Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease.
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ABSTRACT:
SUBMITTER: van Agteren JE
PROVIDER: S-EPMC6464526 | biostudies-literature | 2017 Feb
REPOSITORIES: biostudies-literature
Publications
Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease.
van Agteren Joseph Em JE Hnin Khin K Grosser Dion D Carson Kristin V KV Smith Brian J BJ
The Cochrane database of systematic reviews 20170223
<h4>Background</h4>In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD).<h4>Objectives</h4>To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique.<h4>Search methods</h4>Stud ...[more]
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Project description:Chronic obstructive pulmonary disease (COPD) is the most extensively studied and researched disease in pulmonology and a cause of significant morbidity, mortality, and financial burden on patient's family and country's economy. Its management continues to be a challenge to both the physician and the patient's family. So far, it is preventable and treatable but not curable. Emphysema, a phenotype of COPD, is the most debilitating condition associated with progressive exercise intolerance and severe dyspnea. Despite decades of research, medical treatments available so far have helped improve quality of life and slowed down the decline in respiratory function but did not significantly improve the survival benefits. Though surgical lung volume reduction (LVR) procedures have shown some promise in context to functional gains and survival but, only in a carefully selected group of patients, bronchoscopic LVR procedures are yet to explore their full potential and limitations. This paper retrospectively studied the developments so far, medical and surgical, with special emphasis on the bronchoscopic procedures of lung volume reduction, and tried to comparatively analyze the risks and benefits of each one of them through various trials and studies done to date.
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Project description:Emphysema is one of the pathological manifestations of chronic obstructive pulmonary disease (COPD), which leads to lung hyperinflation, decreased activity of the diaphragm, decreased compliance of the lung, and difficulties in gas exchange. The clinical effect of pharmacological treatment for patients with severe emphysema is limited. In recent years, the emergence of bronchoscopic lung volume reduction (BLVR) has opened up the possibility for the management of COPD with severe emphysema. The article aims to summarize the development, procedure, and methodology of BLVR as well as its clinical efficacy.
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Project description:Bronchoscopic lung volume reduction (BLVR) offers alternative novel treatments for patients with emphysema. Comprehensive evidence for comparing different BLVR remains unclear. To estimate the effects of different BLVR on patients with emphysema. PubMed, EMBASE, Cochrane Library, and Web of Science databases from January 2001 to August 2017 were searched. Randomized clinical trials evaluated effects of BLVR on patients with emphysema. The relevant information was extracted from the published reports with a predefined data extraction sheet, and the risk of bias was assessed with the Cochrane risk of bias tools. Pair-wise metaanalyses were made using the random-effects model. A random-effects network meta-analysis was applied within a Bayesian framework. The quality of evidence contributing to primary outcomes was assessed using the GRADE framework. 13 trials were deemed eligible, including 1993 participants. The quality of evidence was rated as moderate in most comparisons. Medical care (MC)was associated with the lowest adverse events compared with intrabronchial valve (IBV)(-2.5,[-4.70 to -0.29]), endobronchial valve (EBV) (-1.73, [-2.37 to -1.09]), lung volume reduction coils (LVRC) (-0.76, [-1.24 to -0.28]), emphysematous lung sealant (ELS) (-1.53, [-2.66 to -0.39]), and airway bypass(-1.57, [-3.74 to 0.61]). Adverse events in LVRC were lower compared with ELS (-0.77,[-2.00 to 0.47]). Bronchoscopic thermal vapor ablation (BTVA) showed significant improvement in FEV1 compared with MC (0.99, [0.37 to 1.62]), IBV (1.25, [0.25 to 2.25]), and LVRC (0.72, [0.03 to 1.40] ). Six minute walking distance (6 MWD) in ELS was significantly improved compared with other four BLVR, sham control, and MC (-1.96 to 1.99). Interestingly, MC showed less improvement in FEV1 and 6MWDcompared with EBV (-0.45, [-0.69 to -0.20] and -0.39, [-0.71 to -0.07], respectively). The mortality in MC and EBV was lower compared with LVRC alone (-0.38, [-1.16 to 0.41] and -0.50, [-1.68 to 0.68], respectively). BTVA and EBV led to significant changes in St George's respiratory questionnaire (SGRQ) compared with MC alone (-0.74, [-1.43 to -0.05] and 0.44, [0.11 to 0.78], respectively). BLVR offered a clear advantage for patients with emphysema. EBV had noticeable beneficial effects on the improvement of forced expiratory volume 1, 6MWD and SGRQ, and was associated with lower mortality compared with MC in different strategies of BLVR.
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Project description:BackgroundCompletion of pulmonary rehabilitation is recognised in chronic obstructive pulmonary disease (COPD) guidelines as a key opportunity to consider systematically whether a respiratory review to assess potential suitability for a lung volume reduction (LVR) procedure might be appropriate. We describe the development of a simple decision-support tool (the LVR-PR tool) to aid clinicians working in pulmonary rehabilitation, to operationalise this process.MethodsWe took an iterative mixed methods approach, which was partnership-based and involved an initial consensus survey, focus groups and an observational study cohort at multiple pulmonary rehabilitation centres.ResultsDiagnosis (97%), exercise capacity (84%), breathlessness (78%) and co-morbidities (76%) were acknowledged to be essential items for assessing basic LVR eligibility. Collating prior investigations and assessing patient understanding were considered useful but not essential. Clinician concerns included; streamlining the tool; access to clinical information and investigations; and care needed around introducing LVR therapies to patients in a PR setting. Access to clearer information about LVR procedures, the clinician's role in considering eligibility and how educational resources should be delivered were identified as important themes from patient group discussions. The LVR-PR tool was considered to be feasible and valid for implementation in a variety of PR services across the UK subject to the provision of appropriate health professional training. Clinicians working in specialist LVR centres across the UK who were not otherwise involved in the development process confirmed the tool's validity using the content validity index (CVI).InterpretationThe LVR-PR tool appears to be an acceptable tool that can be feasibly implemented in PR services subject to good quality educational resources for both patients and healthcare professionals.
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Project description: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.
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Project description:Purpose:Bronchoscopic lung volume reduction (BLVR) is a valuable treatment option for carefully selected patients with severe COPD. There is limited knowledge about the characteristics and outcomes of patients referred to a specialized center for BLVR. The study objectives were to investigate the selection rate for BLVR treatment in patients referred for this treatment and to investigate the differences between patients that were selected for BLVR and patients that were not. Patients and Methods:We performed a retrospective analysis of patients with severe COPD who were referred to our hospital to assess eligibility for BLVR treatment. Our parameters included demographics, comorbidity, chest computed tomography characteristics, reasons for rejection from BLVR treatment and patient survival. Results:In total, 1500 patients were included (mean age 62 years, 50% female and forced expiratory volume in 1 s 33% of predicted). Out of this group, 282 (19%) patients were selected for BLVR treatment. The absence of a suitable target lobe for treatment, an unsuitable disease phenotype and insufficient lung hyperinflation were the most important factors for not being selected. Patients that were selected for any BLVR option lived significantly longer than the group of patients that were not selected for BLVR (median 3060 versus 2079 days, P<0.001). Conclusion:We found that only a small proportion of patients that are referred for BLVR treatment is eligible for a BLVR treatment, indicating a need for both better referral tools and for the development of new therapies for this group of patients. Furthermore, our data suggest that selection for BLVR is associated with a significant survival benefit.
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Project description:BackgroundLung volume reduction surgery (LVRS) is a treatment option for selected patients with severe chronic obstructive pulmonary disease (COPD) and emphysema. The positive effects of LVRS on exercise capacity are well known. In contrast, the effect of LVRS on daily physical activity (PA) is less clear.MethodsIn a prospective case-control study we evaluated selected patients with severe COPD and emphysema who underwent LVRS and COPD patients following usual care. Controls were matched for age, severity of airflow obstruction (FEV1) and hyperinflation [residual volume to total lung capacity (RV/TLC)]. Treatment effect of LVRS on activity parameters was analysed using univariable regression model adjusting for treatment group.ResultsA total of 19 patients underwent LVRS and 16 COPD patients without a surgical intervention during the study period were included. The median (quartile) FEV1%pred was 28% (range, 21-33%), RV/TLC was 69% (range, 64-73%) in cases while controls had a median (quartile) FEV1%pred of 33% (range, 28.5-49.5%) and a RV/TLC of 58% (range, 49-61%). Age and body mass index (BMI) were comparable between both groups. Number of steps per day following LVRS was comparable to before the intervention (mean change: -115, 95% CI: -994.6 to 764.3, P=0.779) and was not significantly different to the change in control subjects (mean treatment effect: 931.4, 95% CI: -252.4 to 2,115.1, P=0.117).ConclusionsThe results from this study reveal that patients undergoing LVRS did not increase their daily level of PA despite improvement of exercise capacity and symptoms.
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Project description: Not available
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