Lung Volume Reduction Surgery Research Articles

Bilateral lung volume reduction surgery outperforms the unilateral approach in functional improvement.

Lung volume reduction surgery (LVRS) is an established treatment approach for patients with severe pulmonary emphysema, enhancing lung function and quality of life in selected patients. Functional benefits and outcomes after uni- versus bilateral lung volume reduction remain a topic of debate. A retrospective analysis of patients undergoing LVRS from January 2018 to October 2022 was conducted. After encouraging initial results, the standard unilateral LVRS approach was switched to bilateral. The goal of this study was to assess the impact on functional outcomes at 3 and 6 months post-surgery compared to preoperative levels for the uni- versus the bilateral approach. A total of 83 patients were included (43 bilateral, 40 unilateral). Baseline demographic and functional parameters were comparable between groups. The most common complication was prolonged air leak in 19 patients (11 in the unilateral group, 8 in the bilateral group). Two patients died perioperatively (2.4%). Overall, LVRS improved forced expiratory volume in 1 s by 8.3% after 3 and 12.5% after 6 months postoperatively compared to baseline. Bilateral surgery presented significantly superior forced expiratory volume in 1 s improvement than unilateral approach at both 3 (29.2% versus 2.9%; P = 0.0010) and 6 months (21.5% versus 3%; P = 0.0310) postoperatively. Additionally, it reduced hyperinflation (residual volume) by 23.1% after 3 months and by 17.5% after 6 months, compared to reductions of 16% and 9.1% in the unilateral group. Bilateral approach resulted in better functional outcomes 3 and 6 months postoperatively compared to unilateral surgery.

Outcomes of lung volume reduction surgery for emphysema: unilateral and bilateral

Outcomes of lung volume reduction surgery for emphysema: unilateral and bilateral

Pulmonary and Systemic Immune Profiles Following Lung Volume Reduction Surgery and Allogeneic Mesenchymal Stromal Cell Treatment in Emphysema.

Emphysema in patients with chronic obstructive pulmonary disease (COPD) is characterized by progressive inflammation. Preclinical studies suggest that lung volume reduction surgery (LVRS) and mesenchymal stromal cell (MSC) treatment dampen inflammation. We investigated the effects of bone marrow-derived MSC (BM-MSC) and LVRS on circulating and pulmonary immune cell profiles in emphysema patients using mass cytometry. Blood and resected lung tissue were collected at the first LVRS (L1). Following 6-10 weeks of recovery, patients received a placebo or intravenous administration of 2 × 106 cells/kg bodyweight BM-MSC (n = 5 and n = 9, resp.) in week 3 and 4 before the second LVRS (L2), where blood and lung tissue were collected. Irrespective of BM-MSC or placebo treatment, proportions of circulating lymphocytes including central memory CD4 regulatory, effector memory CD8 and γδ T cells were higher, whereas myeloid cell percentages were lower in L2 compared to L1. In resected lung tissue, proportions of Treg (p = 0.0067) and anti-inflammatory CD163- macrophages (p = 0.0001) were increased in L2 compared to L1, while proportions of pro-inflammatory CD163+ macrophages were decreased (p = 0.0004). There were no effects of BM-MSC treatment on immune profiles in emphysema patients. However, we observed alterations in the circulating and pulmonary immune cells upon LVRS, suggesting the induction of anti-inflammatory responses potentially needed for repair processes.

Current Practices for Severe Alpha-1 Antitrypsin Deficiency Associated COPD and Emphysema

Alpha-1 antitrypsin deficiency is a genetic disorder that can lead to chronic obstructive pulmonary disease and emphysema. Although it is the most well-studied genetic risk factor for emphysema, data is still scarce. Traditionally, medical therapy is similar to standard chronic obstructive pulmonary disease patients. Over the past several decades, enzyme augmentation therapy has emerged as a highly utilized alpha-1 antitrypsin-specific therapy. It has become the standard of care for severe alpha-1 antitrypsin deficiency despite unclear effects on a multitude of clinical outcomes. Significant data supports interventional therapies, including lung volume reduction surgery and bronchoscopic lung volume reduction, for chronic obstructive pulmonary disease patients without alpha-1 antitrypsin deficiency. These interventions have less robust data in the treatment of alpha-1 antitrypsin-induced chronic obstructive pulmonary disease. This review will explore the data regarding various treatment options for severe alpha-1 antitrypsin deficiency associated with chronic obstructive pulmonary disease and emphysema.

Lung volume reduction surgery: a micro-costing analysis from a national tertiary referral Centre.

Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease (COPD). LVRS has recently been commissioned by the NHS England. In this study, a costing model was developed to analyse cost and resource implications of different LVRS procedures. Three pathways were defined by their surgical procedures: bronchoscopic endobronchial valve insertion (EBV-LVRS), video assisted (VATS-LVRS), and robotic assisted LVRS (RATS-LVRS). The costing model considered use of hospital resources from the LVRS decision until 90-days after hospital admission. The model was calibrated with data obtained from an observational study, electronic health records, and expert opinion. Unit costs were obtained from the hospital finance department and reported in 2021-Euros. VATS-LVRS was associated with the lowest cost at €12,896 per patient. This compares to the costs of EBV-LVRS at €15,598 per patient and €13,305 per patient for RATS-LVRS. A large component of EBV-LVRS costs were accrued secondary to complications, including revision EBV-LVRS. This study presents a comprehensive model framework for the analysis of hospital-related resource use and costs for the three surgical modalities. In the future, service commissioning agencies, hospital management, and clinicians can use this framework to determine their modifiable resource use (composition of surgical teams, use of staff and consumables, planned length of stay, and revision rates for EBV-LVRS) and to assess the potential cost implications of changes in these parameters.

The Impact of Changing Race-Specific Equations for Lung Function Tests among Veterans with Chronic Obstructive Pulmonary Disease.

Rationale: The American Thoracic Society recommended a single reference equation for spirometry, but the impact on patients is not known. Objectives: To estimate the effect of changing to a single reference equation among veterans with chronic obstructive pulmonary disease (COPD). Methods: A cross-sectional study was conducted including veterans aged ⩾40 to ⩽89 years with COPD and spirometry results from 21 facilities between 2010 and 2019. We collected race and ethnicity data from the electronic health record. We estimated the percentage change in the number of veterans with lung function meeting clinical thresholds used to determine eligibility for lung resection for cancer, lung volume reduction surgery (LVRS), and lung transplantation referral. We estimated the change for each level of U.S. Department of Veterans Affairs service connection and financial impact. Results: We identified 44,892 veterans (Asian, 0.5%; Black, 11.8%; White, 80.8%; and Hispanic, 1.8%). When changing to a single reference equation, Asian and Black veterans had reduced predicted lung function that could result in less surgical lung resection (4.4% and 11.1%, respectively) while increasing LVRS (1.7% and 3.8%) and lung transplantation evaluation for Black veterans (1.2%). White veterans had increased predicted lung function and could experience increased lung resection (8.1%), with less LVRS (3.3%) and lung transplantation evaluation (0.9%). Some Asian and Black veterans could experience increases in monthly disability payments (+$540.38 and +$398.38), whereas White veterans could see a decrease (-$588.79). When aggregated, Hispanic veterans experienced changes attributable to their racial identity and, because this sample was predominantly Hispanic White, had similar results to White veterans. Conclusions: Changing the reference equation could affect access to treatment and disability benefits, depending on race. If adopted, the use of discrete clinical thresholds needs to be reassessed, considering patient-centered outcomes.

Twenty four-month follow-up after bullectomy, unilateral and bilateral lung volume reduction surgery: a single-center retrospective analysis of consecutive cases

PurposeWhile pharmacologic therapy remains the cornerstone of lung emphysema treatment, surgery is an additional therapeutic option in selected patient groups with advanced emphysema. The aim of lung volume reduction surgery (LVRS) is to improve lung function, exercise capacity, quality of life and survival. We sought to determine the therapeutic value of surgical resection in specific patients with lung emphysema.Patients and methodsA retrospective study was performed consisting of 58 patients with lung emphysema who underwent surgical intervention over a 10-year period and were followed for 2 years postoperatively. The clinical characteristics recorded were FEV1 (forced expiratory volume in 1 s), the 6-min walk test (6-MWT), the Modified Medical Research Council (mMRC), body mass index (BMI) and quality of life prior to and 6, 12 and 24 months after surgical intervention. Moreover, all peri- and post-operative complications were noted.ResultsOut of 58 emphysema patients (72% male, FEV1 (L) 2.21 ± 0.17, RV (L) 3.39 ± 0.55), 19 underwent surgical bullectomy, 31 unilateral LVRS and 8 sequential bilateral LVRS. Six months after surgery, there was a statistically significant improvement in FEV1, RV, TLC, 6-MWT and mMRC. Over a period of 12 to 24 months postoperatively, clinical benefit gradually declines most likely due to COPD progression but patients still experienced a significant improvement in FEV1. The most common postoperative complications were persistent air leakage (> 7 days), arrhythmia and subcutaneous emphysema in 60%, 51.6% and 22.4%, respectively. No deaths were observed after surgical intervention.ConclusionIn a selected patient population, surgery led to significant improvement of lung function parameters, exercise capacity and quality of life. Over a period of 12 to 24 months postoperatively, clinical benefit gradually decreased most likely due to COPD progression.

Lung volume reduction surgery is safe and feasible after initial endobronchial valve treatment for emphysema patients.

Bronchoscopic lung volume reduction with endobronchial valves is a guideline treatment leading to improved pulmonary function, exercise tolerance and quality of life, in patients with advanced emphysema, severe hyperinflation and no collateral ventilation. After valve treatment, loss of the initial lung volume reduction effect can occur, as well as local valve-induced complications such as persistent haemoptysis. In these cases, a surgical lobectomy can be considered to achieve similar efficacy outcomes. We evaluated the safety and feasibility of a video-assisted thoracoscopic surgery lobectomy after valve treatment. This single-centre retrospective study included patients who underwent an elective lobectomy after previous valve treatment. Data were evaluated for safety and efficacy for the additional surgical procedure. Twenty-one patients [73% female, median age 67 (7) years, forced expiratory volume in 1 s 29 (7) %pred, and residual volume 223 (58) %pred] were included. There was no 90-day mortality and there were no postoperative intensive care admissions. Pulmonary infections (14%) and prolonged air leak (14%) were the most common complications. In patients who underwent surgery due to loss or lack of effect of valve treatment, a lobectomy led to a significant improvement in pulmonary function; median forced expiratory volume in 1 s +75 (193) ml (P < 0.013), forced vital capacity +450 (572) ml (P = 0.001), residual volume -665 (715) ml (P = 0.005). In patients who underwent a lobectomy because of complications of valve treatment, all complications were resolved after surgery. We demonstrate that an elective lobectomy after an initial valve treatment is safe and feasible and restores the lung volume reduction effect.

Bronchoscopic Lung Volume Reduction as the Treatment of Choice versus Robotic-Assisted Lung Volume Reduction Surgery in Similar Patients with Emphysema - An Initial Experience of the Benefits and Complications.

There is an assumption that because EBLVR requires less use of hospital resources, offsetting the higher cost of endobronchial valves, it should therefore be the treatment of choice wherever possible. We have tested this hypothesis in a retrospective analysis of the two in similar groups of patients. In a 4-year experience, we performed 177 consecutive LVR procedures: 83 patients underwent Robot Assisted Thoracoscopic (RATS) LVRS and 94 EBLVR. EBLVR was intentionally precluded by evidence of incomplete fissure integrity or intra-operative assessment of collateral ventilation. Unilateral RATS LVRS was performed in these cases together with those with unsuitable targets for EBLVR. EBLVR was uncomplicated in 37 (39%) cases; complicated by post-procedure spontaneous pneumothorax (SP) in 28(30%) and required revision in 29 (31%). In the LVRS group, 7 (8%) patients were readmitted with treatment-related complications, but no revisional procedure was needed. When compared with uncomplicated EBLVR, LVRS had a significantly longer operating time: 85 (14-82) vs 40 (15-151) minutes (p<0.001) and hospital stay: 7.5 (2-80) vs 2 (1-14) days (p<0.01). However, LVRS had a similar total operating time to both EBLVR requiring revision: 78 (38-292) minutes and hospital stay to EBLVR complicated by pneumothorax of 11.5 (6.5-24.25) days. Use of critical care was significantly longer in RATS group, and it was also significantly longer in EBV with SP group than in uncomplicated EBV group. Endobronchial LVR does use less hospital resources than RATS LVRS in comparable groups if the recovery is uncomplicated. However, this advantage is lost if one includes the resources needed for the treatment of complications and revisional procedures. Any decision to favour EBLVR over LVRS should not be based on the assumption of a smoother, faster perioperative course.

Management of Refractory Chronic Obstructive Pulmonary Disease: A Review.

Chronic obstructive pulmonary disease (COPD) is a common condition with an estimated prevalence of 12% in adults over the age of 30 years worldwide. COPD is a leading cause of morbidity and mortality globally, with a substantial economic and social burden. There are an estimated 3 million deaths annually due to COPD. However, most of the patients with COPD respond to routine interventions like bronchodilator therapy, assessing supplemental oxygen needs, smoking cessation, vaccinations, and pulmonary rehabilitation. There is a significant number of patients who unfortunately progress to have persistent symptoms despite these interventions. Refractory COPD is not yet formally defined. Patients with severe persistent symptoms or exacerbations despite appropriate care can be considered to have refractory COPD. Managing refractory COPD needs a multidimensional approach. In this review article, we will discuss essential interventions like ensuring adequate inhaler techniques, exploring the need for non-invasive ventilatory support, use of chronic antibiotics and phosphodiesterase inhibitors to advanced therapies like bronchoscopic lung volume reduction surgery, and the upcoming role of anti-IL5 agents in managing patients with refractory COPD. We will also discuss non-pharmacologic interventions like psycho-social support and nutritional support. We will conclude by discussing the palliative care aspect of managing patients with refractory COPD. Through this review article, we aim to better the approach to managing patients with refractory COPD and discuss new upcoming therapies.

First in Human Phase 1 Clinical Trial of Stereotactic Irradiation to Achieve Lung Volume Reduction (SILVR) in Severe Emphysema

PurposeOnly a subset of patients with severe emphysema qualify for lung volume reduction surgery or endobronchial valves. We previously demonstrated that Stereotactic Ablative Radiotherapy (SABR) of lung tumors reduces lung volume in treated lobes by creating localized lung fibrosis. We aimed to determine the safety and, secondarily, explore the efficacy of Stereotactic Irradiation for Lung Volume Reduction (SILVR) over 18 months following intervention in patients with severe emphysema. Methods and materialsWe conducted a single-arm prospective clinical trial in eligible patients with severe emphysema treated with unilateral SABR (45 Gy in three fractions) to a target within the most emphysematous region. Primary outcome was safety i.e., incidence of grade≥3 adverse events. Secondary outcomes of efficacy were also explored. ResultsEight subjects received the intervention. Median (range) baseline characteristics were age 73 years (63-78), FEV1% 28.5% (19.0-42.0), DLCO% 40% (24.0-67.0), and BODE index 5.5 (5-9). The incidence of grade≥3 adverse events was 3/8 (37.5%). The relative Δtarget lobe volume was -23.1% (-1.6,-41.5) and -26.5% (-20.6,-40.8) at six and 18 months, respectively. Absolute ΔFEV1% was greater in subjects with BODE index ≤5 vs. ≥6 (+12.0% vs. -2.0%). The mean baseline lung density (in Hounsfield units, reflecting the amount of preserved parenchyma) within the intermediate dose volume (V60BED3) correlated with the absolute Δtarget lobe volume at 18 months. ConclusionsStereotactic Irradiation for Lung Volume Reduction appears to be safe, with a signal for efficacy as a novel therapeutic alternative for patients with severe emphysema. SILVR may be most safe/effective in patients with lower BODE index and/or less parenchymal destruction.

Safety of Home Discharge With a Chest Tube After Bronchoscopic Lung Volume Reduction Complicated by Persistent Airleak.

The incidence of pneumothorax after bronchoscopic lung volume reduction (BLVR) using Zephyr (Pulmonx Corporation) endobronchial valves is ~26%. Many patients who develop a postprocedural pneumothorax require chest tube placement. If a persistent airleak is present, patients tolerating waterseal can be discharged home with a mini-atrium with a low risk of empyema. Data were collected on patients from the Epic (Epic System Corporation) electronic medical record between July 2019 and November 2022. Our retrospective study reviewed a total of 102 BLVR procedures. Twenty-six of these procedures were complicated by a pneumothorax post-BLVR (25%). After 24 procedures, patients were discharged home with a chest tube after a persistent airleak. The primary endpoint of the study was the incidence of intrapleural infection in this population. The secondary endpoint was the average length of time the chest tube was in place until outpatient removal. Out of the 24 discharge events, 2 events (8.3%) were complicated by an intrapleural infection before chest tube removal. The average number of days requiring a chest tube until outpatient removal was 16.9 days, which is similar to the duration observed in patients discharged home with a chest tube after lung volume reduction surgery. Discharging patients home with a chest tube after BLVR therapy is safe and may reduce hospital length of stay. Our study shows the incidence of intrapleural infection after home discharge with a chest tube after BLVR is low.

Endobronchial coil lung volume reduction performed on patients with emphysema dominant COPD: Long term follow-up results.

Chronic obstructive pulmonary disease (COPD) is a commonly seen, preventable, and treatable disease with permanent respiratory symptoms and air entrapment that is caused by particle exposure. In case of limited response to traditional treatment protocols, lung volume reduction may be performed in patients with emphysema dominant patterns. In this study, long term follow-up results of the patients who had been operated on by minimal invasive bronchoscopic lung volume reduction surgery by coil placement were reported. Records of the patients operated on by coil placement were retrospectively investigated, and pulmonary function test (PFT), echocardiography (ECHO), six-minute walking test (6MWT), tomography images, ventilation scintigraphy, and clinical summaries were evaluated. Out of 34 initial candidates, 18 patients were included in the study. Wilcoxon signed-rank test and Spearman's rho were utilized to compare interventions and follow-up testing. The average age of 18 patients was 62 (50-74) years, and except for one patient, all were males (n= 17). Fifteen patients were operated bilaterally, and the rest were unilaterally operated, with an average of 10 coils placed per coil placement. An average of 90 days was between bronchoscopic coil placement, with a follow-up duration of 45 days in between. Mean total follow-up duration was 794 (± 424) days. Pneumonia and pneumonitis were seen in 33% of patients within the first month. Mortality from respiratory causes was found to be 11%, while mortality from all causes was found to be 22%. Statistical difference was observed regarding 6MWT after bronchoscopic volume reduction when compared the initial preoperative values. However, this difference was later lost statistically at the second follow-up performed after the completion of both sides. A benefit in improved resting saturation was observed after the second procedure, which was not evident after unilateral intervention. However, similiar to 6MWT, this benefit was lost at the second follow-up, with resting saturation instead being effected negatively. No difference was observed in PFT results; however, a correlation was seen between FEV1 and walking distance. No specific correlation had been seen in the ECHO evaluation. Benefits regarding 6MWT and resting saturation were observed in patients undergoing minimal invasive bronchoscopic lung volume reduction surgery with coils. This benefit was evident in the short term but was lost as the follow-up duration increased. A relatively high morbidity and mortality rate was also present, further stating the risky nature of pulmonary intervention, even minimally invasive procedures, on patients with COPD.

Implementation of an enhanced recovery protocol for lung volume reduction surgery: an observational cohort study.

Lung volume reduction surgery (LVRS) is an established therapeutic option for advanced emphysema. To improve patients' safety and reduce complications, an enhanced recovery protocol (ERP) was implemented. This study aims to describe and evaluate the short-term outcome of this ERP. This retrospective single-centre study included all consecutive LVRS patients (1 January 2017 until 15 September 2020). An ERP for LVRS was implemented and stepwise optimised from 1 August 2019, it consisted of changes in pre-, peri- and postoperative care pathways. Patients were compared before and after implementation of ERP. Primary outcome was incidence of postoperative complications (Clavien-Dindo), and secondary outcomes included chest tube duration, incidence of prolonged air leak (PAL), length of stay (LOS) and 90-day mortality. Lung function and exercise capacity were evaluated at 3 and 6 months post-LVRS. Seventy-six LVRS patients were included (pre-ERP: n=41, ERP: n=35). The ERP cohort presented with lower incidence of postoperative complications (42% vs 83%, P=0.0002), shorter chest tube duration (4 vs 12 days, P<0.0001) with a lower incidence of PAL (21% vs 61%, P=0.0005) and shorter LOS (6 vs 14 days, P<0.0001). No in-hospital mortality occurred in the ERP cohort versus 4 pre-ERP. Postoperative forced expiratory volume in 1 s was higher in the ERP cohort compared to pre-ERP at 3 months (1.35 vs 1.02 l) and at 6 months (1.31 vs 1.01 l). Implementation of ERP as part of a comprehensive reconceptualisation towards LVRS, demonstrated fewer postoperative complications, including PAL, resulting in reduced LOS. Improved short-term functional outcomes were observed at 3 and 6 months.

Lung volume reduction surgery is safe and leads to functional improvement in patients who fail or cannot undergo bronchoscopic lung volume reduction

BackgroundBronchoscopic lung volume reduction (BLVR) has supplanted surgery in the treatment of patients with advanced emphysema, but not all patients qualify for it. Our study aimed to investigate the outcomes of lung volume reduction surgery (LVRS) among patients who either failed BLVR or were not candidates for it. MethodsWe conducted a retrospective analysis of patients who underwent LVRS for upper lobe–predominant emphysema at a single tertiary center between March 2018 and December 2022. The main outcomes measures were preoperative and postoperative respiratory parameters, perioperative morbidity, and mortality. ResultsA total of 67 LVRS recipients were evaluated, including 10 who had failed prior valve placement. The median patient age was 69 years, and 35 (52%) were male. All procedures were performed thoracoscopically, with 36 patients (53.7%) undergoing bilateral LVRS. The median hospital length of stay was 7 days (interquartile range, 6-11 days). Prolonged air leak (>7 days) occurred in 20 patients. There was one 90-day mortality from a nosocomial pneumonia (non–COVID-related) and no further deaths at 12 months. There were mean improvements of 10.07% in forced expiratory volume in 1 second and 4.74% in diffusing capacity of the lung for carbon monoxide, along with a mean decrease 49.2% in residual volume (P < .001 for all). The modified Medical Research Council dyspnea scale was improved by 1.84 points (P < .001). ConclusionsLVRS can be performed safely in patients who are not candidates for BLVR and those who fail BLVR and leads to significant functional improvement. Long-term follow-up is necessary to ensure the sustainability of LVRS benefits in this patient population.

A Relationship Between Preoperative Inspiratory Lung Resistance And Emphysema-Reduction Surgery Outcome

Background Surgery to reduce lung volume has recently been reintroduced to alleviate dyspnea and improve exercise tolerance in selected patients with emphysema. A reliable means of identifying patients who are likely to benefit from this surgery is needed. Methods We measured lung resistance during inspiration, static recoil pressure at total lung capacity, static lung compliance, expiratory flow rates, and lung volumes in 29 patients with chronic obstructive lung disease before lung-volume–reduction surgery. The changes in the forced expiratory volume in one second (FEV1) six months after surgery were related to the preoperatively determined physiologic measures. A response to surgery was defined as an increase in the FEV1 of at least 0.2 liters and of at least 12 percent above baseline values. Results Of the 29 patients, 23 had some improvement in FEV1 including 15 who met the criteria for a response to surgery. Among the variables considered, only preoperative lung resistance during inspiration predicted changes in expiratory flow rates after surgery. Inspiratory lung resistance correlated significantly and inversely with improvement in FEV1 after surgery (r=—0.63, P&lt;0.001). A preoperative criterion of an inspiratory resistance of 10 cm of water per liter per second had a sensitivity of 88 percent (14 of 16 patients) and a specificity of 92 percent (12 of 13 patients) in identifying patients who were likely to have a response to surgery. Conclusions Preoperative lung resistance during inspiration appears to be a useful measure for selecting patients with emphysema for lung–volume– reduction surgery

Endobronchial Valves for the Management of Severe Emphysema

What Is the Issue?&#x0D; &#x0D; People with severe emphysema who do not experience relief with non-invasive therapies such as medication, physical activity, and smoking cessation may need advanced treatments.&#x0D; Endobronchial valves are an alternative therapy that may improve exercise capacity and quality of life, and are less invasive compared to lung reduction surgery or transplants.&#x0D; &#x0D; What Did We Do?&#x0D; &#x0D; A 2019 CADTH report summarized clinical effectiveness evidence for valves compared to standard care. CADTH sought to update this evidence with new clinical research and include information on cost-effectiveness, which was not part of the previous report.&#x0D; A research information specialist conducted a literature search of the peer-reviewed and grey literature with a search strategy focused on emphysema and endobronchial valves. The search was limited to English-language documents published since 2018. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.&#x0D; &#x0D; What Did We Find?&#x0D; &#x0D; We did not find systematic reviews or health technology assessments published since 2018 that contained clinical evidence not already captured in the 2019 CADTH report. Two RCTs provide updated clinical evidence for endobronchial valves compared to standard care, and 1 RCT contains evidence on valves compared to lung surgery.&#x0D; The evidence suggests that valves may improve lung function, breathing ability, and physical activity in middle-aged and older adults with emphysema compared to standard care; the effect on quality of life and safety is unclear. The previous CADTH report showed lung function, breathing ability, physical activity, and quality of life were favourable for valve treatment compared to standard care.&#x0D; The previous CADTH report showed that valves resulted in harmful outcomes compared to standard care; however, in the current review, safety was difficult to assess due to poor reporting.&#x0D; When comparing valves to lung surgery, lung surgery may improve quality of life compared to valves; other outcomes did not favour one therapy over another.&#x0D; For cost-effectiveness, valves may be favourable compared to standard medical care, while their cost-effectiveness compared to lung volume reduction surgery is unclear.&#x0D; One study was conducted in Canada, and no studies were conducted in children and younger adults.&#x0D; &#x0D; What Does it Mean?&#x0D; &#x0D; Endobronchial valves are a potential therapy for people with severe emphysema with some favourable clinical and cost outcomes, but the evidence for their safety is unclear.&#x0D; Decision-makers may wish to consider the balance of favourable and harmful effects in existing evidence before more high-quality evidence in Canada, especially for safety, is available.&#x0D;

Predictors of reoperation after lung volume reduction surgery

ObjectivesLung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation.Our aim was to analyse reoperations after LVRS and identify potential predictors.MethodsConsecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3–5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered.ResultsIn total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11–33) vs. 5 days (3–11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02).ConclusionsOur incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line.Graphical abstractKey question: What characterizes reoperations after lung volume reduction surgeries?Key findings: Lung injuries were predominantly located away from the original surgical site.Take home message: Lung injuries remote from the stapler line is frequent during reoperation after lung volume reduction surgery.Location of lung injuries found during reoperation after lung volume reduction surgery

Lung Volume Reduction Surgery (Clinical Cases)

Emphysema is a chronic lung disease in which the walls of the alveoli in the lungs weaken and collapse; leaving abnormally large residual spaces filled with air even when the patient exhales. The most common symptoms of emphysema are shortness of breath (dyspnea); cough; fatigue; and weight loss. Emphysema often coexists with chronic obstructive pulmonary disease. The treatment of emphysema requires a multidisciplinary approach; including education; exercise; tobacco cessation; oral and inhaled medications; oxygen therapy; and lung transplantation. Lung volume reduction surgery (LVRS) may be an option for patients who experience shortness of breath and whose pulmonary function tests show severe obstruction and enlarged lungs. The surgery aims to remove the least functional part of the lung to improve airflow; diaphragm; and chest wall mechanics; as well as alveolar gas exchange in the remaining lung. Objective — to familiarize doctors with the clinic’s experience in reducing lung volume in patients with bullous emphysema. Materials and methods. Our clinic performed the following surgical interventions to reduce lung volume: VATS resection of large (giant) lung bullae — 14 (77.7 %) cases; VATS lo­­bec­tomy — 2 (11.1 %); lobectomy through thoracotomy — 1 (5.6 %); VATS sublobar resection — 1 (5.6 %). Results and discussion. There were no fatalities. The following postoperative complications were recorded: prolonged under-expansion of the operated lung in 5 (27.7 %) cases; empyema of the residual pleural cavity with bronchial fistula in 1 (5.6 %). The overall incidence of postoperative complications was 33.3 %. Two patients with prolonged underdistension of the operated lung required reoperation (VATS revision of the pleural cavity and redilation). The patient who developed pleural empyema with a bronchial fistula underwent bronchial blockage with a satisfactory result. In all cases of LVRS; a positive clinical effect was recorded in the first 3 months after surgery. During the follow-up period of up to 2 years; only 2 (11.1 %) patients showed no clinical effect and signs of progression of chronic obstructive pulmonary disease and respiratory failure were observed. Conclusions. Lung volume reduction surgery is a method of treating bullous lung disease that allows achieving overall treatment effectiveness in the follow-up period of up to 3 months in 100 % of cases; and in the follow-up period of up to 2 years — in 89.9 %. The high rate of postoperative complications in LVRS requires a physician to carefully select patients for surgery and monitor their condition daily in the postoperative period.

Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions.

Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.