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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.
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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
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Fiorelli A, Santoriello C, De Felice A, Ferrigno F, Carlucci A, De Ruberto E, Mastromarino R, Occhiati L, Messina G, Santoriello E, Vicidomini G, Polverino M, Santini M. Bronchoscopic lung volume reduction with endobronchial valves for heterogeneous emphysema: long-term results. J Vis Surg 2017; 3:170. [PMID: 29302446 DOI: 10.21037/jovs.2017.10.04] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 10/04/2017] [Indexed: 11/06/2022]
Abstract
Background Bronchoscopic lung volume reduction (BLVR) with implant of one-way endobronchial valves (EBV) is a feasible treatment for management of heterogeneous emphysema (HE) with clinical benefits in the early follow-up. We aimed to evaluate the long-terms results and safety of this procedure in a consecutive series of patients with HE. Methods It was a retrospective single center study including all consecutive patients with HE undergoing EBV treatment and completing at least 5 years of long-term follow-up. Patients were splitted into Collapse and No-Collapse Group if a lobar collapse or not were obtained after valves implant. The difference of functional data and quality of life (QoL) before and after the procedure (measured at 3, 6, 9, 12 months from the valve implantation, and then annually up to a maximum of 5 years) were statistically evaluated to show the long-term benefits of the procedure (primary endpoint). Yet, morbidity, mortality and survival rates were also recorded to show the safe of the treatment (secondary endpoint). Results Thirty-three patients were included in the study. Of these, three patients underwent a bilateral treatment. Collapse Group patients (n=27) presented a significant improvement in FEV1% (+17%; P=0.001); in FVC% (+18%; P=0.002); in RV% (-39%; P=0.003); in 6MWT (P=0.001) and in SGRQ (P=0.001) in the early 12 months of follow-up and no significant decline was seen later. Conversely, No-Collapse Group (n=9) did not have significant benefits. No major complications and death related to the procedure were observed. The 1-,2-,3-,4- and 5-year survival rates were 100%, 90%, 78%, 71% and 71%, respectively. Collapse Group had a better survival than No-Collapse Group (45 vs. 24 months; P=0.001). Conclusions Our study confirmed that the lobar collapse is the key success of EBV treatment and the early improvements of respiratory function could be maintained up to five years from the valves implant.
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Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Carlo Santoriello
- Department of Pneumology and Endoscopic Unit, Ospedale Scarlato, Scafati, Italy
| | | | - Francesco Ferrigno
- Department of Pneumology, Villa Stabia Hospital, Castellamare di Stabia, Italy
| | - Annalisa Carlucci
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Emanuele De Ruberto
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Rossella Mastromarino
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Lisa Occhiati
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Gaetana Messina
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Elena Santoriello
- Department of Pneumology and Endoscopic Unit, Ospedale Scarlato, Scafati, Italy
| | - Giovanni Vicidomini
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Polverino
- Department of Pneumology and Endoscopic Unit, Ospedale Scarlato, Scafati, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
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Wang Y, Lai TW, Xu F, Zhou JS, Li ZY, Xu XC, Chen HP, Ying SM, Li W, Shen HH, Chen ZH. Efficacy and safety of bronchoscopic lung volume reduction therapy in patients with severe emphysema: a meta-analysis of randomized controlled trials. Oncotarget 2017; 8:78031-78043. [PMID: 29100445 PMCID: PMC5652834 DOI: 10.18632/oncotarget.19352] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 06/29/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Increasing randomized controlled trials (RCTs) indicate that bronchoscopic lung volume reduction (BLVR) is effective for severe emphysema. In this meta-analysis, we investigated the efficacy and safety of BLVR in patients with severe emphysema. METHODS PubMed, Embase and the Cochrane Library and reference lists of related articles were searched, and RCTs that evaluated BLVR therapy VS conventional therapy were included. Meta-analysis was performed only when included RCTs ≥ 2 trials. RESULTS In total, 3 RCTs for endobronchial coils, 6 RCTs for endobronchial valves (EBV) and 2 RCTs for intrabronchial valves (IBV) were included. Compared with conventional therapy, endobronchial coils showed better response in minimal clinically important difference (MCID) for forced expiratory volume in 1s (FEV1) (RR = 2.37, 95% CI = 1.61 - 3.48, p < 0.0001), for 6-min walk test (6MWT) (RR = 2.05, 95% CI = 1.18 - 3.53, p = 0.01), and for St. George's Respiratory Questionnaire (SGRQ) (RR = 2.32, 95% CI = 1.77 - 3.03, p < 0.00001). EBV therapy also reached clinically significant improvement in FEV1 (RR = 2.96, 95% CI = 1.49 - 5.87, p = 0.002), in 6MWT (RR = 2.90, 95% CI = 1.24 - 6.79, p = 0.01), and in SGRQ (RR = 1.53, 95% CI = 1.22 - 1.92, p = 0.0002). Both coils and EBV treatment achieved statistically significant absolute change in FEV1, 6MWT, and SGRQ from baseline, also accompanied by serious adverse effects. Furthermore, subgroup analysis showed there was no difference between homogeneous and heterogeneous emphysema in coils group. However, IBV group failed to show superior to conventional group. CONCLUSIONS Current meta-analysis indicates that coils or EBV treatment could significantly improve pulmonary function, exercise capacity, and quality of life compared with conventional therapy. Coils treatment could be applied in homogeneous emphysema, but further trials are needed.
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Affiliation(s)
- Yong Wang
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tian-Wen Lai
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Xu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jie-Sen Zhou
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zhou-Yang Li
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xu-Chen Xu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hai-Pin Chen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Song-Min Ying
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Li
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hua-Hao Shen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- State Key Lab of Respiratory Disease, Guangzhou, China
| | - Zhi-Hua Chen
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Leong P, Le Roux PY, Callahan J, Siva S, Hofman MS, Steinfort DP. Reduced ventilation-perfusion (V/Q) mismatch following endobronchial valve insertion demonstrated by Gallium-68 V/Q photon emission tomography/computed tomography. Respirol Case Rep 2017; 5:e00253. [PMID: 28808575 PMCID: PMC5550810 DOI: 10.1002/rcr2.253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/30/2017] [Accepted: 06/24/2017] [Indexed: 12/20/2022] Open
Abstract
Endobronchial valves (EBVs) are increasingly deployed in the management of severe emphysema. Initial studies focussed on volume reduction as the mechanism, with subsequent improvement in forced expiratory volume in 1 s (FEV1). More recent studies have emphasized importance of perfusion on predicting outcomes, though findings have been inconsistent. Gallium‐68 ventilation–perfusion (V/Q) photon emission tomography (PET)/computed tomography (CT) is a novel imaging modality with advantages in spatial resolution, quantitation, and speed over conventional V/Q scintigraphy. We report a pilot case in which V/Q‐PET/CT demonstrated discordant findings compared with quantitative CT analysis, and directed left lower lobe EBV placement. The patient experienced a significant improvement in 6‐min walk distance (6MWD) without change in spirometry. Post‐EBV V/Q‐PET/CT demonstrated a marked decrease in unmatched (detrimental) V/Q areas and improvement in overall V/Q matching on post‐EBV V/Q‐PET/CT. These preliminary novel findings suggest that EBVs improve V/Q matching and may explain the observed functional improvements.
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Affiliation(s)
- Paul Leong
- Department of Respiratory Medicine Melbourne Health Melbourne Australia
| | - Pierre-Yves Le Roux
- Division of Radiation Oncology and Cancer Imaging Peter MacCallum Cancer Centre Melbourne Australia.,Department of Nuclear Medicine Brest University Hospital Brest France
| | - Jason Callahan
- Division of Radiation Oncology and Cancer Imaging Peter MacCallum Cancer Centre Melbourne Australia.,Department of Medicine, University of Melbourne Melbourne Australia
| | - Shankar Siva
- Division of Radiation Oncology and Cancer Imaging Peter MacCallum Cancer Centre Melbourne Australia.,Department of Medicine, University of Melbourne Melbourne Australia
| | - Michael S Hofman
- Department of Nuclear Medicine Brest University Hospital Brest France.,Department of Medicine, University of Melbourne Melbourne Australia
| | - Daniel P Steinfort
- Department of Respiratory Medicine Melbourne Health Melbourne Australia.,Department of Medicine, University of Melbourne Melbourne Australia
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Pearmain L, Krysiak P, Blaikley J, Alaloul M. Persistent air leak after pulmonary transplantation. BMJ Case Rep 2017; 2017:bcr-2017-220176. [PMID: 28751430 PMCID: PMC5614144 DOI: 10.1136/bcr-2017-220176] [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] [Accepted: 06/28/2017] [Indexed: 11/03/2022] Open
Abstract
A 59-year-old man with bilateral apical emphysema underwent a double lung transplant for end-stagechronic obstructive pulmonary disease leaving remnant right apical native tissue due to pleural adhesions. Initial postoperative course was uneventful until the chest drains were removed. This revealed a small pneumomediastinum, which progressively increased in size causing gross surgical emphysema. Re-insertion of the chest drain stabilised the patient so that the cause could be identified and corrected. Two bronchoscopies excluded anastomotic dehiscence as a cause. Therefore the subcostal wound was refashioned under video-assisted thoracoscopic surgery in case there was a defect. Unfortunately this also failed to halt the air leak; therefore another cause was sought. A multidisciplinary team meeting review of the radiology revealed that the patient's native bullous tissue was still inflated. Subsequent bronchoscopy revealed a native bronchial communication, due to variant anatomy, proximal to the surgical anastomosis. This was subsequently occluded using a bronchial valve allowing the patient to make a swift recovery.
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Affiliation(s)
- Laurence Pearmain
- Department of Respiratory Medicine, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
- Piper Hanley Group, University of Manchester Institute of Human Development, Manchester, UK
| | - Piotr Krysiak
- Department of Respiratory Medicine, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - John Blaikley
- Department of Respiratory Medicine, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
- Division of infection, Immunity and Respiratory medicine, University of Manchester, Manchester, UK
| | - Mohamed Alaloul
- Department of Respiratory Medicine, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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Slebos DJ, Shah PL, Herth FJF, Valipour A. Endobronchial Valves for Endoscopic Lung Volume Reduction: Best Practice Recommendations from Expert Panel on Endoscopic Lung Volume Reduction. Respiration 2016; 93:138-150. [PMID: 27992862 DOI: 10.1159/000453588] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/17/2016] [Indexed: 11/19/2022] Open
Abstract
Endoscopic lung volume reduction (ELVR) is being adopted as a treatment option for carefully selected patients suffering from severe emphysema. ELVR with the one-way endobronchial Zephyr valves (EBV) has been demonstrated to improve pulmonary function, exercise capacity, and quality of life in patients with both heterogeneous and homogenous emphysema without collateral ventilation. In this "expert best practices" review, we will highlight the practical aspects of this therapy. Key selection criteria for ELVR are hyperinflation with a residual volume >175% of predicted, forced expiratory volume <50% of predicted, and a 6-min walking distance >100 m. Patients with repeated infectious complications, severe bronchiectasis, and those with unstable cardiovascular comorbidities should be excluded from EBV treatment. The procedure may be performed with either conscious sedation or general anesthesia and positive pressure mechanical ventilation using a flexible endotracheal tube or a rigid bronchoscope. Chartis and EBV placement should be performed in 1 procedure when possible. The sequence of valve placement should be orchestrated to avoid obstruction and delivery of subsequent valves. If atelectasis has not occurred by 1 month after procedure, evaluate valve position on CT and consider replacing the valves that are not optimally positioned. Pneumothorax is a common complication and typically occurs in the first 2 days following treatment. A management algorithm for pneumothorax has been previously published. Long-term sequelae from EBV therapy do occur but are easily manageable.
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Affiliation(s)
- Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Yin Y, Hou G, Herth FJ, Wang XB, Wang QY, Kang J. Significant lung volume reduction with endobronchial valves in a patient despite the presence of microcollaterals masked by low-flow Chartis phenotype. Int J Chron Obstruct Pulmon Dis 2016; 11:2913-2917. [PMID: 27920518 PMCID: PMC5125985 DOI: 10.2147/copd.s118919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Satisfactory functional outcomes following bronchoscopic lung volume reduction (BLVR) using endobronchial valves (EBVs) depend on the absence of collateral ventilation (CV) between the target and adjunct lobes. The Chartis system has proven to be useful for determining whether CV is present or absent, but this system can also erroneously indicate the absence of CV, which can lead to BLVR failure. Here, we describe low-flow Chartis phenotype in the target lobe resulted in difficult judgment of existence of CV. Consequently, BLVR with EBVs implanted into the right upper bronchus failed to reduce lung volume or induce atelectasis. Inserting another EBV into the right middle bronchus blocked the latent CV, which led to significant lung volume reduction in the right upper lobe (RUL) and right middle lobe (RML) and to improve the pulmonary function, 6-min walking distance, and St George respiratory questionnaire scores over a 2-week follow-up period. Low flow in the target lobe is a unique Chartis phenotype and represents the uncertainty of CV, which is a risk factor for the failure of BLVR using EBVs. Clinicians should be aware of this possibility and might be able to resolve the problem by blocking the RUL and RML between which the CV occurs.
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Affiliation(s)
- Yan Yin
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | - Gang Hou
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | - Felix J Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Xiao-Bo Wang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | - Qiu-Yue Wang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, People's Republic of China
| | - Jian Kang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, People's Republic of China
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