Bronchoscopic lung volume reduction explained

Bronchoscopic lung volume reduction (BLVR) is a procedure to reduce the volume of air within the lungs. BLVR was initially developed in the early 2000s[1] [2] as a minimally invasive treatment for severe COPD that is primarily caused by emphysema. BLVR evolved from earlier surgical approaches first developed in the 1950s[3] to reduce lung volume by removing damaged portions of the lungs via pneumonectomy or wedge resection. Procedures include the use of valves, coils, or thermal vapour ablation.

Procedures

BLVR involves the use of valves, coils, or thermal vapour ablation.

Valves

Endobronchial valves are inserted using a bronchoscope into sections of the lungs damaged by emphysema. Endobronchial valves are medical devices that allow air to exit these sections but not to re-enter. The valves, in effect, cause damaged lung tissue to deflate, thereby reducing the excessive lung volume (hyperinflation) caused by emphysema. Two endobronchial valves have been approved by the FDA for BLVR: Zephyr and Spiration.

Zephyr valve

Zephyr, manufactured by Pulmonx Corporation, obtained FDA approval in June, 2018,[4] after a clinical research trial (LIBERATE)[5] led by principal investigator Gerard Criner, MD, of Temple University Hospital.

In the trial, a total of 190 subjects were randomized across 24 hospital sites into two groups. One group received an endobronchial valve. The other received “standard of care” (SOC) under the current guidelines for hyperinflation due to emphysema. The trial found the endobronchial valve reduced residual lung volume and improved exercise tolerance as compared to the SOC group.

Spiration valve

Spiration, manufactured by Spiration, Inc., obtained FDA approval in December, 2018,[6] after a clinical trial (EMPROVE) showed the valve improved pulmonary function scores among trial participants. The Spiration valve subsequently was first used in treatment by Dr. Criner at Temple University Hospital.

The procedure

BLVR valves are placed into the lungs using a catheter through a bronchoscope. During the one-hour procedure, the patient receives anesthesia through an intravenous line. After the procedure, patients usually remain in the hospital for at least four days. During hospitalization, the patient receives a series of chest X-rays to monitor the position of the valves. An outpatient follow-up appointment is scheduled for seven to 10 days after the procedure. Additional imaging tests, such as X-rays, and bronchoscopies may be required[7] weeks, months or years following the initial BLVR procedure.

Benefits and risks

!Benefits!Risks
Improved lung function[8] COPD exacerbation[9]
Improved exercise tolerance[10] Respiratory failure[11]
ReversiblePneumothorax
Lower risk of injury and infection[12] Pneumonia
Clinical research has found that BLVR confers measurable benefits, including:

BLVR also carries risks, among them:

Research

The first clinical research study of BLVR valve implantation was published in the New England Journal of Medicine in 2010.[15] Since that time, nearly 80 additional papers have been published related to the efficacy[16] [17] of BLVR, inclusion criteria,[18] anesthesia management[19] during BLVR, and related topics. Key studies include:

Notes and References

  1. Marruchella. Almerico. Faverio. Paola. Bonaiti. Giulia. Pesci. Alberto. October 2018. History of lung volume reduction procedures. Journal of Thoracic Disease. 10. Suppl 27. S3326–S3334. 10.21037/jtd.2018.04.165. 2072-1439. 6204342. 30450238 . free .
  2. Sabanathan. S.. Richardson. J.. Pieri-Davies. S.. February 2003. Bronchoscopic lung volume reduction. The Journal of Cardiovascular Surgery. 44. 1. 101–108. 0021-9509. 12627080.
  3. DeCamp. Malcolm M.. McKenna. Robert J.. Deschamps. Claude C.. Krasna. Mark J.. 2008-05-01. Lung Volume Reduction Surgery. Proceedings of the American Thoracic Society. 5. 4. 442–446. 10.1513/pats.200803-023ET. 1546-3222. 2645317. 18453353.
  4. Web site: FDA approves novel device for treating breathing difficulty from severe emphysema. Commissioner. Office of the. 2020-02-20. FDA. en. 2020-03-18.
  5. Criner. Gerard J.. Sue. Richard. Wright. Shawn. Dransfield. Mark. Rivas-Perez. Hiram. Wiese. Tanya. Sciurba. Frank C.. Shah. Pallav L.. Wahidi. Momen M.. de Oliveira. Hugo Goulart. Morrissey. Brian. 2018-11-01. A Multicenter Randomized Controlled Trial of Zephyr Endobronchial Valve Treatment in Heterogeneous Emphysema (LIBERATE). American Journal of Respiratory and Critical Care Medicine. 198. 9. 1151–1164. 10.1164/rccm.201803-0590OC. 1535-4970. 29787288. 46894678.
  6. Health. Center for Devices and Radiological. 2019-12-20. Spiration Valve® System - P180007. FDA. en.
  7. Klooster. Karin. Hartman. Jorine E.. ten Hacken. Nick H.T.. Slebos. Dirk-Jan. January 2017. One-Year Follow-Up after Endobronchial Valve Treatment in Patients with Emphysema without Collateral Ventilation Treated in the STELVIO Trial. Respiration. 93. 2. 112–121. 10.1159/000453529. 0025-7931. 5348732. 27974713.
  8. Web site: Lung volume reduction procedures for emphysema. 2015-12-07. British Lung Foundation. en. 2020-03-18.
  9. Fernandez-Bussy. Sebastian. Labarca. Gonzalo. Herth. Felix J. F.. 2018. Bronchoscopic Lung Volume Reduction in Patients with Severe Emphysema. Seminars in Respiratory and Critical Care Medicine. en. 39. 6. 685–692. 10.1055/s-0038-1676774. 30641586. 58559837. 1069-3424.
  10. Lee. Eung Gu. Rhee. Chin Kook. 2019-05-14. Bronchoscopic lung volume reduction using an endobronchial valve to treat a huge emphysematous bullae: a case report. BMC Pulmonary Medicine. 19. 1. 92. 10.1186/s12890-019-0849-z. 1471-2466. 6518705. 31088437 . free .
  11. Bronchoscopic lung volume reduction procedures for moderate to severe chronic obstructive pulmonary disease. The Cochrane Database of Systematic Reviews. 2017. 10.1002/14651858.CD012158.pub2. 28230230. en. 2020-03-18. Van Agteren. J. E.. Hnin. K.. Grosser. D.. Carson. K. V.. Smith. B. J.. 2017. 2 . CD012158. 6464526.
  12. Gordon. Matthew. Duffy. Sean. Criner. Gerard J.. August 2018. Lung volume reduction surgery or bronchoscopic lung volume reduction: is there an algorithm for allocation?. Journal of Thoracic Disease. 10. Suppl 23. S2816–S2823. 10.21037/jtd.2018.05.118. 2072-1439. 6129811. 30210836 . free .
  13. Criner. Gerard J.. Sue. Richard. Wright. Shawn. Dransfield. Mark. Rivas-Perez. Hiram. Wiese. Tanya. Sciurba. Frank C.. Shah. Pallav L.. Wahidi. Momen M.. de Oliveira. Hugo Goulart. Morrissey. Brian. 2018-05-22. A Multicenter Randomized Controlled Trial of Zephyr Endobronchial Valve Treatment in Heterogeneous Emphysema (LIBERATE). American Journal of Respiratory and Critical Care Medicine. 198. 9. 1151–1164. 10.1164/rccm.201803-0590OC. 29787288. 46894678. 1073-449X.
  14. Web site: Bronchoscopic Lung Volume Reduction Benefits and Risks. Temple Health. en. 2020-03-18.
  15. Sciurba. Frank C.. Ernst. Armin. Herth. Felix J. F.. Strange. Charlie. Criner. Gerard J.. Marquette. Charles H.. Kovitz. Kevin L.. Chiacchierini. Richard P.. Goldin. Jonathan. McLennan. Geoffrey. VENT Study Research Group. 2010-09-23. A randomized study of endobronchial valves for advanced emphysema. The New England Journal of Medicine. 363. 13. 1233–1244. 10.1056/NEJMoa0900928. 1533-4406. 20860505. 20.500.12613/6399. free. free.
  16. Kumar. Abhishek. Dy. Rajany. Singh. Kanwaljit. Jeffery Mador. M.. February 2017. Early Trends in Bronchoscopic Lung Volume Reduction: A Systematic Review and Meta-analysis of Efficacy Parameters. Lung. 195. 1. 19–28. 10.1007/s00408-016-9969-x. 1432-1750. 28005150. 1753916.
  17. Wang. Yong. Lai. Tian-Wen. Xu. Feng. Zhou. Jie-Sen. Li. Zhou-Yang. Xu. Xu-Chen. Chen. Hai-Pin. Ying. Song-Min. Li. Wen. Shen. Hua-Hao. Chen. Zhi-Hua. 2017-09-29. Efficacy and safety of bronchoscopic lung volume reduction therapy in patients with severe emphysema: a meta-analysis of randomized controlled trials. Oncotarget. 8. 44. 78031–78043. 10.18632/oncotarget.19352. 1949-2553. 5652834. 29100445.
  18. May. Nadine. Niehaus-Gebele. Christa. Reichenberger. Frank. Behr. Jürgen. Gesierich. Wolfgang. February 2020. Screening for Bronchoscopic Lung Volume Reduction: Reasons for Not Receiving Interventional Treatment. Lung. 198. 1. 221–228. 10.1007/s00408-019-00303-7. 1432-1750. 31832749. 209331149.
  19. Grande. Bastian. Loop. Torsten. August 2018. Anaesthesia management for bronchoscopic and surgical lung volume reduction. Journal of Thoracic Disease. 10. Suppl 23. S2738–S2743. 10.21037/jtd.2018.02.46. 2072-1439. 6129807. 30210826 . free .
  20. Web site: National Emphysema Treatment Trial (NETT) National Heart, Lung, and Blood Institute (NHLBI). www.nhlbi.nih.gov. 2020-03-18.
  21. Klooster. Karin. ten Hacken. Nick H.T.. Hartman. Jorine E.. Kerstjens. Huib A.M.. van Rikxoort. Eva M.. Slebos. Dirk-Jan. 2015-12-10. Endobronchial Valves for Emphysema without Interlobar Collateral Ventilation. New England Journal of Medicine. 373. 24. 2325–2335. 10.1056/NEJMoa1507807. 0028-4793. 26650153. free. 2066/152186. free.

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