Target Lobe Research Articles

Clinical Impact of Compensatory Hyperinflation of the Nontreated Adjacent Lobe After Bronchoscopic Lung Volume Reduction with Valves.

BackgroundBronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBV) can be a successful treatment for end-stage emphysema patients. The reduction of hyperinflation enhances ventilatory mechanics and diaphragm function. Understanding predictors for treatment success is crucial for further improvements.PurposeThe aim of this study was to assess the effect of the target lobe volume reduction (TLVR) in relation to the ipsilateral lung volume reduction (ILVR), affected by the compensatory expansion of the adjacent lobe, on the outcome after BLVR with valves.Patients and MethodsThe volumetric relationship of ILVR% to TLVR%, addressed as Reduction Ratio (R), was recorded in 82 patients and compared to changes in lung function, physical performance and quality of life. A small value for R implies a relatively low volume reduction of the ipsilateral lung (ILVR) compared to the volume reduction of the target lobe (TLVR). Additionally, the minimal clinically important difference (MCID) for R was calculated.ResultsPatients with a smaller Reduction Ratio (R <0.2) showed minor improvements at the 3 months follow-up compared to patients with R ≥0.2 (mean changes of 39 mL (5.8%), –395 mL (–4.9%) and 96 mL (7.1%) versus 231 mL (33%), –1235 mL (–20%) and 425 mL (29%) in the forced expiratory volume in 1s (FEV1), residual volume (RV) and inspiratory vital capacity (IVC), respectively, and –3 m and 0 points versus 20.4 m and –3.4 points in the 6-minute-walking-distance (6MWD) and COPD assessment test (CAT) score respectively). With a combined value of 0.185, a MCID for R was calculated with established anchors (FEV1, RV, and 6MWD) for emphysema patients.ConclusionExtensive compensatory hyperinflation of the adjacent non-treated lobe after BLVR results in decreased ILVR, which is responsible for a lack of meaningful improvements in ventilatory mechanics and clinical outcome, despite technically successful lobe volume reduction.

Position statement on endoscopic lung volume reduction in South Africa: 2022 update.

Chronic obstructive pulmonary disease (COPD) remains one of the most common causes of morbidity and mortality in South Africa. Endoscopic lung volume reduction (ELVR) was first proposed by the South African Thoracic Society (SATS) for the treatment of advanced emphysema in 2015. Since the original statement was published, there has been a growing body of evidence that a certain well-defined sub-group of patients with advanced emphysema may benefit from ELVR, to the point where the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines and the United Kingdom National Institute for Health and Care Excellence (NICE) advocate the use of endoscopic valves based on level A evidence. Patients aged 40 - 75 years with severe dyspnoea (COPD Assessment Test score ≥10) despite maximal medical therapy and pulmonary rehabilitation, with forced expiratory volume in one second (FEV1) 20 - 50%, hyperinflation with residual volume (RV) >175% or RV/total lung capacity (TLC) >55% and a six-minute walking distance (6MWD) of 100 - 450 m (post-rehabilitation) should be referred for evaluation for ELVR, provided no contraindications (e.g. severe pulmonary hypertension) are present. Further evaluation should focus on the extent of parenchymal tissue destruction on high-resolution computed tomography (HRCT) of the lungs and interlobar collateral ventilation (CV) to identify a potential target lobe. Commercially available radiology software packages and/or an endobronchial catheter system can aid in this assessment. The aim of this statement is to provide the South African medical practitioner and healthcare funders with an overview of the practical aspects and current evidence for the judicious use of the valves and other ELVR modalities which may become available in the country.

Clinical outcomes and quantitative CT analysis after bronchoscopic lung volume reduction using valves for advanced emphysema

BackgroundBronchoscopic lung volume reduction (BLVR) using Zephyr endobronchial valve (EBV) and intrabronchial valve (IBV) has been shown to improve lung function and exercise capacity in severe emphysema. However, changes in airway structures and whether these are related to the clinical improvements remain unclear.MethodsA retrospective study was performed on patients treated with BLVR. We compared changes in 2nd-, 3rd-, and 4th-generation bronchial structures after therapy, including wall thickness (WT), percentage of wall thickness (WT%), intraluminal area (LA), wall area (WA), and WA%. Responder and non-responder subgroup analysis according to minimum clinically important difference (MCID) which was defined as an improvement of 15% in forced expiratory volume in 1 s (FEV1) and 26 m in 6 min walk distance (6MWD) was conducted.ResultsOf the 19 patients, 11 were treated with EBV and 8 with IBV. In ipsilateral non-target lobes, WT% decreased significantly in 3rd-generation bronchi at 1 month, 3, and 6 months, as well as their WA% at 1 month and 6 months. Non-responders, who were unable to achieve MCID, showed no consistent bronchial wall changes. And their LA of 3rd-generation bronchi decreased especially at 1 month. After BLVR, the target lobe volume decreased significantly until 12 months of follow-up. The volume of ipsilateral lobes could increase correspondingly and achieve the best improvements at 6 months. The contralateral lung volume showed slight amelioration but there was no statistical significance.ConclusionsBoth airway structures and lung volumes showed changes after BLVR. The 3rd- and 4th-bronchial walls tend to be thinner, which were consistent with clinical improvements. Further studies are needed to prove this conclusion and find detect potential mechanics.

Robotic Surgery and Adjunctive Technology: Stretching the Limits of What Is Possible

Chronic obstructive pulmonary disease is the fourth leading cause of death in the world and is a significant cause of mortality and morbidity. Although medical management is the standard of care, as the symptoms progress and lung function declines, nonmedical options become available to patients. Lung volume reduction surgery has been a well-established surgery for the treatment of severe emphysema since the National Emphysema Treatment Trial in 2003 showed a survival advantage for patients with upper lobe emphysema and low baseline exercise capacity. 1 Mannino D.M. Kiriz V.A. Changing the burden of COPD mortality. Int J Chron Obstruct Pulmon Dis. 2006; 1: 219-233 PubMed Google Scholar For patients without upper lobe emphysema, alternative modalities have been investigated to improve functional status. Endoscopic lung volume reduction is an emerging nonsurgical strategy to help bridge the gap between optimal medical management and surgery. In patients with severe emphysema, results from the Improving Patient Outcomes by Selective Implantation of the Zephyr EBV (IMPACT) trial and the Pulmonx Endobronchial Valves Used in Treatment of Emphysema (LIBERATE) study have shown excellent improvements in patient’s lung function, exercise capacity, and quality of life over medical therapy. 2 Fishman A. Martinez F. Naunheim K. et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003; 348: 2059-2073 Crossref PubMed Scopus (1656) Google Scholar ,3 Criner G.J. Sue R. Wright S. et al. A multicenter randomized controlled trial of Zephyr endobronchial valve treatment in heterogeneous emphysema (LIBERATE). Am J Respir Crit Care Med. 2018; 198: 1151-1164 Crossref PubMed Scopus (160) Google Scholar Robotic Lung Volume Reduction Surgery With Extracorporeal Membrane OxygenationThe Annals of Thoracic SurgeryVol. 114Issue 5PreviewLobectomy for consolidation of failed endoscopic lung volume reduction for emphysema has been reported in selected patients with favorable results but with considerable morbidity. The challenging issues in such patients are frailty caused by severe emphysema itself, poor tolerance to single-lung ventilation, target lobe hyperinflation, and inability to use gas inflation for the minimally invasive resection. Careful planning, including use of a robotic platform and extracorporeal membrane oxygenation support, can circumvent such difficulties and ensure a safe, minimally invasive resection in the high-risk emphysematous patient. Full-Text PDF

Bilateral endobronchial valves treatment for severe emphysema.

Bilateral endobronchial valves treatment can lead to additional significant benefits in patients who respond to the first procedure and have a clear target lobe on both lungs but increases the rate of complications https://bit.ly/3J0mZ8h

Clinical significance of the diverse interlobar veins hidden in the upper oblique fissure.

BackgroundThe interlobar veins hidden in the upper oblique fissure (UOF) of the right lung are usually mismanaged cursorily according to the target lobe, which results in accidental injury of the interlobar veins and complications. The detailed classification of interlobar veins based on surgical anatomical analysis is of great clinical significance.MethodsThree-dimensional computed tomography bronchography and angiography (3D-CTBA) reconstructed images of 398 patients from January 2019 to June 2020 were retrospectively analyzed. The interlobar veins in the UOF were observed and classified according to their morphology and distribution. The classification model was further validated in 153 patients who underwent surgery involving dissection of the UOF, and related surgical results were analyzed.ResultsThe distribution of interlobar veins was diverse, and the general morphology could be divided into 2 main categories and 30 subtypes in the 3D-CTBA images of the 398 patients. Analysis of the 153 patients’ surgical data showed that 60 patients suffered from interlobar vein injury. Interlobar veins hidden in an incomplete UOF were the most susceptible to accidental damage (χ2=12.856, P=0.020). A receiver operating characteristic (ROC) curve analysis showed that an interlobar vein diameter larger than 2.4 mm for the oblique fissure interlobar vein type or less than 2 mm for the mediastinal interlobar vein type was associated with a higher risk of injuries (P<0.001).ConclusionsThe diversity of interlobar veins and the completeness of the UOF were noteworthy risk factors in surgery involving dissection of the UOF.

Implementation of Bronchoscopic Lung Volume Reduction Using One-Way Endobronchial Valves: A Retrospective Single-Centre Cohort Study

Background: Bronchoscopic lung volume reduction (BLVR) using 1-way endobronchial valves (EBV) has become a guideline treatment in patients with advanced emphysema. Evidence from this minimally invasive treatment derives mainly from well-designed controlled trials conducted in high-volume specialized intervention centres. Little is known about real-life outcome data in hospitals setting up this novel treatment and which favourable conditions are required for a continuous successful program. Objectives: In this study, we aim to evaluate the eligibility rate for BLVR and whether the implementation of BLVR in our academic hospital is feasible and yields clinically significant outcomes. Method: A retrospective evaluation of patients treated with EBV between January 2016 and August 2019 was conducted. COPD assessment test (CAT), forced expiratory volume in 1 s (FEV1), residual volume (RV), and 6-min walking test (6MWT) were measured at baseline and 3 months after intervention. Paired sample t tests were performed to compare means before and after intervention. Results: Of 350 subjects screened, 283 (81%) were not suitable for intervention mostly due to lack of a target lobe. The remaining 67 subjects (19%) underwent bronchoscopic assessment, and if suitable, valves were placed in the same session. In total, 55 subjects (16%) were treated with EBV of which 10 did not have complete follow-up: 6 subjects had their valves removed because of severe pneumothorax (n = 2) or lack of benefit (n = 4) and the remaining 4 had missing follow-up data. Finally, 45 patients had complete follow-up at 3 months and showed an average change ± SD in CAT −4 ± 6 points, FEV1 +190 ± 140 mL, RV −770 ± 790 mL, and +37 ± 65 m on the 6MWT (all p < 0.001). After 1-year follow-up, 34 (76%) subjects had their EBV in situ. Conclusion: Implementing BLVR with EBV is feasible and effective. Only 16% of screened patients were eligible, indicating that this intervention is only applicable in a small subset of highly selected subjects with advanced emphysema, and therefore a high volume of COPD patients is essential for a sustainable BLVR program.

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

LEFT UPPER LOBE ATELECTASIS WITH PNEUMOTHORAX THREE YEARS AFTER BRONCHOSCOPIC LUNG VOLUME REDUCTION SURGERY

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bronchoscopic lung volume reduction surgery (BLVRS) is a minimally invasive treatment option for severe emphysema with hyperinflation and air trapping. The one-way valves are designed to induce lobar atelectasis. The most common complication is pneumothorax, which usually develops within 72 hours after BLVRS. We present a case of delayed atelectasis with a large left pneumothorax, 3 years after left upper lobe (LUL) BLVRS with three Zypher® valves. CASE PRESENTATION: A 64 year-old-female with a past medical history of severe emphysema on oxygen presented to a local hospital with dyspnea. Chest radiography revealed a large left pneumothorax. CT chest also showed complete LUL atelectasis. Of note in 2018, the patient underwent LUL BLVRS without interval development of atelectasis. Given the new findings, a chest tube was placed. She was transferred to our hospital for interventional pulmonary consultation after 6 days of conservative management for persistent air leak. Bronchoscopy revealed three Zypher® valves occluding the LUL and lingula. Balloon occlusion of the left main stem resulted in air leak cessation. Subsegmental occlusion of the left lower lobe superior segment revealed no change, but there was significant air leak reduction after anteromedial segment occlusion. A 5 mm Spiration® valve was then deployed, causing the air leak in the pleurovac to switch from continuous to intermittent. Over the next 48 hours, the air leak resolved with near resolution of the pneumothorax. Chest tube was removed, and the patient was discharged home after 24 hour observation. DISCUSSION: BLVRS is a minimally invasive treatment option for emphysema with hyperinflation and air trapping. Endobronchial valves are placed in a target lobe after fissure integrity confirmation. The goal is to cause deflation and subsequent atelectasis of the target lobe. However, 30-40% of patient do not develop immediate lobar atelectasis. The exact mechanism behind such a delay is not clear. It has been postulated by Nabil Jarad, et al., that a breach in fissure integrity prior to valve placement could account for lack of immediate atelectasis. Alternatively, there may have been a paravalvular leak accounting for the lack of response initially. We present a case of delayed left upper lobar atelectasis with pneumothorax, 3 years after BLVRS with appropriately placed Zypher® valves. The patient was managed with balloon occlusion bronchoscopy with Spiration® valve placement instead of Zypher® valve removal. CONCLUSIONS: The possibility of delayed lobar atelectasis with pneumothorax after BLVRS is something that interventionists should consider discussing with patients who do not develop lobar atelectasis after BLVRS with appropriately placed endobronchial valves. The risk of pneumothorax has been described to be the highest in the first 72 hours post-procedure, but as seen with our patient, it can still happen after 3 years. REFERENCE #1: Creber P, Bendall O, Jarad N. Delayed Response to Endobronchial Emphysema Valve Insertion. Clin Respirat Med. 2018; 1(1): 1003. REFERENCE #2: Franzen D, Straub G, Freitag L. Complications after bronchoscopic lung volume reduction. J Thorac Dis. 2018;10(Suppl 23):S2811-S2815. doi:10.21037/jtd.2018.06.66. REFERENCE #3: Shah PL, Herth FJF. Current status of bronchoscopic lung volume reduction with endobronchial valvesThorax 2014;69:280-286. DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response No relevant relationships by MAYKEL IRANDOST, source=Web Response No relevant relationships by Abid Khokar, source=Web Response No relevant relationships by Jonathan Munoz, source=Web Response no disclosure submitted for Ali Saeed; No relevant relationships by Andrew Talon, source=Web Response

Video-Assisted Thoracic Surgery Lobectomy.

Video-assisted thoracoscopic surgery (VATS) has been established as the surgical approach of choice for lobectomy in patients with early-stage non-small cell lung cancer (NSCLC). Patients with clinical stage I NSCLC with no lymph node metastasis are considered candidates for VATS lobectomy. To rule out the presence of metastasis to lymph nodes or distant organs, patients should undergo meticulous clinical staging. Assessing patients’ functional status is required to ensure that there are no medical contraindications, such as impaired pulmonary function or cardiac comorbidities. Although various combinations of the number, size, and location of ports are available, finding the best method of port placement for each surgeon is fundamental to maximize the efficiency of the surgical procedure. When conducting VATS lobectomy, it is always necessary to comply with the following oncological principles: (1) the vessels and bronchus of the target lobe should be individually divided, (2) systematic lymph node dissection is mandatory, and (3) touching the lymph node itself and rupturing the capsule of the lymph node should be minimized. Most surgeons conduct the procedure in the following sequence: (1) dissection along the hilar structure, (2) fissure division, (3) perivascular and peribronchial dissection, (4) individual division of the vessels and bronchus, (5) specimen retrieval, and (6) mediastinal lymph node dissection. Surgeons should obtain experience in enhancing the exposure of the dissection target and facilitating dissection. This review article provides the basic principles of the surgical techniques and practical maneuvers for performing VATS lobectomy easily, safely, and efficiently.

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

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

Two-Stage Bronchoscopic Endobronchial Valve Treatment Can Lead to Progressive Lung Volume Reduction and May Decrease Pneumothorax Risk.

BackgroundSince successful development of endobronchial valves (EBV) as treatment for severe emphysema, its main complication, pneumothorax, remains an important concern.ObjectiveWe hypothesized that a two-step EBV implantation, during two distinct iterative procedures could lead to a more progressive target lobe volume reduction (TLVR) and thus ipsilateral lobe re-expansion, resulting in a significant decrease in the pneumothorax rate.MethodsThis retrospective bi-center study carried out by Limoges and Toulouse University Hospitals included patients following the inclusion criteria established by the BLVR expert panel. All patients were treated by two distinct procedures: first, EBVs were placed in all but the most proximal segment or sub-segment. The remaining segment was treated subsequently. All patients had a complete evaluation before treatment, and 3 months after the second procedure.ResultsOut of 58 patients included, only 4 pneumothoraxes (7%) occurred during the study. The other complications were pneumonia and severe COPD exacerbation (8.6% and 13.7% of patients, respectively). Significant improvement was found for FEV1 (+19.6 ± 25%), RV (−468 ± 960mL), 6MWD (30 ± 85m), BODE Index (−1.4 ± 1.8 point) and TLVR (50.6 ± 35.1%). Significant TLVR (MCID) was obtained in 74.1% of patients (43/58).ConclusionThis new approach using EBV could reduce the incidence of pneumothorax without increasing other complication rates. Clinical and physiological outcomes are similar to those reported in studies using the conventional single-step treatment.

Use of Ventilation-Perfusion Single-Photon Emission Computed Tomography to Select the Target Lobe for Endobronchial Valve Lung Volume Reduction

Background: Quantitative planar ventilation-perfusion (VQ) has a complementary role in target lobe selection for endobronchial valve lung volume reduction (EBV-LVR), especially in homogenous disease. We investigated a novel method of lung lobar quantitation using VQ single-photon emission computed tomography (SPECT) with computed tomography (CT) to generate a parameter called the ventilation-perfusion differential index (VQDI). Aim: The aim of this study was to validate VQDI as a parameter for target lobe selection in EBV-LVR against the gold standard test of quantitative computed tomography (qCT). Methods: This study was a prospective, multi-centre, single-blinded, observational study of EBV-LVR patients. Baseline and 3-month post intervention VQ SPECT and qCT were performed. The target lobe was chosen using qCT and planar VQ report (CT_TL) whilst blinded to VQDI. Post EBV-LVR, our nuclear physician, blinded to CT_TL, selected a target lobe using deidentified VQDI (VQDI_TL). Inter-rater agreement between CT_TL and VQDI_TL was calculated by Kappa statistic. Treatment outcomes were analysed with a linear mixed-effects model. Results: There was a high concordance between CT_TL and VQDI_TL in 16 patients (89%, Kappa statistic = 0.85). Post EBV-LVR, our subjects showed significant changes in FEV1 (mean difference [MD] +150 mL, p < 0.001), target lobe volume reduction (MD −973 mL, p < 0.001), residual volume (MD −800 mL, p < 0.001), and St. George’s Respiratory Questionnaire score (MD −11, p = 0.001). Improvements in 6-minute walk distances did not reach statistical significance. Conclusion: In this study of treatment responders, EBV-LVR target lobe selection using VQDI concurs with qCT and thus supports its value for this purpose. It complements qCT and may potentially be of synergistic value especially in homogenous emphysema.

Identifying Responders and Exploring Mechanisms of Action of the Endobronchial Coil Treatment for Emphysema

Background: So far, 3 randomized controlled trials have shown that the endobronchial treatment using coils is safe and effective. However, the more exact underlying mechanism of the treatment and best predictors of response are unknown. Objectives: The aim of the study was to gain more knowledge about the underlying physiological mechanism of the lung volume reduction coil treatment and to identify potential predictors of response to this treatment. Methods: This was a prospective nonrandomized single-center study which included patients who were bilaterally treated with coils. Patients underwent an extensive number of physical tests at baseline and 3 months after treatment. Results: Twenty-four patients (29% male, mean age 62 years, forced expiratory volume in 1 s [FEV₁] 26% pred, residual volume (RV) 231% pred) were included. Three months after treatment, significant improvements were found in spirometry, static hyperinflation, air trapping, airway resistance, treated lobe RV and treated lobes air trapping measured on CT scan, exercise capacity, and quality of life. The change in RV and airway resistance was significantly associated with a change in FEV₁, forced vital capacity, air trapping, maximal expiratory pressure, dynamic compliance, and dynamic hyperinflation. Predictors of treatment response at baseline were a higher RV, larger air trapping, higher emphysema score in the treated lobes, and a lower physical activity level. Conclusions: Our results confirm that emphysema patients benefit from endobronchial coil treatment. The primary mechanism of action is decreasing static hyperinflation with improvement of airway resistance which consequently changes dynamic lung mechanics. However, the right patient population needs to be selected for the treatment to be beneficial which should include patients with severe lung hyperinflation, severe air trapping, and significant emphysema in target lobes.

Endoscopic Lung Volume Reduction with Autologous Blood: What is the Evidence?

Biological lung volume reduction (BioLVR) is a novel and low-cost endobronchial treatment method aimed at reducing the volume of the target lung lobe using biological agents, including fibrin-based hydrogel, fibrinogen, and autologous blood (AB) with thrombin. BioLVR induces local inflammation, resulting in acute airway obstruction, resorption atelectasis, fibrosis, and finally tissue remodeling by contraction of the target lobe and reduction in the lung volume, similar to the application of hot water vapor and foam. In addition, patients with severe impairment in lung function and quality of life may refuses to undergo surgery, resulting in limited treatment options. In such complex clinical scenarios, BioLVR with AB appears to be a good therapeutic option. These treatment modalities resulted in favorable outcomes in patients with heterogeneous and bullous emphysema, pulmonary lymphangioleiomyomatosis, and giant bullous lesions. AB applications result in functional improvement, improvement in the quality of life, decrease in dyspnea scores, and reduction in the size of bullae. Based on the available evidence, application of AB for lung volume reduction is minimally invasive and well tolerated by patients. There was no incidence of pneumothorax or mortality. This review aimed to investigate the benefits, complications, and future perspectives of AB application as BioLVR in the treatment of hyperinflated lung diseases.

Reduction of COPD Hyperinflation by Endobronchial Valves Improves Intercostal Muscle Morphology on Ultrasound.

Background and ObjectivesParasternal intercostal ultrasound morphology reflects spirometric COPD severity. Whether this relates to the systemic nature of COPD or occurs in response to hyperinflation is unknown. We aimed to assess changes in ultrasound parasternal intercostal muscle quantity and quality (echogenicity) in response to relief of hyperinflation. We hypothesised that reduction in hyperinflation following endobronchial valve (EBV) insertion would increase ultrasound parasternal thickness and decrease echogenicity.MethodsIn this prospective cohort study, eight patients with severe COPD underwent evaluation of health-related quality of life, lung function, and sonographic thickness of 2nd parasternal intercostal muscles and diaphragm thickness, both before and after EBV insertion. Relationships between physiological and radiographic lung volumes, quality of life and ultrasound parameters were determined.ResultsBaseline FEV1 was 1.02L (SD 0.37) and residual volume (RV) was 202% predicted (SD 41%). Median SGRQ was 63.26 (range 20–70.6). Change in RV (−0.51 ± 0.9L) following EBV-insertion showed a strong negative correlation with change in parasternal thickness (r = −0.883) ipsilateral to EBV insertion, as did change in target lobe volume (−0.89 ± 0.6L) (r = −0.771). Parasternal muscle echogenicity, diaphragm thickness and diaphragm excursion did not significantly change.ConclusionsDynamic changes in intercostal muscle thickness on ultrasound measurement occur in response to relief of hyperinflation. We demonstrate linear relationships between intercostal thickness and change in hyperinflation following endobronchial valve insertion. This demonstrates the deleterious effect of hyperinflation on intrinsic inspiratory muscles and provides an additional mechanism for symptomatic response to EBVs.

Extent of Segmentectomy That Achieves Greater Lung Preservation Than Lobectomy

This study sought to clarify the extent of segmentectomy that achieves greater lung preservation than lobectomy. This was a single-center retrospective cohort study involving 374 patients with lung cancer who were treated with either lobectomy or segmentectomy between 2013 and 2018. The percentage of preserved pulmonary function (%PPF) after surgery was compared among patients who underwent lobectomy (n= 164), segmentectomy of 2 or more segments (Seg ≥2S; n= 42), and segmentectomy of less than 2 segments (Seg <2S; n= 168). Using perfusion scintigraphy, forced expiratory volume in 1 second of the preserved target lobe was measured to examine its effect on the %PPF. The number of resected subsegments (SSs) in segmentectomy that made the %PPF higher than that observed with lobectomy was also examined. Mean %PPF was lowest in those patients who underwent lobectomy (86%), followed by Seg ≥2S (89%) and Seg <2S (95%) (P < .001), but the difference between the lobectomy and Seg ≥2S was not significant (P= .21). The forced expiratory volume in 1 second of the preserved target lobe was significantly lower in the Seg ≥2S group than in the Seg <2S group (P < .001). The number of resected SSs was 6 to 12 inlobectomy, 4 to 7 in Seg ≥2S, and 1 to 4 in Seg <2S.Although the %PPF after segmentectomy of less than 5 SSs (Seg <5SS) was significantly higher than that after lobectomy (P < .001), the %PPF after segmentectomy of 5 or more SSs (Seg ≥5SS) was notsignificantly different from that after lobectomy (P= .68). Both the Seg ≥2S and Seg ≥5SS groups did not differ from lobectomy in %PPF because of the low function of preserved target lobe.

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

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

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.

Yttrium-90 Portal Vein Radioembolization in Sprague-Dawley Rats: Dose-Dependent Imaging and Pathological Changes in Normal Liver.

Portal vein embolization (PVE) is an established neoadjuvant method to induce future liver remnant hypertrophy prior to surgical resection of hepatic tumors. The purpose of our study was to examine the feasibility of PVE with glass 90Y microspheres (Y90 PVE) in Sprague-Dawley rats. We tested the hypothesis that increased doses of Y90 PVE would increase target lobe fibrosis and atrophy. Twenty-two rats were assigned to four groups for Y90 PVE to the right median lobe: very high- (273.8MBq; n = 2), high- (99.9MBq; n = 10), medium- (48.1MBq; n = 5), and low-dose (14.8MBq; n = 5). An untreated control group included seven rats. 90Y PET/CT of 90Y distributions confirmed lobar targeting. MRI volumes were measured at baseline, 2-, 4-, 8- and 12-weeks. Explanted hepatic lobes were weighed, sectioned, and stained for H&E and immunohistochemistry. Digitized slides allowed quantitative measurements of fibrosis (20 foci/slide). Ex vivo measurements confirmed 91-97% activity was localized to the target lobe (n = 4). The percent growth of the target lobe relative to baseline was -5.0% (95% CI -17.0-6.9%) for high-, medium dose rats compared to + 18.6% (95% CI + 7.6-29.7%) in the low-dose group at 12-weeks (p = 0.0043). Radiation fibrosis increased in a dose-dependent fashion. Fibrotic area/microsphere was 22,893.5, 14,946.2 ± 2253.3, 15,304.5 ± 4716.6, and 5268.8 ± 2297.2μm2 for very high- (n = 1), high- (n = 4), medium- (n = 3), and low-dose groups (n = 5), respectively. Y90 PVE was feasible in the rat model, resulted in target lobe atrophy, and dose-dependent increases in hepatic fibrosis at 12weeks. The onset of imaging-based volumetric changes was 8-12weeks.