Surgical Lung Volume Reduction Research Articles

Role of quantitative planar lung perfusion scintigraphy and tomography in identifying target lobes in patients with emphysematous phenotype of advanced chronic obstructive pulmonary disease: a retrospective cross-sectional study.

Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable disease. Despite optimal medical therapy and pulmonary rehabilitation, bronchoscopic and surgical lung volume reduction may still be necessary. Identifying the target lobe is crucial for the success of these treatments. This study aims to compare the role of quantitative planar lung perfusion scintigraphy (QPLPS) with quantitative lung computed tomography (StratX®), which is used in identifying the target lobe before the Zephyr® endobronchial valve (EBV) placement in patients with the emphysematous phenotype of advanced COPD. A single-center retrospective cross-sectional study was performed in the Department of Pulmonology at the University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital between June 2019 and June 2022. The study included 46 patients with the emphysematous phenotype of advanced COPD, who were all candidates for Zephyr® EBV therapy. The target lobes were assessed using the QPLPS and StratX® and the agreement between the methods was analyzed by the Kappa statistic method. Additionally, demographic characteristics, respiratory function tests, distributions of emphysema, and 6-minute walk test results of patients were recorded. The median age was 67 (42-80) years and 42 (91.3%) were male. In QPLPS, the perfusion percentages were 7.47%±3.31%, 9.59%±2.67%, and 13.32%±2.59% for the 1st, 2nd and 3rd target lobes, respectively while in StratX®, the voxel densities were 68.28%±9.16%, 63.79%±7.42%, and 60.69%±5.35%. In StratX®, the fissure integrity (FI) at the target lobe was 76.25%±21.18%, 84.68%±17.67%, and 86.19%±13.19%, respectively. There was a significant agreement between the methods in identifying the first, second, and third target lobes in all patients (Kappa coefficient: 0.897, 0.700, and 0.522), and also in identifying the first and second target lobes in patients with heterogeneous (Kappa coefficient: 0.879, and 0.735), and homogeneous subgroups (Kappa coefficient: 0.919, and 0.672). There is an agreement between QPLPS and StratX® in identifying the target lobe in patients with severe emphysema, including those with homogeneous diseases. However, StratX® may be preferred, considering that it also predicts FI.

Endoscopic Lung Volume Reduction Prior to Lung Transplantation Does Not Increase Postoperative Pulmonary Complications

Introduction: Lung transplantation (LTx) remains the only therapeutic option for selected patients with end-stage lung disease. In comparison to surgical lung volume reduction, few data exist on the risks and benefits of pretransplant endoscopic lung volume reduction (eLVR). Here, we investigate the risk of postoperative pulmonary complications (PPCs) after LTx in patients with emphysematous lung disease bridged with eLVR until transplantation. Methods: Eighty-two patients with emphysematous lung disease who underwent double-LTx (DLTx) were included and retrospectively evaluated. Statistical analysis was performed using SPSS and GraphPad Prism software. Results: 28/82 patients underwent eLVR prior to DLTx. eLVR patients spent comparable time on the waitlist; however, they were older at the time of DLTx (median 60 vs. 58 years, p = 0.02). Both groups showed comparable 90-day (92%) and long-term survival (eLVR 1-/5-/10-year survival: 92/88/77%, vs. control: 89/77/67%, p = 0.5). The odds for PPCs were similar in patients with and without eLVR (OR 0.7; 95% CI: 0.3–1.7), as well as major perioperative surgical and cardiovascular complications. In the entire cohort, we found ≥1 PPC to be a risk factor for death within 90 days (OR 9.7, 95% CI: 1.3–110). Among the PPCs, pneumonia (HR 4.6 95% CI: 1.1–14.9, p = 0.02) and ARDS (HR 11.2 95% CI: 1.6–229.2, p = 0.04) were identified as independent risk factors for reduced long-term survival. Conclusions: eLVR does not increase the risk for PPCs, surgical complications, or reduced survival after LTx in patients with emphysematous lung disease and can serve as a bridge to LTx.

Surgical or bronchoscopic lung volume reduction for emphysema therapy

More than 20 years ago, surgical lung volume reduction (LVRS) was already established in patients with advanced emphysema as a palliative therapy option that reduces respiratory distress and improves lung function and quality of life. In addition, bronchoscopic procedures (BLVR) aimed at volume reduction have existed for just over 10 years. The advantages and disadvantages of LVRS and BLVR are discussed in this article.

Bronchoscopic Management of COPD and Advances in Therapy.

Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent and morbid disease marked by irreversible structural changes in the lungs. Bronchoscopic therapies have significantly expanded the treatment armamentarium for patients with persistent symptoms by reducing the physiologic detriments of hyperinflation in a less invasive fashion than surgical lung volume reduction. The spectrum of bronchoscopic techniques to reduce hyperinflation includes endobronchial valves, coils, thermal ablation, and biologic sealants. Other therapies focus on reducing parasympathetic tone and mucus hypersecretion and include targeted lung denervation, bronchial rheoplasty, and cryospray techniques. In this article, we will review the variety of techniques for bronchoscopic lung volume reduction, both established and investigational, along with their respective benefits and complications and will briefly review other investigational therapies for COPD.

Cost-effectiveness analysis of surgical lung volume reduction compared with endobronchial valve treatment in patients with severe emphysema

Lung volume reduction, either by surgery or bronchoscopically by endobronchial valve treatment have been shown to be a cost-effective alternative compared with conservative therapy. However, there is no comparative analysis of lung volume reduction by surgery and bronchoscopic lung volume reduction using endobronchial valves. The aim of this retrospective study was to provide a cost-effectiveness analysis of lung volume reduction by surgery compared with bronchoscopic lung volume reduction using endobronchial valves. The effectiveness of lung volume reduction was assessed using forced expiratory volume in the first second (FEV1), residual volume (RV) and 6-minute walking distance (6MWD), measured at baseline and at 4 to 12 weeks. Cost unit accounting derived from SwissDRG was used as a surrogate of the costs from the payer's perspective. In total, 67 patients (37 men and 30 women) with a mean age of 68.3 ± 7.4 years were included. Both clinical effectiveness and costs were comparable between surgical and bronchoscopic lung reduction. The incremental cost-effectiveness ratios (ICERs) for bronchoscopic compared with lung volume reduction by surgery for FEV1, RV and 6MWD were -101, 4 and 58, respectively. For RV and 6MWD, it could be shown that endobronchial valve treatment is justified as a probably cost-effective alternative to lung volume reduction by surgery. Endobronchial valve treatment resulted in an improvement of 0.25 quality-adjusted life years (QALYs) and an ICER of € 7657 per QALY gained. A robust statement on the superiority of one of the two procedures in terms of cost-effectiveness cannot be made from the present study. Therefore, the study is not suitable for resource allocation. Two upcoming trials comparing lung volume reduction surgery and endobronchial valve treatment may be able to answer this question.

Meta-analysis and Systematic Review of Bronchoscopic Lung Volume Reduction Through Endobronchial Valves in Severe Emphysema.

Pharmacologic therapeutics for advanced emphysema have limited benefit. Bronchoscopic lung volume reduction with endobronchial valves (EBVs) have reported improvements in lung function, breathlessness, and quality of life through randomized clinical trials, with less morbidity as comparted to Surgical Lung volume Reduction. We here present a Meta-analysis and systematic review of bronchoscopic lung volume reduction in advanced chronic obstructive lung disease patients. PubMed (NLM), Embase (Elsevier), and Web of Science (Clarivate Analytics) search was conducted using a combination of keywords and subject headings. The search was confined to the last 15 years and was completed on October 23, 2020. Only placebo-controlled randomized control trials of emphysema patients with EBV were included. Quality assessment was done by 2 independent reviewers. Nine studies were included for the meta-analysis with a total number of 1383 patients of whom 888 received EBV and 495 standard of care (SOC) medications. Our Metanalysis show statistically significant improvement in forced expiratory volume in first second, percentage forced expiratory volume in first second, St. George's respiratory questionnaire, and 6-minute walk distance in EBV group compared with SOC. Residual volume had statistically significant reduction after EBV placement compared with SOC. These differences continued to be present during short-term (<=6 mo) and long-term follow-up (>=6 mo). These improvements were even higher when the EBV patients'. Collateral ventilation was negative/fissure was intact (CV-/FI >90%). The rate of hemoptysis and pneumothorax was higher in the EBV group compared with SOC, however, did not lead to increased fatal outcomes. In conclusion, EBV has favorable effects on patients' outcomes in patients who have heterogeneous emphysema particularly with no collateral ventilation.

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

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

Endoscopic lung volume reduction coils for patients with severe emphysema-a single-centre retrospective analysis.

Patients with chronic obstructive pulmonary disease and lung emphysema may benefit from surgical or endoscopic lung volume reduction (ELVR). Previously reported outcomes of nitinol coil-based ELVR techniques have been ambiguous. The analysis was done to analyse outcomes of ELVR with nitinol coils in patients with severe pulmonary emphysema. From September 2013 to November 2014, our centre performed a total of 41 coil implantations on 29 patients with severe emphysema. Coils were bronchoscopically placed during general anaesthesia. Twelve out of 29 patients received staged contralateral treatments up to 112 days later to avoid bilateral pneumothorax. Lung function and 6-min walking distance were assessed 1 week prior, 1 week after as well as 6-12 months after the procedure. Patients were followed up to 48 months after ELVR and overall mortality was compared to a historic cohort. While coil-based ELVR led to significant short-term improvement of vital capacity (VC, +0.14 ± 0.39 l, P = 0.032) and hyperinflation (Δ residual volume/total lung capacity -2.32% ± 6.24%, P = 0.022), no significant changes were observed in 6-min walking distance or forced expiratory volume in 1 s. Benefits were short-lived, with only 15.4% and 14.3% of patients showing sustained improvements in forced expiratory volume in 1 s or residual volume after 6 months. Adverse events included haemoptysis (40%) and pneumothorax (3.4%), major complications occurred in 6.9% of cases. Overall survival without lung transplant was 63.8% after 48 months following ELVR, differing insignificantly from what BODE indices of patients would have predicted as median 4-year survival (57%) at the time of ELVR treatment. ELVR with coils can achieve small and short-lived benefits in lung function at the cost of major complications in a highly morbid cohort. Treatment failed to improve 4-year overall survival. ELVR coils are not worthwhile the risk for most patients with severe emphysema.

Bronchoscopic lung volume reduction: status quo.

Emphysema is associated with irreversible loss of lung compliance leading to gas trapping and hyperinflation. Surgical lung volume reduction has proven to improve lung function, exercise capacity, cardiac health and survival in patients with advanced emphysema; however, this procedure is associated with significant morbidity and mortality. Bronchoscopic lung volume reduction (BLVR) has emerged as an alternative approach for these patients. In this article, we review the different techniques used for the purpose of this procedure, its advantages and disadvantages. In addition, we discuss in length valve therapy and the studies that led to its recent FDA approval. Finally, we provide thought-provoking challenges that may be topics for further future investigation to enhance the efficacy and benefit of this technique.

Clinical vignette of bronchoscopic thermal vapour ablation: Malaysians’ first experience

We report a case of severe emphysema with bullae in a patient who underwent the new technique of bronchoscopic lung volume reduction to the right upper lobe. He was symptomatic with breathlessness and frequent exacerbations. He was not deemed suitable for a surgical lung volume reduction or bullectomy due to a very low forced expiratory volume in one second (FEV1). Endobronchial valves were not considered due to the incomplete fissures. The case was carefully screened, and was discussed in a multidisciplinary meeting prior to the final decision. This was the first case in Malaysia of bronchoscopic thermal vapour ablation (BTVA) for severe advanced emphysema. Multiple experts were involved prior, during and after the procedure. Despite having a poor lung reserve, he came through the procedure successfully with no immediate complications. His serial spirometry showed a 50% improvement at six months compared to baseline. This case highlights the important role of a multidisciplinary meeting, expert opinion and the careful selection of which patients should undergo BTVA. The procedure should be carried out at a centre of excellence in order to achieve a successful procedure.

Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure

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

Bronchoscopic lung volume reduction with valves: What should the internist know?

Traditional therapies for emphysema such as bronchodilators and anti-inflammatory drugs have limited value due to permanent structural changes in the emphysematous lung that result in hyperinflation. Surgical lung volume reduction partially corrects hyperinflation by removing emphysematous lung and is an option in selected patients, but it carries a risk of morbidity and death. Valve therapy is a less-invasive option that involves bronchoscopic implantation of 1-way valves in emphysematous lung segments to allow air flow and mucus clearance in the direction of central airways. The authors review the rationale, evidence, and applications of valve therapy.

Emerging Interventional Pulmonary Therapies for Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease is a condition characterized by progressive airflow limitation caused by airway and parenchymal inflammation. Current medical therapies, including bronchodilators, corticosteroids, and anti-inflammatory medications, have been shown to variably improve pulmonary function or quality of life without providing a long-term mortality benefit. Mortality benefits to therapy have been demonstrated in only 2 therapeutic interventions to date: long-term use of daily supplemental oxygen and surgical lung volume reduction (LVRS) for upper-lobe-predominant disease in patients with a low baseline exercise capacity. Newer bronchoscopic techniques for lung volume reduction (bLVR) have attracted interest from clinicians and researchers. To achieve successful results, these advanced therapies require an interdisciplinary approach between general and interventional pulmonologists and thoracic radiologists. In this article, we aim to review the latest interventional pulmonary techniques for treatment of chronic obstructive pulmonary disease with an emphasis on bLVR. We will review the bLVR preprocedure imaging evaluation, postprocedure imaging findings, and explore the potential benefits and risks of therapy based on the most recent clinical trial evidence.

Normalisation ventilatoire après réduction de volume pulmonaire naturelle consécutive à une infection pulmonaire

Lung volume reduction can be effective in appropriately selected patients with severe emphysema and is associated with reduced breathlessness and improved survival. Spontaneous resolution of emphysematous bullae can also sometimes occur. We report a case of severe smoking-related emphysema in a 60-year-old patient, who presented in October 2013 with a right upper lobe acute community-acquired pneumonia on the background of previously undocumented emphysema. The patient improved following treatment with co-amoxiclav and serial radiology showed progressive cicatricial retraction. Nine months later there had been a major functional improvement characterized by a complete normalization of the patient's ventilatory parameters, specifically a 45% improvement in FEV1. In the literature, the average FEV1 improvement obtained by surgical or endoscopic lung volume reduction techniques does not exceed 28%. Rarely, emphysematous bullae resolve following infections. Further studies of the mechanisms involved in these natural regressions may be of interest in the development of new therapeutics.

Computed Tomography Imaging for Novel Therapies of Chronic Obstructive Pulmonary Disease.

Novel therapeutic options in chronic obstructive pulmonary disease (COPD) require delicate patient selection and thus demand for expert radiologists visually and quantitatively evaluating high-resolution computed tomography (CT) with additional functional acquisitions such as paired inspiratory-expiratory scans or dynamic airway CT. The differentiation between emphysema-dominant and airway-dominant COPD phenotypes by imaging has immediate clinical value for patient management. Assessment of emphysema severity, distribution patterns, and fissure integrity are essential for stratifying patients for different surgical and endoscopic lung volume reduction procedures. This is supported by quantitative software-based postprocessing of CT data sets, which delivers objective emphysema and airway remodelling metrics. However, the significant impact of scanning and reconstruction parameters, as well as intersoftware variability still hamper comparability between sites and studies. In earlier stage COPD imaging, it is less clear as to what extent quantitative CT might impact decision making and therapy follow-up, as emphysema progression is too slow to realistically be useful as a mid-term outcome measure in an individual, and longitudinal data on airway remodelling are still very limited.

A New-Designed Lung-Bending Device for Bronchoscopic Lung Volume Reduction of Severe Emphysema: A Feasibility Study in Pigs

Background: Bronchoscopic therapies are less invasive alternatives of surgical lung volume reduction for severe emphysema. Bending of lung tissue by implanting metallic coils into bronchi is one of the procedures. A new-designed device with a similar rationale, Reverser, has been developed with some improvements. Objectives: The aim of the study was to evaluate the safety and feasibility of the Reversers. Methods: Twelve healthy pigs were randomly divided into 3 groups (groups A, B, and C). The Reversers were implanted bronchoscopically into the selected airways using a proprietary delivery system. Physical examination, chest fluoroscopy, computed tomography (CT) scans, and bronchoscopic observations were performed before implantation and during the follow-up period. Necropsy was performed respectively at 1 month (group A), 3 months (group B), and 6 months (group C) after implantation. Results: A total of 47 Reversers were implanted successfully. The procedure was feasible and well tolerated by all pigs. No severe complications, such as pneumothorax, abscesses, and airway hemorrhage, were found. No unintended injuries or death occurred. Mild granulation and inflammation were observed in the airway wall. Opacities around Reversers were shown on CT scans in some pigs. In the pigs with opacities, histological evaluation revealed widened alveolar septa due to inflammatory cell infiltration in the vicinity of the Reversers. On the analysis of CT data, there was a trend for volume reduction of the treated lung at 1 and 3 months after treatment compared with baseline. Conclusions: This study showed that Reversers were safe and feasible for bronchoscopic lung volume reduction in pigs.

Surgical and Endoscopic Lung Volume Reduction (LVR) Prior to Lung Transplantation (LuTX)

Purpose Although lung transplantation and lung volume reduction (both surgically and endoscopically: LVRS/ELVR) are well established therapies for end-stage emphysema patients, data on LVR prior to LuTX remains scarce. Thus, we aim to analyze the impact of pre-transplant LVR on post-LuTX outcomes. Methods From 1/2015 to 5/2018, 55 patients underwent bilateral LuTX for COPD and α1-AT deficiency at our center. Of those, 7 patients (12.7%) had surgical LVR prior to LuTX and 14 (25.5%) had endoscopic LVR. Those patients were compared to the other 34 patients without previous intervention. Data is presented as LVRS (n=7) vs. ELVR (n=14) vs. controls (n=34). Results Despite a significantly different distribution in sex (female: 21.4% vs. 57.1% vs. 64.7%; p=0.023), no other differences were observed in all other recipient characteristics (age: 58 vs 56 vs. 56 years | BMI: 23.2 vs. 20.9 vs. 22.15 | TLCr: 9.6 vs. 7.9 vs. 7.8L | PAP: 33 vs. 30 vs. 30mmHg | waiting time: 271 (15-2350) vs. 747 (48-2161) vs. 1098 (6-3962) days). The lung allocation score (LAS) at time of LuTX did not show any clinically relevant differences between the three groups (32.5 vs. 32.2 vs. 32.9; p=0.028). 4 patients underwent bilateral LVRS, 3 unilateral LVRS. ELVR was performed with valves in 9 cases and with coils in 6 cases, evenly distributed in all lobes. Median duration from LVR to listing for LuTX was 303 (LVRS) and 508 (ELVR) days. Median duration from LVR to LuTX was 961 (397-3194) and 823 (8-2704) days respectively. After LuTX no significant differences were observed in ICU stay (7 vs. 10 vs. 11 days), hospitalization (48 vs. 41 vs. 51 days) and lung function (3-months post-LuTX FEV1: 80% vs. 78% vs. 79% | 3-months RV: 118% vs. 120% vs. 125%). No significant differences were observed in survival (1 and 3year survival: 100% vs. 100% vs. 85.3; p=0.07). Conclusion In our recent cohort of patients, LVRS and ELVR prior to lung transplantation did not impact short- and medium-term post-LuTX outcomes. Although the benefit and the precise indications of the different LVR methods remain to be elucidated in prospective trials, LVRS and ELVR can be safely considered for patients prior to lung transplantation.

Pharmacological and non-pharmacological management of COPD; limitations and future prospects: a review of current literature

This article aimed to summarize the pharmacological and non-pharmacological management of COPD and limitations and prospects of the currently available pharmacological therapies in the management of COPD. COPD is a complex comorbid disease that irreversibly affects the pulmonary system and is considered the fifth leading cause of death worldwide. Currently, the diagnosis, assessment and management of COPD are difficult because of its complex syndrome involving numerous pulmonary and extra-pulmonary components. It is diagnosed based on the subjective and objective findings of a chronic cough, sputum production, dyspnoea, exercise intolerance and spirometry values. The GOLD report recommends bronchodilators as the first-line treatment agents in all stages of COPD severity, commonly combined with inhaled corticosteroids (ICS), methylxanthines and antibiotics, depending upon the condition and symptoms of patients. Non-pharmacological treatments of COPD include smoking cessation, influenza and pneumococcal vaccination, pulmonary rehabilitation, LTOT and surgical lung volume reduction. The efficacy of the therapy is directly related to the patients’ inhaler use training and education. A new future in COPD medication is essential to ensure the optimal management of COPD. New alternative sources should be considered in the treatment of COPD. New approaches such as e-technology can play an essential role in improving compliance and adherence to therapy. New therapies with better and long-lasting effects and minimized side effects need to be discovered to improve the pharmacological management of COPD.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE - THERAPY AND REHABILITATION

The basis of pharmacological treatment are bronchodilatory drugs, which include sympathomimetic and anticholinergic drugs. Another group of drugs dilating the bronchi is methylxanthines. In the treatment of stable course of COPD, the most common way of administering drugs is by inhalation route. Antibiotic treatment is used when the infection is the cause of COPD intensification. In patients with COPD, controlled oxygen therapy is also used. The methods of COPD surgical treatment include: (1) surgical lung volume reduction (IZOP), that is the removal of the most altered emphysema, (2) emphysema excision (bulelectomy), that is excision of emphysema which helps lung function and reduces dyspnoea, (3) transplantation of lungs is performed in patients with very advanced COPD. Respiratory rehabilitation is a supplement to pharmacological treatment. In order to implement the rehabilitation, rehabilitation programmes developed by medical centers and other healthcare institutions have been created. The current rehabilitation consists of several elements: (1) education, (2) physical exercise, (3) behavioral interaction.

Bronchoscopic Lung Volume Reduction in Patients with Severe Emphysema.

Bronchoscopic lung volume reduction (BLVR) is a minimally invasive procedure for patients with symptomatic severe emphysema who may not be candidates for surgical lung volume reduction. BLVR has been shown to improve both functional and clinical outcomes with a relatively low risk of severe complications. Any potential candidate to BLVR should be on optimal pharmacological and nonpharmacological treatment. Radiographic and pulmonary function testing provide key data to help identify potential BLVR candidates. A variety of BLVR techniques have been published with different associated benefits and risks. Current strategies include either blocking procedures such as endobronchial valves and intrabronchial valves or nonblocking procedures such as endobronchial coils and bronchoscopic thermal vapor ablation. The aim of this review is to describe current options of BLVR including their efficacy and safety based on available data.