Pulmonary Medicine, March 2006
The Pulmonary Medicine Journal Scan is the clinician's guide to the latest clinical research findings in The American Journal of Respiratory and Critical Care Medicine, Annals of Allergy, Asthma, and Immunology, the Journal of Allergy and Clinical Immunology, and other important journals. Short summaries of feature articles include links to the article abstracts when available. (Access to full-text articles usually requires registration at the specific journal's Web site.)
Wan IY, Toma TP, Geddes DM, et al.
Chest. 2006:129;518-526
Lung volume reduction surgery (LVRS) has been shown to improve survival in a subset of patients with upper-lobe predominant disease and low exercise capacity in the National Emphysema Treatment Trial (NETT) study. In addition, it has been shown to improve quality of life and exercise capacity in other subgroups of patients. LVRS is not without risk and sometimes results in prolonged air leaks and protracted hospital stays, and carries a perioperative mortality of 7.9%. It is a natural evolution that less invasive forms of lung volume reduction (LVR), specifically via the bronchoscopic route, are now being sought. This article reports the largest series to date of patients who have undergone endobronchial LVR with the Emphasys EBV (Emphasys Medical, Redwood City, California).
Data were obtained from 9 centers through a multicenter registry. The major inclusionary criteria included age 50-80, symptomatic emphysema with shortness of breath on daily activities despite maximal medical therapy, an FEV1 ≥ 20% predicted, PaCo2 ≤ 55 mm Hg, a DLco ≥ 25%, and no pulmonary hypertension or evidence of active pulmonary infection. A total of 98 patients were included in the report. Baseline pulmonary function parameters included an FEV1 of 30.1%, residual volume (RV) of 244.3%, a total lung capacity of 128.4%, and a DLco of 32.7%. Baseline 6-minute walk distance was 303 meters. A total of 396 valves were placed for an average of 4.0 ±1.6 per patient (range,1-8). Most commonly, patients had valves placed unilaterally in the right upper lobe (40%), followed by bilateral upper lobe placement (25%). Other valve placements were in the lower lobes and the left upper lobe. There were significant improvements seen in the FEV1 (10.7%), the forced vital capacity (9%), RV (-4.9%), and exercise tolerance (23%). Eight complications occurred that were regarded as serious (8.2%), including 1 death (1%). Thirty patients had other complications, including 17 chronic obstructive pulmonary disease (COPD) exacerbations and 5 pneumonias in nontreated lobes. It appears that there were a total of 9 pneumothoraces (10%), which the authors attribute to lung volume changes. Subset analysis revealed a greater improvement in those patients with lobar exclusion with an increase in the FEV1 of 14% and exercise tolerance of 26.7%. Somewhat paradoxically, a still greater improvement was seen in the subgroup of patients with unilateral lobar placement (FEV1 increase of 16.3% and exercise tolerance increase of 40.6%). Patients with baseline FEV1s < 30% predicted had improvements in the FEV1 of 20.6% vs those with FEV1s > 30% predicted (1.3%, P = .0011). Similarly, patients with RV > 225% had an improvement in the FEV1 of 17.2% vs 0.2% for those with a low RV (P = .006).
The results of this study are quite encouraging. Not only was a significant improvement seen in the various pulmonary function and exercise parameters, but this was at an apparent relatively low risk of complications and mortality. This analysis of a registry also suggests that there are specific subgroups of patients in whom more of a benefit is likely to be seen. Specifically, it appears that those patients with lower FEV1s and more hyperinflation are most likely to respond to unilateral lobar exclusion. The encouraging results of this study are tempered by the fact that this was a retrospective review of registry data. The results of a prospective study of the Emphasys valve are eagerly awaited and needed. If the results of this retrospective analysis are verified, then endobronchial LVR will be a welcome addition to our limited armamentarium of options for patients with advanced COPD.
Abstract
http://www.medscape.com/medline/abstract/16537847
Chest
The Pulmonary Medicine Journal Scan is the clinician's guide to the latest clinical research findings in The American Journal of Respiratory and Critical Care Medicine, Annals of Allergy, Asthma, and Immunology, the Journal of Allergy and Clinical Immunology, and other important journals. Short summaries of feature articles include links to the article abstracts when available. (Access to full-text articles usually requires registration at the specific journal's Web site.)
Bronchoscopic Lung Volume Reduction for End-Stage Emphysema: Report on the First 98 Patients
Wan IY, Toma TP, Geddes DM, et al.
Chest. 2006:129;518-526
Lung volume reduction surgery (LVRS) has been shown to improve survival in a subset of patients with upper-lobe predominant disease and low exercise capacity in the National Emphysema Treatment Trial (NETT) study. In addition, it has been shown to improve quality of life and exercise capacity in other subgroups of patients. LVRS is not without risk and sometimes results in prolonged air leaks and protracted hospital stays, and carries a perioperative mortality of 7.9%. It is a natural evolution that less invasive forms of lung volume reduction (LVR), specifically via the bronchoscopic route, are now being sought. This article reports the largest series to date of patients who have undergone endobronchial LVR with the Emphasys EBV (Emphasys Medical, Redwood City, California).
Data were obtained from 9 centers through a multicenter registry. The major inclusionary criteria included age 50-80, symptomatic emphysema with shortness of breath on daily activities despite maximal medical therapy, an FEV1 ≥ 20% predicted, PaCo2 ≤ 55 mm Hg, a DLco ≥ 25%, and no pulmonary hypertension or evidence of active pulmonary infection. A total of 98 patients were included in the report. Baseline pulmonary function parameters included an FEV1 of 30.1%, residual volume (RV) of 244.3%, a total lung capacity of 128.4%, and a DLco of 32.7%. Baseline 6-minute walk distance was 303 meters. A total of 396 valves were placed for an average of 4.0 ±1.6 per patient (range,1-8). Most commonly, patients had valves placed unilaterally in the right upper lobe (40%), followed by bilateral upper lobe placement (25%). Other valve placements were in the lower lobes and the left upper lobe. There were significant improvements seen in the FEV1 (10.7%), the forced vital capacity (9%), RV (-4.9%), and exercise tolerance (23%). Eight complications occurred that were regarded as serious (8.2%), including 1 death (1%). Thirty patients had other complications, including 17 chronic obstructive pulmonary disease (COPD) exacerbations and 5 pneumonias in nontreated lobes. It appears that there were a total of 9 pneumothoraces (10%), which the authors attribute to lung volume changes. Subset analysis revealed a greater improvement in those patients with lobar exclusion with an increase in the FEV1 of 14% and exercise tolerance of 26.7%. Somewhat paradoxically, a still greater improvement was seen in the subgroup of patients with unilateral lobar placement (FEV1 increase of 16.3% and exercise tolerance increase of 40.6%). Patients with baseline FEV1s < 30% predicted had improvements in the FEV1 of 20.6% vs those with FEV1s > 30% predicted (1.3%, P = .0011). Similarly, patients with RV > 225% had an improvement in the FEV1 of 17.2% vs 0.2% for those with a low RV (P = .006).
The results of this study are quite encouraging. Not only was a significant improvement seen in the various pulmonary function and exercise parameters, but this was at an apparent relatively low risk of complications and mortality. This analysis of a registry also suggests that there are specific subgroups of patients in whom more of a benefit is likely to be seen. Specifically, it appears that those patients with lower FEV1s and more hyperinflation are most likely to respond to unilateral lobar exclusion. The encouraging results of this study are tempered by the fact that this was a retrospective review of registry data. The results of a prospective study of the Emphasys valve are eagerly awaited and needed. If the results of this retrospective analysis are verified, then endobronchial LVR will be a welcome addition to our limited armamentarium of options for patients with advanced COPD.
References
National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348:2059-2073.
Abstract
http://www.medscape.com/medline/abstract/16537847
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