Dominik Herzog

Outcomes of Endobronchial Valve Treatment Based on the Precise Criteria of an Endobronchial Catheter for Detection of Collateral Ventilation under Spontaneous Breathing.

Background: Endoscopic lung volume reduction with valves is a valid therapeutic option for COPD patients with severe emphysema. The exclusion of interlobar collateral ventilation (CV) is an important predictor of clinical success. Objectives: Recently, a catheter-based endobronchial in vivo measurement system (Chartis, Pulmonx, USA) has become routine in the clinical evaluation of CV status in target lobes, but the criteria for phenotyping CV by Chartis evaluation have not yet been defined. We asked the questions, how many phenotypes can be identified using Chartis, what are the exact criteria to distinguish them, and how do the Chartis phenotypes respond to valve insertionκ Methods: In a retrospective study, 406 Chartis assessments of 166 patients with severe COPD were analyzed. Four Chartis phenotypes, CV positive (CV+), CV negative (CV-), low flow (LF) and low plateau were identified. Fifty-two patients without CV were treated with valves and followed for 3 months. Results: The Chartis phenotypes were discriminated with respect to decline in expiratory peak flow, increase in resistance index and change in total exhaled volume after 1, 2, 3, 4 and 5 min of measurement time (p < 0.0001, ANOVA), and the cutoff criteria were defined accordingly. To examine the application of these phenotyping criteria, students applied them to 100 Chartis assessments, and they demonstrated almost perfect inter- and intraobserver agreements (κ > 0.9). Compared to baseline, CV- and LF patients with ipsilateral CV- lobe showed an improvement in FEV1 (p < 0.05), vital capacity (p < 0.05) and target lobe volume reduction (p < 0.005) after valve insertion. Conclusion: This study describes the most prevalent Chartis phenotypes.

Modifying Post-Operative Medical Care after EBV Implant May Reduce Pneumothorax Incidence.

Objective Endoscopic lung volume reduction (ELVR) with valves has been shown to improve COPD patients with severe emphysema. However, a major complication is pneumothoraces, occurring typically soon after valve implantation, with severe consequences if not managed promptly. Based on the knowledge that strain activity is related to a higher risk of pneumothoraces, we asked whether modifying post-operative medical care with the inclusion of strict short-term limitation of strain activity is associated with a lower incidence of pneumothorax. Methods Seventy-two (72) emphysematous patients without collateral ventilation were treated with bronchial valves and included in the study. Thirty-two (32) patients received standard post-implantation medical management (Standard Medical Care (SMC)), and 40 patients received a modified medical care that included an additional bed rest for 48 hours and cough suppression, as needed (Modified Medical Care (MMC)). Results The baseline characteristics were similar for the two groups, except there were more males in the SMC cohort. Overall, ten pneumothoraces occurred up to four days after ELVR, eight pneumothoraces in the SMC, and only two in the MMC cohorts (p=0.02). Complicated pneumothoraces and pneumothoraces after upper lobe treatment were significantly lower in MMC (p=0.02). Major clinical outcomes showed no significant differences between the two cohorts. Conclusions In conclusion, modifying post-operative medical care to include bed rest for 48 hours after ELVR and cough suppression, if needed, might reduce the incidence of pneumothoraces. Prospective randomized studies with larger numbers of well-matched patients are needed to confirm the data.

Lung perfusion and emphysema distribution affect the outcome of endobronchial valve therapy.

The exclusion of collateral ventilation (CV) and other factors affect the clinical success of endoscopic lung volume reduction (ELVR). However, despite its benefits, the outcome of ELVR remains difficult to predict. We investigated whether clinical success could be predicted by emphysema distribution assessed by computed tomography scan and baseline perfusion assessed by perfusion scintigraphy. Data from 57 patients with no CV in the target lobe (TL) were retrospectively analyzed after ELVR with valves. Pulmonary function tests (PFT), St George’s Respiratory Questionnaire (SGRQ), and 6-minute walk tests (6MWT) were performed on patients at baseline. The sample was grouped into high and low levels at the median of TL perfusion, ipsilateral nontarget lobe (INL) perfusion, and heterogeneity index (HI). These groups were analyzed for association with changes in outcome parameters from baseline to 3 months follow-up. Compared to baseline, patients showed significant improvements in PFT, SGRQ, and 6MWT (all P≤0.001). TL perfusion was not associated with changes in the outcome. High INL perfusion was significantly associated with increases in 6MWT (P=0.014), and high HI was associated with increases in forced expiratory volume in 1 second (FEV1), (P=0.012). Likewise, there were significant correlations for INL perfusion and improvement of 6MWT (r=0.35, P=0.03) and for HI and improvement in FEV1 (r=0.45, P=0.001). This study reveals new attributes that associate with positive outcomes for patient selection prior to ELVR. Patients with high perfusions in INL demonstrated greater improvements in 6MWT, while patients with high HI were more likely to respond in FEV1.

COPD treatment: about collateral channels and collapsing airways.

Collateral channels inside the human lungs? This phenomenon, first described by Kohn [1] in 1893, is the subject of recent investigations in the field of endoscopic lung volume reduction (ELVR) for the treatment of severe chronic obstructive pulmonary disease (COPD). ELVR with valves is a new and promising therapeutic option for irreversibly damaged emphysematous lungs. The aim of the therapy is the complete occlusion of a lobe, with endobronchial one-way valves delivered through a bronchoscope to intentionally induce a targeted atelectasis of the most damaged lobe. Many studies have described improvements in lung function, quality of life and exercise capacity in a subset of severe COPD patients, where interlobar collateral ventilation was an exclusion criterion for valve treatment [2–8]. Interlobar collateral ventilation is defined as the ventilation of alveolar structures through passages or channels that bypass the normal airways, and includes the interalveolar pores of Kohn, the bronchiole–alveolar communications of Lambert and the interbronchiolar pathways of Martin [9–14]. Collateral ventilation is present not only in COPD lungs, but also in healthy lungs [15]. The physiological function of the collateral channels is still unknown; in COPD patients they might provide channels of low resistance to better ventilate less emphysematous lung segments. The importance of collateral ventilation was ignored for over a century, but now, with their role in ELVR and the development of new bronchoscopic techniques, the study of these little channels has gained enormously in importance. Dynamic airway collapse during Chartis doesn’t identify the presence of collateral channels in that specific lobe http://ow.ly/YGV0G

Interventionelle bronchologische Therapie@@@Interventional bronchological therapy: Eine kritische Bestandsaufnahme@@@A critical evaluation

ZusammenfassungHintergrundChronisch obstruktive Lungenerkrankungen (COPD) sind unheilbare, progredient fortschreitende Erkrankungen, die durch eine irreversible Obstruktion der kleinen Atemwege gekennzeichnet sind. Insbesondere wenn medikamentöse Behandlungsversuche bei Patienten mit schwerer COPD nicht den gewünschten Erfolg bringen, steht ein neues Therapiekonzept zur kausalen Behandlung der Lungenüberblähung zur Verfügung: die endoskopische Lungenvolumenreduktion. Man unterscheidet die reversible okkludierende Behandlung mit endobronchialen Ventilen von den irreversiblen nicht okkludierenden Verfahren wie Thermoablation, Bronchialkleber, Stents und Spiralen.MethodenEs erfolgte ein systematischer Vergleich der wichtigsten Verfahren der Lungenvolumenreduktion bezüglich klinischer Outcomes und Komplikationsprofil basierend auf Literaturrecherchen und klinischer Erfahrung.ErgebnisseEine vollständige Okklusion bei heterogen verteiltem Lungenemphysem und kompletten Fissuren sind die wichtigsten Prädiktionsmarker für eine erfolgreiche Ventiltherapie. Wichtigste Komplikation ist die hohe Pneumothoraxrate. Die ähnlich wirksamen irreversiblen Verfahren könnten für Patienten mit Kollateralverbindungen zwischen den Lungenlappen eine mögliche Therapieoption darstellen, wobei die Studienlage für endgültige Schlussfolgerungen noch nicht ausreichend ist.SchlussfolgerungZusammengefasst stellen interventionelle bronchologische Maßnahmen für COPD-Patienten mit ausgeprägtem Emphysem und fortgeschrittenem Krankheitsstadium eine neue Therapiemöglichkeit dar. Noch ist kein Verfahren zur breiten Anwendung im klinischen Alltag geeignet.AbstractBackgroundChronic obstructive pulmonary disease (COPD) is an incurable progressive disease which is characterized by an irreversible occlusion of the small airways. Especially when pharmaceutical treatment attempts do not bring the desired success in patients with severe COPD, a new therapeutic concept for causal treatment of pulmonary emphysema is now available: endoscopic lung volume reduction. A differentiation is made between reversible occlusive treatment with endobronchial valves and irreversible nonocclusive procedures, such as thermoablation, bronchial glue, stents and spirals.MethodsA systematic comparison of the most important procedures for lung volume reduction with respect to clinical outcome and complication profile was carried out based on a literature search and clinical experience.ResultsA complete occlusion in heterogeneously distributed lung emphysema and complete fissures are the most important predictive markers for successful valve therapy. The most important complication is the high rate of pneumothorax. The similarly effective irreversible procedure can be a possible therapy option for patients with collateral connections between the lung lobes but the current evidence from studies is insufficient for final conclusions to be drawn.ConclusionIn summary interventional bronchological measures represent a new therapy option for COPD patients with severe emphysema and advanced disease stage. However, none of the procedures are currently suitable for broad application in the clinical routine.

Interventionelle bronchologische TherapieInterventional bronchological therapy

ZusammenfassungHintergrundChronisch obstruktive Lungenerkrankungen (COPD) sind unheilbare, progredient fortschreitende Erkrankungen, die durch eine irreversible Obstruktion der kleinen Atemwege gekennzeichnet sind. Insbesondere wenn medikamentöse Behandlungsversuche bei Patienten mit schwerer COPD nicht den gewünschten Erfolg bringen, steht ein neues Therapiekonzept zur kausalen Behandlung der Lungenüberblähung zur Verfügung: die endoskopische Lungenvolumenreduktion. Man unterscheidet die reversible okkludierende Behandlung mit endobronchialen Ventilen von den irreversiblen nicht okkludierenden Verfahren wie Thermoablation, Bronchialkleber, Stents und Spiralen.MethodenEs erfolgte ein systematischer Vergleich der wichtigsten Verfahren der Lungenvolumenreduktion bezüglich klinischer Outcomes und Komplikationsprofil basierend auf Literaturrecherchen und klinischer Erfahrung.ErgebnisseEine vollständige Okklusion bei heterogen verteiltem Lungenemphysem und kompletten Fissuren sind die wichtigsten Prädiktionsmarker für eine erfolgreiche Ventiltherapie. Wichtigste Komplikation ist die hohe Pneumothoraxrate. Die ähnlich wirksamen irreversiblen Verfahren könnten für Patienten mit Kollateralverbindungen zwischen den Lungenlappen eine mögliche Therapieoption darstellen, wobei die Studienlage für endgültige Schlussfolgerungen noch nicht ausreichend ist.SchlussfolgerungZusammengefasst stellen interventionelle bronchologische Maßnahmen für COPD-Patienten mit ausgeprägtem Emphysem und fortgeschrittenem Krankheitsstadium eine neue Therapiemöglichkeit dar. Noch ist kein Verfahren zur breiten Anwendung im klinischen Alltag geeignet.AbstractBackgroundChronic obstructive pulmonary disease (COPD) is an incurable progressive disease which is characterized by an irreversible occlusion of the small airways. Especially when pharmaceutical treatment attempts do not bring the desired success in patients with severe COPD, a new therapeutic concept for causal treatment of pulmonary emphysema is now available: endoscopic lung volume reduction. A differentiation is made between reversible occlusive treatment with endobronchial valves and irreversible nonocclusive procedures, such as thermoablation, bronchial glue, stents and spirals.MethodsA systematic comparison of the most important procedures for lung volume reduction with respect to clinical outcome and complication profile was carried out based on a literature search and clinical experience.ResultsA complete occlusion in heterogeneously distributed lung emphysema and complete fissures are the most important predictive markers for successful valve therapy. The most important complication is the high rate of pneumothorax. The similarly effective irreversible procedure can be a possible therapy option for patients with collateral connections between the lung lobes but the current evidence from studies is insufficient for final conclusions to be drawn.ConclusionIn summary interventional bronchological measures represent a new therapy option for COPD patients with severe emphysema and advanced disease stage. However, none of the procedures are currently suitable for broad application in the clinical routine.

Interventionelle bronchologische Therapie

ZusammenfassungHintergrundChronisch obstruktive Lungenerkrankungen (COPD) sind unheilbare, progredient fortschreitende Erkrankungen, die durch eine irreversible Obstruktion der kleinen Atemwege gekennzeichnet sind. Insbesondere wenn medikamentöse Behandlungsversuche bei Patienten mit schwerer COPD nicht den gewünschten Erfolg bringen, steht ein neues Therapiekonzept zur kausalen Behandlung der Lungenüberblähung zur Verfügung: die endoskopische Lungenvolumenreduktion. Man unterscheidet die reversible okkludierende Behandlung mit endobronchialen Ventilen von den irreversiblen nicht okkludierenden Verfahren wie Thermoablation, Bronchialkleber, Stents und Spiralen.MethodenEs erfolgte ein systematischer Vergleich der wichtigsten Verfahren der Lungenvolumenreduktion bezüglich klinischer Outcomes und Komplikationsprofil basierend auf Literaturrecherchen und klinischer Erfahrung.ErgebnisseEine vollständige Okklusion bei heterogen verteiltem Lungenemphysem und kompletten Fissuren sind die wichtigsten Prädiktionsmarker für eine erfolgreiche Ventiltherapie. Wichtigste Komplikation ist die hohe Pneumothoraxrate. Die ähnlich wirksamen irreversiblen Verfahren könnten für Patienten mit Kollateralverbindungen zwischen den Lungenlappen eine mögliche Therapieoption darstellen, wobei die Studienlage für endgültige Schlussfolgerungen noch nicht ausreichend ist.SchlussfolgerungZusammengefasst stellen interventionelle bronchologische Maßnahmen für COPD-Patienten mit ausgeprägtem Emphysem und fortgeschrittenem Krankheitsstadium eine neue Therapiemöglichkeit dar. Noch ist kein Verfahren zur breiten Anwendung im klinischen Alltag geeignet.AbstractBackgroundChronic obstructive pulmonary disease (COPD) is an incurable progressive disease which is characterized by an irreversible occlusion of the small airways. Especially when pharmaceutical treatment attempts do not bring the desired success in patients with severe COPD, a new therapeutic concept for causal treatment of pulmonary emphysema is now available: endoscopic lung volume reduction. A differentiation is made between reversible occlusive treatment with endobronchial valves and irreversible nonocclusive procedures, such as thermoablation, bronchial glue, stents and spirals.MethodsA systematic comparison of the most important procedures for lung volume reduction with respect to clinical outcome and complication profile was carried out based on a literature search and clinical experience.ResultsA complete occlusion in heterogeneously distributed lung emphysema and complete fissures are the most important predictive markers for successful valve therapy. The most important complication is the high rate of pneumothorax. The similarly effective irreversible procedure can be a possible therapy option for patients with collateral connections between the lung lobes but the current evidence from studies is insufficient for final conclusions to be drawn.ConclusionIn summary interventional bronchological measures represent a new therapy option for COPD patients with severe emphysema and advanced disease stage. However, none of the procedures are currently suitable for broad application in the clinical routine.