Bronchoscopic lung volume reduction gives physicians an innovative option for helping patients breathe easier and become more active. This procedure is FDA-approved and involves the insertion of tiny valves in the airways.
“Emphysema is a debilitating disease affecting about 14 million people in the U.S.,” said Jonathan Kurman, MD, director of interventional pulmonology and MCW faculty member. “It involves irreversible destruction of lung tissue, leading to reduced elastic recoil of the lung. This leads to progressive lung hyperinflation and gas trapping. Patients have chronic dyspnea and diminished exercise tolerance, which reduces their quality of life and life expectancy. Diseased tissue not only continues to worsen but also interferes with healthy, functional lung tissue by compressing it. Emphysema becomes a ‘vicious cycle.’”
Unfortunately, current medical therapies, including oxygen, bronchodilators and steroids, do not interrupt this cycle of hyperinflation. Patients remain short of breath and limited in their ability to tolerate exercise.
A nonsurgical alternative
Bronchoscopic lung volume reduction presents a nonsurgical alternative for treating emphysema.
“One-way valves block off the most diseased lobe of the lung and allow air to drain out of that lobe but not enter it,” Dr. Kurman said. “That leads to progressive deflation of that lobe, as if it were not there, accomplishing the same thing that resection would but without undergoing major surgery with its associated comorbidity and comortality risk.”
Bronchoscopic lung volume reduction helps to resolve hyperinflation, which allows the healthy lobes to expand and the diaphragm to assume a more normal position. It does not reduce progression, but it does improve lung function, breathlessness, quality of life, exercise tolerance and overall health status.
The procedure is performed in the bronchoscopy suite under general anesthesia. After inserting the bronchoscope through an endotracheal tube, physicians assess for the presence of collateral ventilation.
“This is air entering the target lobe through small ‘back door’ airways that may have developed,” Dr. Kurman said. “If collateral ventilation is present, then blocking off the main airway will not have an effect because air is still getting in, and, at that point, we stop the procedure.”
Dr. Kurman said most patients pass this final physiological assessment and get the valves.
The entire procedure takes about 30 minutes, during which physicians typically place three to four valves in the target lobe in order to completely block the airways. Valves are available in three sizes.
“We take the worst lobe out of commission and that lets healthier lobes and the diaphragm function more effectively,” he said.
Following the procedure, patients stay in the hospital for three days to be monitored for pneumothorax. Patients experience relief when the target lobe deflates and the other lobes and diaphragm re-expand and shift back into normal position. Sometimes the target lobe deflates quickly, while other times it takes several days.
Better breathing, better living
After this procedure, patients generally still need bronchodilators, although they may not need as high a dose or use them as frequently. The procedure does not cure the disease. Rather, it lets patients breathe easier and have a better quality of life.
Patients being considered for the procedure must meet specific criteria and undergo diagnostic testing to confirm they are good candidates for the procedure. Testing includes pulmonary function testing, including spirometry with and without a bronchodilator; measurement of lung volumes and diffusion capacity; and a six-minute walk test. Patients must also have quit smoking at least four months prior, have a BMI of <35, and have a high-resolution (<1.5 mm slices) chest CT scan.
Exclusion criteria include prior lung transplant, lung volume reduction surgery, sternotomy or lobectomy. If patients have decompensated heart failure with an ejection fraction of <45%, their heart function should first be optimized if possible.
In addition, uncontrolled pulmonary hypertension, severe hypercapnia (PaCO2 >50 mm Hg on room air), severe hypoxemia (PaO2 <45 mm Hg on room air), and the presence of large bullae occupying >30% of either lung also exclude patients.
“We’re happy to perform the entire pre-op assessment, since we can do everything here,” Dr. Kurman said. “But we certainly welcome any referring physician who would like to initiate that process.”
Studies have found that approximately one out of every four patients evaluated qualify for the procedure.
“This is a breakthrough therapy for hundreds, if not thousands, of people here in Wisconsin,” Dr. Kurman said. “The key is to refer patients before they are too sick to qualify. It is better to send them earlier. Then, we can put them on our radar, so to speak, and monitor them until they qualify.”
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