When less is more:
Lung volumes reduction surgery
for advanced emphysema
Dr Andrew Hardy
Acute & Respiratory Medicine
[email protected]
@abh826
Conflicts of interest
Company
Speaker fees
GSK, Pfizer
Educational support
Almirall, Boehringer, Novartis, Pfizer
Independent
consultancy work
Pfizer
Learning outcomes
• Physiological principles underlying the
treatment
• What surgical treatment options are available
for patients with severe emphysema
• How to assess patients for LVRS in a general
respiratory clinic
• Local process for accessing these interventions
Structure
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Physiology: Why should it work?
Evidence: Does it work?
Local service
Cases
Summary
Physiology
Hyperinflation
• Increased end expiratory lung volumes
• Static hyperinflation
– Reduced lung elastance- loss of elastic recoil
– Chest wall recoil unaffected
• Dynamic hyperinflation
– Prolonged lung emptying but fixed time for breath
– Incomplete alveolar emptying
– Increased alveolar end-expiratory pressure
Expert Rev. Respir. Med, 1–19 (2014)
Consequences
• Reduced force generating capacity of
respiratory muscles
• Diaphragm flattening
– reduced ventilatory reserve
• Cardio-circulatory consequences
– reduced LV volume, stroke volume, cardiac output
Expert Rev. Respir. Med, 1–19 (2014)
Expert Rev. Respir. Med, 1–19 (2014)
Expert Rev. Respir. Med, 1–19 (2014)
How to treat?
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Bronchodilation (reduce airflow limitation)
Ventilatory support (overcome intrinsic PEEP)
Change inspired gas (increase FiO2, Heliox)
Breathing control (improve tidal volume)
Exercise training (reduce O2 requirements)
Inspiratory muscle training
Lung volume reduction
LVRS: The evidence
Brantigan, 1957
• First case reports of LVRS
• 75% reported symptom improvement
• 18% post operative mortality
NETT, 2003
• 1218 patients randomised to surgical lung
volume reduction or standard therapy
• Excluded if FEV1 <20% or DLCO <20%
• Not smoking, pulm rehab prior to randomisation
• Mean age 66, FEV1 26%, RV 220%
o
• 1 end point: Mortality at 24 months
o
• 2 end points: Exercise capacity, QOL
N Engl J Med 348;21: 2059-2073
• 90 day mortality
– 7.9% surgery
– 1.3% medical
N Engl J Med 348;21: 2059-2073
Exercise capacity
All patients
Upper lobe, low exercise capacity
N Engl J Med 348;21: 2059-2073
Summary
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Not smoking & complete pulmonary rehab
Excluded if FEV1 <20% or DLCO <20%
No overall mortality benefit
90 day mortality 7.5% with surgery
Sub-group analysis
– most benefit in those with a combination of upper
lobe predominance & low exercise capacity
VENT, 2010
• 321 patients randomised to endobronchial valve
or standard therapy
• Not smoking, pulm rehab prior to randomisation
• No sham procedure
• Mean age 65, FEV1 30%, RV 216%
o
• 1 end point: Change in FEV1 & 6MWD
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• 1 safety end points: Composite of 6 outcomes
N Engl J Med 363;13: 1233-1244
Respirology Volume 19, Issue 8, pages 1126–1137
Outcomes, 6 months
EBV
Control
P
4.3%
-2.5%
0.005
34.5ml
-25.4ml
0.002
Median % 6MWD change
2.5%
-3.2%
0.04
Median 6MWD change
9.3m
-10.7m
0.007
SGRQ (QOL score, -4 points=CS)
-2.8
0.6
0.04
% change in FEV1
FEV1 change
Outcomes, 90 days
EBV
Control
P
Any complication
4.2%
0%
0.06
Death
0.9%
0.0%
1.00
COPD exacerbation
7.9%
1.1%
0.03
Pneumonia
2.3%
2.3%
1.00
Haemoptysis
5.6%
0%
0.02
Pneumothorax
4.2%
0%
0.56
Summary
• Improvement in lung function & exercise
capacity
• Lower risk than surgical LVRS
• Sub group analysis
– most effective if “complete fissures”
• Control group had no intervention
Interlobar fissues
• Requirements for effective valve treatment
– the selected lobe should collapse
– expansion of other less diseased lobes
• Collateral ventilation- present in upto 50%
– airways between different lobes which cross the
interlobular fissures “incomplete fissure”
– if present then lobe still ventilated and does not
collapse
Fissure assessment
Respirology Volume 19, Issue 8, pages 1126–1137
BeLieVeR-HIFi, 2015
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50 patients; Sham bronchoscopy vs EBV
Ex smokers, heterogenous emphysema
Mean age 62, FEV1 31%, RV 232%
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1 end point: Change in FEV1 at 3 months
Lancet 386:1066-73
Outcome
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• 2 end point (all NS)
– CAT -2 points vs 0
– SGRQ -4.40 vs -3.57
– 6MWD +25m vs +3m
Lancet 386:1066-73
Other options
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Sealant- block airway, ?mucous retention
Thermal vapor ablation
Lung denervation- remove muscarinic tone
Lung coils
Coils
• MOA unclear
– “Retensioning” airways
– Improve recoil
– Reduce air trapping
• Homogenous disease
• Independent of fissures
– 60 patients, no control
– Bilateral treatment
12 months
FEV1
+110ml
RV
-710ml
RV%
-14%
6MWD
+51.4m
SGRQ
-11.1
Thorax 1014;69:980-986
Coils
Coils
Local process
When to consider
• COPD
– Exercise limitation MRC 3+ or CAT>10
– Ex-smoker and completed pulmonary rehabilitation
– Volumetric HRCT, 1mm slices- showing emphysema
– PFT showing RV>180%
– But, if FEV1 & DLCO <30%- consider for transplant
• Refer to Mr Nil Chaudhuri or Dr Doitchyn Dimov
• How many should be referred? My practice ~5%
What happens next
• Discussion at MDT
– Quantitative perfusion scanning
– CPEX +/- 6MWD
• Decision on suitability for surgery
• Decision on type of surgery
• Clinic review in Leeds to discuss options
Perfusion scanning
• Target left lower lobe
Perfusion scanning
• No obvious target lobe
Cases
GE Age 59
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Severe breathlessness and anxiety
Exercise tolerance 30 yards
40 pack year ex smoker, PR February 2015
CAT 33
CT: Upper lobe emphysema
PFT: FEV1 24% DLCO 39% RV 197%
GE Age 59
GE Age 59
• MDT: VQ, CPEX
• Charteris Negative
• Endobronchial valves
– 3x 4mm valves to LUL
– 3 days in hospital, no complications
• Follow up
– CAT 25 (improvement 8 points)
– CT January 2015
AF Age 62
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ET<100 yards, recurrent exacerbations
Ex smoker 50PY, Pulm rehab March 2014
CAT 17
CT: Emphysema, severe RUL, moderate LUL
PFT: FEV1 1.0 (47%), DLCO 28% RV 180%
AF Age 62
AF Age 62
• MDT: VQ, CPEX
• Charteris negative
• Endobronchial valves August 2015
– 4 valves to RUL, 3 days in hospital
• Follow up
– CT: Good evidence of lobar collapse
– PFT: RV 125% (-56%)
– CAT: unchanged, subjectively no different
AT Age 45
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SOB on heavier exertion, slow on hills
Ex smoker Feb 2013 40PY, PR February 2014
CAT 24
CT: Moderate-severe emphysema, worse at
apices
• Perfusion scan: Good perfusion left lower lobe
• PFT: FEV1 0.62 (22%), DLCO 25%, RV 246%
AT Age 45
AT Age 45
AT Age 45
• MDT: VQ, CPEX
• Endobronchial valves July 2014
– 2x 4mm & 5.5mm valves to LUL
– 2 days in hospital, no complications
• Contacted by patient in August
– Coughed up valve (incidence 4.7%)
• 2nd valve placement October 2014
– 5.5mm valve, 2 days in hospital
AT Age 45
• June 2015
– Feels no better, CAT 32 (increased 8 points)
– CT: Incomplete lobar collapse
– PFT: RV 228% (-18%)
• October 2015
– 3rd valve placement, 3 days in hospital
• December 2015
– Referral for transplant assessment
Summary
• Treatment for breathlessness in severe emphysema
• Consider if high residual volumes and limited exercise
capacity
• Current options
– Surgical lung volumes reduction: Open, VATS
– Endobronchial treatments: Valves (Coils, sealant)
• MDT approach, thorough physiological assessment
• May require multiple visits to tertiary centre