RESPIRATORY
Bronchoscopic thermal
ablation for emphysema
This article focuses on bronchoscopic thermal vapour ablation, which uses
heated water vapour to produce a thermal reaction that leads to an initial localised
inflammatory response followed by permanent fibrosis and atelectasis
Paul Zarogoulidis
MD PhD
Director of Pulmonary
Department,
‘Bioclinic’ Private
Hospital, Thessaloniki,
Greece
Wolfgang Hohenforst-
Schmidt MD
Pulmonary Department,
Sana Private Hospital,
Hof, Germany
Chronic obstructive pulmonary disease (COPD) is
a chronic disease that affects different systems of
the body. Heart failure and morbidity is strongly
associated with this disease. 1 COPD is closely
monitored by pulmonary function tests and
imaging techniques, such as CT of the thorax.
One of the main concerns is whether a patient
will develop respiratory deficiency and will
require life-long oxygen supplement on a 24-hour
basis. Moreover, these patients tend to develop
different patterns within the lung parenchyma
such as emphysema or bronchiectasis, or both.
The damage that develops (phenotype) depends
Figure 1 The vapour ablation system
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on the patient's genotype. Lack of α1-antitrypsin
if any also plays a role in the development of
emphysema or bronchiectasis. Emphysema is
differentiated as homogenous or heterogenous;
however, one of the main issues is the lack of
definition for each diagnosis. Lung volume
reduction surgery (LVRS) is known to be an
invasive therapeutic option for some patients,
for others currently we have different minimal
invasive techniques. 2 Based on randomised
controlled trials of medical management
compared with LVRS (National Emphysema
Treatment Trial (NETT)), LVRS-treated patients
obtained improvements in lung function,
symptoms, exercise tolerance and quality of life
relative to the medically treated group. 3 While
long-term survival was improved, there was
significant morbidity and mortality associated
with surgery. 3 The NETT study is considered as
substantial evidence that benefits can be achieved
with lung volume reduction (LVR) particularly
those with heterogeneous emphysema and upper
lobe predominance. 3,4 Currently we can use
different types of valves, coils, glue and thermal
vapour ablation. Careful selection of a specific
method is necessary before the application for
each patient. The six minute walking test
(6MWD), pulmonary function tests, nutrition, and
special imaging techniques are used to assess
each patient. One of the most important issues is
to present to the patient what to expect after each
procedure; and that the main goal is improved
quality of life. Moreover, that after every
procedure constant monitoring and further
non-medical rehabilitation with respiratory
exercise and special nutrition is required. This
article focuses on bronchoscopic thermal vapour
ablation (BTVA), which uses heated water vapour
to produce a thermal reaction that leads to an
initial localised inflammatory response followed
by permanent fibrosis and atelectasis. The
remodelling results in reductions in tissue and air
volume of the targeted regions of the
hyperinflated lung. 5 In an early preclinical animal
study, higher doses were used than in humans
and a dose-dependent volume reduction was
observed. Slightly moderate evidence of serious
risk was observed. Nineteen out of twenty
animals studied survived the procedure; the one
death was due to severe pneumothorax. 6 Eleven
patients underwent the current protocol
confirmed using a lower dose of unilateral BTVA
with an acceptable safety profile. The efficacy