometry or exercise tolerance, have been only modest. Refining patient selection and dose of treatment are subjects of ongoing research to improve the efficacy data. Safety profiles are more promising, with rare procedure-related mortality and fewer complications experienced than with surgical lung volume reduction. The field of bronchoscopic lung volume reduction continues to evolve, with the aim of making symptom palliation more available to a wider range of patients at lower risks.
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Affiliation(s)
- Armin Ernst
- Pulmonary, Critical Care and Sleep Medicine, St Elizabeth Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02135, USA.
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Abstract
PURPOSE OF REVIEW To revise the current nonpharmacologic methods used in the care of patients undergoing lung volume reduction surgery (LVRS). RECENT FINDINGS A recent report of the unquestionable palliative role of LVRS awakened a renewed interest in the procedure as a valid treatment alternative in selected patients with severe emphysema. SUMMARY A detailed description of the foundations of the approach to patients undergoing LVRS is described to provide guidance for daily practice.
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Bibliography. Current world literature. Thoracic anesthesia. Curr Opin Anaesthesiol 2011; 24:111-3. [PMID: 21321525 DOI: 10.1097/aco.0b013e3283433a20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bronchoscopic lung volume reduction. Pulm Med 2010; 2011:610802. [PMID: 21738874 PMCID: PMC3115677 DOI: 10.1155/2011/610802] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 10/09/2010] [Accepted: 11/09/2010] [Indexed: 11/17/2022] Open
Abstract
The application of lung volume reduction surgery in clinical practice is limited by high postoperative morbidity and stringent selection criteria. This has been the impetus for the development of bronchoscopic approaches to lung volume reduction. A range of different techniques such as endobronchial blockers, airway bypass, endobronchial valves, thermal vapor ablation, biological sealants, and airway implants have been employed on both homogeneous as well as heterogeneous emphysema. The currently available data on efficacy of bronchoscopic lung volume reduction are not conclusive and subjective benefit in dyspnoea scores is a more frequent finding than improvements on spirometry or exercise tolerance. Safety data are more promising with rare procedure-related mortality, few serious complications, and short hospital length of stay. The field of bronchoscopic lung volume reduction continues to evolve as ongoing prospective randomized trials build on earlier feasibility data to clarify the true efficacy of such techniques.
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40
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Sexton P, Garrett JE, Rankin N, Anderson G. Endoscopic lung volume reduction effectively treats acute respiratory failure secondary to bullous emphysema. Respirology 2010; 15:1141-5. [PMID: 20723138 DOI: 10.1111/j.1440-1843.2010.01824.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Emphysema often affects the lungs in a heterogeneous fashion, and collapse or removal of severely hyperinflated portions of lung can improve overall lung function and symptoms. The role of lung volume reduction (LVR) surgery in selected patients is well established, but that of non-surgical LVR is still being defined. In particular, use of endobronchial LVR is still under development. This case report describes a 48-year-old non-smoker with severe bullous emphysema complicated by acute hypercapnic respiratory failure, who was successfully treated by endobronchial valve placement while intubated in an intensive care unit.
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Affiliation(s)
- Paul Sexton
- Department of Respiratory Medicine, Middlemore Hospital, Mangere, Auckland, New Zealand
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Berger RL, Decamp MM, Criner GJ, Celli BR. Lung volume reduction therapies for advanced emphysema: an update. Chest 2010; 138:407-17. [PMID: 20682529 DOI: 10.1378/chest.09-1822] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Observational and randomized studies provide convincing evidence that lung volume reduction surgery (LVRS) improves symptoms, lung function, exercise tolerance, and life span in well-defined subsets of patients with emphysema. Yet, in the face of an estimated 3 million patients with emphysema in the United States, < 15 LVRS operations are performed monthly under the aegis of Medicare, in part because of misleading reporting in lay and medical publications suggesting that the operation is associated with prohibitive risks and offers minimal benefits. Thus, a treatment with proven potential for palliating and prolonging life may be underutilized. In an attempt to lower risks and cost, several bronchoscopic strategies (bronchoscopic emphysema treatment [BET]) to reduce lung volume have been introduced. The following three methods have been tested in some depth: (1) unidirectional valves that allow exit but bar entry of gas to collapse targeted hyperinflated portions of the lung and reduce overall volume; (2) biologic lung volume reduction (BioLVR) that involves intrabronchial administration of a biocompatible complex to collapse, inflame, scar, and shrink the targeted emphysematous lung; and (3) airway bypass tract (ABT) or creation of stented nonanatomic pathways between hyperinflated pulmonary parenchyma and bronchial tree to decompress and reduce the volume of oversized lung. The results of pilot and randomized pivotal clinical trials suggest that the bronchoscopic strategies are associated with lower mortality and morbidity but are also less efficient than LVRS. Most bronchoscopic approaches improve quality-of-life measures without supportive physiologic or exercise tolerance benefits. Although there is promise of limited therapeutic influence, the available information is not sufficient to recommend use of bronchoscopic strategies for treating emphysema.
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Affiliation(s)
- Robert L Berger
- Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Deaconess, Boston, MA 02215, USA.
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Herth FJF, Eberhard R, Gompelmann D, Slebos DJ, Ernst A. Bronchoscopic lung volume reduction with a dedicated coil: a clinical pilot study. Ther Adv Respir Dis 2010; 4:225-31. [PMID: 20538661 DOI: 10.1177/1753465810368553] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Lung volume reduction aims to improve symptoms by reducing hyperinflation. Endoscopic approaches so far have generally been hampered in their efficacy by collateral ventilation (CV). We sought to determine the safety and feasibility of a new endoscopic lung volume reduction approach independent of the effects of CV. METHODS Patients with severe emphysema were eligible. Inclusion and exclusion criteria were modeled after the National Emphysema Treatment Trial (NETT) study. Homogenous and heterogeneous disease was allowed. Treatment consisted of the placement of coils into the parenchyma of the most diseased area with the intent of achieving parenchymal compression. Primary endpoints were safety and feasibility assessments. Secondary endpoints were efficacy outcomes. RESULTS Eleven patients underwent 21 procedures. Procedures were performed under general anesthesia and lasted 45+/-15 minutes and per procedure 4.9+/-0.6 coils were placed. All procedures were well tolerated. The total follow-up time was 7-11 months and in that time 33 adverse events were reported, none of them severe. No pneumothorax occurred. Efficacy seemed better in heterogeneous rather than homogenous disease. CONCLUSION Endoscopic lung volume reduction with coils is safe and feasible. Further studies of the efficacy are indicated.
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Abstract
Lung volume reduction surgery has proven benefits in emphysema. However, high postoperative morbidity and stringent selection criteria for suitable candidates are limitations in clinical practice. Endoscopic approaches to lung volume reduction have used a range of different techniques such as endobronchial blockers, airway bypass, endobronchial valves, biologic sealants, and airway implants to address the limitations of surgery. The underlying physiologic mechanisms of endoscopic modalities vary, and homogeneous and heterogeneous emphysema are targeted. Currently available data on efficacy of bronchoscopic lung volume reduction are not consistently conclusive, and subjective benefit in dyspnea scores is a more frequent finding than improvements on spirometry or exercise tolerance. The safety data are more promising, with rare procedure-related mortality, fewer complications than lung volume reduction surgery, and short hospital length of stay. The field of bronchoscopic lung volume reduction continues to evolve as ongoing prospective randomized trials aim to clarify the efficacy data from earlier feasibility and safety studies.
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Affiliation(s)
- Armin Ernst
- Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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Choong CK, Mahesh B, Patterson GA, Cooper JD. Concomitant Lung Cancer Resection and Lung Volume Reduction Surgery. Thorac Surg Clin 2009; 19:209-16. [DOI: 10.1016/j.thorsurg.2009.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
The objective of lung volume reduction surgery (LVRS) is the safe, effective, and durable palliation of dyspnea in appropriately selected patients with moderate to severe emphysema. Appropriate patient selection and preoperative preparation are prerequisites for successful LVRS. An effective LVRS program requires participation by and communication between experts from pulmonary medicine, thoracic surgery, thoracic anesthesiology, critical care medicine, rehabilitation medicine, respiratory therapy, chest radiology, and nursing. The critical analysis of perioperative outcomes has influenced details of the conduct of the procedure and has established a bilateral, stapled approach as the standard of care for LVRS. The National Emphysema Treatment Trial (NETT) remains the world's largest multi-center, randomized trial comparing LVRS to maximal medical therapy. NETT purposely enrolled a broad spectrum of anatomic patterns of emphysema. This, along with the prospective, audited collection of extensive demographic, physiologic, radiographic, surgical and quality-of-life data, has positioned NETT as the most robust repository of evidence to guide the refinement of patient selection criteria for LVRS, to assist surgeons in providing optimal intraoperative and postoperative care, and to establish benchmarks for survival, complication rates, return to independent living, and durability of response. This article reviews the evolution of current LVRS practice with a particular emphasis on technical aspects of the operation, including the predictors and consequences of its most common complications.
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