Turning Down the Volume? Considering New Tools for Refractory Dyspnea

This post was written by Michael W. Hess, MPH, RRT, RPFT

Imagine, if you will, one of the people in your care living with COPD. You have been following this person for many years, and you have watched their symptoms steadily worsen, gradually eroding their quality of life. You have advanced their therapy by the book, first adding bronchodilators, then corticosteroids, even phosphodiesterase inhibitors and ongoing antibiotic therapy. They have been through rounds of pulmonary rehabilitation. When you saw them last year, they had just started long-term oxygen therapy but still managed to get out and about regularly. But today they show up in your clinic and they tell you that they’re just tired. They’re tired of being short of breath all the time. They’re tired of having to watch the grandkids play instead of joining in. They’re tired of slowly giving up one hobby after another because they simply do not have the energy anymore. They don’t want to endure a major procedure like a lung transplant, but they’re not ready to just throw in the towel, either.

“Isn’t there anything else you can do?” they may ask.

For a long time, you would have had to answer, “No, not really.” However, now there is bronchoscopic lung volume reduction (BLVR), a non-pharmacological therapy that has been steadily growing in availability and popularity. It fills the gap between maximal medication management and invasive surgical procedures, and it does, in fact, offer additional hope to many frustrated at the lack of symptom relief.

BLVR is an evolution of traditional invasive lung volume reduction, where one or more sections of damaged lung tissue are removed surgically. Recall the pathophysiology of emphysema, where alveoli enlarge, consolidate, overexpand and cause air trapping, limiting the expansion of still-healthy lung units. The removal of some of this emphysematous tissue allows the remaining lung to once again inflate and exchange gas more normally, relieving some measure of dyspnea.¹ BLVR is a less-invasive procedure that requires no incisions. Instead, with the most common procedure, a flexible bronchoscope is used to insert a handful of tiny one-way endobronchial valves into the airways of a part of the diseased lung, avoiding most of the complications associated with traditional surgery. Once placed, the valves isolate the treated lung lobe allowing trapped air to escape the over-inflated alveoli but prevent air from entering, causing the treated lobe to gradually collapse and the surrounding tissue to regain normal function.

The idea of a minimally invasive procedure with a lower risk profile requiring only a few days in the hospital (compared to up to a week for the fully invasive surgery option) delivering better breathing is quite appealing to many. However, patient selection is critical when considering this option. Some people with emphysema have “backup” routes where air can flow outside the normal bronchial tree. This phenomenon, known as collateral ventilation, can allow enough air to bypass the valve-occluded airways that the target segments cannot collapse.² Thus, this procedure is limited to patients that have little to no collateral ventilation in those areas.

Ideal candidates have a confirmed diagnosis of emphysema, reduced lung function with hyperinflation, compromised quality of life, and no collateral ventilation. Physicians trained in BLVR use specialized techniques that help detect collateral ventilation and identify those likely to benefit from the procedure.³ According to a recently published study from the Netherlands, eligible patients who were treated reported an improved quality of life and nearly a thousand days of additional lifespan (based on median survival), speaking to the potential benefit in the right individual.⁴ The demonstrated benefits of BLVR has solidly established this therapy into the mainstream of COPD management. Both the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the COPD Foundation mention them in strategy recommendations for relatively advanced cases of emphysema-predominant COPD, with GOLD giving the evidence behind the procedure its strongest rating, grade A.⁵

The part of life where one must live with severe symptoms of COPD used to be a time of discouragement, if not outright despair. Reaching the point where someone’s dyspnea became essentially refractory to therapy meant there was little additional hope a health care professional could offer. But this is no longer the case. Now, when someone walks into your clinic asking if you have more to offer them, you can simply answer, “Yes.”

This blog post was supported by Pulmonx.

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