HHE Respiratory 2019 - Page 13

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.