Lung volume reduction surgery or bronchoscopic lung volume reduction: is there an algorithm for allocation?

Bronchoscopic Lung Volume Reduction as the Treatment of Choice versus Robotic-Assisted Lung Volume Reduction Surgery in Similar Patients with Emphysema - An Initial Experience of the Benefits and Complications

Objective

There is an assumption that because EBLVR requires less use of hospital resources, offsetting the higher cost of endobronchial valves, it should therefore be the treatment of choice wherever possible. We have tested this hypothesis in a retrospective analysis of the two in similar groups of patients.

Methods

In a 4-year experience, we performed 177 consecutive LVR procedures: 83 patients underwent Robot Assisted Thoracoscopic (RATS) LVRS and 94 EBLVR. EBLVR was intentionally precluded by evidence of incomplete fissure integrity or intra-operative assessment of collateral ventilation. Unilateral RATS LVRS was performed in these cases together with those with unsuitable targets for EBLVR.

Results

EBLVR was uncomplicated in 37 (39%) cases; complicated by post-procedure spontaneous pneumothorax (SP) in 28(30%) and required revision in 29 (31%). In the LVRS group, 7 (8%) patients were readmitted with treatment-related complications, but no revisional procedure was needed. When compared with uncomplicated EBLVR, LVRS had a significantly longer operating time: 85 (14-82) vs 40 (15-151) minutes (p<0.001) and hospital stay: 7.5 (2-80) vs 2 (1-14) days (p<0.01). However, LVRS had a similar total operating time to both EBLVR requiring revision: 78 (38-292) minutes and hospital stay to EBLVR complicated by pneumothorax of 11.5 (6.5-24.25) days. Use of critical care was significantly longer in RATS group, and it was also significantly longer in EBV with SP group than in uncomplicated EBV group.

Conclusion

Endobronchial LVR does use less hospital resources than RATS LVRS in comparable groups if the recovery is uncomplicated. However, this advantage is lost if one includes the resources needed for the treatment of complications and revisional procedures. Any decision to favour EBLVR over LVRS should not be based on the assumption of a smoother, faster perioperative course.

Basilar Predominant Emphysema: Thinking beyond Alpha-1-Antitrypsin Deficiency

Basilar predominant emphysema, or disproportionate emphysematous involvement of the lung bases compared to the apices, is an uncommon radiographic pattern of emphysema traditionally associated with alpha-1-antitrypsin deficiency (AATD). We present a case of a 59-year-old female with 41 pack-year tobacco use, Stage IV COPD with supplemental oxygen, and bibasilar predominant emphysema who successfully underwent bronchoscopic lung volume reduction. She presented with recurrent hospitalizations for frequent exacerbations. After lung reduction, the patient displayed improvement in functional status without hospitalizations at the 15-month follow-up. Careful history taking is essential for any patients diagnosed with lower lobe emphysema to elucidate the underlying etiology. This case challenges the notion that basilar emphysema is sensitive or specific for AATD and emphasizes that this pattern of emphysema has a broad differential diagnosis and alternative etiologies should be considered. Our patient was ultimately diagnosed with smoking-related emphysema, with atypical bibasilar involvement. Furthermore, basilar predominant emphysema should be considered a separate entity from its apical predominant counterpart.

Isolated Elevation in Lung Residual Volume Is Associated With Airway Diseases

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lung volume reduction in real clinical practice

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

Lung volume reduction in emphysema: a pragmatic prospective cohort study

Limited guidance exists for the implementation of lung volume reduction interventions in routine clinical care. We designed a pragmatic study to evaluate a strategy including endoscopic lung volume reduction (ELVR) and lung volume reduction surgery (LVRS) in heterogeneous emphysema. This prospective monocentre cohort study evaluated ELVR versus no-ELVR, followed by a cohort study evaluating LVRS. Primary outcome was the proportion of subjects with a forced expiratory volume in 1 s (FEV₁) improvement of ⩾100 mL at 3-month follow-up. Changes in FEV₁, residual volume (RV), 6-min walk distance (6MWD) and quality of life (St George's Respiratory Questionnaire (SGRQ)) were evaluated at 6-month follow-up. Hospital stay and treatment-related serious adverse events were monitored. From 106 subjects screened, 38 subjects were enrolled comparing ELVR (n=20) with no-ELVR (n=18). After 6 months' follow-up, eligible patients were referred for LVRS (n=16) with another 6-month follow-up. At 3-month follow-up, 70% of ELVR compared to 11% of no-ELVR (p<0.001) and 69% of LVRS had an FEV₁ improvement of ⩾100 mL. Between-group differences (mean±sem) for ELVR versus no-ELVR at 6-month follow-up were FEV₁ +0.21±0.05 L; RV -0.95±0.21 L; 6MWD 58±17 m and SGRQ -18±5 points. At 6-month follow-up, within-group differences (mean±sem) for LVRS showed FEV₁ +0.27±0.06 L; RV -1.49±0.22 L and 6MWD +75±18 m. Serious adverse events in 81% versus 45% of subjects (p=0.04) and a median hospital stay of 15 versus 5 days (p<0.001) were observed for LVRS versus ELVR, respectively. This pragmatic prospective cohort study supports a clinical approach with ELVR as a less invasive first option and LVRS as powerful alternative in severe heterogeneous emphysema.

Chronic obstructive pulmonary disease - diagnosis and management of stable disease; a personalized approach to care, using the treatable traits concept based on clinical phenotypes. Position paper of the Czech Pneumological and Phthisiological Society

This position paper has been drafted by experts from the Czech national board of diseases with bronchial obstruction, of the Czech Pneumological and Phthisiological Society. The statements and recommendations are based on both the results of randomized controlled trials and data from cross-sectional and prospective real-life studies to ensure they are as close as possible to the context of daily clinical practice and the current health care system of the Czech Republic. Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable heterogeneous syndrome with a number of pulmonary and extrapulmonary clinical features and concomitant chronic diseases. The disease is associated with significant mortality, morbidity and reduced quality of life. The main characteristics include persistent respiratory symptoms and only partially reversible airflow obstruction developing due to an abnormal inflammatory response of the lungs to noxious particles and gases. Oxidative stress, protease-antiprotease imbalance and increased numbers of pro-inflammatory cells (mainly neutrophils) are the main drivers of primarily non-infectious inflammation in COPD. Besides smoking, household air pollution, occupational exposure, low birth weight, frequent respiratory infections during childhood and also genetic factors are important risk factors of COPD development. Progressive airflow limitation and airway remodelling leads to air trapping, static and dynamic hyperinflation, gas exchange abnormalities and decreased exercise capacity. Various features of the disease are expressed unequally in individual patients, resulting in various types of disease presentation, emerging as the "clinical phenotypes" (for specific clinical characteristics) and "treatable traits" (for treatable characteristics) concept. The estimated prevalence of COPD in Czechia is around 6.7% with 3,200-3,500 deaths reported annually. The elementary requirements for diagnosis of COPD are spirometric confirmation of post-bronchodilator airflow obstruction (post-BD FEV₁/VCmax <70%) and respiratory symptoms assessement (dyspnoea, exercise limitation, cough and/or sputum production. In order to establish definite COPD diagnosis, a five-step evaluation should be performed, including: 1/ inhalation risk assessment, 2/ symptoms evaluation, 3/ lung function tests, 4/ laboratory tests and 5/ imaging. At the same time, all alternative diagnoses should be excluded. For disease classification, this position paper uses both GOLD stages (1 to 4), GOLD groups (A to D) and evaluation of clinical phenotype(s). Prognosis assessment should be done in each patient. For this purpose, we recommend the use of the BODE or the CADOT index. Six elementary clinical phenotypes are recognized, including chronic bronchitis, frequent exacerbator, emphysematous, asthma/COPD overlap (ACO), bronchiectases with COPD overlap (BCO) and pulmonary cachexia. In our concept, all of these clinical phenotypes are also considered independent treatable traits. For each treatable trait, specific pharmacological and non-pharmacological therapies are defined in this document. The coincidence of two or more clinical phenotypes (i.e., treatable traits) may occur in a single individual, giving the opportunity of fully individualized, phenotype-specific treatment. Treatment of COPD should reflect the complexity and heterogeneity of the disease and be tailored to individual patients. Major goals of COPD treatment are symptom reduction and decreased exacerbation risk. Treatment strategy is divided into five strata: risk elimination, basic treatment, phenotype-specific treatment, treatment of respiratory failure and palliative care, and treatment of comorbidities. Risk elimination includes interventions against tobacco smoking and environmental/occupational exposures. Basic treatment is based on bronchodilator therapy, pulmonary rehabilitation, vaccination, care for appropriate nutrition, inhalation training, education and psychosocial support. Adequate phenotype-specific treatment varies phenotype by phenotype, including more than ten different pharmacological and non-pharmacological strategies. If more than one clinical phenotype is present, treatment strategy should follow the expression of each phenotypic label separately. In such patients, multicomponental therapeutic regimens are needed, resulting in fully individualized care. In the future, stronger measures against smoking, improvements in occupational and environmental health, early diagnosis strategies, as well as biomarker identification for patients responsive to specific treatments are warranted. New classes of treatment (inhaled PDE3/4 inhibitors, single molecule dual bronchodilators, anti-inflammatory drugs, gene editing molecules or new bronchoscopic procedures) are expected to enter the clinical practice in a very few years.

Endobronchial valve vs coil for lung volume reduction in emphysema: results from a tertiary care centre in Turkey

BACKGROUND

Bronchoscopic lung volume reduction (BLVR) by either the endobronchial valve (EBV) or coil (EBC) procedure is recommended for severe emphysematous patients. BLVR applications generally help healthy lung areas ventilate more comfortably by reducing the hyperinflation and improving the contraction capacity of diaphragm.

OBJECTIVES

Compare our experience with valve and coil BLVR devices.

DESIGN

Retrospective.

SETTING

Single tertiary care centre.

PATIENTS AND METHODS

Demographic data, vital signs, pulmonary function tests (PFTs), the six-minute walking test (6MWT), vital signs, arterial blood gases and complications were recorded.

MAIN OUTCOME MEASURES

Change in PFTs and completion of the 6MWT.

SAMPLE SIZE

60 Turkish men with a diagnosis of chronic pulmonary lung disease.

RESULTS

Clinical and demographic characteristics were similar in patients who underwent EBV and EBC. Thirty (96.8%) EBV patients and 27 (93.1%) of the EBC patients were able to properly complete the PFT before the procedures, but all complied after the procedures. Significant improvement in PFTs were achieved after the procedure and there were no statistically significant differences in post-procedure performance. For the 6MWT, the completion rate improved from 15 (48.4%) to 19 (61.3%) patients in the EBV patients (P=.125) and from 19 (65.5%) to 21 (72.4%) patients in the EBC patients (P=.500). There was no significant difference in completion rates for the walking test for either group (median 32 meters in EBV patients and 37 meters in EBC patients; P=.652). Vital signs and arterial blood gases were similar in the two groups. The rates of complications were similar in both groups.

CONCLUSION

Endobronchial valves and coils are safe and effective methods for BLVR for patients with severe emphysema.

LIMITATIONS

Relatively small sample, retrospective design, single-centre retrospective study.

CONFLICT OF INTEREST

None.

Recent Advances in Interventional Pulmonology

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

Impacts of Coil Treatment on Anxiety and Depression in Emphysema

Chronic obstructive pulmonary disease (COPD) is a widespread, preventable, and treatable disease. Emphysema is one of the primary components of COPD and manifests itself via decrease in elastic recoil, hyperinflation, and increase in air trapping. Various lung-volume-reduction treatments have come up in recent years for late-stage emphysema patients. Mental disorders and especially anxiety and depression are among the frequently encountered comorbid cases observed in COPD. The aim of our study was to examine the impact of coil treatment applied for late-stage COPD-emphysema diagnosed patients on the accompanying anxiety and depressive symptoms. A total of 21 patients diagnosed with emphysema that meet the suitability criteria for coil treatment were included in the study. The accompanying anxiety and depressive symptoms of the patients were assessed via beck anxiety inventory (BAI) and beck depression inventories (BDI-I) prior to the procedure and one month later. All patients were male with an age average of 66.5 ± 5.5 (57-76). Among patients without a psychiatric diagnosis, BAI scores before and after coil treatment were determined, respectively, as 12.1 ± 6.3 (4-26) and 11.2 ± 9.3 (0-28), whereas BDI-I scores before and after coil treatment were determined, respectively, as 13.5 ± 10.4 (1-31) and 8.8 ± 10.6 (0-34), with a statistically significant difference between them. Also among patients with a psychiatric diagnosis, both anxiety and depressive symptoms decreased after coil treatment, and this reduction was found more significant for anxiety. Coil treatment as a current and novel treatment method for COPD-emphysema diagnosed patients with or without psychiatric comorbidity has a positive impact on anxiety and depressive symptoms.

Interventional Pulmonology: A Focused Review for Primary Care Physicians

Interventional pulmonology (IP) has evolved in recent decades, and recent advances have greatly expanded the services offered by IP physicians. IP is best defined as the use of advanced techniques for the evaluation and treatment of benign and malignant pulmonary disorders. The field has further advanced with the recent establishment of a board certification via the American Association of Bronchology and Interventional Pulmonology and the release in 2017 of accreditation standards for specialized fellowship training. This article provides a broad overview of the field to serve as a resource for primary care physicians.