HHE Respiratory 2019 | Page 4

TABLE 1 General inclusion and exclusion criteria 6 Indication Contraindication 1 Emphysema findings in computed tomography 2 FEV1: 15–50% (15–45% for coils) 3 TLC: >100% and RV: >175% 4 6MWT: 100–500m (150–450m for coils) 5 mMRC: ≥ point 6 PAB: <50mmHg 7 DLCO: >20% 8 Smoking cessation: >8 Week (>6 month for valve) 9. Refractory to optimal treatment 10 Refractory to pulmonary rehabilitation 1 Frequent COPD exacerbation episodes (>2 hospitalisations per year) 2 Severe hypercapnia PCO2: >60mmHg (>55 for coils) or severe hypoxia (PaO2 <45 mmHg). 3 Bullous lesion on a single lung more than 1/3 > more than 4cm 4 History of lung surgery; lobectomy, pneumoectomy 5 Clinically significant bronchiectasis 6 Severe pulmonary hypertension 7 Congestive heart failure ( LVEF <35%) 8 Serious comorbidities (lung cancer, stroke, etc) 9 Use of an oral anticoagulant FEV1: forced expiration volume in 1s; RV: residual volume; TLC: total lung capacity; PAB: pulmonary arterial pressure; PaCO2: arterial partial pressure of carbon dioxide; 6MWT: 6-minute walking test; mMRC: Modified British Medical Research Council; DLCO: diffusing capacity for carbon monoxide; LVEF, left ventricular ejection fraction volume reduction surgery have been investigated, and minimally invasive methods have been developed. The new and alternative treatment modalities, which are known as endoscopic lung volume reduction (ELVR) procedures, exert their effects through five main mechanisms: reduction of airway trapping; reduction of bronchoconstriction; improvement of elastic recoil; induction of local inflammatory reactions; and airway blockage. 6 These ELVR procedures are endobronchial valve (EBV), coil, thermal vapour ablation, bio-lung volume reduction, targeted lung denervation, and airway bypass stent. An expert panel report on the EBV and coil methods has been published, 7 and the other three procedures are currently in development. With increasing published evidence of effectiveness and safety, ELVR techniques have been available in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines since 2017 and are recommended in a range of situations, from the presence of refractory conditions to maximal medical treatment regimens and pulmonary rehabilitation programs. 1 Indications and patient selection The major indication for treatment with ELVR methods is COPD of GOLD stage III or IV with FIGURE 1 Treatment algorithm for patients with severe emphysema COPD with severe emphysema Optimal medical treatment Pulmonary rehabilitation Consider roflimulast FEV1 15–45%, RV >225%, RV/TLC ≥0.58 and indication for ELVR treatment Homogeneous type Heterogeneous type Not candidate for ELVR, bullectomy or LVRS Large bullae (single lung more than 1/3 or >4cm) Consider lung transplantation if FEV1 <15–20% Collateral ventilation? Bullectomy or LVRS Yes Coils, TVA, or LVRS* No Valve, coils, or LVRS* COPD, chronic obstructive pulmonary disease; ELVR, endoscopic lung volume reduction; LVRS, lung volume reduction surgery; FEV1, forced expiratory volume in 1s; RV, residual volume; TLC, total lung capacity; lVA, thermal vapour ablation; LVRS*, only for heterogeneous emphysema. Algorithm quoted and modified from references 1,10 4 HHE 2019 | hospitalhealthcare.com