1
|
Brown MV, Badiei A, Jersmann H, Fon A, Chew CG, Lorraine B, Nguyen P. A 6-year experience of Zephyr endobronchial valves for severe emphysema in an Australian single-centre cohort. Intern Med J 2024; 54:871-881. [PMID: 38247402 DOI: 10.1111/imj.16319] [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: 08/06/2023] [Accepted: 11/14/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Endobronchial valve (EBV) insertion for lung volume reduction is a management option for patients with severe emphysema. One-way valves cause lobar deflation and improve lung function, exercise capacity and quality of life. AIMS To retrospectively analyse and compare the outcomes of the first 57 patients treated with EBVs between 2015 and 2021 at the Royal Adelaide Hospital to international standards. METHODS Clinical outcomes of forced expiratory volume in 1 s (FEV1), residual volume (RV), treated lobe volume reduction (TLVR) and 6-min walk distance (6MWD) at 3, 6 and 12 months after valve insertion were reviewed against established minimally clinically important differences (MCIDs). Complications and subjective breathlessness measured by Borg scores were also reviewed. RESULTS Fifty-seven patients were included. At 12 months, 77.2% achieved TLVR. FEV1 improved by 170 mL (95% confidence interval (CI): 100-250, P < 0.001), 80 mL (95% CI: 10-150, P = 0.019) and 40 mL (95% CI: -60 to 130, P 0.66) at 3, 6 and 12 months respectively. RV improved by -610 mL (95% CI: -330 to -900, P < 0.0001) at 3 months, -640 mL (95% CI: -360 to -920, P < 0.0001) at 6 months and -360 mL (95% CI: -60 to -680, P = 0.017) at 12 months. 6MWD improved by 57.34 m (95% CI: 36.23-78.45, P < 0.0001) and 44.93 m (95% CI: 7.19-82.67, P = 0.02) at 3 and 6 months. Borg score improved by -0.53 (95% CI: 0.11 to -1.2, P = 0.11) and -0.49 (95% CI: 0.17 to -1.15, P = 0.16) at 3 and 6 months. Complication rates aligned with international standards with mucous/infection (26.3%) and pneumothorax (17.5%) as the most common. Subgroup analysis signalled improved outcomes in patients with heterogeneous emphysema. CONCLUSION Our study represents the first publicly funded Australian analysis of EBVs. The results align with international prospective trials demonstrating improved lung function and exercise capacity. Australians with severe emphysema and gas trapping should be referred to a multidisciplinary centre for consideration of EBVs.
Collapse
Affiliation(s)
- Michael V Brown
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Arash Badiei
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Hubertus Jersmann
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Fon
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Respiratory and Sleep Medicine, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Chong G Chew
- Department of Nuclear Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Brett Lorraine
- SA Medical Imaging, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Phan Nguyen
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
2
|
Koster TD, Shah PL, Valipour A, Criner GJ, Herth FJF, Sue R, Hogarth DK, Martin RT, Mahajan AK, Alalawi R, Kopas L, Cohen A, Wood DE, Kurman J, Shargill NS, Dransfield M, Slebos DJ, Perch M. Optimizing clinical outcomes for bronchoscopic lung volume reduction with Zephyr® valves. Respir Med 2024; 227:107639. [PMID: 38642906 DOI: 10.1016/j.rmed.2024.107639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/27/2024] [Accepted: 04/15/2024] [Indexed: 04/22/2024]
Abstract
Bronchoscopic lung volume reduction treatment with Zephyr one-way valves is an effective guideline-based treatment option for patients with severe emphysema and hyperinflation. However, in some cases the treatment response is less than anticipated or there might be a loss of initial treatment effect. Reasons for the lack of response can include incorrect assessment of collateral ventilation, improper valve placement, or patient related factors. Loss of initial benefit can be due to granulation tissue formation and subsequent valve dysfunction, or there may be side effects such as excessive coughing or infectious problems. Careful follow-up after treatment with valves is important and evaluation with a CT scan and/or bronchoscopy is helpful if there is no improvement after treatment or loss of initial benefit. This paper aims to describe the most important causes and provide a strategy of how to approach and manage these patients.
Collapse
Affiliation(s)
- T David Koster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Pallav L Shah
- Royal Brompton Hospital, Department of Pulmonology, London, United Kingdom; National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Klinik Floridsdorf, Vienna Health Care Group, Vienna, Austria
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Felix J F Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center Heidelberg (TLRCH), University of Heidelberg, Heidelberg, Germany
| | - Richard Sue
- Advanced Lung Institute, Banner University Phoenix, Phoenix, AZ, USA
| | - Douglas K Hogarth
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
| | - Ralitza T Martin
- Piedmont/MD Anderson Healthcare Network System, Houston, TX, USA
| | | | - Raed Alalawi
- Banner Health, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Lisa Kopas
- Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX, USA
| | - Avi Cohen
- Henry Ford Health System, Detroit, MI, USA
| | - Douglas E Wood
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Jonathan Kurman
- Division of Pulmonary & Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Mark Dransfield
- Division of Pulmonary, Allergy and Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michael Perch
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Herat Center, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
3
|
Tada DK, Teng P, Vyapari K, Banola A, Foster G, Diaz E, Kim GHJ, Goldin JG, Abtin F, McNitt-Gray M, Brown MS. Quantifying lung fissure integrity using a three-dimensional patch-based convolutional neural network on CT images for emphysema treatment planning. J Med Imaging (Bellingham) 2024; 11:034502. [PMID: 38817711 PMCID: PMC11135203 DOI: 10.1117/1.jmi.11.3.034502] [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: 12/13/2023] [Revised: 04/19/2024] [Accepted: 05/03/2024] [Indexed: 06/01/2024] Open
Abstract
Purpose Evaluation of lung fissure integrity is required to determine whether emphysema patients have complete fissures and are candidates for endobronchial valve (EBV) therapy. We propose a deep learning (DL) approach to segment fissures using a three-dimensional patch-based convolutional neural network (CNN) and quantitatively assess fissure integrity on CT to evaluate it in subjects with severe emphysema. Approach From an anonymized image database of patients with severe emphysema, 129 CT scans were used. Lung lobe segmentations were performed to identify lobar regions, and the boundaries among these regions were used to construct approximate interlobar regions of interest (ROIs). The interlobar ROIs were annotated by expert image analysts to identify voxels where the fissure was present and create a reference ROI that excluded non-fissure voxels (where the fissure is incomplete). A CNN configured by nnU-Net was trained using 86 CT scans and their corresponding reference ROIs to segment the ROIs of left oblique fissure (LOF), right oblique fissure (ROF), and right horizontal fissure (RHF). For an independent test set of 43 cases, fissure integrity was quantified by mapping the segmented fissure ROI along the interlobar ROI. A fissure integrity score (FIS) was then calculated as the percentage of labeled fissure voxels divided by total voxels in the interlobar ROI. Predicted FIS (p-FIS) was quantified from the CNN output, and statistical analyses were performed comparing p-FIS and reference FIS (r-FIS). Results The absolute percent error mean (±SD) between r-FIS and p-FIS for the test set was 4.0% (± 4.1 % ), 6.0% (± 9.3 % ), and 12.2% (± 12.5 % ) for the LOF, ROF, and RHF, respectively. Conclusions A DL approach was developed to segment lung fissures on CT images and accurately quantify FIS. It has potential to assist in the identification of emphysema patients who would benefit from EBV treatment.
Collapse
Affiliation(s)
- Dallas K. Tada
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Pangyu Teng
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Kalyani Vyapari
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Ashley Banola
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - George Foster
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Esteban Diaz
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Grace Hyun J. Kim
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Jonathan G. Goldin
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Fereidoun Abtin
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Michael McNitt-Gray
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| | - Matthew S. Brown
- The University of California, Los Angeles (UCLA), David Geffen School of Medicine at UCLA, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, Los Angeles, California, United States
| |
Collapse
|
4
|
Zurmati BM. Comment on: Identifying responders and exploring mechanisms of action of the endobronchial coil treatment for emphysema. Respir Med 2023; 217:107343. [PMID: 37399978 DOI: 10.1016/j.rmed.2023.107343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023]
|
5
|
Galloy AE, Reinhardt JM, Raghavan ML. Role of lung lobar sliding on parenchymal distortion during breathing. J Appl Physiol (1985) 2023; 135:534-541. [PMID: 37439240 PMCID: PMC10538991 DOI: 10.1152/japplphysiol.00631.2022] [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: 10/20/2022] [Revised: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023] Open
Abstract
Sliding between lung lobes along lobar fissures is a poorly understood aspect of lung mechanics. The objective of this study was to test the hypothesis that lobar sliding helps reduce distortion in the lung parenchyma during breathing. Finite element models of left lungs with geometries and boundary conditions derived from medical images of human subjects were developed. Effect of lobar sliding was studied by comparing nonlinear finite elastic contact mechanics simulations that allowed and disallowed lobar sliding. Lung parenchymal distortion during simulated breath-holds and tidal breathing was quantified with the model's spatial mean anisotropic deformation index (ADI), a measure of directional preference in volume change that varies spatially in the lung. Models that allowed lobar sliding had significantly lower mean ADI (i.e., lesser parenchymal distortion) than models that disallowed lobar sliding under simulations of both tidal breathing (5.3% median difference, P = 0.008, n = 8) and lung deformation between breath-holds at total lung capacity and functional residual capacity (3.2% median difference, P = 0.03, n = 6). This effect was most pronounced in the lower lobe where lobar sliding reduced parenchymal distortion with statistical significance, but not in the upper lobe. In addition, more lobar sliding was correlated with greater reduction in distortion between sliding and nonsliding models in our study cohorts (Pearson's correlation coefficient of 0.95 for tidal breathing, 0.87 for breath-holds, and 0.91 for the combined dataset). These findings are consistent with the hypothesis that lung lobar sliding reduces parenchymal distortion during breathing.NEW & NOTEWORTHY The role of lobar sliding in lung mechanics is poorly understood. Delineating this role could help explain how breathing is affected by anatomical differences between subjects such as incomplete and missing lobar fissures. We used computational contact mechanics models of lungs from human subjects to delineate the effect of lobar sliding by comparing simulations that allowed and disallowed sliding. We found evidence consistent with the hypothesis that lung lobar sliding reduces parenchymal distortion during breathing.
Collapse
Affiliation(s)
- Adam E Galloy
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Joseph M Reinhardt
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
| | - Madhavan L Raghavan
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, United States
| |
Collapse
|
6
|
Althof ZW, Gerard SE, Eskandari A, Galizia MS, Hoffman EA, Reinhardt JM. Attention U-net for automated pulmonary fissure integrity analysis in lung computed tomography images. Sci Rep 2023; 13:14135. [PMID: 37644125 PMCID: PMC10465516 DOI: 10.1038/s41598-023-41322-y] [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: 02/01/2023] [Accepted: 08/24/2023] [Indexed: 08/31/2023] Open
Abstract
Computed Tomography (CT) imaging is routinely used for imaging of the lungs. Deep learning can effectively automate complex and laborious tasks in medical imaging. In this work, a deep learning technique is utilized to assess lobar fissure completeness (also known as fissure integrity) from pulmonary CT images. The human lungs are divided into five separate lobes, divided by the lobar fissures. Fissure integrity assessment is important to endobronchial valve treatment screening. Fissure integrity is known to be a biomarker of collateral ventilation between lobes impacting the efficacy of valves designed to block airflow to diseased lung regions. Fissure integrity is also likely to impact lobar sliding which has recently been shown to affect lung biomechanics. Further widescale study of fissure integrity's impact on disease susceptibility and progression requires rapid, reproducible, and noninvasive fissure integrity assessment. In this paper we describe IntegrityNet, an attention U-Net based automatic fissure integrity analysis tool. IntegrityNet is able to predict fissure integrity with an accuracy of 95.8%, 96.1%, and 89.8% for left oblique, right oblique, and right horizontal fissures, compared to manual analysis on a dataset of 82 subjects. We also show that our method is robust to COPD severity and reproducible across subject scans acquired at different time points.
Collapse
Affiliation(s)
- Zachary W Althof
- 5601 Seamans Center for the Engineering Arts and Sciences, University of Iowa Roy J. Carver Department of Biomedical Engineering, Iowa City, IA, 52242, USA
| | - Sarah E Gerard
- University of Iowa Department of Radiology, Iowa City, IA, USA
| | - Ali Eskandari
- University of Iowa Department of Radiology, Iowa City, IA, USA
| | | | - Eric A Hoffman
- 5601 Seamans Center for the Engineering Arts and Sciences, University of Iowa Roy J. Carver Department of Biomedical Engineering, Iowa City, IA, 52242, USA
- University of Iowa Department of Radiology, Iowa City, IA, USA
| | - Joseph M Reinhardt
- 5601 Seamans Center for the Engineering Arts and Sciences, University of Iowa Roy J. Carver Department of Biomedical Engineering, Iowa City, IA, 52242, USA.
- University of Iowa Department of Radiology, Iowa City, IA, USA.
| |
Collapse
|
7
|
Raoof S, Shah M, Braman S, Agrawal A, Allaqaband H, Bowler R, Castaldi P, DeMeo D, Fernando S, Hall CS, Han MK, Hogg J, Humphries S, Lee HY, Lee KS, Lynch D, Machnicki S, Mehta A, Mehta S, Mina B, Naidich D, Naidich J, Ohno Y, Regan E, van Beek EJR, Washko G, Make B. Lung Imaging in COPD Part 2: Emerging Concepts. Chest 2023; 164:339-354. [PMID: 36907375 PMCID: PMC10475822 DOI: 10.1016/j.chest.2023.02.049] [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: 10/06/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/13/2023] Open
Abstract
The diagnosis, prognostication, and differentiation of phenotypes of COPD can be facilitated by CT scan imaging of the chest. CT scan imaging of the chest is a prerequisite for lung volume reduction surgery and lung transplantation. Quantitative analysis can be used to evaluate extent of disease progression. Evolving imaging techniques include micro-CT scan, ultra-high-resolution and photon-counting CT scan imaging, and MRI. Potential advantages of these newer techniques include improved resolution, prediction of reversibility, and obviation of radiation exposure. This article discusses important emerging techniques in imaging patients with COPD. The clinical usefulness of these emerging techniques as they stand today are tabulated for the benefit of the practicing pulmonologist.
Collapse
Affiliation(s)
- Suhail Raoof
- Northwell Health, Lenox Hill Hospital, New York, NY.
| | - Manav Shah
- Northwell Health, Lenox Hill Hospital, New York, NY
| | - Sidney Braman
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | - Dawn DeMeo
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | - James Hogg
- University of British Columbia, Vancouver, BC, Canada
| | | | - Ho Yun Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Department of Health Sciences and Technology, Sungkyunkwan University, ChangWon, South Korea
| | - Kyung Soo Lee
- Sungkyunkwan University School of Medicine, Samsung ChangWon Hospital, ChangWon, South Korea
| | | | | | | | | | - Bushra Mina
- Northwell Health, Lenox Hill Hospital, New York, NY
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Hartman JE, Roodenburg SA, van Dijk M, Koster TD, Klooster K, Slebos DJ. Response to endobronchial valve treatment: it's all about the target lobe. ERJ Open Res 2023; 9:00155-2023. [PMID: 37465561 PMCID: PMC10350677 DOI: 10.1183/23120541.00155-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/15/2023] [Indexed: 07/20/2023] Open
Abstract
Background Bronchoscopic lung volume reduction using endobronchial valves (EBV) has been shown to be beneficial for severe emphysema patients. The most important predictor of treatment response is absence of collateral ventilation between the treatment target and ipsilateral lobe. However, there are still a substantial number of nonresponders and it would be useful to improve the pre-treatment identification of responders. Presumably, predictors of response will be multifactorial, and therefore our aim was to explore whether we can identify response groups using a cluster analysis. Methods At baseline and 1 year follow-up, pulmonary function, exercise capacity and quality of life were measured. A quantitative chest computed tomography scan analysis was performed at baseline and 2-6 months follow-up. The cluster analysis was performed using a hierarchical agglomerative method. Results In total, 428 patients (69% female, mean±sd age 61±8 years, forced expiratory volume in 1 s 27±8% predicted, residual volume 254±50% pred) were included in our analysis. Three clusters were generated: one nonresponder cluster and two responder clusters. Despite solid technical procedures, the nonresponder cluster had significantly less clinical response after treatment compared to the other clusters. The nonresponder cluster was characterised by significantly less emphysematous destruction, less air trapping and a higher perfusion of the target lobe, and a more homogeneous distribution of emphysema and perfusion between the target and ipsilateral lobe. Conclusions We found that target lobe characteristics are the discriminators between responders and nonresponders, which underlines the importance of visual and quantitative assessment of the potential treatment target lobe when selecting patients for EBV treatment.
Collapse
Affiliation(s)
- Jorine E. Hartman
- Department of Pulmonary diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sharyn A. Roodenburg
- Department of Pulmonary diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marlies van Dijk
- Department of Pulmonary diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - T. David Koster
- Department of Pulmonary diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| |
Collapse
|
9
|
Welling JBA, Koster TD, Slebos DJ. From plugging air leaks to reducing lung volume: a review of the many uses of endobronchial valves. Expert Rev Med Devices 2023; 20:721-727. [PMID: 37409351 DOI: 10.1080/17434440.2023.2233435] [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: 04/26/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION One-way endobronchial valve treatment improves lung function, exercise capacity, and quality of live in patients with severe emphysema and hyperinflation. Other areas of therapeutic application include treatment of persistent air leak (PAL), giant emphysematous bullae, native lung hyperinflation, hemoptysis, and tuberculosis. AREAS COVERED In this review, we will assess the clinical evidence and safety of the different applications of one-way endobronchial valves (EBV). EXPERT OPINION There is solid clinical evidence for the use of one-way EBV for lung volume reduction in emphysema. Treatment with one-way EBV can be considered for the treatment of PAL. The application of one-way EBV for giant bullae, post lung transplant native lung hyperinflation, hemoptysis, and tuberculosis is under investigation and more research is required to investigate the efficacy and safety of these applications.
Collapse
Affiliation(s)
- Jorrit B A Welling
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - T David Koster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
10
|
DeMarco B, MacRosty CR. Bronchoscopic Management of COPD and Advances in Therapy. Life (Basel) 2023; 13:life13041036. [PMID: 37109565 PMCID: PMC10147055 DOI: 10.3390/life13041036] [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: 03/16/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent and morbid disease marked by irreversible structural changes in the lungs. Bronchoscopic therapies have significantly expanded the treatment armamentarium for patients with persistent symptoms by reducing the physiologic detriments of hyperinflation in a less invasive fashion than surgical lung volume reduction. The spectrum of bronchoscopic techniques to reduce hyperinflation includes endobronchial valves, coils, thermal ablation, and biologic sealants. Other therapies focus on reducing parasympathetic tone and mucus hypersecretion and include targeted lung denervation, bronchial rheoplasty, and cryospray techniques. In this article, we will review the variety of techniques for bronchoscopic lung volume reduction, both established and investigational, along with their respective benefits and complications and will briefly review other investigational therapies for COPD.
Collapse
Affiliation(s)
- Benjamin DeMarco
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Christina R MacRosty
- Section of Interventional Pulmonology and Pulmonary Oncology, Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| |
Collapse
|
11
|
Tonkin J, Shah PL. Sealing the gap in bronchoscopic lung volume reduction. Respirology 2022; 27:1012-1014. [PMID: 36104311 DOI: 10.1111/resp.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 12/13/2022]
Affiliation(s)
- James Tonkin
- Royal Brompton Hospital, London, UK.,Imperial College London, National Heart and Lung Institute, London, UK
| | - Pallav L Shah
- Royal Brompton Hospital, London, UK.,Imperial College London, National Heart and Lung Institute, London, UK.,Chelsea & Westminster Hospital, London, UK
| |
Collapse
|
12
|
Leppig JA, Song L, Voigt DC, Feldhaus FW, Ruwwe-Gloesenkamp C, Saccomanno J, Lassen-Schmidt BC, Neumann K, Leitner K, Hubner RH, Doellinger F. When Treatment of Pulmonary Emphysema with Endobronchial Valves Did Not Work: Evaluation of Quantitative CT Analysis and Pulmonary Function Tests Before and After Valve Explantation. Int J Chron Obstruct Pulmon Dis 2022; 17:2553-2566. [PMID: 36304970 PMCID: PMC9596192 DOI: 10.2147/copd.s367667] [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: 04/05/2022] [Accepted: 09/17/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose To investigate changes in quantitative CT analysis (QCT) and pulmonary function tests (PFT) in pulmonary emphysema patients who required premature removal of endobronchial valves (EBV). Patients and Methods Our hospital’s medical records listed 274 patients with high-grade COPD (GOLD stages 3 and 4) and pulmonary emphysema who were treated with EBV to reduce lung volume. Prior to intervention, a complete evaluation was performed that included quantitative computed tomography analysis (QCT) of scans acquired at full inspiration and full expiration, pulmonary function tests (PFT), and paraclinical findings (6-minute walking distance test (6MWDT) and quality of life questionnaires). In 41 of these 274 patients, EBV treatment was unsuccessful and the valves had to be removed for various reasons. A total of 10 of these 41 patients ventured a second attempt at EBV therapy and underwent complete reevaluation. In our retrospective study, results from three time points were compared: Before EBV implantation (BL), after EBV implantation (TP2), and after EBV explantation (TP3). QCT parameters included lung volume, total emphysema score (TES, ie, the emphysema index) and the 15th percentile of lung attenuation (P15) for the whole lung and each lobe separately. Differences in these parameters between inspiration and expiration were calculated (Vol. Diff (%), TES Diff (%), P15 Diff (%)). The results of PFT and further clinical tests were taken from the patient’s records. Results We found persistent therapy effect in the target lobe even after valve explantation together with a compensatory hyperinflation of the rest of the lung. As a result of these two divergent effects, the volume of the total lung remained rather constant. Furthermore, there was a slight deterioration of the emphysema score for the whole lung, whereas the TES of the target lobe persistently improved. Conclusion Interestingly, we found evidence that, contrary to our expectations, unsuccessful EBV therapy can have a persistent positive effect on target lobe QCT scores.
Collapse
Affiliation(s)
- Jonas Alexander Leppig
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany,Correspondence: Jonas Alexander Leppig, Department of Radiology, Charité Universitätsmedizin Berlin, Charité Campus Virchow-Klinikum, Augustenburger Platz 1, Berlin, 13353, Germany, Tel + 49 30 450 627 283, Fax + 49 30 450 527 911, Email
| | - Lan Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Dorothea C Voigt
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Felix W Feldhaus
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Ruwwe-Gloesenkamp
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jacopo Saccomanno
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Konrad Neumann
- Institute of Biometrics and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Katja Leitner
- Department of Internal Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Ralf H Hubner
- Department of Internal Medicine/Infectious Diseases and Respiratory Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Doellinger
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
13
|
Joshi A, Verma R, Rai AM, Mittal P, Bhandari B, Razdan S. Variations in Pulmonary Fissure: A Source of Collateral Ventilation and Its Clinical Significance. Cureus 2022; 14:e23121. [PMID: 35425671 PMCID: PMC9004548 DOI: 10.7759/cureus.23121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2022] [Indexed: 11/05/2022] Open
|
14
|
Marchese R, Lo Nigro C, Scaduto F. Use of bronchoscopic steam thermal ablation (BTVA) in a clinically compromised patient. J Cardiothorac Surg 2022; 17:16. [PMID: 35130938 PMCID: PMC8822822 DOI: 10.1186/s13019-022-01756-3] [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: 09/25/2020] [Accepted: 01/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background Bronchoscopic lung volume reduction (BLVR) techniques improve lung function and increase exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) and BLVR treatment is included in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) treatment guidelines for these patients. BTVA (Intervapor Uptake Medical, Tustin, CA, USA) represents a recent therapy of this group that allows to treat sublobar areas and for this reason is used clinically compromised patients, like in this case report.
Case presentation In this paper we describe a case report of an 85-year-old male with severe respiratory failure and a diagnosis of emphysema presented with dyspnea and clinical worsening, despite the best medical therapy practiced. For comorbidity and pathology’s features he was excluded from surgical treatment options, like lung volume reduction surgical (LVRS) and from positioning of endobronchial valves (EBV) for the presence of collateral ventilation and he was addressed to BTVA. The procedure was successful for this patient.
Conclusions This case supports recent suggestions that BTVA can be a good alternative treatment for patients properly selected.
Collapse
Affiliation(s)
- Roberto Marchese
- Private Hospital La Maddalena: Casa di Cura La Maddalena SpA, Palermo, Italy.
| | - Chiara Lo Nigro
- Private Hospital La Maddalena: Casa di Cura La Maddalena SpA, Palermo, Italy
| | - Federica Scaduto
- Private Hospital La Maddalena: Casa di Cura La Maddalena SpA, Palermo, Italy
| |
Collapse
|
15
|
Saccomanno J, Ruwwe-Glösenkamp C, Neumann K, Doellinger F, Lenga P, Pappe E, Suttorp N, Witzenrath M, Hübner RH. Impact of Ventilation Modes on Bronchoscopic Chartis Assessment Outcome in Candidates for Endobronchial Valve Treatment. Respiration 2021; 101:408-416. [PMID: 34864739 DOI: 10.1159/000520082] [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: 02/10/2021] [Accepted: 10/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endobronchial valve therapy has proven to reduce lung hyperinflation and decrease disease burden in patients with severe lung emphysema. Exclusion of collateral ventilation (CV) of the targeted lobe by using an endobronchial assessment system (Chartis; PulmonX, Drive Redwood City, CA, USA) in combination with software-based fissure integrity analysis (FCS [fissure completeness score]) of computed tomography scans of the lung are established tools to select appropriate patients for endobronchial valve treatment. So far, there is no conclusive evidence if the ventilation mode during bronchoscopy impacts the outcome of Chartis assessments. METHODS Patients with Chartis assessments and software-based quantification of FCS (StratX; PulmonX, Drive Redwood City, CA, USA) were enrolled in this retrospective study. During bronchoscopy, pulmonary fissure integrity was evaluated with the Chartis assessment system in each patient first under spontaneous breathing and subsequently under high-frequency (HF) jet ventilation. RESULTS In total, 102 patients were analyzed. Four Chartis phenotypes CV positive (CV+), CV negative (CV-), low flow, and low plateau in spontaneous breathing and HF jet ventilation were identified. The frequency of each Chartis phenotype per lobe was similar in both settings. When comparing Chartis assessments in spontaneous breathing and HF jet ventilation, there was an overall good concordance rate for all analyzed fissures. In agreement, receiver operating characteristic analysis of the FCS showed an almost similar prediction for CV+ and CV- status independent of the ventilation modes. CONCLUSION Chartis assessment in spontaneous breathing and HF jet ventilation had similar rates in detecting CV in lung emphysema. Our results suggest that both modes are equivalent for the assessment of CV.
Collapse
Affiliation(s)
- Jacopo Saccomanno
- Department of Infectious Diseases and Respiratory Medicine, Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Ruwwe-Glösenkamp
- Department of Infectious Diseases and Respiratory Medicine, Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Konrad Neumann
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Doellinger
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Pavlina Lenga
- Department of Infectious Diseases and Respiratory Medicine, Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Pappe
- Department of Infectious Diseases and Respiratory Medicine, Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Norbert Suttorp
- Department of Infectious Diseases and Respiratory Medicine, Charité -Universitätsmedizin Berlin, Berlin, Germany.,German Center for Lung Research, DZL, Giessen, Germany
| | - Martin Witzenrath
- Department of Infectious Diseases and Respiratory Medicine, Charité -Universitätsmedizin Berlin, Berlin, Germany.,German Center for Lung Research, DZL, Giessen, Germany
| | - Ralf-Harto Hübner
- Department of Infectious Diseases and Respiratory Medicine, Charité -Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
16
|
van der Molen MC, Hartman JE, Vermeulen CJ, van den Berge M, Faiz A, Kerstjens HAM, Charbonnier JP, Vanfleteren LEGW, Slebos DJ. Determinants of Lung Fissure Completeness. Am J Respir Crit Care Med 2021; 204:807-816. [PMID: 34126038 DOI: 10.1164/rccm.202102-0260oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: New advanced bronchoscopic treatment options for patients with severe chronic obstructive pulmonary disease (COPD) have led to increased interest for COPD phenotyping, including fissure completeness. Objectives: We investigated clinical, environmental, and genetic factors contributing to fissure completeness in patients with and without COPD. Methods: We used data from 9,926 participants of the COPDGene study who underwent chest computed tomographic (CT) scans. Fissure completeness was calculated from CT scans after quantitative CT analysis at baseline and 5-year follow-up. Clinical and environmental factors, including sex, race, smoking, COPD, emphysema, maternal smoking during pregnancy and maternal COPD, were tested for impact on fissure completeness. Genome-wide association analyses were performed separately in non-Hispanic White subjects and African American subjects. Measurements and Main Results: African American subjects had significantly higher fissure completeness than non-Hispanic White subjects for all three fissures (P < 0.001). There was no change in fissure completeness between baseline and 5-year follow-up. For all fissures, no clinically relevant differences in fissure completeness were found for other clinical or environmental factors, including COPD severity. Rs2173623, rs264866, rs2407284, rs7310342, rs4904145, rs6504172, and rs7209556 showed genome-wide significant associations with fissure completeness in non-Hispanic White subjects. In African American subjects, rs264866, rs4904145 and rs6504172 were identified as significant associations. Rs2173623, rs6504172, and rs7209556 lead to WNT5A and HOXB antisense RNA expression, which play an important role during embryogenesis. Conclusions: Fissure completeness is genetically determined and not dependent on age, sex, smoking status, the presence and severity of COPD (including exacerbation frequency), maternal smoking during pregnancy, or maternal COPD.
Collapse
Affiliation(s)
- Marieke C van der Molen
- Department of Pulmonary Diseases
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jorine E Hartman
- Department of Pulmonary Diseases
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Cornelis J Vermeulen
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Maarten van den Berge
- Department of Pulmonary Diseases
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alen Faiz
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Respiratory Bioinformatics and Molecular Biology, University of Technology Sydney, Sydney, Australia
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Lowie E G W Vanfleteren
- COPD Centre, Institute of Medicine, and
- Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| |
Collapse
|
17
|
Kida H, Muraoka H, Morikawa K, Inoue T, Mineshita M. Pleurodesis After Bronchial Occlusion for Inoperable Secondary Spontaneous Pneumothorax. J Bronchology Interv Pulmonol 2021; 28:290-295. [PMID: 34191760 DOI: 10.1097/lbr.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In many cases of secondary spontaneous pneumothorax (SSP), surgery is not feasible. Furthermore, in cases with a collapsed lung or numerous air leaks, pleurodesis is ineffective, and treatment options are severely limited. For these cases, bronchial occlusion might be the only effective treatment, despite the low success rate. If, however, bronchial occlusion can expand the lung and reduce air leakage, it can positively amplify later effects on pleurodesis, resulting in a powerful treatment. We reviewed the clinical data of patients who underwent bronchial occlusion with endobronchial Watanabe spigot (BO-EWS) and pleurodesis to investigate the usefulness of bronchial occlusion therapy in inoperable SSP patients. MATERIALS AND METHODS This single-center, retrospective study reviewed 36 cases of inoperable SSP patients who underwent pleurodesis after BO-EWS from April 2007 to October 2018. Twenty cases were allocated to the air leak analysis group, and 16 cases were included in the pneumothorax volume analysis group. The Robert David Cerfolio classification and the Collins method were used to evaluate air leak and pneumothorax volume, respectively. RESULTS Pneumothorax volumes decreased significantly after BO-EWS from 29.1%±17.3% to 12.1%±8.8%, while the air leak score decreased from 2.9±1.4 to 1.2±1.0. The success rate for chest tube removals in cases that underwent pleurodesis after BO-EWS was 85.0% (17/20). CONCLUSIONS This study demonstrated the synergistic effectiveness of BO-EWS and the usefulness of pleurodesis treatment in inoperable SSP patients with lung collapse or numerous air leaks. We believe that this treatment will benefit patients with inoperable SSP which, until now, has had few treatment options.
Collapse
Affiliation(s)
- Hirotaka Kida
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
| | - Hiromi Muraoka
- Department of Internal Medicine, Division of Respiratory Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Kei Morikawa
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
| | - Takeo Inoue
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
| | - Masamichi Mineshita
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
| |
Collapse
|
18
|
Ashraf O, Disilvio B, Young M, Ghosh S, Cheema T. Surgical Interventions for COPD. Crit Care Nurs Q 2021; 44:49-60. [PMID: 33234859 DOI: 10.1097/cnq.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) treatment is aimed at managing the disease rather than cure, with a focus on improving quality of life and decreasing exacerbations. Interventional therapies, including lung volume reduction surgery, bullectomy, lung transplantation, and bronchoscopic lung volume reduction treatment using endobronchial valves, are treatment options for patients with COPD who are symptomatic due to hyperinflation despite optimal medical management. We will review the current literature to provide a comprehensive summary of the currently available scientific data, discuss typical treatment-related side effects, and evidence-based management approach and recommendations for patient selection in clinical practice.
Collapse
Affiliation(s)
- Obaid Ashraf
- Division of Pulmonary Critical Care Medicine, Allegheny Health Network, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | | | | | | |
Collapse
|
19
|
Abstract
Background: Coils and endobronchial valves are the most widely used bronchoscopic lung volume reduction devices in patients with advanced emphysema. However, the choice of each specific device depends on emphysema characteristics (homogeneous vs. heterogeneous) and presence of lobar collateral ventilation (CV). These devices have not been compared in a head-to-head study design.Objectives: To conduct a network comparative meta-analysis studying the effect of valves in patients with heterogeneous emphysema without CV, and to also study the effects of valves and coils in patients with mixed homogeneous and heterogeneous emphysema.Data Sources and Data Extraction: PubMed and Web of Science were searched for potentially includable randomized active comparator trials from inception to January 20, 2020, and data were extracted in the working sheets of Comprehensive Meta-analysis.Synthesis: Network meta-analysis was conducted in R program using package "netmeta."Results: In patients with heterogeneous emphysema without CV, both Spiration and Zephyr valves showed significant increases in forced expiratory volume in 1 second (FEV1) (0.11 L [95% confidence interval (CI), 0.05 to 0.16] and 0.14 L [0.08 to 0.19], respectively) and in reducing St. Georges Respiratory Questionnaire (SGRQ) scores (-9.32 [-14.18 to -4.45] and -8.14 [-11.94 to -4.35], respectively) as compared with control, with no significant interintervention differences. Only Zephyr valves showed significant improvement (52.3 m [95% CI, 26.53 to 77.93]) in six-minute walk distance (6MWD). Both were ranked as equally efficacious in these patients. In the mixed homogeneous and heterogeneous emphysema group of patients, both Zephyr valves and coils showed significant increases in FEV1 and 6MWD and reduction in SGRQ, as compared with control. Although there were no significant interintervention differences, the magnitude of improvement in these parameters was highest with Zephyr valves (e.g., 6MWD increased by 56.74 m [23.66 to 89.81] vs. 30.31 m [4.00 to 56.63]) in coils), ranking them first. In both populations, these interventions showed a statistically significant association with procedure-related pneumothorax but not with chronic obstructive pulmonary disease exacerbation.Conclusions: In patients with heterogeneous emphysema without CV, both Zephyr and Spiration valves were equally efficacious in FEV1 and SGRQ improvement. However, in the mixed patients with homogeneous and heterogeneous emphysema, Zephyr valves show relative superiority over coils especially with respect to improvement in 6MWD.
Collapse
|
20
|
Affiliation(s)
- Justin L Garner
- Royal Brompton and Harefield NHS Foundation Trust, 4964, London, United Kingdom of Great Britain and Northern Ireland.,Chelsea and Westminster Hospital NHS Foundation Trust, 9762, London, United Kingdom of Great Britain and Northern Ireland.,Imperial College London National Heart and Lung Institute, 90897, London, United Kingdom of Great Britain and Northern Ireland;
| | - Sujal R Desai
- Royal Brompton and Harefield NHS Foundation Trust, 4964, Radiology, London, United Kingdom of Great Britain and Northern Ireland.,Imperial College London National Heart and Lung Institute, 90897, London, United Kingdom of Great Britain and Northern Ireland.,Margaret Turner-Warwick Centre for Fibrosing Lung Disease, London, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
21
|
Goldin JG. The Emerging Role of Quantification of Imaging for Assessing the Severity and Disease Activity of Emphysema, Airway Disease, and Interstitial Lung Disease. Respiration 2021; 100:277-290. [PMID: 33621969 DOI: 10.1159/000513642] [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: 04/23/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
There has been an explosion of use for quantitative image analysis in the setting of lung disease due to advances in acquisition protocols and postprocessing technology, including machine and deep learning. Despite the plethora of published papers, it is important to understand which approach has clinical validation and can be used in clinical practice. This paper provides an introduction to quantitative image analysis techniques being used in the investigation of lung disease and focusses on the techniques that have a reasonable clinical validation for being used in clinical trials and patient care.
Collapse
Affiliation(s)
- Jonathan Gerald Goldin
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California, USA,
| |
Collapse
|
22
|
Endobronchial Valves for the Treatment of Advanced Emphysema. Chest 2020; 159:1833-1842. [PMID: 33345947 PMCID: PMC8129734 DOI: 10.1016/j.chest.2020.12.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/23/2020] [Accepted: 12/11/2020] [Indexed: 01/31/2023] Open
Abstract
Bronchoscopic lung volume reduction with one-way endobronchial valves is a guideline treatment option for patients with advanced emphysema that is supported by extensive scientific data. Patients limited by severe hyperinflation, with a suitable emphysema treatment target lobe and with absence of collateral ventilation, are the responders to this treatment. Detailed patient selection, a professional treatment performance, and dedicated follow up of the valve treatment, including management of complications, are key ingredients to success. This treatment does not stand alone; it especially requires extensive knowledge of COPD for which the most appropriate treatment is discussed in a multidisciplinary approach. We discuss the endobronchial valve treatment for emphysema and provide a guideline for patient selection, treatment guidance, and practice tools, based on our own experience and literature.
Collapse
|
23
|
Milne S, Sin DD. Biomarkers in Chronic Obstructive Pulmonary Disease: The Gateway to Precision Medicine. Clin Chest Med 2020; 41:383-394. [PMID: 32800193 DOI: 10.1016/j.ccm.2020.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a highly heterogeneous disease with limited adequate treatments. Biomarkers-which may relate to disease susceptibility, diagnosis, prognosis, or treatment response-are ideally suited to dissecting such a complex disease and form a critical component of the precision medicine paradigm. Not all potential candidates, however, make good biomarkers. To date, only plasma fibrinogen has been approved by regulatory bodies as a biomarker of exacerbation risk for clinical trial enrichment. This review outlines some of the challenges of biomarker research in COPD and highlights novel and promising biomarker candidates.
Collapse
Affiliation(s)
- Stephen Milne
- Centre for Heart Lung Innovation and Division of Respiratory Medicine, University of British Columbia, Room 166, St Paul's Hospital, 1081 Burrard St, Vancouver, British Columbia V6Z 1Y6, Canada; Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2006, Australia.
| | - Don D Sin
- Centre for Heart Lung Innovation and Division of Respiratory Medicine, University of British Columbia, Room 166, St Paul's Hospital, 1081 Burrard St, Vancouver, British Columbia V6Z 1Y6, Canada
| |
Collapse
|
24
|
Wang R, Paul S, Truong V, Munavvar M. Bronchoscopic interventions for emphysema: Current status. Lung India 2020; 37:518-529. [PMID: 33154215 PMCID: PMC7879872 DOI: 10.4103/lungindia.lungindia_8_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/02/2020] [Indexed: 11/04/2022] Open
Abstract
Chronic obstructive pulmonary disease is a prevalent and progressive disease. The recently developed bronchoscopic lung volume reduction (BLVR) techniques offer personalized therapeutic options in subgroups of patients with severe emphysema. Endobronchial and intrabronchial valves (EBV/IBV) achieve lung volume reduction by lobar atelectasis. The lung volume reduction coils (LVRCs) and bronchoscopic thermal vapor ablation (BTVA) induce tissue compression, either mechanically or through inflammatory processes. While the effects of EBV/IBV are reversible by removing the implants, the effects of LVRC are partially reversible and that of BTVA is irreversible. The presence of interlobar collateral ventilation (CV) impacts on EBV/IBV treatment outcome due to its mechanism of action. Therefore, using radiological and endoscopic techniques to assess CV has a vital importance. Current evidence of BLVR demonstrates acceptable safety and short-term clinical efficacy. However, head-to-head trials are lacking, and further research is needed to establish long-term clinical benefit, durability, and cost-effectiveness of these techniques.
Collapse
Affiliation(s)
- Ran Wang
- School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Suman Paul
- Department of Respiratory, Lancashire Teaching Hospital NHS Foundation Trust, Preston, United Kingdom
| | - Vi Truong
- School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Mohammed Munavvar
- School of Biological Sciences, The University of Manchester, Manchester; Department of Respiratory, Lancashire Teaching Hospital NHS Foundation Trust, Preston, United Kingdom
| |
Collapse
|
25
|
Abstract
OBJECTIVE This article reviews the anatomy, histology, and disease processes of pulmonary fissures, with emphasis on clinical implications of accessory and incomplete fissures. CONCLUSION Accessory and incomplete pulmonary fissures are often overlooked during routine imaging but can have profound clinical importance. Knowledge of fissure anatomy could improve diagnostic accuracy and inform prognosis for oncologists, interventional pulmonologists, and thoracic surgeons.
Collapse
|
26
|
West CT, Slim N, Steele D, Chowdhury A, Brassett C. Are textbook lungs really normal? A cadaveric study on the anatomical and clinical importance of variations in the major lung fissures, and the incomplete right horizontal fissure. Clin Anat 2020; 34:387-396. [DOI: 10.1002/ca.23661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Charles T. West
- Human Anatomy Teaching Group, Anatomy Building, University of Cambridge Cambridge UK
- Department of Colorectal Surgery University Hospital Southampton NHS Foundation Trust UK
| | - Naim Slim
- Human Anatomy Teaching Group, Anatomy Building, University of Cambridge Cambridge UK
| | - Duncan Steele
- Department of Cardiothoracic Surgery King's College Hospital NHS Foundation Trust UK
| | - Alexander Chowdhury
- Department of Thoracic Surgery Royal Brompton and Harefield NHS Foundation Trust UK
| | - Cecilia Brassett
- Human Anatomy Teaching Group, Anatomy Building, University of Cambridge Cambridge UK
| |
Collapse
|
27
|
Wienker J, Karpf-Wissel R, Funke F, Taube C, Wälscher J, Winantea J, Maier S, Mardanzai K, Darwiche K. Predictive value of Chartis measurement for lung function improvements in bronchoscopic lung volume reduction. Ther Adv Respir Dis 2020; 14:1753466620932507. [PMID: 32615853 PMCID: PMC7339075 DOI: 10.1177/1753466620932507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Bronchoscopic lung volume reduction (BLVR) via valve
implantation can be achieved by targeting severely hyperinflated and
emphysematously destructed lung areas in patients with chronic obstructive
lung disease. Lack of collateral ventilation (CV) is important for good
outcomes with BLVR. CV can be measured using the catheter-based Chartis
system. The aim of this study was to evaluate the correlation between total
exhaled volume drained from the target lobe measured by Chartis and clinical
outcomes after BLVR in CV-negative patients. Methods: From January 2016 to March 2019, 60 patients were included in this
retrospective single-center analysis. Drained volume (TVol) measured by
Chartis was recorded and compared with lung function and physical
performance parameters. Outcome variables included the percentage change in
lung function [forced expiratory volume in 1 s (FEV1), residual
volume (RV), and inspiratory vital capacity (IVC)]. Secondary outcomes were
the degree of target lobe volume reduction (TLVR), change in 6-min walk
distance (6MWD), and change in chronic obstructive pulmonary disease (COPD)
assessment test (CAT) score. Results: Drained volume correlated significantly with post-BLVR change in
FEV1 (r = 0.663), IVC
(r = 0.611), RV (r = −0.368), and TLVR
(r = 0.635) (all p < 0.05). In
a priori-defined patient subgroups based on drained
volume [<100 ml (n = 19), 100−400 ml
(n = 33), and >400 ml (n = 8)]; mean
changes in FEV1 were 2.6%, 17.4%, and 51.3%; in RV were −3.9%,
−10.6%, and −23.8%; in IVC were −4.0%, 10.6%, and 62.4%; and in TLVR were
525 ml (39%), 1375 ml (73%) and 1760 ml (100%), respectively. There were no
significant correlations between absolute and percentage changes in 6MWD and
the CAT score. Lung volume reduction was diagnosed in 32 (53%) cases. Conclusion: Drained volume measured by the Chartis system correlated with functional
improvement in CV-negative patients undergoing BLVR. The reviews of this paper are available via the supplemental
material section.
Collapse
Affiliation(s)
- Johannes Wienker
- Department of Pneumology, Division of Interventional Pneumology, University Medicine Essen-Ruhrlandklinik, Tüschener Weg 40, Essen, NRW 45239, Germany
| | - Rüdiger Karpf-Wissel
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, Essen, Nordrhein-Westfalen, Germany
| | - Faustina Funke
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, Essen, Nordrhein-Westfalen, Germany
| | - Christian Taube
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, Essen, Nordrhein-Westfalen, Germany
| | - Julia Wälscher
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, Essen, Nordrhein-Westfalen, Germany
| | - Jane Winantea
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, Essen, Nordrhein-Westfalen, Germany
| | - Sandra Maier
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
| | - Khaled Mardanzai
- Department of Thoracic Surgery, University Medicine Essen-Ruhrlandklinik, Essen, Nordrhein-Westfalen, Germany
| | - Kaid Darwiche
- Department of Pneumology, University Medicine Essen-Ruhrlandklinik, Essen, Nordrhein-Westfalen, Germany
| |
Collapse
|
28
|
Klooster K, Koster TD, Ruwwe-Glösenkamp C, Theilig D, Doellinger F, Saccomanno J, Kerstjens HAM, Slebos DJ, Hübner RH. An Integrative Approach of the Fissure Completeness Score and Chartis Assessment in Endobronchial Valve Treatment for Emphysema. Int J Chron Obstruct Pulmon Dis 2020; 15:1325-1334. [PMID: 32606642 PMCID: PMC7294564 DOI: 10.2147/copd.s242210] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/20/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Lung volume reduction using one-way endobronchial valves is a bronchoscopic treatment for patients with severe emphysema without collateral ventilation between the treatment target lobe and the ipsilateral lobe(s). CT-scan fissure analysis is often used as a surrogate to predict the absence of collateral ventilation. We aimed to evaluate the predictive value of the fissure completeness score (FCS) compared to the functional Chartis measurement of collateral ventilation and to provide cut-off values of the FCS in patient selection. Patients and Methods Multicenter study in patients eligible for treatment with one-way valves. The FCS was calculated by quantitative CT analysis (Thirona, the Netherlands) and compared to status of interlobar collateral ventilation measured with Chartis system (PulmonX, USA). Thresholds were calculated for the predictive values of the presence of collateral ventilation. Results An FCS >95% of the left major fissure had a positive predictive value (PPV) of 91%, with 1 in 11 fissures demonstrating collateral ventilation with Chartis measurement, whereas an FCS of ≤80% had a negative predictive value (NPV) of 100% for the presence of collateral ventilation. For the right major fissure, the NPV was 100% for an FCS ≤90%, but 69.7% for the right upper lobe fissure. Conclusion Quantitative CT analysis is recommended in all patients evaluated for endobronchial valves. Patients with incomplete fissures (left major fissure: FCS <80%; right major fissure: <90%) can be excluded from Chartis measurement and endobronchial valve treatment. In patients with more complete fissures, the FCS is not specific enough for endobronchial valve treatment decisions. In this case, additional Chartis measurements are always recommended in the right lung. For the left lung, Chartis assessments may be omitted if the FCS is >95%.
Collapse
Affiliation(s)
- Karin Klooster
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - T David Koster
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | | | - Dorothea Theilig
- Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Department of Radiology, Berlin, Germany
| | - Felix Doellinger
- Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Department of Radiology, Berlin, Germany
| | - Jacopo Saccomanno
- Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Department of Pneumology, Berlin, Germany
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Dirk-Jan Slebos
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Ralf-Harto Hübner
- Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Department of Pneumology, Berlin, Germany
| |
Collapse
|
29
|
Welling JBA, Koster TD, Hartman JE, van Dijk M, Kerstjens HAM, Klooster K, Slebos DJ. Temporary Right Middle Lobe Occlusion with a Blocking Device to Enable Collateral Ventilation Measurement of the Right Major Fissure. Respiration 2020; 99:516-520. [PMID: 32516782 DOI: 10.1159/000507401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/19/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Absence of interlobar collateral ventilation is essential to achieve lobar volume reduction after endobronchial valve (EBV) treatment and can be assessed using the Chartis measurement. However, especially in lower lobe measurements, Chartis can be complicated by the "no-flow phenomenon", during which a sudden cessation of flow is observed, leading to an unreliable measurement. If this phenomenon occurs in the right lower lobe, when measuring collateral flow over the right major fissure, the entrance to the right middle lobe should be occluded, and the Chartis balloon should be placed in the right upper lobe. Both Watanabe spigots and balloon catheters can be used to achieve occlusion. OBJECTIVE Our aim was to demonstrate that right middle lobe occlusion with a blocking device is helpful in obtaining a reliable Chartis outcome in case of the no-flow phenomenon in the right lower lobe. METHODS We performed a retrospective analysis of patients scheduled for EBV treatment in an EBV registry between September 2016 and September 2019. RESULTS We included 15 patients with severe emphysema (median age 63 years [range 47-73], 73% female, and FEV1 24% [range 19-36] of predicted), who required temporary middle lobe occlusion (12 Watanabe spigot, 3 balloon catheter). After occlusion, a reliable Chartis outcome was obtained in all patients. CONCLUSION Temporary middle lobe occlusion using a blocking device is helpful in obtaining a reliable Chartis outcome in case of a right lower lobe no-flow phenomenon.
Collapse
Affiliation(s)
- Jorrit B A Welling
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, .,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands,
| | - T David Koster
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jorine E Hartman
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marlies van Dijk
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
30
|
Shah PL, Slebos DJ. Bronchoscopic interventions for severe emphysema: Where are we now? Respirology 2020; 25:972-980. [PMID: 32363706 DOI: 10.1111/resp.13835] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023]
Abstract
Patients with severe emphysema have limited treatment options and only derive a small benefit from optimal medical treatment. The only other therapy to have significant clinical beneficial effect in emphysema is LVRS but the perceived risk and invasiveness of surgery has fuelled bronchoscopic approaches to induce lung volume reduction. There are multiple bronchoscopic methods for achieving volume reduction in severe emphysema: EBV, airway bypass procedure, endobronchial coils, thermal (vapour) sclerosis and chemical sclerosis (sealants). Optimal patient selection is key to successful patient outcomes. This review discusses bronchoscopic approaches for emphysema treatment which has progressed through clinical trials to clinical practice.
Collapse
Affiliation(s)
- Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, Chelsea and Westminster Hospital, London, UK
| | - Dirk-Jan Slebos
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| |
Collapse
|
31
|
Welling JBA, Hartman JE, Augustijn SWS, Kerstjens HAM, Vanfleteren LEGW, Klooster K, Slebos DJ. Patient Selection for Bronchoscopic Lung Volume Reduction. Int J Chron Obstruct Pulmon Dis 2020; 15:871-881. [PMID: 32368033 PMCID: PMC7185646 DOI: 10.2147/copd.s240848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/10/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Bronchoscopic lung volume reduction (BLVR) is a valuable treatment option for carefully selected patients with severe COPD. There is limited knowledge about the characteristics and outcomes of patients referred to a specialized center for BLVR. The study objectives were to investigate the selection rate for BLVR treatment in patients referred for this treatment and to investigate the differences between patients that were selected for BLVR and patients that were not. Patients and Methods We performed a retrospective analysis of patients with severe COPD who were referred to our hospital to assess eligibility for BLVR treatment. Our parameters included demographics, comorbidity, chest computed tomography characteristics, reasons for rejection from BLVR treatment and patient survival. Results In total, 1500 patients were included (mean age 62 years, 50% female and forced expiratory volume in 1 s 33% of predicted). Out of this group, 282 (19%) patients were selected for BLVR treatment. The absence of a suitable target lobe for treatment, an unsuitable disease phenotype and insufficient lung hyperinflation were the most important factors for not being selected. Patients that were selected for any BLVR option lived significantly longer than the group of patients that were not selected for BLVR (median 3060 versus 2079 days, P<0.001). Conclusion We found that only a small proportion of patients that are referred for BLVR treatment is eligible for a BLVR treatment, indicating a need for both better referral tools and for the development of new therapies for this group of patients. Furthermore, our data suggest that selection for BLVR is associated with a significant survival benefit.
Collapse
Affiliation(s)
- Jorrit B A Welling
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jorine E Hartman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sonja W S Augustijn
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Lowie E G W Vanfleteren
- COPD Center, Sahlgrenska University Medical Hospital and Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Karin Klooster
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk-Jan Slebos
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
32
|
Combined Thoracoscopic Surgical Stapling and Endobronchial Valve Placement For Lung Volume Reduction With Incomplete Lobar Fissures. J Bronchology Interv Pulmonol 2020; 27:128-134. [DOI: 10.1097/lbr.0000000000000617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
33
|
Computed Tomography Imaging for Novel Therapies of Chronic Obstructive Pulmonary Disease. J Thorac Imaging 2019; 34:202-213. [PMID: 30550404 DOI: 10.1097/rti.0000000000000378] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Novel therapeutic options in chronic obstructive pulmonary disease (COPD) require delicate patient selection and thus demand for expert radiologists visually and quantitatively evaluating high-resolution computed tomography (CT) with additional functional acquisitions such as paired inspiratory-expiratory scans or dynamic airway CT. The differentiation between emphysema-dominant and airway-dominant COPD phenotypes by imaging has immediate clinical value for patient management. Assessment of emphysema severity, distribution patterns, and fissure integrity are essential for stratifying patients for different surgical and endoscopic lung volume reduction procedures. This is supported by quantitative software-based postprocessing of CT data sets, which delivers objective emphysema and airway remodelling metrics. However, the significant impact of scanning and reconstruction parameters, as well as intersoftware variability still hamper comparability between sites and studies. In earlier stage COPD imaging, it is less clear as to what extent quantitative CT might impact decision making and therapy follow-up, as emphysema progression is too slow to realistically be useful as a mid-term outcome measure in an individual, and longitudinal data on airway remodelling are still very limited.
Collapse
|
34
|
Collateral Ventilation Measurement Using Chartis: Procedural Sedation vs General Anesthesia. Chest 2019; 156:984-990. [PMID: 31421111 DOI: 10.1016/j.chest.2019.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/02/2019] [Accepted: 07/31/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Absence of interlobar collateral ventilation is key to successful endobronchial valve treatment in patients with severe emphysema and can be functionally assessed by using the Chartis measurement. This system has been validated during spontaneous breathing, undergoing procedural sedation (PS), but can also be performed under general anesthesia. Performing the Chartis measurement under PS is often challenging because of coughing, mucus secretion, and difficulties in maintaining an adequate level of sedation. The objective of this study was to investigate whether there is a difference in Chartis measurement outcomes between PS and general anesthesia. METHODS In this prospective study, patients underwent Chartis measurements under both PS and general anesthesia. Study outcomes were Chartis measurement duration, number of measurements, feasibility, and success rate. RESULTS The study included 30 patients with severe emphysema (mean age, 62 years; median FEV1, 29% of predicted). Chartis measurement duration was significantly longer under PS than under general anesthesia (mean, 20.3 ± 4.2 min vs 15.1 ± 4.4 min; P < .001). There was no difference in the number (median [range]) of measurements performed (2 [1-3] for PS vs 1 [1-3] for general anesthesia; P = 1.00). Chartis measurement was more feasible during general anesthesia (median sum of all feasibility scores, 12 [range, 6-26] for PS vs 7 [5-13] for general anesthesia; P < .001). There was no statistical difference in success rate: 77% of PS cases vs 97% of general anesthesia cases (P = .07). CONCLUSIONS This study found that Chartis measurement under general anesthesia is faster and more feasible to perform compared with performance with PS, without affecting measurement outcomes. TRIAL REGISTRATION Clinicaltrials.gov; No. NCT03205826; URL: www.clinicaltrials.gov.
Collapse
|
35
|
[Interventional treatment of tracheopleural and bronchopleural fistulas]. Chirurg 2019; 90:697-703. [PMID: 31161248 DOI: 10.1007/s00104-019-0977-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Interventional bronchoscopy is an indispensable option to manage bronchopleural and tracheopleural fistulas in patients in a poor general condition and at high risk for developing postoperative complications. METHODS This article is based on a search in the PubMed database for relevant publications and own experiences as surgeons and pneumologists. RESULTS Various interventional techniques can be used for the treatment of bronchopleural and tracheopleural fistulas. Currently, the insertion of stents or endobronchial valves is the most frequently used treatment. Ideally, the attending anesthesiologist will have experience with high frequency jet ventilation and the attending surgeon will have experience with rigid bronchoscopy, flexible bronchoscopy, and interventional bronchoscopy. DISCUSSION Due to a lack of standardized treatment recommendations, individual treatment plans must be decided according to the location of the bronchopleural or tracheopleural fistula and taking existing comorbidities into account.
Collapse
|
36
|
Flandes J, Soto FJ, Cordovilla R, Cases E, Alfayate J. Bronchoscopic Lung Volume Reduction. Clin Chest Med 2019; 39:169-180. [PMID: 29433712 DOI: 10.1016/j.ccm.2017.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Since the publication of the National Emphysema Treatment Trial study, lung volume reduction (LVR) has been considered a therapeutic alternative for patients with advanced obstructive lung disease. The high complication rate of surgical LVR has led to the development of bronchoscopic LVR (BLVR). Of the currently available BLVR alternatives, coils and unidirectional endobronchial valves lead the list. The choice of each device depends on emphysema characteristics and presence of collateral ventilation. Evaluation of these patients at centers with expertise in interventional pulmonology and management of BLVR is strongly recommended.
Collapse
Affiliation(s)
- Javier Flandes
- Bronchology and Interventional Pulmonology Unit, IIS-Fundación Jiménez Díaz, CIBERES, Avenida Reyes Catolicos No 2, Madrid 28040, Spain.
| | - Francisco J Soto
- Pulmonary and Critical Care, Department of Medicine, University of Tennessee Medical Center, 1940 Alcoa Hwy e, Knoxville, TN 37920, USA
| | - Rosa Cordovilla
- Bronchology and Interventional Pulmonology Unit, Salamanca University Hospital, Paseo de San Vicente 58, Salamanca 37007, Spain
| | - Enrique Cases
- Bronchology and Interventional Pulmonology Unit, La Fe University Hospital, Avenida Fernando Abril Martorell 106, Valencia 46026, Spain
| | - Javier Alfayate
- Bronchology and Interventional Pulmonology Unit, IIS-Fundación Jiménez Díaz, CIBERES, Avenida Reyes Catolicos No 2, Madrid 28040, Spain
| |
Collapse
|
37
|
Kloth C, Thaiss WM, Fritz J, Nikolaou K, Beer M, Hetzel J, Ioanoviciu SD, Horger M. Prediction of response to endobronchial coiling based on morphologic emphysema characterization of the lung lobe to be treated and the ipsilateral non-treated lobe as well as on functional computed tomography-data: correlation with clinical and pulmonary function. J Thorac Dis 2019; 11:93-102. [PMID: 30863577 DOI: 10.21037/jtd.2018.12.64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To test if the emphysema type of the targeted lobe, ipsilateral non-targeted lobe, and lobes of the contralateral lung impact outcome of endobronchial lung volume reduction (ELVR) treatment, and to document lobar volume changes in treated and non-treated lung lobes. Methods Thirty patients (16 men, 14 women; median age, 66±6 years; range, 48-78 years) underwent chest-computed tomography (CT) before and after endobronchial coiling for lung volume reduction (LVR) at our institution between December 2011 and March 2016. Forty-five pulmonary lobes were coiled. We classified the treated lobes into homogenous or heterogeneous emphysema phenotype based on the distribution of voxels showing tissue attenuation of less than -950 HU. Clinical response was defined as an increase or consistency in the walking distance (6MWT) 6 months after LVR-therapy. Lung volume changes were compared for treated, ipsilateral, and contralateral lobes. Additionally, pulmonary function tests (PFT), chronic obstructive pulmonary disease (COPD) assessment test (CAT), and blood gas analysis were performed. Results Responder (19/30, 63.3%) showed a significant improvement of 6 MWT from 281.05 to 335.26 (P=0.001). Non-responder (11/30, 36.7%) showed a decrease in 6MWT from 308.18 to 255.45 (P=0.001). Responders showed a significant reduction in CAT test from 23.23 to 20.73 points (P=0.038) and pCO2 from 42.94 to 40.31 (P=0.001), whereas non-responders showed an increase in pCO2 (P=0.003; from 44.27 to 47.45). There were no significant changes in PFT-parameters. In responders, there was a significant volume reduction in treated lobes from 1,627.68 to 1,519.21 mL (P=0.009). In responders, treated lobes/non-treated ipsilateral lobes were homogenous (n=11/5) and heterogeneous (n=10/28). In non-responders, treated lobes/non-treated ipsilateral were homogenous (n=5/4) and heterogeneous (n=7/16). In responders and non-responders, the emphysema phenotype in treated, ipsilateral non-treated and even contralateral lobes (P=0.250) did not differ and or change significantly before and after therapy. Only the volume of treated lobes in responders changed significantly after coiling. Conclusions The emphysema-phenotype in the targeted and non-targeted ipsilateral lobe has no impact on the outcome of endobronchial coiling for LVR and also does not change significantly after treatment, whereas the volume of the treated lobe significantly decreases in responders.
Collapse
Affiliation(s)
- Christopher Kloth
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | | | - Jan Fritz
- Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiological Science, Baltimore, MD, USA
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Tübingen, Germany
| | - Meinrad Beer
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Jürgen Hetzel
- Department of Internal Medicine II, Eberhard-Karls-University, Tübingen, Germany
| | | | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University, Tübingen, Germany
| |
Collapse
|
38
|
Janssen R, Piscaer I, Franssen FME, Wouters EFM. Emphysema: looking beyond alpha-1 antitrypsin deficiency. Expert Rev Respir Med 2019; 13:381-397. [DOI: 10.1080/17476348.2019.1580575] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Rob Janssen
- Department of Pulmonary Medicine, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Ianthe Piscaer
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frits M. E. Franssen
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- CIRO, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Emiel F. M. Wouters
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
- CIRO, Center of Expertise for Chronic Organ Failure, Horn, The Netherlands
| |
Collapse
|
39
|
Gerard SE, Patton TJ, Christensen GE, Bayouth JE, Reinhardt JM. FissureNet: A Deep Learning Approach For Pulmonary Fissure Detection in CT Images. IEEE TRANSACTIONS ON MEDICAL IMAGING 2019; 38:156-166. [PMID: 30106711 PMCID: PMC6318012 DOI: 10.1109/tmi.2018.2858202] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Pulmonary fissure detection in computed tomography (CT) is a critical component for automatic lobar segmentation. The majority of fissure detection methods use feature descriptors that are hand-crafted, low-level, and have local spatial extent. The design of such feature detectors is typically targeted toward normal fissure anatomy, yielding low sensitivity to weak, and abnormal fissures that are common in clinical data sets. Furthermore, local features commonly suffer from low specificity, as the complex textures in the lung can be indistinguishable from the fissure when the global context is not considered. We propose a supervised discriminative learning framework for simultaneous feature extraction and classification. The proposed framework, called FissureNet, is a coarse-to-fine cascade of two convolutional neural networks. The coarse-to-fine strategy alleviates the challenges associated with training a network to segment a thin structure that represents a small fraction of the image voxels. FissureNet was evaluated on a cohort of 3706 subjects with inspiration and expiration 3DCT scans from the COPDGene clinical trial and a cohort of 20 subjects with 4DCT scans from a lung cancer clinical trial. On both data sets, FissureNet showed superior performance compared with a deep learning approach using the U-Net architecture and a Hessian-based fissure detection method in terms of area under the precision-recall curve (PR-AUC). The overall PR-AUC for FissureNet, U-Net, and Hessian on the COPDGene (lung cancer) data set was 0.980 (0.966), 0.963 (0.937), and 0.158 (0.182), respectively. On a subset of 30 COPDGene scans, FissureNet was compared with a recently proposed advanced fissure detection method called derivative of sticks (DoS) and showed superior performance with a PR-AUC of 0.991 compared with 0.668 for DoS.
Collapse
Affiliation(s)
- Sarah E. Gerard
- Department of Biomedical Engineering, University of Iowa, Iowa City, IA, 52242 USA ()
| | - Taylor J. Patton
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI, 53705 USA
| | - Gary E. Christensen
- Departments of Electrical and Computer Engineering and Radiation Oncology, University of Iowa, Iowa City, IA, 52242 USA
| | - John E. Bayouth
- Department of Radiation Oncology, University of Wisconsin-Madison, Madison, WI, 53792 USA
| | - Joseph M. Reinhardt
- Department of Biomedical Engineering, University of Iowa, Iowa City, IA, 52242 USA ()
| |
Collapse
|
40
|
Fiorelli A, Poggi C, Anile M, Cascone R, Carlucci A, Cassiano F, Andreetti C, Tiracorrendo M, Diso D, Serra N, Venuta F, Rendina EA, Santini M, D’Andrilli A. Visual analysis versus quantitative CT analysis of interlobar fissure integrity in selecting emphysematous patients for endobronchial valve treatment. Interact Cardiovasc Thorac Surg 2018; 28:751-759. [DOI: 10.1093/icvts/ivy340] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/04/2018] [Accepted: 11/19/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Camilla Poggi
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Marco Anile
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Roberto Cascone
- Thoracic Surgery Unit, Università della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Annalisa Carlucci
- Thoracic Surgery Unit, Università della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Francesco Cassiano
- Thoracic Surgery Unit, Università La Sapienza, Sant’Andrea Hospital, Rome, Italy
| | - Claudio Andreetti
- Thoracic Surgery Unit, Università La Sapienza, Sant’Andrea Hospital, Rome, Italy
| | - Matteo Tiracorrendo
- Thoracic Surgery Unit, Università La Sapienza, Sant’Andrea Hospital, Rome, Italy
| | - Daniele Diso
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Nicola Serra
- Statistic Unit, Department of Public Health, University of Naples, ‘Federico II’, Naples, Italy
| | - Federico Venuta
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery Unit, Università La Sapienza, Sant’Andrea Hospital, Rome, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antonio D’Andrilli
- Thoracic Surgery Unit, Università La Sapienza, Sant’Andrea Hospital, Rome, Italy
| |
Collapse
|
41
|
CT Imaging-Based Low-Attenuation Super Clusters in Three Dimensions and the Progression of Emphysema. Chest 2018; 155:79-87. [PMID: 30292758 DOI: 10.1016/j.chest.2018.09.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/31/2018] [Accepted: 09/06/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Distributions of low-attenuation areas in two-dimensional (2-D) CT lung slices are used to quantify parenchymal destruction in patients with COPD. However, these segmental approaches are limited and may not reflect the true three-dimensional (3-D) tissue processes that drive emphysematous changes in the lung. The goal of this study was to instead evaluate distributions of 3-D low-attenuation volumes, which we hypothesized would follow a power law distribution and provide a more complete assessment of the mechanisms underlying disease progression. METHODS CT scans and pulmonary function test results were acquired from an observational database for N = 12 patients with COPD and N = 12 control patients. The data set included baseline and two annual follow-up evaluations in patients with COPD. Three-dimensional representations of the lungs were reconstructed from 2-D axial CT slices, with low-attenuation volumes identified as contiguous voxels < -960 Hounsfield units. RESULTS Low-attenuation sizes generally followed a power law distribution, with the exception of large, individual outliers termed "super clusters," which deviated from the expected distribution. Super cluster volume was correlated with disease severity (% total low attenuation, ρ = 0.950) and clinical measures of lung function including FEV1 (ρ = -0.849) and diffusing capacity of the lung for carbon monoxide Dlco (ρ = -0.874). To interpret these results, we developed a personalized computational model of super cluster emergence. Simulations indicated disease progression was more likely to occur near existing emphysematous regions, giving rise to a biomechanical, force-induced mechanism of super cluster growth. CONCLUSIONS Low-attenuation super clusters are defining, quantitative features of parenchymal destruction that dominate disease progression, particularly in advanced COPD.
Collapse
|
42
|
Fiorelli A, D'Andrilli A, Bezzi M, Ibrahim M, Anile M, Diso D, Cusumano G, Terminella A, Luzzi V, Innocenti M, Novali M, Carelli E, Freda C, Natale G, Peritore V, Poggi C, Failla G, Basile M, Mazzucca E, Conforti S, Serra N, Torre M, Venuta F, Rendina EA, Santini M, Andreetti C. Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: results of a multicenter study. J Thorac Dis 2018; 10:S3315-S3325. [PMID: 30450237 DOI: 10.21037/jtd.2018.06.69] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes. Methods It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV1); of -8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant. Results One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those <350 mL (n=43) had a statistically significant higher improvement in FEV1 (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (-10.0%±4.8% vs. -4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (-15.0±2.9 vs. -8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV1 (19.0%±3.9%), RV (-10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (-15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described. Conclusions Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach.
Collapse
Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio D'Andrilli
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Michela Bezzi
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | - Mohsen Ibrahim
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Marco Anile
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Daniele Diso
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Giacomo Cusumano
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Alberto Terminella
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Valentina Luzzi
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | | | - Mauro Novali
- Interventional Pneumology Unit, Spedili Civili Brescia, Brescia, Italy
| | - Emanuele Carelli
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Chiara Freda
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Giovanni Natale
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Valentina Peritore
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Camilla Poggi
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Giuseppe Failla
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Marco Basile
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Emilia Mazzucca
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | | | - Nicola Serra
- Department of Pediatrics, University Federico II of Naples, Naples, Italy
| | - Massimo Torre
- Thoracic Surgery Unit, Ospedale Niguarda, Milan, Italy
| | - Federico Venuta
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Claudio Andreetti
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| |
Collapse
|
43
|
Welling JBA, Hartman JE, Ten Hacken NHT, Franz I, Charbonnier JP, van Rikxoort EM, Kerstjens HAM, Klooster K, Slebos DJ. Chartis Measurement of Collateral Ventilation: Conscious Sedation versus General Anesthesia - A Retrospective Comparison. Respiration 2018; 96:480-487. [PMID: 30114707 DOI: 10.1159/000490733] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Absence of interlobar collateral ventilation using the Chartis measurement is the key predictor for successful endobronchial valve treatment in severe emphysema. Chartis was originally validated in spontaneous breathing patients under conscious sedation (CS); however, this can be challenging due to cough, mucus secretion, mucosal swelling, and bronchoconstriction. Performing Chartis under general anesthesia (GA) avoids these problems and may result in an easier procedure with a higher success rate. However, using Chartis under GA with positive pressure ventilation has not been validated. OBJECTIVES In this study we investigated the impact of anesthesia technique, CS versus GA, on the feasibility and outcomes of Chartis measurement. METHODS We retrospectively analyzed all Chartis measurements performed at our hospital from October 2010 until December 2017. RESULTS We analyzed 250 emphysema patients (median forced expiratory volume in 1 s 26%, range 12-52% predicted). In 121 patients (48%) the measurement was performed using CS, in 124 (50%) using GA, and in 5 (2%) both anesthesia techniques were used. In total, 746 Chartis readings were analyzed (432 CS, 277 GA, and 37 combination). Testing under CS took significantly longer than GA (median 19 min [range 5-65] vs. 11 min [3-35], p < 0.001) and required more measurements (3 [1-13] vs. 2 [1-6], p < 0.001). There was no significant difference in target lobe volume reduction after treatment (-1,123 mL [-3,604 to 332] in CS vs. -1,251 mL [-3,333 to -1] in GA, p = 0.35). CONCLUSIONS In conclusion, Chartis measurement under CS took significantly longer and required more measurements than under GA, without a difference in treatment outcome. We recommend a prospective trial comparing both techniques within the same patients to validate this approach.
Collapse
Affiliation(s)
- Jorrit B A Welling
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jorine E Hartman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Nick H T Ten Hacken
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ina Franz
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Groningen, the Netherlands
| | - Jean-Paul Charbonnier
- Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands
| | - Eva M van Rikxoort
- Radboud University Medical Center, Department of Radiology and Nuclear Medicine, Nijmegen, the Netherlands
| | - Huib A M Kerstjens
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Karin Klooster
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk-Jan Slebos
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| |
Collapse
|
44
|
Valipour A. Valve therapy in patients with emphysematous type of chronic obstructive pulmonary disease (COPD): from randomized trials to patient selection in clinical practice. J Thorac Dis 2018; 10:S2780-S2796. [PMID: 30210832 PMCID: PMC6129808 DOI: 10.21037/jtd.2018.08.86] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 08/16/2018] [Indexed: 01/16/2023]
Abstract
In recent years a number of endoscopic methods have emerged to treat patients with severe emphysematous type of chronic obstructive pulmonary disease (COPD), who are primarily symptomatic due to hyperinflation despite optimal medical management. Of these techniques, implantation of endobronchial one-way valves into targeted airways of isolated emphysematous lobes appears to be one of the most promising innovations. Results from randomized controlled trials of valve therapy for emphysema show consistent benefits in terms of lung function, exercise capacity, symptoms, and quality of life. This review aims to provide a comprehensive summary of the currently available scientific data, discussion of typical treatment related side effects, and recommendations for patient selection in clinical practice.
Collapse
Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Ludwig-Boltzmann-Institute for COPD and Respiratory Epidemiology, Otto-Wagner-Spital, Sanatoriumsstrasse 2, 1140 Wien, Austria
| |
Collapse
|
45
|
Welling JBA, Slebos DJ. Lung volume reduction with endobronchial coils for patients with emphysema. J Thorac Dis 2018; 10:S2797-S2805. [PMID: 30210833 DOI: 10.21037/jtd.2017.12.95] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The lung volume reduction coil treatment is a minimally invasive bronchoscopic treatment option for emphysema patients who suffer from severe hyperinflation. The treatment is aimed at a large group of patients where lung volume reduction surgery and bronchoscopic lung volume reduction using endobronchial valves are no option, or alternatively, can be offered as a bridge to lung transplantation. The nitinol coil exhibits a shape memory effect and is biologically inert. The lung volume reduction coil procedure is performed in two separate treatment sessions, targeting one lobe per session, with the contralateral lobe being treated 4 to 8 weeks after the first session. In one treatment session, around 10 to 14 coils, thereby treating an entire lobe, are being placed. Selecting optimally treated, symptomatic chronic obstructive pulmonary disease (COPD) patients with emphysema and severe hyperinflation, while avoiding significant airway disease such as asthma, chronic bronchitis and bronchiectasis, is key to achieve treatment success. Three randomized clinical trials investigating lung volume reduction coil treatment have been published until now, reporting the results of 452 treated patients up to 12 months after coil treatment. Lung volume reduction coil treatment results in significant improvement of pulmonary function outcomes and quality of life in patients with severe hyperinflation. The most common complications of lung volume reduction coil treatment are: COPD exacerbations, pneumonia, Coil Associated Opacity and an increased risk of pneumothorax. The purpose of this article is to describe the coil technique and review the available literature regarding effect, safety and future perspectives of lung volume reduction with coils for emphysema patients.
Collapse
Affiliation(s)
- Jorrit B A Welling
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
46
|
Bauer C, Eberlein M, Beichel RR. Pulmonary lobe separation in expiration chest CT scans based on subject-specific priors derived from inspiration scans. J Med Imaging (Bellingham) 2018; 5:014003. [PMID: 29487878 DOI: 10.1117/1.jmi.5.1.014003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 01/11/2018] [Indexed: 11/14/2022] Open
Abstract
Segmentation of pulmonary lobes in inspiration and expiration chest CT scan pairs is an important prerequisite for lobe-based quantitative disease assessment. Conventional methods process each CT scan independently, resulting typically in lower segmentation performance at expiration compared to inspiration. To address this issue, we present an approach, which utilizes CT scans at both respiratory states. It consists of two main parts: a base method that processes a single CT scan and an extended method that utilizes the segmentation result obtained on the inspiration scan as a subject-specific prior for segmentation of the expiration scan. We evaluated the methods on a diverse set of 40 CT scan pairs. In addition, we compare the performance of our method to a registration-based approach. On inspiration scans, the base method achieved an average distance error of 0.59, 0.64, and 0.91 mm for the left oblique, right oblique, and right horizontal fissures, respectively, when compared with expert-based reference tracings. On expiration scans, the base method's errors were 1.54, 3.24, and 3.34 mm, respectively. In comparison, utilizing proposed subject-specific priors for segmentation of expiration scans allowed decreasing average distance errors to 0.82, 0.79, and 1.04 mm, which represents a significant improvement ([Formula: see text]) compared with all other methods investigated.
Collapse
Affiliation(s)
- Christian Bauer
- University of Iowa, Department of Electrical and Computer Engineering, Iowa City, Iowa, United States
| | - Michael Eberlein
- University of Iowa, Carver College of Medicine, Iowa City, Iowa, United States
| | - Reinhard R Beichel
- University of Iowa, Department of Electrical and Computer Engineering, Iowa City, Iowa, United States.,University of Iowa, Carver College of Medicine, Iowa City, Iowa, United States
| |
Collapse
|
47
|
Criner G. More Options for Treating Severe Hyperinflation in Advanced Emphysema. Am J Respir Crit Care Med 2017; 196:1496-1498. [DOI: 10.1164/rccm.201709-1799ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gerard Criner
- Temple University School of MedicinePhiladelphia, Pennsylvania
| |
Collapse
|
48
|
Influence of fissure integrity on quantitative CT and emphysema distribution in emphysema-type COPD using a dedicated COPD software. Eur J Radiol 2017; 95:293-299. [PMID: 28987683 DOI: 10.1016/j.ejrad.2017.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/31/2017] [Accepted: 08/14/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Fissure integrity (FI) plays a key role in selecting patients for interventional emphysema therapy. We investigated its interference with automated lobar segmentation in quantitative computed tomography (CT) and emphysema distribution. METHODS CT was available for 50 patients with chronic obstructive pulmonary disease (COPD). Lobe segmentation was performed fully automated by software and corrected manually. FI was evaluated visually using a %-scale. The influence of FI on emphysema ratio (ER=percentage of lung volume with density values<-950 HU), mean lung density (MLD), emphysema and total volume of adjacent lobes was analyzed. Lobe-based results were compared with respect to FI. RESULTS Differences in ER in adjacent lobes for complete vs. incomplete fissures were 12.4% for the right horizontal, 0.2% and 3% for the right oblique and 4.4% for the left oblique fissure (all p>0.05). Results for emphysema comparing automated vs. manually corrected segmentation exceeded clinically acceptable values, but were not significantly affected by FI (p>0.05). The widest limits of agreement for ER and MLD were noted in the right middle lobe ([-14, 17.4%], [-22.4, 32.4 Hounsfield Units]). CONCLUSIONS Automated lobe segmentation and emphysema distribution are not significantly affected by FI. Manual correction of automated lobar segmentation is still recommended in severe emphysema.
Collapse
|
49
|
Zhang M, Wang T, Wang H. A segmental labeling technique for non-intubated thoracoscopic anatomical segmentectomy. J Thorac Dis 2017; 9:1648-1650. [PMID: 28740681 DOI: 10.21037/jtd.2017.05.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Herein we present a method of pulmonary segmental labeling for non-intubated thoracoscopic segmentectomy assisted with artificial pneumothorax, which is assumed to obtain a significant colored inflation-deflation line between target segment and adjacent normal tissues for precise resection.
Collapse
Affiliation(s)
- Miao Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou 221009, China
| | - Tao Wang
- Department of Medical Imaging, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou 221009, China
| | - Heng Wang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou 221009, China
| |
Collapse
|
50
|
van Agteren JEM, Hnin K, Grosser D, Carson KV, Smith BJ. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; 2:CD012158. [PMID: 28230230 PMCID: PMC6464526 DOI: 10.1002/14651858.cd012158.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD). OBJECTIVES To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique. SEARCH METHODS Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016. SELECTION CRITERIA We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available. DATA COLLECTION AND ANALYSIS Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software. MAIN RESULTS AeriSealOne RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV1) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate. Airway bypass stentsTreatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV1 (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high. Endobronchial coilsThree studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV1 (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high. Endobronchial valvesFive studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV1 (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high. Intrabronchial valvesIn the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV1 (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV1 and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high. Vapour ablationOne study of 69 participants found significant mean between-group differences in FEV1 (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate. AUTHORS' CONCLUSIONS Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.
Collapse
Affiliation(s)
| | - Khin Hnin
- Flinders UniversityAdelaideAustralia
| | | | | | - Brian J Smith
- The University of AdelaideSchool of MedicineAdelaideAustralia
| |
Collapse
|