Treatment Of Emphysema Research Articles

Successful treatment of ventilator dependent emphysema with Chartis treatment planning and endobronchial valves

INTRODUCTIONEmphysema is a leading cause of disability and death. Patients who require ventilator support as a result of respiratory failure have limited treatment options. We report a successful outcome for a ventilator dependent patient in whom endobronchial valves were inserted into lobes assessed as being without collateral ventilation. PRESENTATION OF CASEA 54 year old male patient had been ventilator dependent for two months due to respiratory insufficiency from emphysema. Prior to admission, FEV1 was 0.89L (25% predicted) and RV was 4.5L (205% predicted). CT scan showed destruction of right lower and middle lobes and left lower lobe. Chartis assessment showed the absence of collateral ventilation. Zephyr endobronchial valves were placed in left and right lower lobes. Lung volume reduction bilaterally was confirmed on chest X-ray and CT scan the following day. On day three, ventilator support was discontinued and there was no requirement for supplementary oxygen. At 30 days post procedure, the RV reduced to 3.2L (142% predicted) and the FEV1 increased to 1.32L (38% predicted). DISCUSSIONHyperinflation in emphysema compromises lung function. For this ventilator dependent patient, there were no other treatment options. Endoscopic lung volume reduction was successfully achieved by bilateral lower lobe placement of Zephyr endobronchial valves with a prior assessment using Chartis to determine the absence of collateral flow in the targeted lobes. The patient achieved an impressive 48% improvement in FEV1 and a 29% reduction in RV. CONCLUSIONEndoscopic lung volume reduction assisted by Chartis to plan treatment resulted in a clinical and a health-economic benefit.

Endobronchial Valve Treatment for Prolonged Air Leaks of the Lung: A Case Series

An endobronchial valve developed for treatment of severe emphysema has characteristics favorable for bronchoscopic treatment of air leaks. We present the results of a consecutive case series treating complex alveolopleural fistula with valves. Patients with air leaks that persisted after treatment gave consent and compassionate use approval was obtained. Bronchoscopy with balloon occlusion was used to identify the airways to be treated. IBV Valves (Spiration, Redmond, WA) were placed after airway measurement. During a 15-month period, 8 valve placement procedures were performed in 7 patients and all had improvement in the air leak. The median duration of air leakage was 4 weeks before and 1 day after treatment, with a mean of 4.5 days. Discharge within 2 to 3 days of the procedure occurred in 57% of the patients. A median of 3.5 valves (mode, 2.4) were used, and all valve removals were successful. There were no procedural or valve-related complications. Removable endobronchial valves appear to be a safe and effective intervention for prolonged air leaks.

Is lung volume reduction surgery effective in the treatment of advanced emphysema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether lung volume reduction surgery (LVRS) might be superior to medical treatment in the management of patients with severe emphysema. Overall 497 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that LVRS produces superior patient outcomes compared to medical treatment in terms of exercise capacity, lung function, quality of life and long-term (>1 year postoperative) survival. A large proportion of the best evidence on this topic is based on analysis of the National Emphysema Treatment Trial (NETT). Seven studies compared LVRS to medical treatment alone (MTA) using data generated by the NETT trial. They found higher quality of life scores (45.3 vs. 27.5, P<0.001), improved maximum ventilation (32.8 vs. 29.6 l/min, P=0.001) and lower exacerbation rate per person-year (0.27 vs. 0.37%, P=0.0005) with LVRS than MTA. Mortality rates for LVRS were greater up to one year (P=0.01), equivalent by three years (P=0.15) and lower after four years (P=0.06) postoperative compared to MTA. Patients with upper-lobe-predominant disease and low exercise capacity (0.36 vs. 0.54, P=0.003) benefited the most from undergoing LVRS rather than MTA in terms of probability of death at five years compared to patients with non-upper-lobe disease (0.38 vs. 0.45, P=0.03) or upper-lobe-disease with high exercise capacity (0.33 vs. 0.38, P=0.32). Five studies compared LVRS to MTA using data independent from the NETT trial. They found greater six-minute walking distances (433 vs. 300 m, P<0.002), improved total lung capacity (18.8 vs. 7.9% predicted, P<0.02) and quality of life scores (47 vs. 23.2, P<0.05) with LVRS compared to MTA. Even though LVRS has a much greater cost per person over five years ($137,000 vs. $100,200, P<0.001), its improved lung function, greater exercise capacity and better quality of life scores make it a preferable treatment option to MTA, with particular indications for patients with upper-lobe-predominant disease and low exercise capacity.

Role of the chest radiography, spirometry, and high resolution computed tomography in the early diagnosis of the emphysema

PurposeThis study was performed to evaluate the role of the chest radiography pulmonary function tests, and HRCT in the early diagnosis of the emphysema. Materials and methodsThe study included 50 patients who had emphysema. Average age varies between 40 and 60years. All patients were subjected to full history, clinical examination, laboratory investigations, cardiac investigations, chest radiography, pulmonary function tests and HRCT. ResultsI found high sensitivity of the HRCT in the early diagnosis of emphysema if compared with sensitivity of the chest radiography and pulmonary function tests. ConclusionsHRCT has much greater sensitivity than chest radiography in early diagnosing of emphysema. HRCT is also capable of differentiating between the various types of emphysema and assessing its severity. The presence of emphysema can be suspected on chest radiography but this is not a sensitive technique for diagnosis. Also the chest radiography is not a very good indicator for the severity of disease. In addition a precise characterization of the emphysema by HRCT is desirable for adequate therapy and monitoring as well as preoperative assessment of the patient before surgical treatment of emphysema. Compared to spirometry, HRCT shows regional assessment of compartments involved (airways, parenchyma and vasculature). Moreover spirometry has no definite sensitivity.

Awake thoracoscopic bullaplasty

Staple excision of emphysematous bullae through general anesthesia is the standard surgical treatment of bullous emphysema. We have developed a new surgical technique entailing thoracoscopic bullaplasty performed in fully awake patients through sole epidural anesthesia. This prospective nonrandomized trial included 35 patients undergoing awake thoracoscopic bullaplasty between 2002 and 2009. Preoperative work-up included computed tomography with algorithm for quantitative measurement of the bulla volume. Outcome measures included patient's satisfaction with the anesthesia, scored into four grades (1=unsatisfactory; 4=excellent); ratio of arterial oxygen tension to fraction of inspired oxygen (PaO(2)/FiO(2)), and postoperative assessment of standard clinical measures at 6, 12, and 36 months. There were 29 men and six women with a median age of 60 years. Median volume of the bulla was 688 ml. Awake bullaplasty was successfully completed in 34 patients. Perioperatively, PaO(2)/FiAO(2) decreased significantly (analysis of variance (ANOVA), P<0.0001) though remaining satisfactory (>300 mmHg), whereas PaCO(2) increased intraoperatively (ANOVA, P<0.0001) but returned to baseline values 1h after surgery (P=0.20). There was no mortality; four patients had air leaks longer than 7 days. Mean hospital stay was 4.9 ± 2.2 days. Comparisons between pre- to 6-month changes in outcome measures showed improvements (P<0.0001) in forced expiratory volume in 1s (FEV(1)) (+0.37 l), residual volume (-1.16 l), dyspnea index (-2), and standard 6-min walk test (SMWT) (+71 m). These improvements lasted for up to 36 months and in no patient did operated bullae recur. Our study suggests that awake thoracoscopic bullaplasty was well tolerated and easily performed in the majority of the patients, and significant clinical improvements lasted for up to 36 months.

Retinoid treatment of Emphysema in Patients on the Alpha-1 International Registry. The REPAIR study: study design, methodology and quality control of study assessments

Emphysema is characterized by the destruction of alveolar wall and enlargement of alveolar airspaces, resulting in a reduction of the total lung gas exchange area, loss of lung elastic recoil and hyperinflation. The REPAIR study (Retinoid treatment of Emphysema in Patients on the Alpha-1 International Registry) is the first proof-of-concept study of a new potential disease-modifying drug, Palovarotene©, an orally active, gamma selective retinoid agonist in patients with emphysema secondary to alpha-1-antitrypsin deficiency (AATD) as a model population for the general smoke-induced emphysema population. This article describes the study design as well as the effectiveness of the quality control that was implemented on the key efficacy endpoints, based on data derived from the placebo-treated subjects. In this multicentre, multinational study the implementation of standardized procedures included: careful site selection, use of trained staff, regular monitoring and machine calibration, use of biological controls and regular feedback to sites by an independent quality control centre. All of these procedures resulted in high-quality measurements of lung density, spirometry, static lung volumes and gas transfer. It was also confirmed that CT lung density was the most sensitive endpoint followed by TLco, FEV(1) and RV measured by body box.

Lung volume reduction for severe emphysema: do we need a scalpel or a scope?

Resectional lung volume reduction has proven to be superior to medical treatment in reducing dyspnoea and in increasing lung function, survival and quality of life in a very well selected, low risk group of hyperinflated patients with heterogeneous emphysema predominantly in the upper lobe. Nevertheless, this intervention is hampered by an important pulmonary (30%) and cardiovascular (20%) morbidity, mainly as a result of prolonged (>7 days) air leak, and a 5% risk of death as a result of the surgical intervention. Results from ongoing randomised trials are awaited in order to determine whether less invasive, non-resectional lung volume treatment of emphysema via the bronchoscope using endobronchial valves, airway bypass stents or biological adhesives/heated water vapour will yield similar improvement with less morbidity and reduced mortality, compared with surgical resection. Furthermore, it is hoped that endoscopic lung volume reduction techniques may help patients with homogeneous emphysema currently excluded by most teams for the resectional procedure.

Closure of persisting air leaks in patients with severe pleural empyema — use of endoscopic one-way endobronchial valve☆

Parapneumonic pleural empyema is a critical illness with mortality up to 20%. Patients often have severe comorbidity and are not always suitable for major thoracic surgery. Peripheral bronchopleural fistula adds further difficulty. This may result in a situation where recovery is impossible. Therefore, we developed a combination of minimally invasive surgical debridement and closure of the air leak with a bronchoscopic one-way endobronchial valve. Thus far, two patients received the combined treatment. Both patients suffered from a pleural empyema and because of severe comorbidity were not fit for major thoracic surgery. First, minimally invasive surgical debridement of the pleural cavity was performed. In both patients, a persisting peripheral bronchopleural fistula occurred. Via bronchoscopy the leak could be localized in both cases in the lower lobe segment 8. In each case, we implanted an endobronchial one-way valve designed for the treatment of lung emphysema. After the bronchoscopic valve implantation, the leakage ceased in both cases and healing of the pleural empyema was achieved. The valves were subsequently removed via bronchoscopy. Successful closure of peripheral air leaks in patients with pleural empyema using an endoscopic one-way valve is feasible. It is a treatment option in patients who are not fit for major thoracic surgery.

A potential role for endobronchial valves in patients with lung transplant

Native lung hyperinflation (NLH) is a unique condition seen in emphysema patients after single-lung transplant (SLT). The overinflated native lung acts to extrinsically restrict the transplanted lung, impairing graft function. NLH has been treated with surgical lung volume reduction (LVR), 1 Anderson M.B. Kriet J.M. Kapelanski D.P. et al. Volume reduction surgery in the native lung after single lung transplantation for emphysema. J Heart Lung Transplant. 1997; 16: 752-757 PubMed Google Scholar but at the risk of major morbidity and even death. The risk of peri-operative infection is increased in the heavily immunosuppressed patient, and some anti-rejection medications seriously impair wound healing. Recent work with one-way endobronchial valves (EBVs) for the treatment of emphysema has allowed the possibility of LVR without the need for surgery. 2 Toma T.P. Hopkinson N.S. Hillier J. et al. Bronchoscopic volume reduction with valve implants in patients with severe emphysema. Lancet. 2003; 361: 931-933 Abstract Full Text Full Text PDF PubMed Scopus (281) Google Scholar , 3 Endobronchial Valves for Emphysema palliatioN Trial (VENT) preliminary results report. Presented at the European Respiratory Society 17th Annual Congress, Stockholm, Sweden, Sept 20, 2007. Google Scholar The literature on EBV use in NLH is restricted to a single case report in acute NLH, 4 Crespo M.M. Johnson B.A. McCurry K.R. et al. Use of endobronchial valves for native lung hyperinflation associated with respiratory failure in a single-lung transplant recipient for emphysema. Chest. 2007; 131: 214-216 Crossref PubMed Scopus (15) Google Scholar and to date there are no published data on EBV use in chronic NLH.

Bronchoscopic lung volume reduction for pulmonary emphysema: preliminary experience with a new NOVATECH® endobronchial silicone one-way valve

Bronchoscopic lung volume reduction represents a new palliative technique for the treatment of severe emphysema. We report the case of a patient with severe pulmonary emphysema that was successfully treated by the placement of a new, removable, unidirectional endobronchial silicone valve.

Using Science to Improve the Nation's Health System

SINCE BARACK OBAMA BECAME THE 44TH PRESIDENT OF the United States in January 2009, nearly all sectors of society have engaged in intense discussions about the best ways to stimulate the nation’s economy and reform the US health care system. The National Institutes of Health (NIH) has been—and will continue to be—in the middle of such conversations, emphasizing the power of biomedical research to show what health interventions yield the greatest benefits. Health reform and economic concerns may have moved comparative effectiveness research (CER) from relative obscurity into the public policy spotlight. However, CER is not a new concept to NIH, which has long recognized and supported the value of CER for providing evidence-based, wellvalidated approaches to medical care. For instance, nearly 2 decades ago, NIH-supported researchers published results of the Cardiac Arrhythmia Suppression Trial (CAST). To the surprise of many, 3 drugs that suppressed ventricular premature beats (encainide, flecainide, and moricizine) not only failed to reduce the risk of sudden cardiac death, but actually increased arrhythmic death rates. About 14 years later, the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), a comparative effectiveness trial funded by NIH, demonstrated that oral administration of the antiarrhythmic drug amiodarone proved no better than standard heart failure care (such as -blockade), whereas implantation of an internal cardioverter defibrillator reduced mortality by 23%. Despite the positive results of SCD-HeFT, only a subset of patients with heart failure derives benefit from implantable defibrillators. Consequently, NIH, the Agency for Healthcare Research and Quality (AHRQ), and the American College of Cardiology have joined together to support an observational CER study of 3500 patients receiving implantable cardioverter-defibrillators. The 31⁄2-year study, launched in January 2010, should help clinicians better gauge whether a patient is likely to benefit from a defibrillator. Other major CER efforts supported by NIH have compared antipsychotic drugs for the treatment of schizophrenia, strategies for preventing deaths from prostate cancer, antihypertensive medications, treatments for bullous emphysema, and approaches to preventing diabetes. A 2007 report by the CongressionalBudgetOfficecitedNIH’scomparativeeffectiveness studies asprimeexamplesof government-sponsored research that could directly inform clinical practice and public policy. Today, the biomedical research community has an unprecedented opportunity to build on this foundation. The United States urgently needs the evidence to design a system that offers health interventions that are both beneficial and cost-effective. The American Recovery and Reinvestment Act (ARRA) of 2009 appropriated $1.1 billion for CER, with $400 million of that funding allocated to NIH and the remainder to AHRQ and the Office of the Secretary of the Department of Health and Human Services. While the ARRA-mandated report of the Federal Coordinating Council acknowledged that NIH historically has been the largest source of federal support for CER, NIH has important partners in other government agencies, particularly AHRQ. NIH generally contributes to CER by supporting primary research, including both observational studies and randomized control trials. AHRQ’s strength is in conducting secondary comprehensive meta-analyses of multiple studies, seeking to identify overarching conclusions and propose practice guidelines. By the end of September 2009, NIH had committed most of its $400 million ARRA allocation for CER through a variety of mechanisms, including Challenge grants, larger-scale Grand Opportunity grants, pay line expansions, competitive revisions, and administrative supplements. To prioritize these spending decisions, a high-level, trans-NIH committee considered a variety of criteria that met the Federal Coordinating Council’s definition of CER. These criteria included potential public health benefit, variability in practice, low probability for support by nongovernmental sectors, potential for multiplicative effect, focus on diverse populations and subgroups, engagement of communities in research, and application to the stated priorities of the Medicare Modernization Act and the Institute of Medicine (IOM). In addition to providing a much-needed funding boost for CER, ARRA-related activities helped delineate 5 important challenges facing NIH as it considers how to use science to benefit health care reform.

A human surfactant peptide-elastase inhibitor construct as a treatment for emphysema

Two million Americans suffer from pulmonary emphysema, costing $2.5 billion/year and contributing to 100,000 deaths/year. Emphysema is thought to result from an imbalance between elastase and endogenous inhibitors of elastase, leading to tissue destruction and a loss of alveoli. Decades of research have still not resulted in an effective treatment other than stopping cigarette smoking, a highly addictive behavior. On the basis of our previous work, we hypothesize that small molecule inhibitors of human neutrophil elastase are ineffective because of rapid clearance from the lungs. To develop a long-acting elastase inhibitor with a lung pharmacodynamic profile that has minimal immunogenicity, we covalently linked an elastase inhibitor, similar to a trifluoro inhibitor that was used in clinical trials, to a 25-amino-acid fragment of human surfactant peptide B. We used this construct to prevent human neutrophil elastase-induced emphysema in a rodent model. The elastase inhibitor alone, although in a 70-fold molar excess to elastase in a mixture with <0.6% residual elastase activity, provided no protection from elastase-induced emphysema. Covalently combining an endogenous peptide from the target organ with a synthetic small molecule inhibitor is a unique way of endowing an active compound with the pharmacodynamic profile needed to create in vivo efficacy.

Management of bilateral pneumothoraces after talc pleurodesis and unilateral lung volume reduction surgery

Lung volume reduction surgery (LVRS) is one of the surgical options in the treatment of advanced emphysema and may also be considered as a 'bridge' operation to lung transplantation in selected patients. Although its long-term effects are still debatable, some patients significantly benefit from this operation. Secondary spontaneous pneumothorax is one of the commonest complications of severe emphysema that necessitates an emergency drainage procedure. However, there is no satisfactory information regarding the management of this complication occurring after LVRS in the literature. This paper reports a case of bilateral pneumothorax three months after a unilateral LVRS that was performed following a contra-lateral talc pleurodesis for recurrent pneumothorax.

Successful Nonsurgical Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema following ERCP

Complications related to endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, hemorrhage, cholangitis, and perforation. ERCP-related perforation is uncommon, but mortality rates are high. Diagnosis requires a high clinical suspicion for early detection to allow optimal management of the perforation and a better prognosis. Treatment depends on the location and mechanism and increasingly involves nonoperative management. We report a case of successful nonsurgical treatment of a patient with extensive air involving the peritoneum, retroperitoneum, thorax, mediastinum, and subcutaneous tissues following an ERCP perforation.

Predictors of Body Mass Index in Patients With Moderate to Severe Emphysema

ABSTRACTPeople with Chronic Obstructive Pulmonary Disease are at risk for low body weight and the subsequent sequelae of cachexia. The goal of this study was to define the relationship between of degree of emphysema as measured by high resolution chest computerized tomography, body mass index and caloric intake. Subjects from San Diego County were recruited to participate in a multi-center randomized clinical trial to test the Feasibility of Retinoids in the Treatment of Emphysema (FORTE). Forty subjects with Chronic Obstructive Pulmonary Disease, participated in a nutrition substudy and were ex-smokers with FEV1 between 20%–80% predicted. Body mass index was correlated with the degree of emphysema as measured by high resolution chest tomography (CT), r2 = 0.171 p < 0.01 across the full spectrum of disease severity. Dietary intake averaged over four days using 24-hour recalls was inversely correlated with BMI, r2 = 0.471, p < 0.001, indicating a higher energy intake in subjects with low BMI. Pulmonary function tests of percent predicated FEV1 was mildly related to BMI (r2 = 0.086, p < 0.06). A regression model was developed to define the relationship of BMI and degree of emphysema and calorie per kilogram body weight, which accounted for 60% of the variability, p < 0.001. Low body weight in the COPD is related to the degree of emphysema, not due to decreased caloric intake. Subjects with low body weight have compensated by increasing their caloric intake and are meeting their nutritional needs.

Biologic lung volume reduction therapy for advanced homogeneous emphysema

This report summarises phase 2 trial results of biologic lung volume reduction (BioLVR) for treatment of advanced homogeneous emphysema. BioLVR therapy was administered bronchoscopically to 25 patients with homogeneous emphysema in an open-labelled study. Eight patients received low dose (LD) treatment with 10 mL per site at eight subsegments; 17 received high dose (HD) treatment with 20 mL per site at eight subsegments. Safety was assessed in terms of medical complications during 6-month follow-up. Efficacy was assessed in terms of change from baseline in gas trapping, spirometry, diffusing capacity, exercise capacity, dyspnoea and health-related quality of life. There were no deaths or serious medical complications during the study. A statistically significant reduction in gas trapping was observed at 3-month follow-up among HD patients, but not LD patients. At 6 months, changes from baseline in forced expiratory volume in 1 s (-8.0+/-13.93% versus +13.8+/-20.26%), forced vital capacity (-3.9+/-9.41% versus +9.0+/-13.01%), residual volume/total lung capacity ratio (-1.4+/-13.82% versus -5.4+/-12.14%), dyspnoea scores (-0.4+/-1.27 versus -0.8+/-0.73 units) and St George's Respiratory Questionnaire total domain scores (-4.9+/-8.3 U versus -12.2+/-12.38 units) were better with HD than with LD therapy. BioLVR therapy with 20 mL per site at eight subsegmental sites may be a safe and effective therapy in patients with advanced homogeneous emphysema.

A Multicenter Pilot Study of a Bronchial Valve for the Treatment of Severe Emphysema

Background: Chronic obstructive pulmonary disease (COPD) affects millions of people and has limited treatment options. Surgical treatments for severe COPD with emphysema are effective for highly selected patients. A minimally invasive method for treating emphysema could decrease morbidity and increase acceptance by patients. Objective: To study the safety and effectiveness of the IBV® Valve for the treatment of severe emphysema. Methods: A multicenter study treated 91 patients with severe obstruction, hyperinflation and upper lobe (UL)-predominant emphysema with 609 bronchial valves placed bilaterally into ULs. Results: Valves were placed in desired airways with 99.7% technical success and no migration or erosion. There were no procedure-related deaths and 30-day morbidity and mortality were 5.5 and 1.1%, respectively. Pneumothorax was the most frequent serious device-related complication and primarily occurred when all segments of a lobe, especially the left UL, were occluded. Highly significant health-related quality of life (HRQL) improvement (–8.2 ± 16.2, mean ± SD change at 6 months) was observed. HRQL improvement was associated with a decreased volume (mean –294 ± 427 ml, p = 0.007) in the treated lobes without visible atelectasis. FEV₁, exercise tests, and total lung volume were not changed but there was a proportional shift, a redirection of inspired volume to the untreated lobes. Combined with perfusion scan changes, this suggests that there is improved ventilation and perfusion matching in non-UL lung parenchyma. Conclusion: Bronchial valve treatment of emphysema has multiple mechanisms of action and acceptable safety, and significantly improves quality of life for the majority of patients.

Alpha-1 antitrypsin (AAT) deficiency - what are the treatment options?

Alpha-1 antitrypsin (AAT) deficiency is an under-recognized genetic condition that predisposes to liver disease and early-onset emphysema. Although AAT is mainly produced in the liver, its main function is to protect the lung against proteolytic damage from neutrophil elastase. The most common mutation responsible for severe AAT deficiency, the so-called Z variant, reduces serum levels by promoting polymerization of the molecule within the hepatocyte, thereby reducing secretion. Serum levels below the putative protective threshold level of 11 micromolar (μmol/L) increase the risk of emphysema. In addition to the usual treatments for emphysema, infusion of purified AAT from pooled human plasma represents a specific therapy for AAT deficiency and raises serum and epithelial lining fluid levels above the protective threshold. Substantial evidence supports the biochemical efficacy of this approach, particularly for the weekly infusion regimen. Definitive evidence of clinical efficacy is still needed, as the two available randomized controlled trials showed non-significant trends towards slowing rates of loss of lung density on lung computerized axial tomography. However, concordant results of prospective cohort studies suggest that augmentation therapy has efficacy in slowing the rate of decline of lung function in patients with moderate airflow obstruction and severe deficiency of AAT. Overall, augmentation therapy is well-tolerated and, despite its failure to satisfy criteria for cost-effectiveness, is recommended because it is the only currently available specific therapy for AAT deficiency.

COMPASSIONATE USE OF ENDOBRONCHIAL VALVES: IS IT REALLY COMPASSIONATE?

PURPOSE: Endobronchial valves (EBV) are investigational devices for bronchoscopic treatment of emphysema and bronchopleural fistula (BPF) or lung hyperinflation. They selectively block inspiratory airflow and allow drainage in expiration. We describe a patient series with a compassionate use protocol of EBV for which no other options were available.

Clinical analysis for patients with severe chronic emphysema treated by lung volume reduction surgery

Objective To study effectiveness and safety of lung volume reduction surgery(LVRS) in treatment for severe chronic emphysema(chronic obstructive pulmonary disease).Methods Clinical data of 24 patients of severe chronic emphysema undergone with LVRS during January 2004 to June 2007 were analyzed retrospectively.LVRS was performed for the patients after respiratory tract preparation based on their pulmonary function,results of blood gas analysis,cardiac function,as well as physical activity capacity.and surgical incision Was selected based ontargetlocation of emphysema with chest computerized tomography and isotope lung perfusion scanning,22 cases with standard unilateral LVRS via outer post-lateral incision and two with bilateral LVRS via mid-sternal incison.A linear device for cutting and stitching was used in surgical operation to excise the lung tissues of severe emphysema with strips of bovine pericardium to prevent air leakage.Results All the patients were followed-up for 19 months in average and complications occurred in seven of them after operation,including four with leakage of the alveoli.two with cardiac arrhythmia and one with pneumonia,and no death was observed.Pulmonary function and symptoms of dyspnea improved obviously in all the patients after operation,and they all could care for themselves,in general,with scales of dyspnea increased to grade Ⅰ in one case,to grade Ⅱ in 10 cases and to grade Ⅲ in three cases.Conclusions LVRS can improve pulmonary function of selected patients with severe emphysema,to certain extent,and its safety will depend on strict selection of the patients and correct peri-operative care. Key words: Pneumonectomy; Pneumonectomy emphysema; Treatment outcome