Transbronchoscopic Pulmonary Emphysema Treatment

Abstract

To the Editor: Concerning the treatment options for emphysema discussed by Dr. Robert J. McKenna, Jr., in the editorial “Bronchial Blockers for Lung Volume Reduction Surgery: Where Are We and Where Are We Going?” (Journal of Bronchology 2005;12:67-68), some points require clarification. As part of a multidisciplinary team providing care to patients with emphysema, we have considerable experience with both lung volume reduction surgery (LVRS) and the transbronchoscopic approach using one-way valves (EBV). First, it is important to underscore that EBVs are not bronchial blockers, as implied in the editorial's title. Watanabe's spigot indeed works as a blocker, leading to complete occlusion of specific segments of the airway, as would be the case with a foreign body or tumor. This is not so with one-way EBVs, in which air is prevented from entering, but not from leaving, nonfunctional lung segments. Second, the denomination “bronchoscopic LVRS” is inappropriate because the procedure is not surgical and the occurrence of lung volume reduction is not required for improvement-as pointed out by Dr. McKenna himself and shown in early studies.1-3 As we have previously proposed,4 a more adequate designation for this approach is transbronchoscopic pulmonary emphysema treatment (TPET). We agree with Dr. McKenna concerning the need to investigate the role of collateral ventilation and the hypothesis that the presence of EBVs decreases dynamic hyperinflation, which could explain why patients report faster recovery from effort or why none of our patients so far has chosen to remove the valves when given the opportunity. We are far from fully understanding the multiple factors involved in the improvement of patients after insertion of EBVs. However, as Dr. McKenna suggested, we face the future with hope, hard work, and unlimited expectations for TPET. Hugo G. de Oliveira, MD, PhD Amarilio V. Macedo-Neto, MD, PhD Department of Thoracic Surgery Hospital de Clínicas de Porto Alegre Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil