Endobronchial valves: Could they help my patients with emphysema?
Posted on December 08, 2020 |
This article was written by Stephanie Williams, BS, RRT and was reviewed by Byron Thomashow, M.D.
More than 25 years ago, a surgical procedure changed the landscape of emphysema treatments – lung volume reduction surgery (LVRS). The surgical procedure removes emphysematous lung tissue, leaving the healthy tissue able to function better. In carefully selected patients, LVRS reduces dyspnea, increases exercise capacity, and improves quality of life and survival. LVRS was the first therapy since oxygen to show improved survival in advanced chronic obstructive pulmonary disease (COPD). However, LVRS involves a surgical procedure, carries potential risks, and is available in only a limited number of top centers.
Recently, the landscape changed again. There is now a minimally invasive treatment option available for those patients with either heterogeneous or homogenous emphysema – endobronchial valve therapy or, as it is more commonly called, bronchoscopic lung volume reduction (BLVR). This therapy aims to reduce hyperinflation in the lung, improving gas exchange by allowing healthier parts of the lung to expand.1 ”Hyperinflation or air trapping in patients who have severe emphysema is a devastating complication that causes increased shortness of breath, decreased exercise tolerance, and worse quality of life,” says Gerard Criner, MD, Chair and Professor, Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University. A typical treatment usually involves placing multiple valves in the airways via bronchoscopy. This reduces patient risk and makes it a therapy possible for more people. The valves are meant to be permanent but are designed to be removed if that becomes necessary at any time.
The BLVR procedure is just part of the process of helping the patient manage their lung health. Before even being considered for either surgical or bronchoscopic lung volume reduction, COPD patients need to be on a maximum medical regimen that includes inhaled bronchodilators and should have participated in pulmonary rehabilitation and smoking cessation as indicated. Pulmonary rehabilitation is an important part of the BLVR treatment both before pre- and post-procedure. Pulmonary rehab has been demonstrated to reduce dyspnea, increase exercise capacity, and improve quality of life in people living with COPD.2 While we recognize that pulmonary rehabilitation does not make physiologic changes in the lung, or directly improve lung function, it does greatly improve the subjective reporting of symptoms and the ability of the person to achieve goals involving exercise tolerance and feelings of dyspnea.
Though BLVR is generally tolerated well, it should be noted that it is not without risk.3 In addition to risks such as infection or COPD exacerbation, the health care team should have a management plan in place to care for patients who may encounter a pneumothorax as a consequence of the procedure. Clinical trials have shown that the majority of pneumothoraces occurred within the first 72 hours post-procedure.
What is the patient candidate profile for BLVR? Ten years of clinical studies have shown that candidates for BLVR should undergo a thorough patient evaluation, be screened for comorbidities, and should have high resolution CT (HRCT) scan along with quantitative CT results (QCT). There are two FDA-approved valve systems currently available in the United States, and each have their own specific screening recommendations which are outlined clearly on the device manufacturer websites. It is important to stress that as effective as surgical or bronchoscopic lung volume reduction can be, that these procedures are only effective in carefully selected patients.4
This post was sponsored by Olympus.
- Lee, E. G., & Rhee, C. K. (2019). Bronchoscopic lung volume reduction using an endobronchial valve to treat a huge emphysematous bullae: a case report. BMC pulmonary medicine, 19(1), 92. https://doi.org/10.1186/s12890-019-0849-z
- American Thoracic Society Documents “An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation” https://www.atsjournals.org/doi/pdf/10.1164/rccm.201309-1634ST
- Gülşen A. (2018). Bronchoscopic Lung Volume Reduction: A 2018 Review and Update. Turkish thoracic journal, 19(3), 141–149. https://doi.org/10.5152/TurkThoracJ.2018.18044
- Welling, J., Hartman, J. E., Augustijn, S., Kerstjens, H., Vanfleteren, L., Klooster, K., & Slebos, D. J. (2020). Patient Selection for Bronchoscopic Lung Volume Reduction. International journal of chronic obstructive pulmonary disease, 15, 871–881. https://doi.org/10.2147/COPD.S240848