Collateral Ventilation Research Articles

Variations in Pulmonary Fissure: A Source of Collateral Ventilation and Its Clinical Significance.

Introduction: Oblique and horizontal fissures divide the lungs into lobes. Assessing the incompleteness or absence of fissures is important when planning any surgical procedure in this region. This study aimed to investigate the incidence of variations in the fissures and their implication in clinical practice.Methods: The sample consists of 70 formalin-fixed lungs (32 right and 38 left lungs). These lungs were assessed for complete, incomplete, and absent fissures and any variations in the fissures on the sternocostal and mediastinal surfaces.Results: Oblique fissure was incomplete on the sternocostal surface in 18.75% and 21% and on the mediastinal surface in 25% and 21% on the right and left lungs, respectively. Additionally, it was absent in 10.5% of the left lung samples. The horizontal fissure was incomplete in 12.5% on both surfaces and was absent in 25% on the right lung samples, of which 50% had no oblique fissure. No accessory fissure was seen in any of the lungs.Conclusion: Incomplete and absent fissures can be observed in the right as well as the left lung, suggesting the source of collateral ventilation. This study imparts important information to pulmonologists doing bronchoscopic lung volume reduction therapy or bronchopulmonary segment resection and also to radiologists and anatomists.

Use of bronchoscopic steam thermal ablation (BTVA) in a clinically compromised patient

BackgroundBronchoscopic 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 presentationIn 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.ConclusionsThis case supports recent suggestions that BTVA can be a good alternative treatment for patients properly selected.

Katheterbasierte Luftstrommessung zur Beurteilung der Kollateralventilation: Kein Unterschied zwischen Spontanatmung und HF-Jetventilation

<b>Background:</b> 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. <b>Methods:</b> 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. <b>Results:</b> 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. <b>Conclusion:</b> 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.

Аssessment of segmental bronchial blocking success in the comprehensive treatment of patients with destructive pulmonary tuberculosis

The experience of using bronchial valve placement in emphysema treatment and studies on the effect of collateral ventilation in lobar bronchial blocking cast doubt on the effectiveness of this technique at the level of segmental bronchi using a single blocker. The aim of the study is to evaluate the effectiveness of segmental valve placement in the comprehensive treatment of patients with destructive pulmonary tuberculosis. The study is based on the results of evaluation of chest CT data of patients with destructive forms of pulmonary tuberculosis before and after valve placement. The correlations between the selected features were assessed and a model for predicting the cavity closure was built. A statistically significant cor-relation was found between the change in the segment volume after valvular blocking and the closure of the de-struction cavity. As a result, the low efficiency of segmen-tal valve placement in the comprehensive treatment of patients with pulmonary tuberculosis was revealed.

Impact of Ventilation Modes on Bronchoscopic Chartis Assessment Outcome in Candidates for Endobronchial Valve Treatment

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.

QUANTITATIVE CT ASSESSMENT IN THE CT LUNG CANCER SCREENING POPULATION: A POTENTIAL TOOL FOR SCREENING CANDIDATES FOR BRONCHOSCOPIC LUNG VOLUME REDUCTION

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: 15 million Americans are estimated to be eligible for CT lung cancer screening (CTLS) based on the U.S. Preventive Services Task Force guidelines. Patients who qualify for CTLS are at high-risk for numerous cardio-pulmonary co-morbidities including emphysema.Lung volume reduction surgery (LVRS) has been shown to provide a mortality benefit in a subset of subjects with upper-lobe emphysema and reduced exercise capacity. Due to the morbidity of the surgical procedure it has not achieved widespread use. Now minimally-invasive forms of LVR (bronchoscopic lung volume reduction, BLVR) with endobronchial valves (EBV) wiht placement of one-way EBVs induces atelectasis of emphysematous areas blocked by the valve and redirects airflow to more normal lung. BLVR has been shown to provide benefit in both upper and lower lobe disease in both heterogenous and homogeneous emphysema, provided there is no collateral ventilation (CV) in the target lobe. Qualifying criteria for BLVR includes FEV1 <45% pred., DLCO > 20% pred., TLC > 100% pred., RV > 175% pred. ( in some cases RV > 150%), (≥200% pred. for homogeneous) and BMI < 35. Fissure integrity of approximately 80% on CT predicts the likelihood of absence of CV and likely clinical benefit of BLVR, although CV should be ruled out through a physiological assessment. CTLS may help identify patients who could clinically benefit from BLVR or LVRS. METHODS: This restrospective, single-center study assessed all baseline CTLS exams performed from January 1, 2012 through September 30, 2017. All patients met the National Comprehensive Cancer Network Guidelines Lung Cancer Screening Version 1.2012 high-risk criteria for lung cancer screening. All analysis was performed utilizing a lung analysis software on IntelliSpace Portal 9.0 (CT COPD, Phillips Healthcare, Cleveland, OH USA). Four research assistants blinded to outcomes data performed the analysis and reviewed the multiplanar images and corrected any errors in interlobar segmentation. Attenuation of each voxel within segmented lungs was calculated automatically. Emphysema destruction was calculated as the sum of voxels with attenuation below -950 Hounsfield units (HU). RESULTS: A total of 4673 patients were included in the study. Quantitative global and lobar emphysema scores were obtained on 4495 patients ( 96.2%). A majority of patients 2845 ( 60.9%) had less than 1% emphysema destruction, 1207 ( 25.8%) had between 1-5%, 235 ( 5.0%) between 5-10% and 208 (4.5%) greater than 10%. In our cohort 124 patients (59.6%) with global % LAA ( low attenuation area) -950> 10% had heterogeneous disease defined as a delta of 15% LAA between ipsilateral lobes. There were 182 patients ( 3.9%) who had at least one lobe with at least 20% lung destruction ( %LAA -950> 20%). CONCLUSIONS: Systematic use of quantitative emphysema CT assessment in a lung cancer screening population was able to identify approximately 4% of the lung screening population who may benefit from further evaluation for candidacy for bronchoscopic or surgical lung volume reduction. Further work is needed to compare and standardize the various commercially available quantitative CT algorithms with low dose CT to better incorporate this information with clinical selection pathways for lung volume reduction. CLINICAL IMPLICATIONS: Quantitative CT Assessment may be a potential screening tool in the lung screening CT population for candidacy of bronchoscopic or surgical lung volume reduction. DISCLOSURES: No relevant relationships by Effie Adjei, source=Web Response Grant funding relationship with Genentech Please note: 9/10/2020 Added 04/23/2021 by Lee Gazourian, source=Web Response, value=Grant/Research Support No relevant relationships by Susan Kim, source=Web Response Consultant relationship with Veracyte Please note: 2019-2021 Added 06/23/2021 by Carla Lamb, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Covidien Please note: $1001 - $5000 by andrea mckee, source=Web Response, value=Salary Speaker/Speaker's Bureau relationship with Covidien Please note: $1-$1000 by andrea mckee, source=Web Response, value=Travel Advisor relationship with AstraZeneca Please note: 2019-2021 Added 04/22/2021 by Brady McKee, source=Web Response, value=Advisor Fee No relevant relationships by Timothy MD, source=Web Response No relevant relationships by Elizabeth Pagura, source=Web Response No relevant relationships by Julia Rabazzi, source=Web Response No relevant relationships by Shawn Regis, source=Web Responseresearch relationship with Veracyte Please note: 1/1/18-present Added 06/23/2021 by Kimberly Rieger-Christ, source=Web Response, value=Grant/Research Support No relevant relationships by William Thedinger, source=Web Response No relevant relationships by Christoph Wald, source=Web Response, value=Honoraria Removed 04/22/2021 by Christoph Wald, source=Web Response

Endobronchial Valve (Zephyr) Treatment in Homogeneous Emphysema: One-Year Results from the IMPACT Randomized Clinical Trial

Rationale: The long-term safety and effectiveness of bronchoscopic lung volume reduction with Zephyr endobronchial valves in subjects with severe homogeneous emphysema with little to no collateral ventilation beyond 3 months have yet to be established. Methods: Ninety-three subjects were randomized to either bronchoscopic lung volume reduction with Zephyr valves or standard of care (SoC) (1:1). Zephyr valve subjects were assessed at 3, 6, and 12 months. SoC subjects were assessed at 3 and 6 months; they were then offered crossover to Zephyr valve treatment. Results: The mean group difference (Zephyr valve – SoC) for change in FEV1 from baseline to 6 months was 16.3 ± 22.1% (mean ± SD; p < 0.001). Secondary outcomes showed the mean between-group difference for the six-minute walk distance of +28.3 ± 55.3 m (p = 0.016); St. George’s Respiratory Questionnaire, −7.51 ± 9.56 points (p < 0.001); modified Medical Research Council, −0.42 ± 0.81 points (p = 0.019); BODE index, −0.85 ± 1.39 points (p = 0.006); and residual volume of −430 ± 830 mL (p = 0.011) in favor of the Zephyr valve group. At 6 months, there were significantly more responders based on the minimal clinically important difference for these same measures in the Zephyr valve versus the SoC group. The clinical benefits were persistent at 12 months. The percentage of subjects with respiratory serious adverse events was higher in the Zephyr valve group compared to SoC during the first 30 days post-procedure but not statistically different for the Zephyr valve and SoC groups from 31 days to 6 months, and stable in the Zephyr valve group out to 12 months. There were 2 deaths in the SoC group in the 31-day to 6-month period and none in the Zephyr valve group out to 12 months. Conclusions: Bronchoscopic lung volume reduction with Zephyr valves in subjects with severe homogeneous emphysema and little to no collateral ventilation provides clinically meaningful change from baseline in lung function, quality of life, exercise capacity, dyspnea, and the BODE index at 6 months, with benefits maintained out to 12 months.

An adjusted and time-saving method to measure collateral ventilation with Chartis.

IntroductionBronchoscopic lung volume reduction with endobronchial valves is an important treatment option in selected patients with severe emphysema and absence of collateral ventilation in the treatment target lobe. The Chartis system provides an important physiological assessment of the presence or absence of collateral ventilation. We aimed to evaluate a new feature and determine whether low flow during a Chartis measurement is predictive for the absence of collateral ventilation, and whether this allows for a procedure to be shortened by earlier terminating the Chartis measurement. This is measured with the “volume trend for the previous 20 s” (VT20).MethodsWe retrospectively evaluated 249 Chartis assessments of patients scheduled for bronchoscopic lung volume reduction procedures. The VT20 was calculated, and several thresholds were compared between patients with collateral ventilation (CV positive) and without collateral ventilation (CV negative).Results100% of the CV negative patients reached a threshold of VT20 ≤6 mL, whereas all CV positive patients reached a VT20 ≥7 mL. The median “time saved” between VT20=6 mL and end of assessment was 60 s (range 5–354 s).ConclusionThe threshold of VT20 ≤6 mL is a reliable method to exclude the presence of collateral ventilation when air flow rates are low and can therefore reduce bronchoscopic lung volume procedure times.

Imaging ventilation using 19F perfluorinated gas magnetic resonance imaging: strategies for imaging collateral ventilation

Collateral Ventilation (CV) has become an important clinical issue with the increasing use of bronchoscopic lung volume reduction (BLVR) using endobronchial valve surgery in patients with severe COPD. The endobronchial valve BLVR procedure often uses one way valves to occlude segmental bronchi in lung regions with severe overinflation resulting from airway narrowing and collapse during exhalation. For BLVR to succeed, CV to the treated region must be minimal or absent. Current approaches to evaluating CV for both planning and follow-up of BLVR procedures involve CT imaging to assess fissure closure. Current techniques to assess regional lung function (including CV) are limited. Standard pulmonary function testing involving analysis of inert gas wash-in/wash-out can only provide statistical distributions without anatomic correlates. Herein we propose the use of fluorine magnetic resonance imaging of biologically inert perfluorinated gas mixed with oxygen to evaluate regional ventilation, in particular, interlobar collateral ventilation. We have evaluated normal subjects and subjects diagnosed with chronic obstructive pulmonary disease and have observed gas transfer at lobar fissures consistent with collateral ventilation.

Thoracoscopic Pulmonary Segmentectomy With Collateral Ventilation Method

BackgroundDespite its popularity in recent years, segmentectomy still faces a challenge: the accurate delineation of the intersegmental plane, especially in complex segmentectomy. In this study, we describe a method using collateral ventilation to create an inflation-deflation line for video-assisted thoracoscopic surgery (VATS) segmentectomy and evaluated its efficacy in complex segmentectomy by comparing it with simple segmentectomy. MethodsEnrolled in the study were 264 patients who underwent VATS segmentectomy from January 2017 to September 2018. We classified the clarity of the inflation-deflation line into 4 grades, and the procedures of grade 3 or 4 were considered successful. Meanwhile, we performed a propensity score matching analysis to compare complex and simple segmentectomy. ResultsComplete resection with free margins was achieved in all patients. In inflation-deflation line clarity evaluation, 245 patients were classified as grade 4 (92.8%), 10 as grade 3 (3.8%), 8 as grade 2 (3.0%), and 1 as grade 1 (0.4%). Procedural success (grade 3 or 4) was achieved in 255 patients (96.6%). Prolonged air leak (>5 days) was observed in 11 patients (4.2%). Propensity matching generated 83 pairs of well-matched patients. The proportion of procedural success and the incidence of prolonged air leak (>5 days) were similar in both groups. However, compared with simple segmentectomy, complex segmentectomy was associated with a longer median operative time (159 versus 135 minutes; P < .001). ConclusionsCollateral ventilation method is simple, safe, and effective in VATS segmentectomy to identify the intersegmental plane, and also well-adapted for complex segmentectomy.

Refractory secondary pneumothorax complicated with lung cancer treated by bronchial occlusion: a case report

BackgroundPneumothorax is defined as the presence of air or gas in the pleural cavity. Secondary pneumothorax usually occurs in patients with overt underlying lung disease, most commonly chronic obstructive pulmonary disease (COPD). Patients with poor lung function often suffer from pneumothorax with a persistent air leak. Various strategies have been employed in the treatment of such refractory pneumothorax. Bronchial occlusion with an Endobronchial Watanabe Spigot (EWS) (Novatech, Grasse, France) has been shown to be useful in treating prolonged bronchopleural fistulas. Although the effects of bronchial occlusion with EWS are known, refractory pneumothorax often involves multiple affected bronchi, and in some cases the affected bronchi cannot be easily identified. In addition, secondary pneumothorax associated with advanced lung cancer often prolongs the treatment of pneumothorax, which can significantly reduce patients’ quality of life and prognosis.Case presentationWe report a case of refractory pneumothorax where collateral ventilation was successfully treated by bronchial occlusion of the affected bronchi using multiple methods. In August 2019, an 80-year-old Japanese man with asthma and COPD overlap was admitted for exacerbation triggered by respiratory tract infection. During hospitalization, he presented with chest pain due to pneumothorax. Subsequently, a chest drain tube was inserted and pleurodesis was performed; however, the lung could not be sufficiently expanded and an air leak remained. Further investigation revealed a tumor suspicious for lung cancer at the entrance of the left upper lobe bronchus. Due to poor lung function, surgical treatments were deemed high risk. Therefore, we performed bronchial occlusion using the Endobronchial Watanabe Spigot (EWS). Because we could not determine the affected bronchi by computed tomography (CT), we located the affected bronchi by balloon occlusion test and bronchography with iopamidol. After occlusion, the air leak decreased but still persisted. Thus, we performed pleurodesis twice, and the air leak ceased completely.ConclusionsRefractory secondary pneumothorax, which affected multiple bronchi and developed into collateral ventilation due to lung cancer, was treated successfully with bronchial occlusion and EWS. In cases where the affected bronchi cannot be determined by the balloon occlusion test, bronchography with iopamidol might be an effective treatment.

Using individualized three-dimensional printed airway models to guide airway stent implantation

Airway stents are used to manage central airway obstructions by restoring airway patency. Current manufactured stents are limited in shape and size, which pose issues in stent fenestrations needed to be manually created to allow collateral ventilation to airway branches. The precise location to place these fenestrations can be difficult to predict based on 2-dimensional computed tomography images. Inspiratory computed tomography scans were obtained from 3 patients and analysed using 3D-Slicer™, Blender™ and AutoDesk® Meshmixer™ programmes to obtain working 3D-airway models, which were 3D printed. Stent customizations were made based on 3D-model dimensions, and fenestrations into the stent were cut. The modified stents were then inserted as per usual technique. Two patients reported improved airway performance; however, stents were later removed due to symptoms related to in-stent sputum retention. In a third patient, the stent was removed a few weeks later due to the persistence of fistula leakage. The use of a 3D-printed personalized airway model allowed for more precise stent customization, optimizing stent fit and allowing for cross-ventilation of branching airways. We determine that an airway model is a beneficial tool for stent optimization but does not prevent the development of some stent-related complications such as airway secretions.

THORACOSCOPIC SURGICAL STAPLING AND ENDOBRONCHIAL VALVE PLACEMENT FOR LUNG VOLUME REDUCTION WITH INCOMPLETE LOBAR FISSURES: INITIAL EXPERIENCE

SESSION TITLE: Fellows Obstructive Lung Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Emphysema affects more than 4 million cases diagnosed in the US. Recently, bronchial valves were approved for selected patients with complete lobar fissure and severe hyperinflation. Unfortunately, most patients have collateral ventilation (CV) and thus are not candidates for bronchoscopic lung volume reduction alone. Combined minimally invasive thoracoscopic intervention to complete lung fissure along with bronchial valves (BVs) to achieve lung volume reduction is an appealing treatment for the majority of patients with CV. Our group has recently described the use of this combined procedure in animal models, but this is the first description in clinical practice. CASE PRESENTATION: A 58-year-old woman with severe heterogeneous emphysema and hyperinflation underwent endobronchial bronchial valves placement without significant improvement in her symptoms or pulmonary function tests at her 6 months follow-up visit. Following a multidisciplinary discussion with thoracic surgery, the patient underwent major fissure completion via VATS. The patient tolerated the procedure well and was discharged from the hospital on postoperative day 3. At 1-month follow up, patient-reported progressive improvement in her dyspnea. Her chest radiography showed atelectasis of the target lobe. Her lung function test showed an improvement of 0.1L (4%) in her FEV1, a decrease of 0.5L (27%) in her RV, and an increase of 1.4mL/min/mmHg (18%) in her DLCO. Another 59-year-old woman with severe homogeneous emphysema with hyperinflation. She underwent bronchial valve placement without significant improvement in her symptoms or pulmonary function tests at 12 months follow up visit. Following a multidisciplinary discussion with thoracic surgery, the patient underwent major fissure completion via VATS along with the removal of abundant pleural adhesions. She had an air leak for 3 days that resolved and was discharged home at postoperative day 4. At one month follow up, the patient had no improvement in her dyspnea. Her chest radiography showed hyperinflation without improvement in the lung function test. DISCUSSION: As emphysema remains an irreversible disease, treatment goals are primarily aimed to slow and stabilize disease progression, relieve symptoms, and improve quality of life. The most important factor that may prevent the development of desired lung volume reduction following bronchial valve treatment is CV. We present the first 2 cases in which a thoracoscopic approach was used to complete the interlobar fissures to address CV. The refinement of the technique along with appropriate patient selection is still under progress. CONCLUSIONS: Lobar fissure completion along with bronchial valves is a promising management alternative for patients with CV. Reference #1: Majid A, Kheir F, Alape D, Chee A, Parikh M, DeVore L, et al. Combined Thoracoscopic Surgical Stapling and Endobronchial Valve Placement For Lung Volume Reduction With Incomplete Lobar Fissures: An Experimental Pilot Animal Study. J Bronchol Interv Pulmonol. 2019 Aug;1. Reference #2: Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global Strategy for the Diagnosis, Management, and Prevention of COPD 2020. Reference #3: Koster D, Slebos D-J. The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema. Int J Chron Obstruct Pulmon Dis. 2016 Apr;765. DISCLOSURES: No relevant relationships by Sidhu Gangadharan, source=Web Response No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Daniel Ospina-Delgado, source=Web Response

CONGENITAL BRONCHIAL ATRESIA MASQUERADING AS A LUNG MASS

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Congenital bronchial atresia (CBA) is a rare congenital abnormality resulting from the focal interruption of a lobar, segmental, or subsegmental bronchus. As most patients are asymptomatic, it is difficult to estimate its prevalence. We present a case of a young Hispanic female who was incidentally diagnosed with congenital bronchial atresia during bronchoscopy for a suspected mass. CASE PRESENTATION: A 21 y/o Hispanic female with no medical history was referred to the pulmonology clinic for evaluation of a RUL lung nodule seen on chest radiography during work-up for RUQ pain. A CAT scan revealed a 3 cm RUL mass with surrounding pulmonary hyperlucency. On presentation, the patient denied constitutional or pulmonary symptoms concerning for infection or malignancy. Physical exam revealed decreased breath sounds over the RUL lung field. Initial work-up was negative for endemic infections such as TB or cocci. She also denied recurrent pulmonary infections or lung disease. The patient underwent bronchoscopy with BAL, revealing an anatomical variant of 4-RUL segments with apical posterior segment stenosis visualized but not amenable to passage of the bronchoscope and without end-bronchial or mucosal abnormalities. BAL cultures for AFB, fungal, and bacteria were negative. BAL cocci antigen as well as serum IgG and IgM were negative. Serum QTB and cytology were also negative. At that point, the diagnosis of congenital bronchial atresia was made. DISCUSSION: Bronchial atresia typically is identified as an incidental finding on chest radiography in an asymptomatic older child or adult. The left upper lobe bronchus is most commonly involved, followed by the RUL, RML, and RLL. Due to lack of communication with the normal tracheobronchial tree, infection is uncommon. Radiographic appearance is due to mucoid impaction distal to the occluded bronchus and hyperexpansion of the affected pulmonary segment. Specifically, a perihilar mass is surrounded by a halo of lung that is hyperlucent due to collateral ventilation and gas trapping. Regarding treatment, there is much debate. Some specialists prefer surgery on all patients while others prefer a conservative approach, especially in absence of serious symptoms, such as secondary infection. CONCLUSIONS: The exact cause of bronchial atresia is unknown. It is hypothesized to occur as a focal bronchial interruption before birth. Regardless, most patients present asymptomatically, and many are discovered incidentally on chest imaging. Awareness and high level of suspicion are required to prevent unnecessary additional procedures or surgeries. Review of imaging may help determine chronicity and certain factors such as surrounding hyperluceny, as in our patient, can help lead to this diagnosis. A conservative approach is recommended by most specialists in our review of literature. Surgery should be reserved for those with secondary infections and recurrent symptoms. Reference #1: Wang, Yuqi et al. “Congenital bronchial atresia: diagnosis and treatment.” International journal of medical sciences vol. 9,3 (2012): 207-12. doi:10.7150/ijms.3690. Reference #2: Zylak CJ, Eyler WR, Spizarny DL, et al. Developmental lung anomalies in the adult: radiologic-pathologic correlation. Radiographics 2002;S25–43. DISCLOSURES: No relevant relationships by Katherine Gross, source=Web Response No relevant relationships by Ricardo Herrera, source=Web Response No relevant relationships by Jonathan Munoz, source=Web Response

Micrometer aerosol deposition in normal and emphysematous subacinar models

Emphysema is a chronic respiratory disease characterized by interalveolar septa destruction and enlarged air sacs. How the inhalation dosimetry in the pulmonary acini varies in the time course of emphysema is still unclear. The aim of this study is to numerically evaluate the impact of septal destructions on particle deposition in a pyramid-shape subacinar model that is composed of 496 alveoli. Four emphysematous models were generated by progressively removing the inter-alveolar septa from the normal geometry. Spatial distribution and temporal evolution of particle deposition were quantified in expanding/contracting subacinar models on both total and regional basis using a well-validated discrete-phase Lagrangian model. Airflow fields in the subacinar cavities are sensitive to the septal raptures, with regular, radial streamlines in the proximal alveoli in the normal geometry in contrast to unsymmetrical and recirculating flows in the emphysematous subacini. Intensified collateral ventilation and significantly increased doses in the outer wall and base are observed in disease than heath. The deposition rate of small particles (1–1.5 μm) is more sensitive to the level of septal rapture than large particles (2.5–3 μm). Unexpectedly, more particles per unit area deposit on the outer wall and at the base of the subacinus than on the inner septal walls. The subacinus-averaged doses increase with progressing septal destructions, suggesting an escalating risk factor to the acinar health at the late stages of emphysema.

Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure

Bronchoscopic valve placement constitutes an effective endoscopic lung volume reduction (ELVR) therapy in patients with severe emphysema and low collateral ventilation. After the most destroyed lobe is occluded with valves, significant target lobe volume reduction leads to improvements in lung function, exercise capacity, and quality of life. The effects are not consistent in some patients, leading to long-term therapy failure. We hypothesized that surgical lung volume reduction (LVRS) would reestablish ELVR short-term clinical improvements after ELVR long-term failure. This retrospective single-center analysis included all patients who underwent consolidating LVRS by lobectomy after long-term failure of valve therapy between 2010 and 2015. Changes in forced expiratory volume in 1 second, residual volume, 6-minute walking distance, and Modified Medical Research Council dyspnea score 90 days after ELVR and LVRS were analyzed, and the outcomes of both procedures were compared. LVRS was performed in 20 patients after ELVR failure. A lower lobectomy was performed in 90%. The 30-day mortality of the cohort was 0% and 90-day mortality was 5% (1 of 20). The remaining 19 patients showed a significant increase in forced expiratory volume in 1 second (+27.5% ± 19.4%) and a reduction in residual volume (-21.0% ± 17.4%) and total lung capacity (-11.1% ± 11.1%). This resulted in significant improvements in exercise tolerance (6-minute walking distance:+56 ± 60 m) and relief of dyspnea (ΔModified Medical Research Council:-1.8 ± 1.4 points.). Consolidating LVRS by lobectomy after failure of a previously successful ELVR is feasible and results in significant symptom relief and improvement of lung function.

An Integrative Approach of the Fissure Completeness Score and Chartis Assessment in Endobronchial Valve Treatment for Emphysema.

PurposeLung 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 MethodsMulticenter 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.ResultsAn 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.ConclusionQuantitative 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%.

Lung Volume Reduction in Pulmonary Emphysema.

Severe 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.

Predictive value of Chartis measurement for lung function improvements in bronchoscopic lung volume reduction.

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.

Bronchoscopic interventions for emphysema: Current status.

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.