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Torsani V, Cardoso PFG, Borges JB, Gomes S, Moriya HT, Cruz AFD, Santiago RRDS, Nagao CK, Fitipaldi MF, Beraldo MDA, Junior MHV, Mlček M, Pego-Fernandes PM, Amato MBP. First real-time imaging of bronchoscopic lung volume reduction by electrical impedance tomography. Respir Res 2024; 25:264. [PMID: 38965590 PMCID: PMC11225379 DOI: 10.1186/s12931-024-02877-0] [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: 03/27/2024] [Accepted: 06/11/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Bronchoscopic lung volume reduction (BLVR) with one-way endobronchial valves (EBV) has better outcomes when the target lobe has poor collateral ventilation, resulting in complete lobe atelectasis. High-inspired oxygen fraction (FIO2) promotes atelectasis through faster gas absorption after airway occlusion, but its application during BLVR with EBV has been poorly understood. We aimed to investigate the real-time effects of FIO2 on regional lung volumes and regional ventilation/perfusion by electrical impedance tomography (EIT) during BLVR with EBV. METHODS Six piglets were submitted to left lower lobe occlusion by a balloon-catheter and EBV valves with FIO2 0.5 and 1.0. Regional end-expiratory lung impedances (EELI) and regional ventilation/perfusion were monitored. Local pocket pressure measurements were obtained (balloon occlusion method). One animal underwent simultaneous acquisitions of computed tomography (CT) and EIT. Regions-of-interest (ROIs) were right and left hemithoraces. RESULTS Following balloon occlusion, a steep decrease in left ROI-EELI with FIO2 1.0 occurred, 3-fold greater than with 0.5 (p < 0.001). Higher FIO2 also enhanced the final volume reduction (ROI-EELI) achieved by each valve (p < 0.01). CT analysis confirmed the denser atelectasis and greater volume reduction achieved by higher FIO2 (1.0) during balloon occlusion or during valve placement. CT and pocket pressure data agreed well with EIT findings, indicating greater strain redistribution with higher FIO2. CONCLUSIONS EIT demonstrated in real-time a faster and more complete volume reduction in the occluded lung regions under high FIO2 (1.0), as compared to 0.5. Immediate changes in the ventilation and perfusion of ipsilateral non-target lung regions were also detected, providing better estimates of the full impact of each valve in place. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Vinicius Torsani
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Paulo Francisco Guerreiro Cardoso
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - João Batista Borges
- Institute of Physiology, First Faculty of Medicine, Charles University, Albertov 5, Prague, 128 00, Czech Republic.
| | - Susimeire Gomes
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Henrique Takachi Moriya
- Biomedical Engineering Laboratory, Escola Politecnica da Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Andrea Fonseca da Cruz
- Biomedical Engineering Laboratory, Escola Politecnica da Universidade de Sao Paulo, Sao Paulo, Brasil
| | | | - Cristopher Kengo Nagao
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Mariana Fernandes Fitipaldi
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Marcelo do Amaral Beraldo
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Marcus Henrique Victor Junior
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Mikuláš Mlček
- Institute of Physiology, First Faculty of Medicine, Charles University, Albertov 5, Prague, 128 00, Czech Republic
| | - Paulo Manuel Pego-Fernandes
- Division of Thoracic Surgery, Thoracic Surgery Research Laboratory (LIM 61), Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Marcelo Britto Passos Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
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Ravikumar N, Wagh A, Holden VK, Hogarth DK. Bronchoscopic lung volume reduction in emphysema: a review. Curr Opin Pulm Med 2024; 30:58-67. [PMID: 37916600 DOI: 10.1097/mcp.0000000000001031] [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: 11/03/2023]
Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) poses a substantial burden on the healthcare system and is currently considered the sixth leading cause of death in the United States. Emphysema, as evidenced by severe air-trapping in patients with COPD, leads to significant dyspnea and morbidity. Lung volume reduction via surgery or minimally invasive endobronchial interventions are currently available, which improve lung function and quality of life. RECENT FINDINGS Newer studies have noted a survival benefit in patients post bronchoscopic lung volume reduction vs. those subjected to standard of care. The presence of collateral ventilation is one of the most common impeding factors to placing endobronchial valves, and if placed, these patients might not achieve lobar atelectasis; however, there are newer modalities that are now available for patients with collateral ventilation which we have described. SUMMARY Combining standard of care treatment that includes smoking cessation, bronchodilators, preventive care including vaccinations, pulmonary rehabilitation, and endobronchial treatment using various interventions in decreasing hyperinflation improves quality of life and may improve survival and hence significantly reduce the burden of COPD on healthcare.
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Affiliation(s)
- Nakul Ravikumar
- Department of Medicine, Division of Pulmonary and Critical Care, UMass Chan Medical School-Baystate, Springfield, Massachusetts
| | - Ajay Wagh
- Department of Medicine, Division of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Van K Holden
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - D Kyle Hogarth
- Department of Medicine, Division of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
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Everaerts S, Vandervelde CM, Shah P, Slebos DJ, Ceulemans LJ. Surgical and bronchoscopic pulmonary function-improving procedures in lung emphysema. Eur Respir Rev 2023; 32:230004. [PMID: 38123230 PMCID: PMC10731473 DOI: 10.1183/16000617.0004-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/17/2023] [Indexed: 12/23/2023] Open
Abstract
COPD is a highly prevalent, chronic and irreversible obstructive airway disease without curative treatment. Standard therapeutic strategies, both non-pharmacological and pharmacological, have only limited effects on lung function parameters of patients with severe disease. Despite optimal pharmacological treatment, many patients with severe COPD still have a high burden of dyspnoea and a poor quality of life. If these patients have severe lung emphysema, with hyperinflation as the driver of symptoms and exercise intolerance, lung volume reduction may be an effective treatment with a significant impact on lung function, exercise capacity and quality of life. Currently, different lung volume reduction approaches, both surgical and bronchoscopic, have shown encouraging results and have been implemented in COPD treatment recommendations. Nevertheless, choosing the optimal lung volume reduction strategy for an individual patient remains challenging. Moreover, there is still room for improving durability of effect and safety in all available procedures. Ongoing and innovative research is essential to push this field forwards. This review provides an overview of results and limitations of the current lung volume reduction options for patients with severe lung emphysema and hyperinflation.
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Affiliation(s)
- Stephanie Everaerts
- Department of Pulmonary Diseases, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Christelle M. Vandervelde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Pallav Shah
- Department of Pulmonology, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
- Department of Pulmonology, Chelsea and Westminster Hospital, London, UK
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Both authors contributed equally
| | - Laurens J. Ceulemans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Both authors contributed equally
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The Tale of Two Pneumothoraces after Bronchoscopic Lung Volume Reduction. Ann Am Thorac Soc 2022; 19:1596-1601. [PMID: 36048120 DOI: 10.1513/annalsats.202201-006cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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5
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Taton O, Heinen V, Bondue B, Slebos DJ, Shah PL, Carron K, Moens O, Leduc D. Long-Term Follow-Up of Intralobar Bullae After Endobronchial Valve Treatment for Emphysema. Int J Chron Obstruct Pulmon Dis 2022; 17:1735-1742. [PMID: 35941900 PMCID: PMC9356607 DOI: 10.2147/copd.s363490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022] Open
Abstract
Endoscopic lung volume reduction using unidirectional endobronchial valves is a new technique in the treatment of patients with severe emphysema. However, the movements of the thoracic structures after endobronchial valves insertion are still unpredictable We report the unusual outcome of six patients after valves insertion in the left upper lobe. They all developed a complete atelectasis of the target lobe, a pneumothorax and sequential genuine bullae in the treated left lung of unknown etiology. The chest CT scan prior to the valves insertion was unremarkable. Three patients developed an air–liquid level in the bullae the day before a bacterial infection of their left lower lobe. The three other patients had an uneventful spontaneous resolution of their bullae at long-term follow-up. Therefore, a conservative attitude should be followed in this particular setting.
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Affiliation(s)
- Olivier Taton
- Department of Pneumology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Correspondence: Olivier Taton, Department of Pneumology, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, Brussels, 1070, Belgium, Tel +3225553943, Email
| | - Vincent Heinen
- Department of Pneumology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Benjamin Bondue
- Department of Pneumology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- The Netherlands and GRIAC Research Institute, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Pallav L Shah
- Royal Brompton Hospital, London, UK
- National Heart & Lung Institute, Imperial College, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Kris Carron
- Department of Pneumology, AZ Delta, Menen, Belgium
| | - Olivia Moens
- Department of Radiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Dimitri Leduc
- Department of Pneumology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Patel M, Chowdhury J, Zhao H, Lu X, Roth S, Giovacchini CX, Wahidi MM, Criner G. Meta-analysis and Systematic Review of Bronchoscopic Lung Volume Reduction Through Endobronchial Valves in Severe Emphysema. J Bronchology Interv Pulmonol 2022; 29:224-237. [PMID: 35698281 PMCID: PMC9233031 DOI: 10.1097/lbr.0000000000000872] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pharmacologic therapeutics for advanced emphysema have limited benefit. Bronchoscopic lung volume reduction with endobronchial valves (EBVs) have reported improvements in lung function, breathlessness, and quality of life through randomized clinical trials, with less morbidity as comparted to Surgical Lung volume Reduction. We here present a Meta-analysis and systematic review of bronchoscopic lung volume reduction in advanced chronic obstructive lung disease patients. METHODS PubMed (NLM), Embase (Elsevier), and Web of Science (Clarivate Analytics) search was conducted using a combination of keywords and subject headings. The search was confined to the last 15 years and was completed on October 23, 2020. Only placebo-controlled randomized control trials of emphysema patients with EBV were included. Quality assessment was done by 2 independent reviewers. RESULTS Nine studies were included for the meta-analysis with a total number of 1383 patients of whom 888 received EBV and 495 standard of care (SOC) medications. Our Metanalysis show statistically significant improvement in forced expiratory volume in first second, percentage forced expiratory volume in first second, St. George's respiratory questionnaire, and 6-minute walk distance in EBV group compared with SOC. Residual volume had statistically significant reduction after EBV placement compared with SOC. These differences continued to be present during short-term (<=6 mo) and long-term follow-up (>=6 mo). These improvements were even higher when the EBV patients'. Collateral ventilation was negative/fissure was intact (CV-/FI >90%). The rate of hemoptysis and pneumothorax was higher in the EBV group compared with SOC, however, did not lead to increased fatal outcomes. CONCLUSION In conclusion, EBV has favorable effects on patients' outcomes in patients who have heterogeneous emphysema particularly with no collateral ventilation.
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Affiliation(s)
- Maulin Patel
- The University of Texas Health Science Center at Houston, Department of Medicine, Division of Pulmonary and Critical Care Medicine
| | - Junad Chowdhury
- Inova Fairfax Medical Center, Medical Critical Care Services
| | - Huaqing Zhao
- Lewis Katz School of Medicine at Temple University, Department of Biomedical Education and Data Science
| | - Xiaoning Lu
- Lewis Katz School of Medicine at Temple University, Department of Biomedical Education and Data Science
| | - Stephanie Roth
- Temple University, Department of Biomedical & Research Services Librarian
| | | | - Momen M. Wahidi
- Duke University, Division of Pulmonary, Allergy and Critical Care Medicine
| | - Gerard Criner
- Temple University Hospital, Department of Thoracic Medicine, and Surgery
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7
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Low SW, Swanson KL, Lee JZ, Tan MC, Cartin-Ceba R, Sakata KK, Maldonado F. Complications of Endobronchial Valve Placement for Bronchoscopic Lung Volume Reduction: Insights From the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE). J Bronchology Interv Pulmonol 2022; 29:206-212. [PMID: 35698284 DOI: 10.1097/lbr.0000000000000859] [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: 12/22/2021] [Accepted: 03/26/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with advanced emphysema experience breathlessness due to impaired respiratory mechanics and diaphragm dysfunction. Bronchoscopic lung volume reduction (BLVR) is a minimally invasive bronchoscopic procedure done to reduce hyperinflation and air trapping, promoting atelectasis in the targeted lobe and allowing improved respiratory mechanics. Real-world data on safety and complications outside of clinical trials of BLVR are limited. METHODS We queried the US Food and Drug Administrations (FDA) Manufacturers and User Device Experience database from May 2019 to June 2020 for reports involving BLVR with endobronchial valve (EBV) placement. Events were reviewed for data analysis. RESULTS We identified 124 cases of complications during BLVR with EBV implantation. The most-reported complication was pneumothorax (110/124, 89%), all of which required chest tube placement. A total of 54 of these cases (54/110, 49%) were complicated by persistent air leak requiring additional interventions. Repeat bronchoscopy was needed to remove the valves in 28 patients, 12 were discharged with a Heimlich valve, and 10 had an additional pleural catheter placed. The other complications of BLVR with EBV placement included respiratory failure (6/124, 5%), pneumonia (4/124, 3%), hemoptysis (2/124, 1.6%), valve migration (1/124, 1%), and pleural effusion (1/124, 1%). A total of 14 deaths were reported during that year. CONCLUSION Pneumothorax is the most-reported complication for BLVR with EBV placement, and in 65% of cases, pneumothorax is managed without removing valves. Importantly, 14 deaths were reported during that timeframe. Further studies are needed to estimate the true magnitude of the complications associated with BLVR.
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Affiliation(s)
- See-Wei Low
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Justin Z Lee
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ
| | - Min-Choon Tan
- Medical School, Chang Gung University, Taoyuan City, Taiwan
| | | | | | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Bezel P, Wani J, Wiederkehr G, Bodmer C, Steinack C, Franzen DP. Early Spirometry Following Bronchoscopic Lung Volume Reduction with Endobronchial Valves. J Clin Med 2022; 11:440. [PMID: 35054134 PMCID: PMC8780477 DOI: 10.3390/jcm11020440] [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: 11/14/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023] Open
Abstract
Bronchoscopic lung volume reduction (BLVR) by endobronchial valve (EBV) implantation has been shown to improve dyspnea, pulmonary function, exercise capacity, and quality of life in highly selected patients with severe emphysema and hyperinflation. The most frequent adverse event is a pneumothorax (PTX), occurring in approximately one-fifth of the cases due to intrathoracic volume shifts. The majority of these incidents are observed within 48 h post-procedure. However, the delayed occurrence of PTX after hospital discharge is a matter of concern. There is currently no approved concept for its prevention. Particularly, it is unknown whether and when respiratory manoeuvers such as spirometry post EBV treatment are feasible and safe. As per standard operating procedure at the University Hospital Zurich, early spirometry is scheduled after BLVR and prior to the discharge of the patient in order to monitor treatment success. The aim of our retrospective study was to investigate the feasibility and safety of early spirometry. In addition, we hypothesized that early spirometry could be useful to identify patients at risk for late PTX, which may occur after hospital discharge. All patients who underwent BLVR using EBVs between January 2018 and January 2020 at our hospital were enrolled in this study. After excluding 16 patients diagnosed post-procedure with PTX and four patients for other reasons, early spirometry was performed in 61 cases. There was neither a clinically relevant PTX during or after early spirometry nor a late PTX following hospital discharge. In conclusion, we found early spirometry, conducted not sooner than three days following EBV treatment, to be feasible and safe. Furthermore, early spirometry seems to be a useful predictor for successful BLVR, and it may help to decide whether a patient can be discharged. Given the small sample size and the retrospective design of our study, a prospective study that includes routine chest imaging after early spirometry to definitively exclude PTX is needed to recommend early spirometry as part of the standard protocol following EBV treatment.
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Affiliation(s)
- Pascal Bezel
- Department of Pulmonology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (P.B.); (G.W.); (C.B.); (C.S.); (D.P.F.)
| | - Jasmin Wani
- Department of Pulmonology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (P.B.); (G.W.); (C.B.); (C.S.); (D.P.F.)
| | - Gilles Wiederkehr
- Department of Pulmonology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (P.B.); (G.W.); (C.B.); (C.S.); (D.P.F.)
- Department of Pulmonology, Hirslanden Clinic St. Anna, St. Anna-Strasse 32, 6006 Luzern, Switzerland
| | - Christa Bodmer
- Department of Pulmonology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (P.B.); (G.W.); (C.B.); (C.S.); (D.P.F.)
| | - Carolin Steinack
- Department of Pulmonology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (P.B.); (G.W.); (C.B.); (C.S.); (D.P.F.)
| | - Daniel P. Franzen
- Department of Pulmonology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland; (P.B.); (G.W.); (C.B.); (C.S.); (D.P.F.)
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9
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Garner JL, Shah PL. Endobronchial treatment of severe asthma and severe emphysema with hyperinflation. Curr Opin Pulm Med 2022; 28:52-61. [PMID: 34720098 DOI: 10.1097/mcp.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The field of interventional pulmonology has ushered in a wave of innovations for individuals with obstructive airways disease in whom established medical therapies have failed. Leading the charge are bronchial thermoplasty for severe refractory asthma and uni-directional valves for severe emphysema with hyperinflation: both have received regulatory approvals in the United Kingdom and United States. With the commissioning of these novel treatments comes new challenges relating to implementation, positioning within therapeutic algorithms, honing of patient selection, and establishing long-term safety and benefits beyond 5 years. RECENT FINDINGS This review summarises the evidence for their safety and efficacy, predictors of therapeutic response, mechanism(s) of action and emerging data supporting the durability of outcomes out to at least ten years. SUMMARY It is anticipated the experience of treating increasing numbers of patients, the adoption of international registries, and ongoing research evaluations will serve to optimise these therapies for future generations of patients.
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Affiliation(s)
- Justin L Garner
- Royal Brompton Hospital
- Chelsea & Westminster Hospital
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Pallav L Shah
- Royal Brompton Hospital
- Chelsea & Westminster Hospital
- National Heart and Lung Institute, Imperial College London, London, UK
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Egenod T, Tricard J, Fumat R, Simonneau Y, Favard F, Guillot MS, Collot S, Dupuis M, Melloni B, Vergnenegre A, Guibert N, Dusselier M. Two-Stage Bronchoscopic Endobronchial Valve Treatment Can Lead to Progressive Lung Volume Reduction and May Decrease Pneumothorax Risk. Int J Chron Obstruct Pulmon Dis 2021; 16:1957-1965. [PMID: 34234426 PMCID: PMC8254404 DOI: 10.2147/copd.s307829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Since successful development of endobronchial valves (EBV) as treatment for severe emphysema, its main complication, pneumothorax, remains an important concern. Objective We hypothesized that a two-step EBV implantation, during two distinct iterative procedures could lead to a more progressive target lobe volume reduction (TLVR) and thus ipsilateral lobe re-expansion, resulting in a significant decrease in the pneumothorax rate. Methods This retrospective bi-center study carried out by Limoges and Toulouse University Hospitals included patients following the inclusion criteria established by the BLVR expert panel. All patients were treated by two distinct procedures: first, EBVs were placed in all but the most proximal segment or sub-segment. The remaining segment was treated subsequently. All patients had a complete evaluation before treatment, and 3 months after the second procedure. Results Out of 58 patients included, only 4 pneumothoraxes (7%) occurred during the study. The other complications were pneumonia and severe COPD exacerbation (8.6% and 13.7% of patients, respectively). Significant improvement was found for FEV1 (+19.6 ± 25%), RV (-468 ± 960mL), 6MWD (30 ± 85m), BODE Index (-1.4 ± 1.8 point) and TLVR (50.6 ± 35.1%). Significant TLVR (MCID) was obtained in 74.1% of patients (43/58). Conclusion This new approach using EBV could reduce the incidence of pneumothorax without increasing other complication rates. Clinical and physiological outcomes are similar to those reported in studies using the conventional single-step treatment.
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Affiliation(s)
- Thomas Egenod
- Pulmonology Department, Dupuytren University Hospital, Limoges, France
| | - Jeremy Tricard
- Thoracic Surgery Department, Dupuytren University Hospital, Limoges, France
| | - Romane Fumat
- Pulmonology Department, Toulouse University Hospital, Toulouse, France
| | - Yannick Simonneau
- Pulmonology Department, Dupuytren University Hospital, Limoges, France
| | - Florent Favard
- Physiology Department, Dupuytren University Hospital, Limoges, France
| | | | - Samia Collot
- Radiology Department, Toulouse University Hospital, Toulouse, France
| | - Marion Dupuis
- Pulmonology Department, Toulouse University Hospital, Toulouse, France
| | - Boris Melloni
- Pulmonology Department, Dupuytren University Hospital, Limoges, France
| | - Alain Vergnenegre
- Pulmonology Department, Dupuytren University Hospital, Limoges, France
| | - Nicolas Guibert
- Pulmonology Department, Toulouse University Hospital, Toulouse, France
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van Dijk M, Sue R, Criner GJ, Gompelmann D, Herth FJ, Hogarth DK, Klooster K, Kocks JW, de Oliveira HG, Shah PL, Valipour A, Slebos DJ. Expert Statement: Pneumothorax Associated with One-Way Valve Therapy for Emphysema: 2020 Update. Respiration 2021; 100:969-978. [PMID: 34062550 PMCID: PMC8619763 DOI: 10.1159/000516326] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/14/2021] [Indexed: 11/19/2022] Open
Abstract
For selected patients with advanced emphysema, bronchoscopic lung volume reduction with one-way valves can lead to clinically relevant improvements of airflow obstruction, hyperinflation, exercise capacity, and quality of life. The most common complication of this procedure is pneumothorax with a prevalence of up to ±34% of the treated patients. Patients who develop a pneumothorax also experience meaningful clinical benefits once the pneumothorax is resolved. Timely resolution of a post-valve treatment pneumothorax requires skilled and adequate pneumothorax management. This expert panel statement is an updated recommendation of the 2014 statement developed to help guide pneumothorax management after valve placement. Additionally, mechanisms for pneumothorax development, risk assessment, prevention of pneumothorax, and outcomes after pneumothorax are addressed. This recommendation is based on a combination of the current scientific literature and expert opinion, which was obtained through a modified Delphi method.
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Affiliation(s)
- Marlies van Dijk
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rick Sue
- Advanced Lung Institute, Banner University Phoenix, Phoenix, Arizona, USA
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Daniela Gompelmann
- Department of Internal Medicine II, Division of Pulmonology, Medical University of Vienna, Vienna, Austria
| | - Felix J.F. Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center Heidelberg (TLRCH), University of Heidelberg, Heidelberg, Germany
| | - D. Kyle Hogarth
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois, USA
| | - Karin Klooster
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Janwillem W.H. Kocks
- GRIAC Research Institute, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- General practitioners Research Institute, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Hugo G. de Oliveira
- Serviço de Pneumologia do Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Pallav L. Shah
- Royal Brompton Hospital, London, United Kingdom
- Chelsea & Westminster Hospital, 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
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- GRIAC Research Institute, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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12
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Abstract
AbstractSevere emphysema with hyperinflation presents a therapeutic challenge. Inhaled medication has limited efficacy in individuals with mechanical constraints to the respiratory pump and impaired gas exchange. Lung volume reduction surgery (LVRS) reestablishes some semblance of normal physiology, resecting grossly expanded severely diseased tissue to restore the function of compromised relatively healthy lung, and has been shown to significantly improve exercise capacity, quality of life, and survival, especially in individuals with upper-lobe predominant emphysema and low-baseline exercise capacity, albeit with higher early morbidity and mortality. Bronchoscopic lung volume reduction achieved by deflating nonfunctioning parts of the lung is promoted as a less invasive and safer approach. Endobronchial valve implantation has demonstrated comparable outcomes to LVRS in selected individuals and has recently received approvals by the National Institute of Clinical Excellence in the United Kingdom and the Food and Drug Administration in the United States of America. Endobronchial coils are proving a viable treatment option in severe hyperinflation in the presence of collateral ventilation in selected cases of homogeneous disease. Modalities including vapor and sealant are delivered using a segmental strategy preserving healthier tissue within the same target lobe-efficacy and safety-data are, however, limited. This article will review the data supporting these novel technologies.
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Affiliation(s)
- Justin L. Garner
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- Department of Respiratory Medicine, Chelsea and Westminster Hospital, London, United Kingdom
- Airways Division, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Pallav L. Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- Department of Respiratory Medicine, Chelsea and Westminster Hospital, London, United Kingdom
- Airways Division, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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13
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Chaddha U, Lin J, Hogarth DK. Bronchoscopic Lung Volume Reduction Using Endobronchial Valves: How to Do It. CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-00236-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hartman JE, Vanfleteren LEGW, van Rikxoort EM, Klooster K, Slebos DJ. Endobronchial valves for severe emphysema. Eur Respir Rev 2019; 28:28/152/180121. [PMID: 30996040 DOI: 10.1183/16000617.0121-2018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/08/2019] [Indexed: 11/05/2022] Open
Abstract
The results of the randomised controlled trials investigating the bronchoscopic lung volume reduction treatment using endobronchial valves (EBV) are promising, and have led to their inclusion in treatment guidelines, US Food and Drug Administration approval and inclusion in routine care in an increasing number of countries. The one-way valve treatment has advanced and is now a regular treatment option. However, this new phase will lead to new challenges in terms of implementation. We believe that key issues in future research concern advanced patient selection, improved methods for target lobe selection, increased knowledge on the predictive risk of a pneumothorax, positioning of pulmonary rehabilitation in conjunction with the EBV treatment, the positioning of lung volume reduction surgery versus EBV treatment, and the long-term efficacy, adverse events, impact on exacerbations and hospitalisations, costs and survival. Hopefully, the increasing number of patients treated, the setup of (inter)national registries and future research efforts will further optimise all aspects of this treatment.
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Affiliation(s)
- Jorine E Hartman
- Dept 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
| | - Lowie E G W Vanfleteren
- COPD Centre, Sahlgrenska University Hospital and Institute of Medicine, Gothenburg University, Gothenburg, Sweden.,Dept of Development and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Eva M van Rikxoort
- Depat of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karin Klooster
- Dept 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
- Dept 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
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15
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Herth F, Slebos DJ, Criner G, Valipour A, Sciurba F, Shah P. Endoscopic Lung Volume Reduction: An Expert Panel Recommendation – Update 2019. Respiration 2019; 97:548-557. [DOI: 10.1159/000496122] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
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16
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Li S, Wang G, Wang C, Gao X, Jin F, Yang H, Han B, Zhou R, Chen C, Chen L, Bai C, Shen H, Herth FJF, Zhong N. The REACH Trial: A Randomized Controlled Trial Assessing the Safety and Effectiveness of the Spiration® Valve System in the Treatment of Severe Emphysema. Respiration 2018; 97:416-427. [PMID: 30554211 PMCID: PMC6549456 DOI: 10.1159/000494327] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/05/2018] [Accepted: 10/05/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) has become a leading cause of morbidity and mortality in China, with tobacco smoke, air pollution, and occupational biohazards being the major risk factors. OBJECTIVES The REACH trial is a multicenter, prospective, randomized controlled trial undertaken in China to assess the safety and effectiveness of the Spiration® Valve System (SVS) compared to standard medical care in COPD patients with severe emphysema. METHODS Patients with severe airflow obstruction, hyperinflation, and severe dyspnea with interlobar fissure integrity were evaluated for enrollment. A total of 107 subjects were randomized in a 2: 1 allocation ratio to either the treatment group (SVS valves and medical management) or the control group (medical management alone). RESULTS The 3-month primary endpoint showed statistically significant improvement in forced expiratory volume in 1 s in the treatment group compared to the control group (0.104 ± 0.18 vs. 0.003 ± 0.15 L, p = 0.001), with the difference being durable through 6 months. Statistically significant target lobe volume reduction was achieved at 3 months (mean change 684.4 ± 686.7 mL) and through 6 months (757.0 ± 665.3 mL). Exercise function and quality of life measures improved in the treatment group, but showed a deterioration in the control group. The serious adverse event (SAE) rate was 33% in the treatment group and 24.2% in the control group. The predominance of SAEs were acute exacerbations of COPD in both groups. There was 1 death in the control group and no deaths in the treatment group. CONCLUSION The SVS represents a novel approach for the treatment of severe emphysema with a clinically acceptable risk-benefit profile.
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Affiliation(s)
- Shiyue Li
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guangfa Wang
- Peking University First Hospital, Beijing, China
| | | | - Xinglin Gao
- Guangdong General Hospital, Guangzhou, China
| | - Faguang Jin
- Tangdu Hospital, The Second Teaching Hospital of The Fourth Military Medical University, Xi'an, China
| | - Huaping Yang
- Xiangya Hospital of Central South University, Changsha, China
| | - Baohui Han
- Shanghai Chest Hospital affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Rui Zhou
- The Second Xiangya Hospital of Central South University, Changsha, China
| | - Chengshui Chen
- The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, China
| | - Liangan Chen
- The General Hospital of the Chinese People's Liberation Army (301), Beijing, China
| | - Chunxue Bai
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huahao Shen
- The Second Affiliated Hospital, ZheJiang University School of Medicine, Hangzhou, China
| | - Felix J F Herth
- Thoraxklinik and Translational Lung Research Center, University of Heidelberg, Heidelberg, Germany
| | - Nanshan Zhong
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,
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Van Der Molen MC, Klooster K, Hartman JE, Slebos DJ. Lung volume reduction with endobronchial valves in patients with emphysema. Expert Rev Med Devices 2018; 15:847-857. [DOI: 10.1080/17434440.2018.1538780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Marieke C. Van Der Molen
- Department of Pulmonary Diseases, 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
| | - Jorine E. Hartman
- Department of Pulmonary Diseases, 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
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18
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Franzen D, Straub G, Freitag L. Complications after bronchoscopic lung volume reduction. J Thorac Dis 2018; 10:S2811-S2815. [PMID: 30210835 DOI: 10.21037/jtd.2018.06.66] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bronchoscopic lung volume reduction (BLVR) has been demonstrated an efficient and safe alternative to surgery in multiple randomized trials and retrospective cohort studies. However, despite its minimal invasiveness BLVR is not without potential harm. Complications and their incidents differ significantly between the individual BLVR techniques (valves, coils, vapour or sealant) which are bearing varying device- and intervention-dependent risks. Interventional pulmonologists must be aware of potential side effects and their management to anticipate and ensure highest quality treatment of the severely ill emphysema patient.
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Affiliation(s)
- Daniel Franzen
- Interventional Lung Center, Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Gilles Straub
- Interventional Lung Center, Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Lutz Freitag
- Clinic St. Anna, Hirslanden Group, Lucerne, Switzerland
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Abstract
INTRODUCTION Surgical treatment of severe pulmonary emphysema has so far been associated with relatively high perioperative morbidity and mortality. In the past two decades, novel approaches to lung volume reduction and alternative minimally invasive endoscopic techniques have been developed. This review presents the different techniques (blocking and nonblocking) available until present as well as the appropriate patient selection and possible complications. Areas covered: All available randomized controlled trials (RCTs) have been evaluated. The only blocking technique is the reversible valve implantation. It results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation and its efficacy has been confirmed in various RCTs. Non-blocking techniques that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation, and the polymeric lung volume reduction both inducing inflammatory reaction. These methods have been up to date examined in a few RCTs only. Finally, the targeted lung denervation aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. Expert commentary: Future studies must address the predictors of clinical outcome as well as the reduction of complications to improve both outcome and safety.
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Affiliation(s)
- Konstantina Kontogianni
- a Department of Pneumology and Critical Care Medicine , Thoraxklinik at University of Heidelberg , Heidelberg , Germany.,b Center for Lung Research , Heidelberg , Germany
| | - Ralf Eberhardt
- a Department of Pneumology and Critical Care Medicine , Thoraxklinik at University of Heidelberg , Heidelberg , Germany.,b Center for Lung Research , Heidelberg , Germany
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Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) and emphysema are widespread diseases associated with progressive dyspnea because of airflow limitation and hyperinflation. Fundamental therapeutic strategies consist of pulmonary rehabilitation, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation, and surgical therapeutic approaches. RECENT FINDINGS In the last 14 years, endoscopic therapeutic modalities emerged as a substantial part of severe COPD and emphysema treatment. Techniques of the endoscopic lung volume reduction (ELVR) aim at reduction of hyperinflation. Thereby, the reversible valve implantation of which the efficacy was confirmed in various randomized controlled trials (RCT) results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation. Nonblocking ELVR methods that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation and polymeric lung volume reduction both inducing inflammatory reaction. The nonblocking methods have been examined in only a few RCTs. The targeted lung denervation as a novel bronchoscopic therapy for COPD patients aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves. SUMMARY The review summarizes the various endoscopic treatment approaches for managment of COPD and emphysema, their mechanism of action, their complications and the current available results of the most important RCTs.
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Gompelmann D, Benjamin N, Kontogianni K, Herth FJF, Heussel CP, Hoffmann H, Eberhardt R. Clinical and radiological outcome following pneumothorax after endoscopic lung volume reduction with valves. Int J Chron Obstruct Pulmon Dis 2016; 11:3093-3099. [PMID: 27994448 PMCID: PMC5153254 DOI: 10.2147/copd.s117890] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Valve implantation has evolved as a therapy for patients with advanced emphysema. Although it is a minimally invasive treatment, it is associated with complications, the most common being pneumothorax. Pneumothorax occurs due to the rapid target lobe volume reduction and may be a predictor of clinical benefit despite this complication. OBJECTIVE The objective of this study was to conduct an exploratory data analysis of patients who developed a pneumothorax following endoscopic valve therapy for emphysema. MATERIALS AND METHODS This study performed a retrospective evaluation of pneumothorax management and the impact of pneumothorax on clinical outcomes in 70 patients following valve therapy in 381 consecutive patients. RESULTS Pneumothorax rate following valve therapy was 18%. Pneumothorax management consisted of chest tube insertion, valve removal, and surgical intervention in 87% (61/70), 44% (31/70), and 19% (13/70) of the patients, respectively. Despite pneumothorax, patients experienced modest but significant improvements in lung function parameters (forced expiratory volume in 1 second: 55±148 mL, residual volume: -390±964 mL, total lung capacity: -348±876; all P<0.05). Persistent lobar atelectasis 3 months after recovering from pneumothorax, which was associated with relevant clinical improvement, was observed in only 21% (15/70) of the patients. CONCLUSION Pneumothorax is a frequent severe complication following valve therapy that requires further intervention. Nevertheless, the pneumothorax does not impair the clinical status in the majority of patients. Patients with lobar atelectasis benefit after recovering from pneumothorax in terms of lung function parameters.
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Affiliation(s)
- D Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- German Center for Lung Research
| | - N Benjamin
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
| | - K Kontogianni
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
| | - FJF Herth
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- German Center for Lung Research
| | - CP Heussel
- German Center for Lung Research
- Diagnostic and Interventional Radiology, Thoraxklinik at University of Heidelberg
- Diagnostic and Interventional Radiology, University Hospital Heidelberg
| | - H Hoffmann
- German Center for Lung Research
- Thoracic Surgery, Thoraxklinik at University of Heidelberg, Heidelberg, Germany
| | - R Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg
- German Center for Lung Research
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