Jean-Michel Vergnon

Efficacy predictors of lung volume reduction with zephyr valves in a european cohort

The Endobronchial Valve for Emphysema Palliation Trial (VENT) was a multi-centre, prospective, randomised, controlled trial conducted to evaluate the safety and effectiveness of unilateral endobronchial valve (EBV) treatment. The purpose of this analysis was to assess outcomes in the previously unreported European VENT study cohort. Patients with advanced emphysema were randomly assigned (2:1) to receive Zephyr® (Pulmonx Inc., Redwood City, CA, USA) EBV treatment (n=111) or medical management (n=60). At 6 months, EBV patients demonstrated a significant improvement compared with the controls for mean±sd change in forced expiratory volume in 1 s (7±20% versus 0.5±19%; p=0.067), cycle ergometry (2±14 W versus -3±10 W; p=0.04) and St George’s Respiratory Questionnaire (-5±14 points versus 0.3±13 points; p=0.047). At 12 months, the magnitude of the difference between groups for change from baseline was of similar magnitude to the differences seen at 6 months. Rates for complications did not differ significantly. EBV patients with computed tomography (CT) scans suggestive of complete fissure and lobar occlusion had a mean±sd lobar volume reduction of -80±30% and >50% met minimal clinical difference thresholds. The degree of emphysema heterogeneity did not preclude excellent outcomes. Unilateral lobar volume reduction using EBV treatment is safe and superior clinical results correlated with CT suggestive of complete fissures and successful lobar occlusion. Emphysema heterogeneity was not critical for determining positive outcomes.

Target lobe volume reduction and COPD outcome measures after endobronchial valve therapy.

Endobronchial valve (EBV) therapy may be associated with improvements in chronic obstructive pulmonary disease-related outcomes and may therefore be linked to improvements in the body mass index, airflow obstruction, dyspnoea, exercise capacity (BODE) index. Data from 416 patients with advanced emphysema and hyperinflation across Europe and USA, who were randomised to EBV (n=284) or conservative therapy (n=132) were analysed. Quantitative image analysis was used to compare the volume of the targeted lobe at baseline and at 6 months to determine target lobe volume reduction (TLVR). 44% of patients receiving EBV therapy (versus 24.7% of controls) had clinically significant improvements in the BODE index (p<0.001). BODE index was significantly reduced by mean±sd 1.4±1.8, 0.2±1.3 and 0.1±1.3 points in patients with TLVR >50%, 20%–50% and <20%, respectively (intergroup differences p<0.001), but increased by 0.3±1.2 points in controls. Changes in BODE were predicted by baseline BODE and correlated significantly with lobar exclusion and lung volumes at 6 months. A greater proportion of patients in the treatment group than in the control group achieved a clinically meaningful improvement in BODE index; however, the likelihood of benefit was less than half in both groups. Patients in whom TLVR was obtained had greater improvements in clinical outcomes. Patients treated with EBV were more likely to have a significantly reduced BODE score (44% treated versus 25% controls) http://ow.ly/qXRUy

Endoscopic Management of Idiopathic Tracheal Stenosis

BACKGROUNDnIdiopathic tracheal stenosis (ITS) is a rare condition representing a difficult therapeutic challenge. Endoscopic management is a therapeutic option but long-term results are not established. The aim of this retrospective multicenter study was to analyze long-term outcome after endoscopic management of ITS.nnnMETHODSnNine institutions involved in interventional bronchoscopy were contacted and asked to identify ITS endoscopically treated. A standard form was used to report the main characteristics and long-term outcome after endoscopic management.nnnRESULTSnTwenty-three patients, 96% women, aged 45±16 years, were endoscopically treated for ITS. Time between first symptoms and diagnosis was 19±18 months. Bronchoscopy showed a weblike (61%) or complex (39%) stenosis, located in the upper part of the trachea, mainly in the cricoid area. Endoscopic treatment included mechanical dilation only (52%) or associated with laser or electrocoagulation (30%) and stent placement (18%). All procedures were efficient. The follow-up after endoscopic management was 41±34 months. The ITS recurrence occurred in 30% at 6 months, 59% at 2 years, and 87% at 5 years, with a delay of 14±16 months. The treatment of recurrence (n=13) included endoscopic management in 12 cases.nnnCONCLUSIONSnEndoscopic management of ITS provides a safe and efficient therapeutic option but late recurrences are frequent and require long-term follow-up.

The integrated place of tracheobronchial stents in the multidisciplinary management of large post-pneumonectomy fistulas: our experience using a novel customised conical self-expandable metallic stent

BACKGROUNDnStump dehiscence after pneumonectomy is a cause of morbidity and mortality in patients treated for non-small-cell lung carcinoma. Surgical repair remains the treatment of choice but can be postponed or contraindicated. Bronchoscopic techniques may be an option with curative intent or as a bridge towards definitive surgery. The aim of the study is to evaluate the efficacy and the outcome of a new customised covered conical self-expandable metallic stent in the management of large bronchopleural fistulas complicating pneumonectomies.nnnMETHODSnA case series using chart review of non-operable patients presenting with large bronchopleural fistulas (>6mm) post-pneumonectomies as a definitive treatment with curative intent for non-small-cell lung carcinomas and requiring the use of a dedicated conical shaped stent in two tertiary referral centres.nnnRESULTSnSeven patients presenting large post-pneumonectomy fistulas (between 6 and 12 mm) were included. Cessation of the air leak and clinical improvement was achieved in all the patients after stent placement. Stent-related complications (two migrations and one stent rupture) were successfully managed using bronchoscopic techniques in two patients and surgery in one. Mortality, mainly related to overwhelming sepsis, was 57%. Delayed definitive surgery was achieved successfully in three patients (43%).nnnCONCLUSIONSnThis case series assesses the short-term clinical efficacy of a new customised covered conical self-expandable metallic stent in the multidisciplinary management of large bronchopleural fistulas complicating pneumonectomies in patients deemed non-operable. Long-term benefits are jeopardised by infectious complications.