1 / 55

ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA

ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA. Korkut Bostancı, MD. ENDOBRONCHIAL INTERVENTIONS FOR EMPYSEMA. I have no conflict of interest to declare. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA.

kovit
Download Presentation

ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Korkut Bostancı, MD

  2. ENDOBRONCHIAL INTERVENTIONS FOR EMPYSEMA I have no conflict of interest to declare.

  3. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Emphysema is a progressivediseasecharacterizedbydestruction of lungtissue as a result of inflammationcausedbyexpoauretonoxıousinhaledagentsforextendedperiods • Genetic , occupational, environmentalfactors– %10 Cigarettesmoking– %90 • Despitethebansandcampaigns, duetothenumber of currentandnewsmokersemphysemawillremain as a leadingmorbidity / mortalityformanyyearstocome

  4. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Unique among the COPD in that it involves irreversible destruction of alveolar tissue Decrease in elastic recoil, progresive hyperinflation, premature closure of small airways, air trapping Chronic shortness of breath, limited exercise capacity – reduced quality of life Principal defect is hyperinflation + destruction of elastic tissue – conventional medical treatment is of limited benefit

  5. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA SurgicaltreatmentoptionsforEmphysema • Lungvolumereductionsurgery (LVRS) • Resection of thedamagedareas of lung • Increase in breathingcapacity, reduction in hyperinflation • Provenbeneficialforselectedpatients • NETT trial(17 centers, 1218 patients) N Engl J Med 2003 • Significantimprovment in lungfunction, exercisecapacity, quality of life

  6. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • NETT trial • High incidence of seriouscardiopulmonarycomplications (30 days – 60%) • FEV1 anddiffusioncapacity < 20% predicted – 90-day mortalityfollowing LVRS is significantlyhigh • LVRS is consideredto be a riskyintervention • 3-month mortality 5-10%, morbidity 60% • Length of hospitalstay; 10 days (USA), 22 days (Canada) Annualnumber of LVRS in USA < 300

  7. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA SurgicaltreatmentoptionsforEmphysema • LungTransplantation (LT) • Improvespulmonaryfunctions, functionalcapacity, quality of life • Donor organ shortage! • Annualnumber of LT worldwide <2000 (750 – COPD) • Chronicrejection is a major problem, 5-year mortality 50% • LT – nosignificanteffect on overallmortality in emphysema ?

  8. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • AlternativeTreatment ? • Minimallyinvasivetechniqueshavebeenproposedtoreducethelungvolumewithouthavingtoundergosurgery since thebeginning of the 2000s • EndoscopicinterventionstoreplacetheLVRS • Ingenito EP (experimental – glue) Am J RespirCrit Care Med 2001 • Toma TP (8 patientsendobronchialvalves) Lancet 2003 • Snell GI (10 patientsendobronchialvalves) Chest 2003

  9. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Endoskopiclungvolumereduction (ELVR) • What is common in alldiffrenttechniques of ELVR • Localanesthesia / sedation • Flexiblebroncoscope • Lobar / segmentalatelectasis / fibrosis • Ongoingstudies in almostalltechniques

  10. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Heterogenousemphysema • Reversibleblockingtechniques • Reversiblenonblockingtechniques • Irreversiblenonblockingtechniques Homogenousemphysema • Extraanatomicairway bypass technique

  11. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Reversibleblockingtechniques • Endobronchialvalves • Devicesdesignedtopreventairfromenteringthemostdiseasedareasandtoreducetheairtrapping in time • LVRS-likeeffectifsegmental / lobarresorbtionatelectasisoccurs

  12. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Duckbillvalves – Pulmonx (Emphasys, Zephyr) (endobronchialvalve – EBV) • Umbrellavalves – Olympus (Spiration) (intrabronchialvalve – IBV) • Severaltypes of othervalves

  13. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Watanabe valve Zephyr valve Emphasys valve Miyazawa valve Spiration valve

  14. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Application; • HRCT, ventilation / perfusionscan • Lobe / segment • Right size forthebronchus / number of valves • Preventsairfromentering / allowsventing of expiredgasandsecretions • Can be removedif not working

  15. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA First generation EBV (Emphasys) and loading catheter

  16. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Emphasys valve; • First generation valve of Pulmonx • Used in the first studies of ELVR • Wan IY (9 centers, 98 patients) Chest 2006 • Increase in FEV1 11% • Improvment in 6-MWT 23% • Better results in patients with FEV1 less than 30% predicted • Unilateral placement • Lobar placement

  17. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Second genetation EBV (Zephyr) and loading catheter

  18. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Zephyr valve; • Silicone coated nitinol stent with a one-way valve • Prevents air from entering during inspiration, vents air and secretions during expiration • Offers less resistence to expiratory flow than Emphasys valves • Best results and the largest series of ELVR in the literature

  19. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • VENT trialgroup – VENT trials • Strange C (multi-center, 270 patients) BMC PulmMed 2007 • Sciurba FC (multi-center, 220 patients) N Engl J Med 2010 • Herth FJ (multi-center, 111 patients) EurRespir J 2012 • Significantimprovment in 6-MWT in thevalvegroup • Significantimprovement in dyspnea & quality of life scores • Betterresults in thesubgoupwithheterogeneousemphysema • Fissureincompleteness is a predictor of treatmentresponse • Collateralventilation !

  20. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Chartis collateral ventilation assesment system

  21. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Collateral ventilation assesment

  22. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Collateral ventilation No collateral ventilation

  23. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Zephyr valve deployment

  24. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA right upper lobe - EBV preop postop

  25. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Spiration valve; • Polyurethane membrane coated 6 nitinol support struts – umbrella • Air and mucous escapes around the edges of the membrane

  26. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Spiration IBV and loading catheter

  27. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • First study – IBV pilot study group • Wood DE (5 centers, 28 patients) J Thorac Cardiovasc Surg 2007 • No significant changes in physiological parameters • Improvement in quality of life scores • Springmeyer SC (13 centers, 98 patients) Thorac Surg Clin 2009 • Valves for bilateral upper lobes • Most common complication pneumothorax (8 patients , more on the left) • Significant improvement in quality of life scores • Better quality of life scores even in patients without atelectasis • Reduced ventilation / perfusion mismatch in unblocked lobes

  28. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Spiration IBV deployment

  29. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Right upper lobe - IBV preop postop

  30. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Most common complications of valve placement; • Exacerbations of the disease (5-20%) • Pneumothorax (7-11%) (more on the left) • Postobtructive pneumonia (rare)

  31. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Endobronchial valves; • Published studies are not sufficient (no control arms, small numbers, short follow-up periods, wide variation in number of valves; 4-11) • Limited results in physiological parameters • Significant improvement in FEV1 18-46% • Significant improvement in 6-MWT 11-55% • Better results (~ 85%) in dyspnea and quality of life scores!

  32. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Best results in patients with lobar atelectasis • Lobar atelectasis in different series 25% • Valves are ineffective when no atelectasis? NO ! • Other physiological mechanisms also have a role • Air flow redirects to less diseased areas • Less air trapping • Smaller physiological dead space • Improved V / Q

  33. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Valvetreatment; • Unilateral X bilateral ? Controversial! • Betterresultswhenunilateral in EBV studies! • Betterresultswhenbilateralin IBV studies! • Ongoingstudies on thisissue • Withthe data collecteduptonowendobronchialvalveplacement is concideredto be safer than LVRS

  34. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Reversible nonblocking techniques • Lung volume reduction coil – PneumRx coil

  35. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Preshaped nitinol wire • Straigtened coil in the right size is inserted through the fiberoptic bronchoscope under fluoroscopic guidence • It assumes its preformed shape pulling the airway and the parenchyma • Like in valves, it is possible to remove and reposition the coils

  36. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Bilateral PneumRx coil treatment

  37. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Lung volume reduction coil; • Herth FJ (11 patients) Ther Adv Respir Dis 2010 • Slebos DJ (16 patients) Chest 2011 • Improvement in spirometry, 6-MWT and quality of life scores • Bronchiectasis due to bronchial distortion ? • Pulmonary infarct due to vascular kinking ? • Ongoing studies both in heterogeneous and homogeneous emphysema groups

  38. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Irreversible nonblocking techniques • Bronchoscopic thermal vapor ablation (BTVA) • Aims to induce fibrosis using hot water vapor ! • Inflammatory response is triggered with the steam delivered into the segmental bronchi resulting in fibrosis and volume reduction in the area • No prosthesis, independent from collateral ventilation !

  39. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • BTVA; • Vapor catheter is inserted via flexible bronchoscopy into the targeted bronchus • Segment is isolated with the occlusion baloon • Controlled doses of heated water vapor is given into the segment

  40. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA BTVA procedure

  41. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA BTVA in the right upper lobe

  42. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • BTVA; • Snell GI (11 patients) AnnThoracSurg 2009 • No significantchanges in spirometry • Improvement in pyspneaandquality of life scoresComplications– COPD exacerbation, pneumonia • Snell GI (13 centers, 44 patients) EurRespir J 2011 • Significantimprovement in spirometry, 6-MWT andquality of life scores in patientswithemphysema in theupperlobes • Ongoingstudies .

  43. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Polymeric lung volume reduction (PLVR) – AeriSeal • Damaged alveoli are filled with fibrin hydrogel foam through the working channel of the fiberoptic bronchoscope • As the gas within the foam is absorbed the foam collapses shrinking the parenchyma – resorbtion atelectasis • Independent from collateral ventilation

  44. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA PLVR – AeriSeal application

  45. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • PLVR; • Reilly J (6 patients) Chest 2007 • Improvement in spirometry, 6-MWT, dyspnea scores • Herth FJ (6 centers, 25 paitents) Respiration 2011 • Significant improvement in spirometry, 6-MWT, quality of life and dyspnea scores • Better results when using higher doses of hydrogel and when applying in up to 12 subsegments

  46. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA PLVR in the right upper lobe

  47. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Homogeneous empysema • Airway bypass system – Exhale • Extraanatomic passageways are created through the walls of the bronchi to connect the damaged parenchyma to the native airways • Collapsed small airways are bypassed • Trapped air is drained

  48. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Fenestration site is markedusing a Dopplerprobe • Bronchialwall is puncturedanddilatedwith a baloon • Paclitaxelelutingsteel + siliconestent is placed in thepassage Airway bypass procedure

  49. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA Airway bypass system – Exhale

  50. ENDOBRONCHIAL INTERVENTIONS FOR EMPHYSEMA • Airway bypass system; • Rendina EA (15 patients )J ThoracCardiovascSurg2003 • Feasibilitystudy of theDopplerguidedairway bypass • CardosoPF (35 patients) J ThoracCardiovascSurg 2007 • Median 8 stents – 6. month~70% patency • Significantreduction in theresidualvolume, significantimprovement in dyspneascores • Pneumomediastinum 5% • Fatalhemptysis in onepaitent !

More Related