Endobronchial Valve Placement Research Articles

Diagnostic performance comparison of the Chartis System and high‐resolution computerized tomography fissure analysis for planning endoscopic lung volume reduction

Endobronchial valve (EBV) therapy is optimized in patients who demonstrate little or no collateral ventilation (CV). The accuracy of the Chartis System and visual assessment of high-resolution computerized tomography (HRCT) fissure completeness by a core radiology laboratory for classifying CV status was compared by evaluating the relationship of each method with target lobe volume reduction (TLVR) after EBV placement. Retrospective HRCT fissure analysis of a study population who underwent catheter-based measurement of CV followed by complete occlusion of the targeted lobe by EBV. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the HRCT fissure analysis and the catheter-based measurement of CV for predicting TLVR was determined. Accuracy for correctly classifying TLVR with EBV was similar for Chartis System and HRCT fissure analysis (74 vs 77%). The sensitivity and specificity of the Chartis measurement were 86% and 61% and those of HRCT fissure analysis 75% and 79%. Patients with TLVR ≥ 350 mL had statistically significant improvement in respiratory function, exercise performance and quality of life measures. When evaluating patients for likelihood of successful EBV therapy, the Chartis System CV assessment and HRCT fissure analysis appear to have comparable accuracy. Both techniques were found to be beneficial for EBV procedure planning.

Endobronchial Valves for Advanced Emphysema

Lung volume reduction surgery is a therapeutic option for selected patients with advanced emphysema. However, it is an invasive procedure benefitting only a selected group of patients with heterogeneous upper lobe predominant disease and limited exercise capacity. The most widely studied alternatives are endobronchial valves. Hundreds of patients worldwide have undergone endobronchial valve placement. Although short-term outcomes have been described, little is known about the long-term side effects following this treatment, and endoscopic follow-up is virtually nonexistent. The images, biopsies, and microbiologic evidence accrued from this patient are witnesses to the natural evolution of endobronchial valves in the airways and should offer a word of caution with regard to valve placement in patients with life expectancies exceeding those typical of severe chronic obstructive lung disease.

Clinical challenges of persistent pulmonary air-leaks—Case report

Air leaks are a common problem after pulmonary resection and can be a source of significant morbidity and mortality.The authors describe the case of a 68-year-old male patient who presented with a persistent air-leak after pulmonary resection. Watchful waiting, surgical procedures, as well as medical therapy like pleurodesis and implantation of endobronchial one-way valves on the bronchial segments identified using systematic occlusion of the bronchial segments, were all tried unsuccessfully. During that time the patient remained hospitalized with a chest tube.The instillation of methylene blue through the chest tube was used to identify the segments leading to the persistent air-leak; this enabled successful endobronchial valve placement which sufficiently reduced the size of the air-leak so that the chest tube could be removed.Nonsurgical approaches seem promising and, for some patients may be the only treatment option after all conventional treatments have failed or are considered too high risk.

Endobronchial Valve Placement for a Giant Bulla in a Patient with Hypercapnic Respiratory Failure

Endobronchial Valve Placement for a Giant Bulla in a Patient with Hypercapnic Respiratory Failure

Life-Saving Closure of a Pulmonary Cavity by Endobronchial Valve Placement

Life-Saving Closure of a Pulmonary Cavity by Endobronchial Valve Placement

Endobronchial Valves for Treatment of Bronchopleural Fistula in Granulomatous Polyangitis

Bronchopleural fistula (BPF) is an abnormal communication between the bronchus and the pleural space, commonly occurring after pulmonary resection or due to a spontaneous pneumothorax secondary to an underlying lung disease. We present a case of BPF in the setting of granulomatous polyangitis treated with endobronchial valves (EBV) with a longitudinal follow-up. These 1-way valves allow air and mucus to exit the diseased segment of lung during expiration, but prevent the reentry of air upon inspiration. The targeted segment may undergo atelectasis, achieving nonsurgical lung volume reduction, and allowing the remaining lung to compensate for the loss of volume. The use of these valves has shown to decrease hospitalization, morbidity, and mortality in these patients. In this case, the patient endured a prolonged hospitalization (82 d) and was able to be discharged only 7 days after EBV placement. This facilitated engagement in a pulmonary rehabilitation program, increased physical activity, and ultimately resumption of normal activity for the patient. To our knowledge, this is the first case of EBV used to treat BPF in the setting of underlying granulomatous polyangitis. This underscores the point that in appropriate settings, EBVs can decrease morbidity and mortality, and significantly improve the quality of life.

Anesthetic considerations for interventional pulmonary procedures

To discuss the anesthetic considerations of various procedures now performed by the interventional pulmonologist. With recent technological advances, many of these procedures represent acceptable alternatives to the invasive surgical procedures. For example, the placement of endobronchial valves can substitute for lung reduction surgery and can greatly reduce the postoperative recovery period. However, many of these complex procedures require anesthesia services. The nature and indication for the procedure as well as the patient's overall health will have an impact on the anesthetic choice. New studies have documented common complications from interventional pulmonology procedures and recent ways to avoid these complications have been suggested. Strategies to avoid obstruction, bleeding, pneumothorax and air embolism are discussed in this article. Potential benefits of high frequency jet ventilation in reducing airway pressures and, perhaps, barotraumas are cited. Novel interventional pulmonary procedures are described. As the array of diagnostic and therapeutic pulmonary interventions is expanding, the types of anesthetic techniques and ventilatory modes are varying to fit the procedural requirements. Some pulmonary procedures are best accomplished in the lightly sedated patient, who is breathing spontaneously, whereas procedures that use the working channel of a rigid bronchoscope are better performed in the patient under general anesthesia and mechanical ventilation that often use jet ventilation to minimize respiratory movements.

Endobronchial Valve Management of a Persistent Air Leak Complicating Bullous Emphysema

Abstract SESSION TYPE: Bronchology Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: The frequency of secondary spontaneous pneumothorax (SSP) varies according to the underlying lung disease, and is commonly seen with lymphangioleiomyomatosis but also occurs in COPD. Spontaneous closure of air leaks significantly decline after 5-7 days and surgical management is the standard of care for correcting a persistent air leak. However, co-morbid conditions, severe architectural distortion of the underlying lung parenchyma, and the severity of the underlying lung disease often dissuade surgeons in pursuing corrective surgical options. Endobronchial occlusion with one-way valves is an attractive option when a persistent air leak occurs.CASE PRESENTATION: A 63-year-old white male with a history significant for GOLD IV COPD (FEV1 of 0.37L) presented to the emergency department with respiratory distress requiring intubation. Chest x-ray revealed a right-sided pneumothorax and a chest tube was placed with subsequent re-expansion of the lung. A repeat chest x-ray showed a small residual apical pneumothorax with no air-leak in the chest tube. He was extubated the following morning, but developed hypercapneic respiratory failure and was re-intubated. He was found to have a worsening pneumothorax on the right despite the chest tube, so a second chest tube was placed. The lung adequately re-expanded and he was extubated. However the second chest tube had a persistent and continuous air-leak 5 days after the second chest tube was placed. Cardiothoracic surgery was consulted due to the persistent air leak, but declined operative repair secondary to his poor baseline lung function. The patient was also unable to undergo pleurodesis because he could not tolerate clamping of his chest tube. After maximal medical management, he was transferred to a rehabilation facility with his chest tube on suction. Four days later, he underwent endobronchial valve placement in the right upper lobe (using 5 valves) to slow the air leak. The patient was successfully underwent a talc pleurodesis the following day. He was discharged home with a hemlich valve due to an occasional leak. The chest tube was removed 4 weeks later without complications. The endobronchial valves were not removed due to the terminal stage of his emphysema.DISCUSSION: Persistent air leaks complicating bullous emphysema are problematic. Surgical options should be considered first; however, due to numerous complicating factors, surgical options may not be feasible.CONCLUSIONS: The therapeutic role of endobronchial valves in managing SSP remains to be defined with future studies, but clearly have a role in selected patients with persistent air leaks.1) Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA. Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement. CHEST 2001;119;590-602.DISCLOSURE: The following authors have nothing to disclose: Philip Svigals, Luca Paoletti, Nicholas Pastis, John HugginsNo Product/Research Disclosure InformationMedical University of South Carolina, Charleston, SC.

Do endobronchial valves improve outcomes in patients with emphysema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether endobronchial valves improve outcomes in patients with severe emphysema. Eighty-seven papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Endobronchial Valve for Emphysema Palliation Trial demonstrated that endobronchial valve increased forced expiratory volume in one second by 4.3% (95% confidence interval 1.4-7.2) and decreased by 2.5% in the control group (95% confidence interval -5.4 to 0.4) at a 6-month interval. This benefit is more marked in patients who do not have collateral ventilation into the area of lung being isolated as mapped by bronchoscopic physiological mapping (Chartis) or by computed tomography imaging documenting intact fissures. This evidence is reflected in the Endobronchial Valve for Emphysema Palliation Trial. Patients treated with endobronchial valve with high heterogeneity and complete fissures had greater improvement in forced expiratory volume in one second at 6- and 12-month intervals. We conclude that endobronchial valve placement improves lung function, exercise capacity and quality of life in selected patients with emphysematous diseases.

Das Leck in der Lunge: Bronchoskopische Ventilimplantation zur Behandlung einer persistierenden bronchopleuralen Fistel

Patients with bronchopleural fistula are at an increased risk of morbidity and mortality. Treatment of the air leak includes intrathoracic drainage, antibiotic therapy and closure of the fistula, which conventionally has been performed via surgical means. In patients with limited respiratory capacity, less-invasive alternatives are required. Here we report on a 62-year-old patient with underlying severe COPD, who was admitted with a lung abscess and consecutively developed a persistent bronchopleural fistula. Treatment involved antibiotic therapy and endobronchial one-way valve placement, which resulted in termination of the air leak and full recovery.

Endoscopic lung volume reduction effectively treats acute respiratory failure secondary to bullous emphysema

Emphysema often affects the lungs in a heterogeneous fashion, and collapse or removal of severely hyperinflated portions of lung can improve overall lung function and symptoms. The role of lung volume reduction (LVR) surgery in selected patients is well established, but that of non-surgical LVR is still being defined. In particular, use of endobronchial LVR is still under development. This case report describes a 48-year-old non-smoker with severe bullous emphysema complicated by acute hypercapnic respiratory failure, who was successfully treated by endobronchial valve placement while intubated in an intensive care unit.

Effect of unilateral endobronchial valve insertion on pulmonary ventilation and perfusion: A pilot study

The effects of bronchoscopic lung volume reduction (BLVR) on pulmonary ventilation and perfusion are incompletely understood. In this pilot trial, we investigated serial changes in regional ventilation and perfusion following unilateral endobronchial valve placement in COPD patients with heterogeneous emphysema. At baseline and at days 30 and 90 following BLVR, subjects underwent lung function, 6MWD and St George's Respiratory Questionnaire. Ventilation and perfusion scintigraphy were performed to quantitate and serially compare regional differences. Six out of eight subjects completed the study; all had endobronchial valves targeting their left upper lobe. At day 90 post-BLVR, there was a trend towards an increase in FEV(1) and a mean reduction in St George's Respiratory Questionnaire score of nine units. In the targeted left upper zone there was reduced ventilation and perfusion. Ventilation and perfusion to the right lung; and specifically the right lower zone, significantly increased. There appears to be redistribution of ventilation and perfusion to the contralateral lung following endobronchial valve placement. This may be of importance when assessing patients for unilateral BLVR. Selecting patients with heterogeneous disease is emphasized, taking into consideration not just comparison between upper and lower lobes, but between left and right lungs. A larger trial is currently underway, guided by these findings.

Iatrogenic Air Leak Successfully Treated by Bronchoscopic Placement of Unidirectional Endobronchial Valves

This report describes a patient with persistent air leak after inadvertent placement of a chest drain in a bulla. Chest drain and suction failed to stop the air leak, whereas the surgical repair was judged to be excessively aggressive. In closure, two large endobronchial valves were sequentially positioned in the superior and inferior division of the left upper lobe to completely close it. The result was the collapse of bulla with closure of fistula and complete lung expansion.

IS VIBRATION RESPONSE IMAGING (VRI) USEFUL FOR PLANNING AND CONTROL OF TREATMENT FOR EMPHYSEMA BY ENDOBRONCHIAL VALVES? A PILOT STUDY

PURPOSE: Placement of endobronchial valves (EBV) for treatment of emphysema has gained increasing popularity. Two main issues are finding the optimal target area and quantifiying the results. For the purpose among complex lung function testing and x-ray/CT investigation with isotpes plays an important role. We explored in this preliminary feasibility and safety study, whether VRI could also be applied for this purpose.

Bronchoscopic Lung Volume Reduction in Severe Emphysema

Lung volume reduction surgery (LVRS) produces physiological, symptomatic, and survival benefits in selected patients with advanced emphysema. Because it is associated with significant morbidity, mortality, and cost, nonsurgical alternatives for achieving volume reduction have been developed. Three bronchoscopic lung volume reduction (BLVR) approaches have shown promise and reached later-stage clinical trials. These include the following: (1) placement of endobronchial one-way valves designed to promote atelectasis by blocking inspiratory flow; (2) formation of airway bypass tracts using a radiofrequency catheter designed to facilitate emptying of damaged lung regions with long expiratory times; and (3) instillation of biological adhesives designed to collapse and remodel hyperinflated lung. The limited clinical data currently available suggest that all three techniques are reasonably safe. However, efficacy signals have been substantially smaller and less durable than those observed after LVRS. Studies to optimize patient selection, refine treatment strategies, characterize procedural safety, elucidate mechanisms of action, and characterize short- and longer-term effectiveness of these approaches are ongoing. Results will be available over the next few years and will determine whether BLVR represents a safe and effective alternative to LVRS.

Design of the Endobronchial Valve for Emphysema Palliation Trial (VENT): a non-surgical method of lung volume reduction

BackgroundLung volume reduction surgery is effective at improving lung function, quality of life, and mortality in carefully selected individuals with advanced emphysema. Recently, less invasive bronchoscopic approaches have been designed to utilize these principles while avoiding the associated perioperative risks. The Endobronchial Valve for Emphysema PalliatioN Trial (VENT) posits that occlusion of a single pulmonary lobe through bronchoscopically placed Zephyr® endobronchial valves will effect significant improvements in lung function and exercise tolerance with an acceptable risk profile in advanced emphysema.MethodsThe trial design posted on Clinical trials.gov, on August 10, 2005 proposed an enrollment of 270 subjects. Inclusion criteria included: diagnosis of emphysema with forced expiratory volume in one second (FEV1) < 45% of predicted, hyperinflation (total lung capacity measured by body plethysmography > 100%; residual volume > 150% predicted), and heterogeneous emphysema defined using a quantitative chest computed tomography algorithm. Following standardized pulmonary rehabilitation, patients were randomized 2:1 to receive unilateral lobar placement of endobronchial valves plus optimal medical management or optimal medical management alone. The co-primary endpoint was the mean percent change in FEV1 and six minute walk distance at 180 days. Secondary end-points included mean percent change in St. George's Respiratory Questionnaire score and the mean absolute changes in the maximal work load measured by cycle ergometry, dyspnea (mMRC) score, and total oxygen use per day. Per patient response rates in clinically significant improvement/maintenance of FEV1 and six minute walk distance and technical success rates of valve placement were recorded. Apriori response predictors based on quantitative CT and lung physiology were defined.ConclusionIf endobronchial valves improve FEV1 and health status with an acceptable safety profile in advanced emphysema, they would offer a novel intervention for this progressive and debilitating disease.Trial RegistrationClinicalTrials.gov: NCT00129584

Evolving Endoscopic Approaches for Treatment of Emphysema

Novel endobronchial methods for reducing lung volume in patients with advanced emphysema are currently being evaluated in clinical trials as potential alternatives to lung volume reduction surgery (LVRS). Three bronchoscopic lung volume reduction (BLVR) approaches have shown promise in initial testing: (1) placement of endobronchial one-way valves to promote atelectasis by blocking inspiratory flow; (2) airway bypass tract formation using a radiofrequency catheter to facilitate emptying of damaged lung regions with long expiratory times; and (3) instillation of biological adhesives designed to collapse and remodel hyperinflated lung. The limited clinical data currently available suggests all three techniques are reasonably safe. However, efficacy signals have been smaller and less durable than those observed after LVRS. Studies to optimize patient selection, refine treatment strategies, characterize procedural safety, elucidate mechanisms of action, and characterize short- and longer-term effectiveness of each approach are ongoing.

Successful Treatment of a Giant Emphysematous Bulla by Bronchoscopic Placement of Endobronchial Valves

Surgical bullectomy is the treatment of choice for giant emphysematous bulla. We report a case of successful nonsurgical treatment with bronchoscopic placement of one-way endobronchial valves that are currently under investigation for the treatment of end-stage emphysema. In patients who are poor surgical candidates, this noninvasive bronchoscopic treatment may represent a valuable alternative.

MDCT assessment of lung volume in patients undergoing bronchial stenting for treatment of pulmonary emphysema: correlation with respiratory tests and personal experience

The aid of this study was to evaluate lung volume reduction with multidetector-row computed tomography (MDCT) in patients with emphysema who have undergone endobronchial valve placement. Nine patients with emphysema were studied by low-dose chest MDCT (64-slice Somatom Sensation Cardiac, Siemens) with a collimation of 64 x 0.6 mm and a slice thickness of 1 mm. After treatment, MDCT scans were repeated at 7 and 30 days. A single observer calculated the volume of the treated lobe and of both lungs on a dedicated console. Volume calculations were then compared with the results of lung function tests. Four patients in whom MDCT showed severe emphysema of the right upper lobe (RUL) were selected for endobronchial valve insertion. Volume assessment at 30 days showed a 29% reduction in RUL volume in patient A, a 15% reduction in patient B, a <1% reduction in patient C and a 30% reduction in patient D. Correlation with lung function tests confirmed a major reduction of forced expiratory volume in 1 s (FEV(1)) and vital capacity (VC) and improved walking test results after 7 and 30 days. In patients undergoing endobronchial valve placement, MDCT with dedicated software allows for a better evaluation of volume reduction of a single lobe and of the whole lung.

Video-assisted thoracic surgery lung resection after endobronchial valve placement

1 Endobronchial valve (EBV) placement has emerged as an alternative approach for treating patients with severe emphysema. The improvements in lung function after EBV placement, which allows video-assisted thoracic surgery (VATS) lung resection in a previously nonsurgical candidate, have not been reported. We present a case of VATS lung resection after EBV placement in a patient with severe emphysema to illustrate clinical and surgical aspects in this new category of patients.