Heterogeneous Emphysema Research Articles

Identification of target zones for lung volume reduction surgery using three-dimensional computed tomography rendering.

BackgroundThe key issues for performing lung volume reduction surgery (LVRS) is the identification of the target zones. Recently introduced three-dimensional computed tomography rendering methods are used to identify the morphological distribution and its severity of lung emphysema by densitometry. We demonstrate a new software for emphysema imaging and show the pre- and post-operative results in patients undergoing LVRS planned based on this new technology.MethodsA real-time three-dimensional image analysis software system was used pre- and 3 months post-operatively in five patients with heterogeneous emphysema and a single patient with homogeneous morphology scheduled for LVRS. Focus was on low attenuation areas with <950 HU, distribution on both lungs and the value of the three-dimensional images for planning surgery. Functional outcome was assessed by pulmonary function tests after 3 months.ResultsFive patients underwent bilateral LVRS and one patient had unilateral LVRS. All patients showed a median increase in forced expiratory volume in 1 s of 70% (range 30–120%), compared with baseline values. Hyperinflation (expressed as residual volume/total lung capacity ratio) was reduced by 30% (range 5–32%). In the patients with heterogeneous emphysema, the pre- and post-operative computed tomography scans and the densitometries showed a decrease in low attenuation areas by 23% (right side) and by 17% (left side), respectively.ConclusionWe demonstrate three-dimensional computed tomography-rendered images for planning personalised remodelling of hyperinflated lungs using LVRS. This user-friendly software has the potential to assist surgeons and interventional pulmonologists to select patients and to visualise target areas in LVRS procedures.

Intrabronchial stents in heterogenous emphysema: a highly selected material followed 5 years.

BackgroundEndobronchial lung volume reduction (EBVR) with one-way valves introduced into the most diseased lobe of the lung is a non-invasive method to improve lung function in patients with severe heterogenous emphysema. The problem is to select the right patients for the procedure. Furthermore, the long-term effects have not been reported in most studies.MethodsEBVR was performed in 35 patients with severely handicapping emphysema and with one radiologically clearly enlarged (at least 125%) target lung lobe and clearly visible and complete interlobar fissures on CT. Most of the successful survivors have then been followed for five years.ResultsFive (14%) were primary failures (defined as less than 15% increase of FEV1sec) and 10 (28%) were secondary failures (the valves were coughed up or removed for some reason). In the 21 successful l patients, the improvement of FEV1sec was in the mean 59%. Over the years, FEV1sec gradually decreased but was still higher 5 years later than initially. Of the successful group, 76% were still alive after 5 years, while only 50% were in the refused or failed groups.ConclusionsWith careful selection of patients remarkably good results in lung function can be achieved, and these improvements will last for years though slowly decrease. In addition, the results indicate an improvement in survival with successful EBVR procedure.

Endoscopic Lung Volume Reduction in Relation to Body Mass Index in Patients with Severe Heterogeneous Emphysema

Background: In chronic obstructive pulmonary disease (COPD), body mass index (BMI) is significantly lower in the emphysema-dominant type. Endoscopic lung volume reduction (ELVR) is an innovative way of treating severe emphysema. However, the specific associations of low BMI values and outcomes of ELVR is not well-studied. Objectives: We evaluated associations between initial BMI and changes in major outcomes after endobronchial valve (EBV) placement in patients with heterogeneous severe emphysema. Methods: In a retrospective cohort study, patients were divided into 2 groups based on their baseline BMI (higher BMI ≥21 kg/m² [n = 18] and lower BMI <21 kg/m² [n = 63]). Demographics, procedure data, pulmonary function test and 6-min-walk test (6MWT), dyspnea score (according to the modified Medical Research Council [mMRC] scale), BODE (BMI, airflow obstruction, dyspnea, exercise capacity) index, and complications were recorded. After 6 months, changes in variables (dWeight and dBMI) were recorded. Results: Comparing the 2 groups, we found the following: a dWeight of –2.34 kg and +3.39 kg (p value <0.01) and a dBMI of –0.74 and +1.99 kg/m², in the higher BMI and lower BMI group, respectively (p value <0.01). Changes in forced expiratory volume <1 s (FEV₁), 6MWT, mMRC score, and BODE index were not statistically significant. The most common complication was pneumothorax. The lower BMI group experienced more complications than the higher BMI group (40 vs. 24%). Conclusion: Baseline BMI is relevant when selecting candidates for ELVR. Our results show that the COPD patients with a lower BMI gained a significant amount of weight, thus increasing their BMI after the procedure. The rate of complications was higher in the lower BMI group. These findings should alert physicians and encourage nutritional assessment in this population.

Cardio-Pulmonary Changes After Bronchoscopic Lung Volume Reduction with Endobronchial One-Way Valves.

To evaluate the cardio-pulmonary hemodynamics changes before and after valve treatment, and their correlation with lobe volume reduction. This retrospective multicentre study included consecutive patients undergoing bronchoscopic valve treatment for heterogeneous emphysema. In addition to standard functional evaluation, patients underwent cardiac evaluation by Doppler trans-thoracic echocardiography. The difference in respiratory and cardio-pulmonary hemodynamics indexes before and 3-month after the procedure, and their relationship with changes in lobar volume were evaluated. Seventy-seven patients were included in the study; of these 13 (17%) presented pulmonary hypertension. Only patients with target lobar volume reduction ≥ 563mL (n = 50) presented a significant improvement of forced expiratory volume in one second, residual volume, 6min-walk test, and St. George's Respiratory Questionnaire score; a significant reduction of pulmonary artery pressure, and an improvement of left and right ventricle end-systolic volume; of left and right ventricle end-diastolic volume, and of left and right ventricle stroke volume. The change in residual volume was significantly correlated with changes in forced expiratory volume in one second (r = 0.68; p < 0.001); in 6min-walk test (r = 0.71; p < 0.001); in St. George's Respiratory Questionnaire (r = 0.54; p < 0.001); in pulmonary artery pressure (r = 0.39; p = 0.001), in left (r = 0.28; p = 0.01) and right (r = 0.33; p = 0.002) ventricle end-systolic volume, in left (r = - 0.29; p = 0.008) and right (r = - 0.34; p = 0.007) end-diastolic volume, and in left (r = - 0.76; p = 0.009) and right (r = - 0.718; p = 0.001) ventricle stroke volume. Bronchoscopic valve treatment seemed to have positive effects on cardio-pulmonary hemodynamics, and these changes were correlated with reductions of lobar volume.

Per cent low attenuation volume and fractal dimension of low attenuation clusters on CT predict different long-term outcomes in COPD

BackgroundFractal dimension (D) characterises the size distribution of low attenuation clusters on CT and assesses the spatial heterogeneity of emphysema that per cent low attenuation volume (%LAV) cannot detect. This...

Lung Volume Reduction Surgery in Patients with Heterogenous Emphysema: Selecting Perspective.

BACKGROUND:Lung volume reduction surgery (LVRS) was introduced to alleviate clinical conditions in selected patients with heterogenous emphysema. Clarifying the most suitable patients for LVRS remained unclear.AIM:This study was undertaken to specifically analyze the preoperative factor affecting to LVRS.METHODS:The prospective study was conducted at 103 Military Hospital between July 2014 and April 2016. Severe heterogenous emphysema patients were selected to participate in the study. The information, spirometry, and body plethysmographic pulmonary function tests in 31 patients who underwent LVRS were compared with postoperative outcomes (changing in FEV1 and CAT scale).RESULTS:Of the 31 patients, there was statistically significant difference in the outcome of functional capacity, lung function between two groups (FEV1 ≤ 50% and > 50%) (∆FEV1: 22.46 vs 18.32%; p = 0.042. ∆ CAT: 6.85 vs 5.07; p = 0.048). Changes of the FEV1 and CAT scale were no statistically significant differences in three groups residual volume. Patients with total lung capacity < 140% had more improved than others (∆FEV1: 23.81 vs 15.1%; p = 0.031).CONCLUSION:Preoperative spirometry and body plethysmographic pulmonary function tests were useful measures to selected severe heterogenous emphysema patients for LVRS. Patients with FEV1 ≤ 50%, TLC in the range of 100-140% should be selected.

Influence of Emphysema and Air Trapping Heterogeneity on Pulmonary Function in Patients with COPD.

PurposeTo explore the influence of emphysema and air trapping heterogeneity on pulmonary function changes in patients with stable chronic obstructive pulmonary disease (COPD).Patients and methodsOne hundred and seventy-nine patients with stable COPD were enrolled in this prospective study. All patients underwent low-dose inspiratory and expiratory CT scanning and pulmonary-function tests. CT quantitative data for the emphysema index (EI) on full-inspiration and air trapping (AT) on full-expiration were measured for the whole lung, the right and left lungs, and the cranial-caudal lung zones. The heterogeneity index (HI) values for emphysema and air trapping were determined as the ratio of the difference to the sum of the respective indexes. The cranial-caudal HI and left–right lung HI were compared between mild-to-moderate (GOLD stage I and II) and severe (GOLD stage III and IV) disease groups. The associations between HI and pulmonary-function measurements adjusted for age, sex, height, smoking history, EI and AT of the total lung were assessed using multiple linear regression analysis.ResultsThe absolute values for cranial-caudal HI (AT_CC_HI) and left–right lung HI (AT_LR_HI) on full-expiration were significantly larger in the mild-to-moderate group, while no significant intergroup differences were observed on full-inspiration. COPD patients with lower-zone and/or left-lung predominance showed significantly lower pulmonary function than those with upper-zone and/or right-lung predominance on full-expiration, whereas no significant differences were observed on full-inspiration. The absolute values of AT_CC_HI and AT_LR_HI significantly correlated with pulmonary-function measurements. Higher AT_CC_HI and lower AT_LR_HI absolute values indicated better pulmonary function, after adjusting for age, sex, height, smoking history, EI and AT of the total lung.ConclusionSubjects with more heterogeneous distribution and/or upper-zone predominant and/or right-lung predominant patterns on full-expiration tend to have better pulmonary function. Thus, in comparison with emphysema heterogeneity, AT heterogeneity better reflects the pulmonary function changes in COPD patients.

Predictive Modelling of Lung Function using Emphysematous Density Distribution

Target lung tissue selection remains a challenging task to perform for treating severe emphysema with lung volume reduction (LVR). In order to target the treatment candidate, the percentage of low attenuation volume (LAV%) representing the proportion of emphysema volume to whole lung volume is measured using computed tomography (CT) images. Although LAV% have shown to have a correlation with lung function in patients with chronic obstructive pulmonary disease (COPD), similar measurements of LAV% in whole lung or lobes may have large variations in lung function due to emphysema heterogeneity. The functional information of regional emphysema destruction is required for supporting the choice of optimal target. The purpose of this study is to develop an emphysema heterogeneity descriptor for the three-dimensional emphysematous bullae according to the size variations of emphysematous density (ED) and their spatial distribution. The second purpose is to derive a predictive model of airflow limitation based on the regional emphysema heterogeneity. Deriving the bullous representation and grouping them into four scales in the upper and lower lobes, a predictive model is computed using the linear model fitting to estimate the severity of lung function. A total of 99 subjects, 87 patients with mild to very severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage I~IV) and 12 control participants with normal lung functions (forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) > 0.7) were evaluated. The final model was trained with stratified cross-validation on randomly selected 75% of the dataset (n = 76) and tested on the remaining dataset (n = 23). The dispersed cases of LAV% inconsistent with their lung function outcome were evaluated, and the correlation study suggests that comparing to LAV of larger bullae, the widely spread smaller bullae with equivalent LAV has a larger impact on lung function. The testing dataset has the correlation of r = −0.76 (p < 0.01) between the whole lung LAV% and FEV1/FVC, whereas using two ED % of scales and location-dependent variables to predict the emphysema-associated FEV1/FVC, the results shows their correlation of 0.82 (p < 0.001) with clinical FEV1/FVC.

Improving Lung Function in Severe Heterogenous Emphysema with the Spiration Valve System (EMPROVE). A Multicenter, Open-Label Randomized Controlled Clinical Trial.

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema.Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management.Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control).Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV1 from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV1 responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV1 showed statistically significant improvements between the treatment and control groups—between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060–0.141) and 0.099 L (95% BCI, 0.048–0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax.Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile.Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

IS THERE ANY ASSOCIATION BETWEEN INITIAL BODY MASS INDEX AND MAJOR OUTCOMES AFTER ENDOSCOPIC LUNG VOLUME REDUCTION USING ENDOBRONCHIAL VALVE PLACEMENT?

SESSION TITLE: Monday Electronic Posters 4 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Body mass index (BMI) is has a higher risk of all-cause mortality. In chronic obstructive pulmonary disease (COPD) BMI is significantly lower in emphysema. COPD patients with BMI of <21.75 kg/m2 has a higher risk of death. Endoscopic lung volume reduction (ELVR) using endobronchial valve placement (EBV) is an innovative treatment for severe emphysema with optimal medical therapy. Associations between low BMI and outcomes after ELVR are not well-studied yet. We wanted to explore relations between initial BMI and changes in major outcomes after ELVR in patients with heterogeneous severe emphysema. METHODS: Data were collected at Thoraxklinik University of Heidelberg, Germany. Demography (age, gender, pack-year index, pulmonary function test); procedure (number of EBV, target lobe), changes after ELVR and complications were recorded. Group 1 and group 2 were created according to baseline BMI (G1>21kg/m2; G2< 0.005). Outcomes were the following: changes (d) in forced expiratory volume (dFEV1, % and ml), residual volume (dRV, % and ml), distance during 6-minute walking test (6MWD, m), Modified Medical Research Council dyspnea score (MMRC) and BODE index after treatment. Quantitative data was evaluated with non-parametric test (U-Mann Whitney) and qualitative data was evaluated with Fisher-exact test. Linear regression model was performed to explore baseline BMI and changes in BMI (dBMI) after ELVR (p-value < 0.005). RESULTS: 82 patients were included (G1= 63) and (G2 = 18). Average age was 62.5 years (28-81). Mean BMI in group 1 was 25.59 (21.54-35.6) compared to 19.54 (16.99-20.83) in G2. After treatment, mean change in BMI was -4.28 kg (-38, +48) and G2 reported an improvement of +8.82 kg (-25, +39) (p<0.006), BMI decreased 1.14 kg/m2 (-12.0, +13.4) in G1 and improved +4.389 kg/m2 (-2.7, +15) in G2 (p<0.0001). We found a statistical tendency between change in FEV1 (%) +3.80 in G2 (-4.2, +20.9) compared to +1.2 in G1 (-17.8, +10). In G1 d6MWD was +42.52 mts (-130, +318) and G2 +19.4 mts (-305, +250) (p=0.840). In G1 dMMRC was -0.30 pts (-3, +3), in G2 -0.066 pts (-4, +4) (p=0.272). In G1 dBODE was -0.62 pts (-6, +5), in G2 -0.833 pts (-5, +4) (p= 0.711). Linear regression analysis found an R2 value of 0.3786 in change of BMI (p<0.0001); an R2 value of 0.239 in change of weight (kg) (p<0.0001). In G2, 38.9% of patients had complications, in G1 26.98% (p=0.23). CONCLUSIONS: Baseline BMI is relevant in order to select candidates to ELVR using EBV. In patients with BMI < 21kg/m2, ELVR is associated with increased BMI and weight after treatment. We found correlation between initial BMI, change in BMI and weight after ELVR. CLINICAL IMPLICATIONS: These findings suggest a potential nutritional benefit in this population. The association between BMI and long-term outcomes should be further studied. DISCLOSURES: No relevant relationships by Sebastian Fernandez-Bussy, source=Web Response No relevant relationships by Daniela Gompelmann, source=Web Response Advisory Committee Member relationship with Pulmonx Please note: $1001 - $5000 Added 03/15/2019 by Felix Herth, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Spiration Please note: $1001 - $5000 Added 03/15/2019 by Felix Herth, source=Web Response, value=Consulting fee No relevant relationships by Anna Kornafeld, source=Web Response No relevant relationships by Gonzalo Labarca, source=Web Response

A SINGLE-CENTER RETROSPECTIVE EVALUATION OF ENDOBRONCHIAL VALVES FOR LUNG VOLUME REDUCTION IN EMPHYSEMA PATIENTS

SESSION TITLE: Wednesday Electronic Posters 4 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM PURPOSE: Lung volume reduction (LVR) surgery was shown to improve exercise tolerance in patients with emphysema. Criner et al. (LIBERATE) reinforced the utility of endobronchial valve (EBV) placement in patients with emphysema and hyperinflation to improve lung function. In this study we report our experience with bronchoscopic LVR following the commercial availability of EBVs. METHODS: Retrospective review of patients who were treated by bronchoscopic LVR over a 6-month period at a single site. Inclusion criteria were age ≥40 with emphysema and hyperinflation with Total Lung Capacity (TLC) >100% predicted and Residual Volume (RV) >150% predicted. Data gathered include baseline characteristics, 45-day spirometric data, and complications (pneumothorax, pleural effusion, COPD exacerbation, arrhythmia). The primary endpoint was post bronchodilator response FEV1 ≥ 15% increase from baseline. Secondary endpoints were TLC change, absolute change in FEV1, and complication rates of EBV. RESULTS: A total of 18 patients were treated during this period. The average age of the patients evaluated was 69 years-old. 61% of patients were female (11) and 88.9% were Caucasian (16). Baseline 6 minute walk distance (6MWD) was 251 meters. The average baseline RV was 4.54L (217% of predicted) and baseline post-bronchodilator FEV1 was 750mL (30.3% predicted). At the 45-day mark, our patients had a FEV1 increase of 79.2mL (increase of 3% predicted), 30.7% showed an improvement in FEV1 ≥15% from baseline. RV decrease was on average 190mL. Total lung volume reduction on average was 610mL with 75% exhibiting a decrease ≥350mL. Regarding complications, 38.9% of our patients did have post-procedure pneumothorax with 22.2% of the patients requiring partial or total EBV removal. 27.8% of patients did have post procedure COPD exacerbation requiring medical attention with 80% of those patients having COPD exacerbations in the first 45 days. One patient had a previous treatment with vapor to the contralateral lung and another had alpha 1 antitrypsin deficiency. Both had positive outcomes. CONCLUSIONS: At the 45-day point, our center’s experience provided similar positive results as the LIBERATE study. Additionally, our patients exhibited a comparable incidence of pneumothorax post EBV placement. To our knowledge, this is the first and largest published single center experience on EBV for lung volume reduction since the Food and Drug Administration (FDA) approved the device in June 2018. We anticipate similar positive results at the one-year mark. CLINICAL IMPLICATIONS: Heterogeneous and homogeneous emphysema can be effectively treated with endobronchial valves to improve patients’ lung function. DISCLOSURES: No relevant relationships by Raed Alalawi, source=Web Response No relevant relationships by Richard Sue, source=Web Response No relevant relationships by Steve Tseng, source=Web Response No relevant relationships by Leigha Vick, source=Web Response

Functional benefit of smoking cessation in severe COPD patients undergoing bronchial valve implantation

IntroductionTobacco smoke is the leading cause of chronic obstructive pulmonary disease. The aim of this study is to highlight the effectiveness of smoking cessation along with bronchial valve implantation in subjects with severe COPD. MethodsA sample of 25 patients, current smokers, affected by severe COPD and heterogeneous emphysema who quit smoking were compared with a group of 15 patients who did not quit smoking. Measurements and main resultsPatients performed plethysmography, 6 minute walking test (WT), haemogasanalysis, exhaled CO test (eCO), COPD assessment test (CAT) together with the mMRC test. A clearer improvement of examined parameters was registered in the group of patients who quit smoking by varenicline and counselling. In particular, we observed a significant increase of FEV1 by 350 ml in the abstainers group compared with 100 ml increase in the non-abstainers(p < .05) group. We noticed that the RV% decreased by 30% compared with the 10% in the non-abstainers(p < .001).The CAT value decreased by 20 compared with 10 in current smokers(p < .001) as well as the mMRC score (p < .001) was more improved in abstainers.The total resistances were reduced by 30% versus 10% (p < .01)and notably there was a higher improvement of walking test (30 m versus 5) (p < .001). The eCO was clearly reduced in abstainers, 14 versus 8 (p < .002),. PaO2 increased by 4 mmHg versus 1(p < .0001). ConclusionsSmoking cessation treatment by varenicline strengthens the effects of bronchial valve implantation and shows up its crucial therapeutic role in severe COPD.

Lobar Quantification by Ventilation/Perfusion SPECT/CT in Patients with Severe Emphysema Undergoing Lung Volume Reduction with Endobronchial Valves

Background: Endoscopic lung volume reduction (ELVR) therapy using one-way valves is used to treat chronic obstructive pulmonary disease patients with severe heterogeneous emphysema. A successful treatment results in atelectasis of the treated pulmonary lobe with subsequent reduction of ventilation (V) and perfusion (Q). Objective: We evaluated the effects of ELVR on the targeted lobe using a new 3-dimensional ventilation and perfusion (V/Q) single-photon emission computed tomography (SPECT)/computed tomography (CT) analysis, which allows for simultaneous semi-automatic lobar pulmonary quantification of volume, ventilation and perfusion, on the first consecutive patients treated with ELVR at Rigshospitalet, Denmark. V/Q planar scintigraphy and V/Q SPECT/CT and lung function measurements were performed before and 6 months after intervention. Results: We included 24 subjects (60 years, range 46–74 years; 37.5% men) with a baseline FEV₁ of 25% predicted and RV of 257% predicted. V/Q SPECT/CT-assessed volume of the targeted lobe decreased by a mean of –395 mL and a relative mean of –26.8%, whilst ventilation and perfusion decreased by a relative mean of –37.1 and –25.7%. There was a significant increase in the same parameters of the non-targeted lobe(s) on the ipsilateral side. None of these changes were found in the analysis of planar V/Q imaging. The total lung volume decreased on average by –420 mL. Six months after ELVR, FEV₁ had increased by 22%. Significant correlations were found between changes in FEV₁ and changes in the volume of the treated lobe (SPECT/CT). Conclusion: Semi-automatic SPECT/CT analysis can quantify volume, ventilation and perfusion changes in pulmonary lobes and may be used in the assessment of patient eligibility for ELVR, identifying target lobes, and evaluation of the regional effects of treatment.

Clinical and Quality of Life Outcomes After Lung Volume Reduction Surgery

Lung volume reduction surgery (LVRS) is the definitive treatment for patients with severe emphysema. There is still a need for long-term data concerning the outcomes of this procedure. This study presents long-term longitudinal data on LVRS including correlation of quality of life (QOL) with pulmonary function testing metrics and includes additional analysis of patients with heterogeneous and homogeneous emphysema. Retrospective analysis of data collected from patients undergoing LVRS over a 9-year period at a single center was performed (N= 93). Pulmonary function and 6-minute walk tests as well as QOL questionnaires were administered before and 1 year after surgery. Descriptive statistics were reported for clinical outcomes and QOL indices. Wilcoxon signed-rank tests were used to examine changes from baseline to end of 1-year follow-up. Spearman correlation coefficients were used to evaluate relationships between clinical and QOL outcomes. At 1-year post surgery, mean forced vital capacity (46%, P ≤ .0001), forced expiratory volume (43%, P ≤ .0001), diffusing capacity of the lungs for carbon monoxide (16%, P ≤ .0001), and 6-minute walk distance (20%, P ≤ .0001) were increased from baseline, while residual volume decreased (23%, P ≤ .0001). There was a positive correlation between changes in QOL and forced expiratory volume, forced vital capacity, and, 6-minute walk distance. Patients having heterogeneous disease had greater improvements in forced expiratory volume, forced vital capacity, residual volume, and diffusing capacity of the lungs for carbon monoxide, and greater QOL compared with patients with homogeneous disease. LVRS continues to be a valuable treatment option for patients with advanced emphysema with reproducible improvements in clinical and QOL metrics. Careful patient selection and optimization prior to surgery are crucial to successful outcomes.

An improved random forests approach for interactive lobar segmentation on emphysema detection

Emphysema is one of the most widespread diseases in chronic diseases. Early diagnosis is crucial in slowing down the decline in the lung function of patients. Nowadays, it mainly relies on the pulmonary function test, which suffers from two drawbacks: the pulmonary function test cannot reflect the severity of patients with heterogeneous emphysema accurately and diagnose dyspnea patients. Hence, we propose an approach to analyze emphysema based on computed tomography (CT) images, which can detect the location of emphysema on each lung lobe. For the cases that cannot be automatically segmented, a random forests-based multi-task learning method with granular computing perspective is designed for interactive lobar segmentation. The effectiveness of the proposed emphysema detection method is demonstrated with the CT dataset from 93 patients with chronic obstructive pulmonary diseases. The accuracy of the presented lobar segmentation technique is proved on the CT images that cannot segment lobes. The experimental results show that the proposed interactive lobar segmentation method on locate emphysema about lobes could detect early symptoms of emphysema and reduce \(17.2\%\) of missing diagnosis.

Zephyr Endobronchial Valves Improve FEV1 and Quality of Life in Heterogenous Emphysema

Synopsis: In patients with severe heterogenous emphysema and little or no collateral ventilation in target lobes, Zephyr Endobronchial Valve treatment provides statistical and clinical benefits in lung function and quality of life compared with current standard of care therapies over a 12-month period. Source: Criner GJ, Sue R, Wright S, et al. LIBERATE Study Group. A multicenter randomized controlled trial of Zephyr endobronchial valve treatment in heterogenous emphysema (LIBERATE). Am J Respir Crit Care Med 2018;198:1151–1164.

Applicability of color-coded computed tomography images in lung volume reduction surgery planning.

Adequate patient selection is the key to successful lung volume reduction in patients with pulmonary emphysema. Computed tomography (CT) enables a reliable detection of pulmonary emphysema and allows an accurate quantification of the severity. Our goal was to investigate the usefulness and reliability of color-coded (CC) CT images in classification of emphysema and preoperative lung volume reduction planning. Fifty patients undergoing lung volume reduction surgery at our institution between September 2015 and February 2016 were retrospectively investigated. Three readers visually assessed the amount and distribution patterns of pulmonary emphysema on axial, multi-planar and CC CT images using the Goddard scoring system and a surgically oriented grading system (bilateral markedly heterogenous, bilateral intermediately heterogenous, bilateral homogenous and unilateral heterogenous emphysema). Observer dependency was investigated by using Fleiss' kappa (κ) and the intraclass correlation coefficient (ICC). Results were compared to quantitative results from densitometry measurements and lung perfusion scintigraphy by using Spearman correlation. Recommendations for lung volume reduction sites based on emphysema amount and distribution of all readers were compared to removal sites from the surgical reports. Inter-rater agreement for emphysema distribution rating was substantial for CC images (κ=0.70; 95% CI, 0.64-0.80) and significantly better compared to axial and multiplanar images (P≤0.001). The inter-rater agreement for recommended segment removal was moderate for CC images (κ=0.56; 95% CI, 0.49-0.63) and significantly better compared to axial and multiplanar images (P<0.001). Visual emphysema rating correlated significantly with measurements from densitometry and perfusion scintigraphy in the upper and lower lung zones in all image types. CC CT images allow a precise, less observer-dependent evaluation of distribution of pulmonary emphysema and resection recommendation compared to axial and multiplanar CT images and might therefore be useful in lung volume resection surgery planning.

Assessment of lung functions using impulse oscillometry before and after bronchoscopic lung volume reduction with histoacryl gel

BackgroundMany forms of bronchoscopic lung volume reduction were introduced as a treatment for patients with emphysema surpassing the surgical management and its fatality. Biological bronchoscopic lung volume reduction (BBLVR) proved to be a safe and competent solution inducing collapse of the emphysematous segment(s). Impulse oscillometry (IOS) constitutes an effortless but underused surrogate to spirometry in assessment of pulmonary function. Therefore, the aim of this study was to evaluate the use of IOS before and after BBLVR with histoacryl gel in comparison with spirometry among patients with emphysema.Patients and methodsA prospective comparative follow-up study was performed at Kobry El-Kobba Military Hospital. A total of 30 patients with radiological evidence of heterogenous emphysema or emphysematous bullae were enrolled during the period from July 2014 to April 2015. BBLVR was accomplished by the instillation of the histoacryl gel into the affected segment(s) using standard technique. Clinical, radiological, and functional assessments were done before and 4 weeks after the procedure.ResultsAfter BBLVR, the following outcome was measured: 6-min walk test, partial pressure of O2 in arterial blood, forced expiratory volume in the first second, resistance at 5 Hz, resistance at 20 Hz, and reactance at 5 Hz. They improved with statistical significance among all the patients. There was a negative correlation between forced vital capacity and resistance at 5 Hz in the heterogenous emphysema group (ρ=0.47 and P<0.025); however, the forced expiratory volume at first second showed positive correlation with reactance at 5 Hz in emphysematous bullae group (ρ=0.82 and P<0.023).ConclusionBBLVR with histoacryl gel is associated with improvement in exercise capacity and lung functions. IOS provided comprehensive assessment of the pulmonary functions, which was in good correlation with spirometry.

Prediction of response to endobronchial coiling based on morphologic emphysema characterization of the lung lobe to be treated and the ipsilateral non-treated lobe as well as on functional computed tomography-data: correlation with clinical and pulmonary function.

To test if the emphysema type of the targeted lobe, ipsilateral non-targeted lobe, and lobes of the contralateral lung impact outcome of endobronchial lung volume reduction (ELVR) treatment, and to document lobar volume changes in treated and non-treated lung lobes. Thirty patients (16 men, 14 women; median age, 66±6 years; range, 48-78 years) underwent chest-computed tomography (CT) before and after endobronchial coiling for lung volume reduction (LVR) at our institution between December 2011 and March 2016. Forty-five pulmonary lobes were coiled. We classified the treated lobes into homogenous or heterogeneous emphysema phenotype based on the distribution of voxels showing tissue attenuation of less than -950 HU. Clinical response was defined as an increase or consistency in the walking distance (6MWT) 6 months after LVR-therapy. Lung volume changes were compared for treated, ipsilateral, and contralateral lobes. Additionally, pulmonary function tests (PFT), chronic obstructive pulmonary disease (COPD) assessment test (CAT), and blood gas analysis were performed. Responder (19/30, 63.3%) showed a significant improvement of 6 MWT from 281.05 to 335.26 (P=0.001). Non-responder (11/30, 36.7%) showed a decrease in 6MWT from 308.18 to 255.45 (P=0.001). Responders showed a significant reduction in CAT test from 23.23 to 20.73 points (P=0.038) and pCO2 from 42.94 to 40.31 (P=0.001), whereas non-responders showed an increase in pCO2 (P=0.003; from 44.27 to 47.45). There were no significant changes in PFT-parameters. In responders, there was a significant volume reduction in treated lobes from 1,627.68 to 1,519.21 mL (P=0.009). In responders, treated lobes/non-treated ipsilateral lobes were homogenous (n=11/5) and heterogeneous (n=10/28). In non-responders, treated lobes/non-treated ipsilateral were homogenous (n=5/4) and heterogeneous (n=7/16). In responders and non-responders, the emphysema phenotype in treated, ipsilateral non-treated and even contralateral lobes (P=0.250) did not differ and or change significantly before and after therapy. Only the volume of treated lobes in responders changed significantly after coiling. The emphysema-phenotype in the targeted and non-targeted ipsilateral lobe has no impact on the outcome of endobronchial coiling for LVR and also does not change significantly after treatment, whereas the volume of the treated lobe significantly decreases in responders.

Journal Club - Endobronchial Valve Bronchoscopic Lung Volume Reduction.

It is estimated that approximately 3.5 million American adults have been diagnosed with emphysema, an irreversible destruction of the alveolar lung parenchyma. In advanced cases, the lung damage is so severe that significant air trapping occurs and does not improve with the use of bronchodilators and other conventional medicines used for chronic obstructive pulmonary disease (COPD). Viable surgical options include bullectomy, lung volume reduction surgery (LVRS), and lung transplantation but many patients may not be appropriate candidates for these procedures and/or there are long wait times for transplantation. Recently, the U.S. Food and Drug Administration (FDA) approved the Zephyr® endobronchial valve (EBV) (Zephyr Valve EBV; Pulmonx Corporation, Redwood City, California) for bronchoscopic lung volume reduction for patients with severe emphysema who are not responsive to medical therapy. This 1-way valve, the size of a pencil eraser, is inserted into the targeted diseased portion of the lung. Typically, 4 to 8 valves are inserted into the chosen emphysematous lobe and will allow air to escape out of that region but prevent any further air from entering, leading to deflation, and ultimately, total lobar collapse over a matter of weeks. An earlier study with the Zephyr® valves, the “Endobronchial Valve for Emphysema Palliation Trial, (VENT)” study,1 was a multicenter trial with 321 participants (220 with EBV insertion) that demonstrated statistically significant improvements in forced expiratory volume in 1 second (FEV1) and the 6-minute walk distance test (6MWD) between EBV and standard of care (SoC) groups but these were not clinically meaningful differences (mean change in FEV1 was 60 mL and median difference from baseline 6MWD 19.1 m).1 Post hoc analysis indicated that the best responders were those who demonstrated the following criteria: little to virtually no collateral ventilation to ipsilateral adjacent lobes, complete lobar occlusion achieved with the correct occlusive positioning of the valves in all segmental and sub-segmental airways and complete intact fissures between lobes.2,3 With this information, Pulmonx developed a unique technology-- Chartis (Pulmonx Corporation, Redwood City, California) a device that tests for collateral ventilation to judge the appropriateness of valve insertion.4 The Chartis system consists of a console connected to a balloon catheter with a central channel that is used to occlude the target lobe and to subsequently measure pressure and flow to calculate resistance to airflow and hence to quantify collateral ventilation in that lobe.4 More recently, advanced computed tomography (CT) scan analysis techniques have been developed that can virtually eliminate the need for testing with the Chartis system.5,6 Advanced CT analysis techniques have become a key element of deciding on the appropriateness of candidates. This has been confirmed with several short-term single center studies.2,7,8 The FDA actually granted the Zephyr® valve “breakthrough device” designation, allowing the FDA to provide guidance on efficient device development and to expedite evidence generation and review of the device. This designation generally signals the recognition that there are relatively few viable options for treating the targeted patient population. Indeed, the first study we review by Criner and colleagues, LIBERATE (below) is the first large, prospective, randomized controlled, multicenter study to evaluate the effectiveness, safety and durability of the benefit out to 12 months in patients with severe heterogeneous emphysema and with little to no collateral ventilation in the target lung. In order to expedite approval, the FDA required that, compared to previous studies, the primary endpoints show a greater magnitude of difference between Zephyr valve insertion and SoC versus a sham procedure and then SoC. In this Journal Club we will review this pivotal study that led to the approval of the Zephyr® valve in the United States and other recent studies that have evaluated the efficacy and safety of this device. Note: Abstracts are presented in their original, published format and have not been edited to match JCOPDF style.