in SGRQ total score was 11.0 ± 2.3 and 14.0 ± 2.4
points at three and six months, showing no
difference after three months' observation. Today
the largest difference has been observed in the
activity domain (14.7 ± 2.8 points). Dyspnoea
(according to the mMRC index) improved by a
mean of 0.9 ± 0.2 points at six months (p=0.001)
and by at least one point in 63% of subjects. The
average change in 6MWD has been observed
between 23.5 ± 10.4m (p=0.029) and 46.5 ± 15.0m
(p=0.001) at three and six months, respectively.
The BODE score has been declined by 1.36 ± 0.27
and 1.4 ± 0.27 points at three and six months,
respectively. Chronic obstructive pulmonary
disease stage is improving with FEV1 by
120.4 ± 30.7ml in GOLD stage III (p=0.001) and
171.3 ± 47.1ml in GOLD stage IV profile(p=0.002)
patients. Corresponding improvements in the
SGRQ total score have been observed between
12.4 ± 2.7 points (p=0.001) and 16.3 ± 4.5 (p=0.002)
points at three and six months, respectively. Until
now, the adverse respiratory effects that have
been observed are of respiratory origin, such as:
exacerbation, pneumonia, lower respiratory tract
infection, haemoptysis, and inflammatory
reactions. The adverse effects can occur at
different times after the procedure from day 1 to
past day 90. There is also a report of patient death
67 days after the procedure due to end-stage
COPD. This patient was re-admitted for an
exacerbation of COPD. Usually all patients had
their adverse effects resolved with standard
medical management. Changes in the HRCT of all
the patients were observed.
The inflammatory response in the targeted
area was associated with different clinical
symptoms including fatigue, cough, fever,
dyspnoea, sputum, and haemoptysis. A localised
inflammatory reaction (LIR) within the treated
lobe is expected following BTVA, because this is
the process that results in the atelectasis of a lobe
and treatment of the patient. Unfortunately, the
treated area will typically show infiltrates
radiographically, that could be indistinguishable
from pneumonia. Other symptoms or no syptoms
might present at the same time, such as; fatigue,
sputum, dyspnoea, fever, cough and haemoptysis.
This inflammatory reactions appears to peak
within the first 2–4 weeks and gradually resolves
within 8–12 weeks of BTVA. (Figures 3 and 4) The
patient need to be treated (that is, antibiotics and/
or steroids) based on individual investigator
clinical decisions. The LIR appears to be
responsible for exacerbations and ‘pneumonia’,
given the similarity or symptoms and
radiographic findings. In the treated area a
healing and repair process is characterised by
fibrosis of the airways and parenchyma (that is,
remodelling of the architecture of the lung). The
atelectasis occurs distally from the treated region.
The LVR is expected to increase elastic recoil by
reducing the most compliant areas of the lung.
Decompressing areas of healthy lung allows
References
1 van der Molen T, Kirenga
BJ. COPD: early diagnosis and
treatment to slow disease
progression. Int J Clin Pract
2015;69:513–4.
2 Berger RL et al. Lung volume
reduction therapies for advanced
emphysema: an update. Chest
2010;138:407–17.
3 Weinmann GG, Chiang YP,
Sheingold S. The National
Emphysema Treatment Trial
(NETT): a study in agency
collaboration. Proc Am Thoracic
Soc 2008;5:381-4.
4 Lee SM et al; National
Emphysema Treatment Trial
Figure 3 Radiographical findings on days 1, 3 and 30
Figure 4 Radiographical findings on day 95 with target lobe (right upper lobe) atelectasis
alveolar recruitment and improves the
mechanical positioning of the respiratory
muscles.
The length of
the procedure
is no more than
an hour, and
in the best case
scenario the
patient can
go home the
next day
Research Group. Methodologic
issues in terminating enrollment
of a subgroup of patients in a
multicenter randomized trial.
Clin Trials 2004;1:326–38.
5 Snell G et al. Bronchoscopic
thermal vapour ablation
therapy in the management of
heterogeneous emphysema. Eur
13
HHE 2019 | hospitalhealthcare.com
Conclusions
In summary, BTVA treatment can be used
successfully in patients with heterogeneous
emphysema with upper lobe predominance.
These patients may achieve clinically important
improvements in physiology, quality of life and
exercise tolerance following only a single session
of unilateral BTVA. The procedure has been
reported to be well tolerated, with all patients
being discharged from hospital. Most of the
inflammatory responses can be managed with
standard care with the reasonable expectation of
resolution over a few weeks. All treated patients
have to go under careful selection with all the
previously reported methods. In any case, the
clinical condition of the patient plays a crucial
role on the day of the admission and the patient
must not have signs of exacerbation. Based on
current data, BTVA has a favourable benefit–risk
profile in COPD patients with heterogeneous
emphysema.
Resp J 2012;39:1326–33.
6 Emery MJ et al. Lung volume
reduction by bronchoscopic
administration of steam.
Am J Respir Crit Care Med
2010;182:1282–91.
7 Snell GI et al. A feasibility and
safety study of bronchoscopic
thermal vapor ablation: a novel
emphysema therapy. Ann
Thoracic Surg 2009;88: 1993–8.
8 Celli BR et al. The body-mass
index, airflow obstruction,
dyspnea, and exercise capacity
index in chronic obstructive
pulmonary disease. N Engl J Med
2004;350:1005-12.