HHE Respiratory 2019 - Page 11

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 11 HHE 2019 | hospitalhealthcare.com 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