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
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