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Bronchoscopic lung-volume reduction can help some with severe emphysema

Mayo Clinic Proceedings
Reuters Health - 10/09/2020 - Bronchoscopic lung-volume reduction (BLVR) achieved by endobronchial valve (EBV) placement can be an effective alternative to open lung-volume reduction surgery (LVRS) for relieving symptoms in patients with severe emphysema and air trapping, according to a new review.

"Bronchoscopic lung-volume reduction with endobronchial valve placement should be considered in selected patients with emphysema who have significant shortness of breath and poor quality of life despite best medical therapy," Dr. Sebastian Fernandez-Bussy of Mayo Clinic Florida, in Jacksonville, told Reuters Health by email.

Dr. Fernandez-Bussy and colleagues sought to spread awareness about BLVR and to promote its consideration in patients with advanced COPD and emphysema in their review, published in Mayo Clinic Proceedings.

In the landmark National Emphysema Treatment Trial, LVRS was associated with improvements in exercise capacity and quality of life in some subgroups and prolonged survival in patients with upper-lobe-predominant disease and persistently low exercise tolerance despite pulmonary rehabilitation.

However, LVRS was associated with increased mortality in patients with significantly reduced lung function, and its incremental cost-effectiveness versus medical therapy was $140,000 per quality-adjusted life-year at five years. These undesired outcomes have likely limited its adoption.

BLVR is achieved by bronchoscopic deployment of multiple one-way valves strategically positioned into segments or subsegments of the targeted lobe. When successful, these bronchial systems result in lobar occlusion and atelectasis.

The LIBERATE and EMPROVE trials of the Zephyr Endobronchial Valve and Spiration Valve System, respectively, found statistical and clinically significant improvements in forced expiratory volume in 1 second (FEV1) and quality of life in patients with severe heterogeneous emphysema. The LIBERATE trial also showed a significant improvement in 6-minute walk test distance.

BLVR with EBV has also shown good results in patients with homogeneous emphysema, though the benefits have generally been smaller.

The success of BLVR relies on appropriate patient selection. Ideal candidates include those in whom dyspnea is primarily attributable to hyperinflation and air trapping in the air spaces distal to the terminal bronchioles. Such patients have markedly increased residual volumes.

The absence of collateral ventilation between lobes is also absolutely critical to achieving lobar collapse.

Other criteria for EBV placement include at least four months' abstinence from smoking and vaping, previous completion of pulmonary rehabilitation, optimal nutritional status, and being current with appropriate immunizations.

Numerous absolute and relative contraindications for BLVR and EBV placement are detailed in the review.

The main complication of BLVR with EBV is pneumothorax, whose reported incidence ranges from 20% to 31%, with most cases requiring chest tube placement and with nearly a third of cases requiring removal of at least one endobronchial valve.

Although some patients experience dramatic clinical improvements, trial data support counseling patients to expect more modest improvements, the authors advise. Maximal benefits are generally achieved over a 45- to 90-day period.

Coauthor Dr. David Abia Trujillo, also of Mayo Clinic Florida, told Reuters Health by email, "Surgical lung-volume reduction (SLVR) is only beneficial in selected patients including those who have upper-lobe-predominant disease and clearly defined lung-function measurements. In patients who do not meet the defined criteria, SLVR may actually increase their chance of death. Additionally, it is critical that SLVR be performed by a surgeon and team that are very experienced in the procedure."

"In patients in whom LVR is being considered, the decision to pursue BLVR or SLVR is multifaceted," he said. "SLVR would be preferable in those with incomplete fissures between the involved contiguous lobes. Evaluation of fissure completeness is achieved by a specific CT scanning technique and is part of evaluation of patients before BLVR."

"We hope that physicians and patients consider BLVR with endobronchial valves as a minimally invasive procedure that can markedly improve quality of life," Dr. Fernandez-Bussy said. "Increased awareness of this novel technique by the medical and lay community is needed in order to appropriately identify patients who may benefit from BLVR so they may be referred for care at an experienced center."

Additional research is needed to improve patient selection and to identify alternative techniques to achieve lung-volume reduction, the authors note.

By Will Boggs MD

SOURCE: https://mayocl.in/34Yb1eg Mayo Clinic Proceedings, online August 20, 2020.

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