Prospective randomized trial comparing bilateral lung volume reduction surgery to pulmonary rehabilitation in severe chronic obstructive pulmonary disease

Effects of cardiorespiratory rehabilitation program on submaximal exercise in patients with long-COVID-19 conditions: a systematic review of randomized controlled trials and recommendations for future studies

INTRODUCTION

Long-COVID-19 patients (LC19Ps) often experience cardiovascular and respiratory complications. Cardiorespiratory rehabilitation programs (CRRPs) have emerged as promising interventions to enhance exercise capacity in this population. This systematic review aimed to assess the impact of CRRPs on submaximal exercise performance, specifically the 6-minute walk test (6MWT) outcomes, in LC19Ps through an analysis of available randomized controlled trials (RCTs).

METHODS

A systematic search was conducted in PubMed/Medline and Scopus to identify relevant RCTs. Six RCTs meeting inclusion criteria were included in this review, investigating the effects of CRRPs on 6MWT outcomes in LC19Ps.

RESULTS

The findings from the included RCTs provide compelling evidence supporting the effectiveness of CRRPs in improving submaximal exercise performance in LC19Ps. These results underscore the potential of CRRPs to enhance submaximal exercise capacity and overall functional well-being in this population. However, future research is imperative to determine optimal CRRPs, including duration, intensity, and specific intervention components. Additionally, the long-term sustainability and durability of CRRP-induced improvements warrant further exploration. Future studies should prioritize patient-centric outcomes and address potential implementation barriers.

CONCLUSION

CRRPs show promise in ameliorating submaximal exercise performance among LC19Ps. Further research is needed to refine these programs and ensure their lasting impact on this patient group.

SYSTEMATIC REVIEW REGISTRATION

https://doi.org/10.17605/OSF.IO/HMN38. [Figure: see text].

Advances in Surgical and Mechanical Management of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality in the United States, behind cardiovascular and malignant disorders. As the understanding of the pathogenesis has evolved, it led to targeting mechanical aspects of the disease to improve patient symptoms and quality of life. Modern management of COPD offers a variety of mechanical and surgical treatments for patients with advanced disease who do not achieve benefit from medical therapy alone. These treatments include therapies aimed at lung volume reduction, through surgical or bronchoscopic techniques. While these techniques are established and have proven benefit, others are still under development. Herein we discuss these techniques, aimed at improving clinician recognition of patients that may benefit from these interventions.

Surgical Interventions for COPD

Chronic obstructive pulmonary disease (COPD) treatment is aimed at managing the disease rather than cure, with a focus on improving quality of life and decreasing exacerbations. Interventional therapies, including lung volume reduction surgery, bullectomy, lung transplantation, and bronchoscopic lung volume reduction treatment using endobronchial valves, are treatment options for patients with COPD who are symptomatic due to hyperinflation despite optimal medical management. We will review the current literature to provide a comprehensive summary of the currently available scientific data, discuss typical treatment-related side effects, and evidence-based management approach and recommendations for patient selection in clinical practice.

Effect of induced acute metabolic alkalosis on the V̇E/V̇CO2 response to exercise in healthy adults

We tested the hypothesis that increasing the respiratory control systems' arterial PCO₂ equilibrium point via induced acute metabolic alkalosis by ingestion of sodium bicarbonate (NaHCO₃, 0.3 g/kg) would decrease the ventilatory equivalent for CO₂ (V̇_E/V̇CO₂) at its lowest point ("nadir") during constant-load cycle exercise testing performed at 80 % of peak power output in 18 healthy young adults. Compared to the sodium chloride (4 g) control condition, ingestion of NaHCO₃: increased arterialized venous pH, HCO₃- and PCO₂ at rest by 0.05 ± 0.01 units (mean ± SE), 6.4 ± 0.4 mEq/L and 4.3 ± 0.7 mmHg, respectively (all p < 0.0001); and decreased the V̇_E/V̇CO₂ nadir during exercise by 9.4 % (p < 0.0001) secondary to a 4.7 ± 1.8 L/min decrease in V̇_E (p = 0.019). In conclusion, induced acute metabolic alkalosis by ingestion of NaHCO₃ decreased the V̇_E/V̇CO₂ response to strenuous exercise in healthy adults.

Lung transplantation for emphysema

Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.

Two chair test: a substitute of 6 min walk test appear cardiopulmonary reserve specific

Background

A simple and efficient exercise test possible in a small space is welcome to supplement 6 min walk test (6MWT) that demands a 100 feet corridor to perform.

Methods

The proposed two chair test (2CT) makes a person to sit and move five times between two chairs placed face to face at 5 feet apart and note the changes in pulse-rate (PR) and arterial oxygen saturation (SpO₂) at every 10 s for 2 min after that. Comparison of the post-exercise measurements (PR and SpO₂) with a repeat performance in same patients was done for reproducibility and doing the same after 6MWT and 2CT in another set of patients was meant for for acceptability. The statistical analysis was made on moment to moment change, mean maximal difference and mean cumulative difference for the measurements using p value, z-score, r value and principal component analysis (PCA).

Findings

A total of 40 and 60 volunteers were included for testing reproducibility and acceptability. On both the sets, the difference in most of comparisons between the measured variable (PR and SpO₂) showed the p values remaining insignificant (>0.05), and z-score being <1 SD of the corresponding other and the correlation coefficients (r) remaining excellent (>0.9). Furthermore, the PCA shows complete overlapping. The post-exercise changes did not corelate the walking distance in 6MWT.

Interpretation

The proposed 2CT demands small space and appears reproducible and comparable with 6MWT in terms of its post-exercise impact on PR and SpO₂. This novel test also appears more of cardiopulmonary reserve specific.

Surgical Therapies for Chronic Obstructive Pulmonary Disease

Patients with severe chronic obstructive pulmonary disease who fail maximal medical therapy and bronchoscopic interventions have surgical options to improve lung function, quality of life, and exercise performance. Carefully selected patients with upper lobe predominant emphysema can consider lung volume reduction surgery. Patients with upper lobe-predominant emphysema and low exercise performance have a survival advantage. Patients with large bulla compressing adjacent lung tissue occupying more than one-third of the lung benefit from bullectomy. Patients with advanced chronic obstructive pulmonary disease ineligible for or failing other surgical or bronchoscopic interventions can consider lung transplantation if free from major comorbidities.

Improving Lung Function in Severe Heterogenous Emphysema with the Spiration Valve System (EMPROVE). A Multicenter, Open-Label Randomized Controlled Clinical Trial

Rationale: Less invasive, nonsurgical approaches are needed to treat severe emphysema.

Objectives: To evaluate the effectiveness and safety of the Spiration Valve System (SVS) versus optimal medical management.

Methods: In this multicenter, open-label, randomized, controlled trial, subjects aged 40 years or older with severe, heterogeneous emphysema were randomized 2:1 to SVS with medical management (treatment) or medical management alone (control).

Measurements and Main Results: The primary efficacy outcome was the difference in mean FEV₁ from baseline to 6 months. Secondary effectiveness outcomes included: difference in FEV₁ responder rates, target lobe volume reduction, hyperinflation, health status, dyspnea, and exercise capacity. The primary safety outcome was the incidence of composite thoracic serious adverse events. All analyses were conducted by determining the 95% Bayesian credible intervals (BCIs) for the difference between treatment and control arms. Between October 2013 and May 2017, 172 participants (53.5% male; mean age, 67.4 yr) were randomized to treatment (n = 113) or control (n = 59). Mean FEV₁ showed statistically significant improvements between the treatment and control groups—between-group difference at 6 and 12 months, respectively, of 0.101 L (95% BCI, 0.060–0.141) and 0.099 L (95% BCI, 0.048–0.151). At 6 months, the treatment group had statistically significant improvements in all secondary endpoints except 6-minute-walk distance. Composite thoracic serious adverse event incidence through 6 months was greater in the treatment group (31.0% vs. 11.9%), primarily due to a 12.4% incidence of serious pneumothorax.

Conclusions: In patients with severe heterogeneous emphysema, the SVS shows significant improvement in multiple efficacy outcomes, with an acceptable safety profile.

Clinical trial registered with www.clinicaltrials.gov (NCT01812447).

Interventional Bronchoscopy in the Management of Chronic Obstructive Lung Disease

Background:

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation, hyperinflation and reduced gas exchange that lead to progressive dyspnea. Pulmonary rehabilitation, lifestyle changes, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation and surgical therapeutic approaches are the basic management strategies.

Purpose:

In the last 15 years, various bronchoscopic therapeutic modalities have emerged for severe COPD. The aim of this review is to summarize the effects of these bronchoscopic treatments compared with lung rehabilitation and pharmacological therapies.

Methods:

A PubMed search for the eligible studies and reviews on interventional bronchoscopy and COPD has been conducted.

Results:

Bronchoscopic lung volume reduction (LVR) techniques are targeted to reduce hyperinflation. The efficacy of reversible valve implantation has been confirmed in several randomized controlled trials. It provides clinical benefit in the absence of interlobar collateral ventilation. Nonblocking bronchoscopic LVR with coils, thermal vapor or sealants is independent of collateral ventilation but has not been studied sufficiently. Partially irreversible coil implantation leads to parenchymal compression while irreversible LVR with thermal vapor or sealants induce an inflammatory reaction. Targeted lung denervation ablates parasympathetic pulmonary nerves in COPD for sustainable bronchodilation, and liquid nitrogen metered cryospray destroys hyperplastic goblet cells and excessive submucous glands in the central airways to induce mucosal regeneration in chronic bronchitis.

Conclusion:

The best-examined bronchoscopic LVR method is the valve therapy. The data from the other modalities are still limited. Further studies are required to select the patients that will optimally benefit from a particular treatment and to predict and treat the procedure-related complications.

Mepolizumab in the treatment of eosinophilic chronic obstructive pulmonary disease

Despite maximal medical therapy, a subset of patients with chronic obstructive pulmonary disease continue to suffer acute exacerbations. It is also clear that a subset of this population has elevated blood eosinophils. In addition to clearly responding better to inhaled corticosteroids, it is also possible that this subgroup may benefit from biologic treatments targeting eosinophilic inflammation. Mepolizumab, a humanized monoclonal antibody against interleukin-5 (IL-5), may have a therapeutic effect in a subgroup of patients with COPD and eosinophilic airway inflammation. In this review, we discuss the biologic rationale for mepolizumab targeting IL-5 in eosinophilic COPD as well as the results of recently published clinical trials.

Entropy Analysis for the Evaluation of Respiratory Changes Due to Asbestos Exposure and Associated Smoking

Breathing is a complex rhythmic motor act, which is created by integrating different inputs to the respiratory centres. Analysing nonlinear fluctuations in breathing may provide clinically relevant information in patients with complex illnesses, such as asbestosis. We evaluated the effect of exposition to asbestos on the complexity of the respiratory system by investigating the respiratory impedance sample entropy (SampEnZrs) and recurrence period density entropy (RPDEnZrs). Similar analyses were performed by evaluating the airflow pattern sample entropy (SampEnV') and recurrence period density entropy (RPDEnV'). Groups of 34 controls and 34 asbestos-exposed patients were evaluated in the respiratory impedance entropy analysis, while groups of 34 controls and 30 asbestos-exposed patients were investigated in the analysis of airflow entropy. Asbestos exposition introduced a significant reduction of RPDEnV' in non-smoker patients (p < 0.0004), which suggests that the airflow pattern becomes less complex in these patients. Smoker patients also presented a reduction in RPDEnV' (p < 0.05). These finding are consistent with the reduction in respiratory system adaptability to daily life activities observed in these patients. It was observed a significant reduction in SampEnV' in smoker patients in comparison with non-smokers (p < 0.02). Diagnostic accuracy evaluations in the whole group of patients (including non-smokers and smokers) indicated that RPDEnV' might be useful in the diagnosis of respiratory abnormalities in asbestos-exposed patients, showing an accuracy of 72.0%. In specific groups of non-smokers, RPDEnV' also presented adequate accuracy (79.0%), while in smoker patients, SampEnV' and RPDEnV' presented adequate accuracy (70.7% and 70.2%, respectively). Taken together, these results suggest that entropy analysis may provide an early and sensitive functional indicator of interstitial asbestosis.

Patient Preferences for Endobronchial Valve Treatment of Severe Emphysema

Background: Patients with severe emphysema have limited treatment options. Little is known about patients' willingness to accept risks for new treatments that offer meaningful benefits. Methods: We determined treatment preferences of patients with severe emphysema using a web-based discrete-choice experiment survey. Respondents answered 9 questions that offered choices between 2 hypothetical interventional treatments or continuing current medical management. Variations in 5 attributes defined the 2 interventional treatments: improvement in ability to breathe and carry out day-to-day activities, frequency of hospitalized exacerbations, treatment type, risk of pneumothorax within 30 days of procedure, and risk of death within 3 months. Respondents were recruited through the COPD Foundation's COPD Patient-Powered Research Network and had a self-reported emphysema diagnosis and 2+ score on the modified Medical Research Council Dyspnea Scale. The relative importance of the attributes and the percentage of respondents who would select different treatment options was modeled using random-parameters logit. Results: Among 294 respondents, 51% always chose an interventional treatment option, while 19% always selected continued medical management. The most important change on average was moving from continued medical management (with no improvement in breathlessness) to an interventional treatment with improvement in breathlessness. The model predicted 71% of respondents would select a treatment option similar to removable endobronchial valve implants, 6% would select lung volume reduction surgery (LVRS), and 23% continued medical management. Conclusion: Patients with severe emphysema perceive that a procedure with risks and benefits similar to the Zephyr^® endobronchial valve implants is desirable over continued medical management or LVRS.

Surgical and endoscopic treatment for COPD: patients selection, techniques and results

Chronic obstructive pulmonary disease (COPD) is a very heterogeneous disease characterised by an obstructive lung pattern that constitutes worldwide a major cause of high morbidity and mortality. In the last decades, lung volume reduction surgery (LVRS) has demonstrated to be a potential good alternative to transplantation in patients affected by COPD. The trend toward minimally invasive techniques resulted not only in surgical procedures better tolerated by the patients but also in several endoscopic treatments modality that are rapidly gaining ground.

History of lung volume reduction procedures

Lung volume reduction (LVR) procedures for emphysematous patients were firstly introduced in the second half of the twentieth century. Over time, from the first invasive surgical procedures, new less invasive techniques have been conceived. In regards to the surgical approach, the adoption of VATS and the execution, in selected centers, of a non-resectional approach, with folding of less functional lung tissue, reduced mortality and adverse events risks. As regards to the bronchoscopic approach, endobronchial valves (EBV) and intrabronchial valves (IBV) were initially proposed in the early 2000s to obtain segmental or lobar atelectasis of the more compromised lung parenchyma. Despite showing promising results with respect to improvement of pulmonary function tests, particularly forced expiratory volume in 1st second (FEV₁), and quality of life, and a good safety profile, valves showed disappointing results in presence of collateral ventilation, such as in cases of incomplete fissures. To overcome this technical issue, in the last 10 years, endobronchial coils have been designed and used. Having a compressive effect on the lung parenchyma where they are located, they are not affected by collateral ventilation. Randomized control trials (RCTs) on endobronchial coils showed a significant improvement in FEV₁ and quality of life, however this technique was not immune to side effects, particularly low respiratory tract infections and pneumothoraces. Besides bronchial valves (BV) and coils, airway by-pass stents have also been evaluated in a RCT but without reaching the desired endpoints. Other innovative procedures recently considered and delivered through bronchoscopy regards thermal energy, with vapour therapy, to achieve a scarring reaction of the emphysematous lung parenchyma, and polymeric foams used as lung sealants to achieve absorptive atelectasis. In conclusion, LVR procedures may be considered in carefully selected patients with symptomatic emphysema and severe lung hyperinflation, and might be personalized according to the anatomical characteristics of emphysematous area.

Lung volume reduction surgery or bronchoscopic lung volume reduction: is there an algorithm for allocation?

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the world with the annual number of deaths increasing every year. Alterations in chest wall mechanics, respiratory muscle mechanics, and impaired cardiac function that result from increased air-trapping are well known sequelae of COPD and contribute to increased morbidity and mortality. A reduction in hyperinflation can improve cardiopulmonary function. In selected patients with COPD and an emphysema phenotype, lung volume reduction surgery (LVRS) has demonstrated improvements in symptom burden and mortality. Minimally invasive bronchoscopic techniques that reduce end-expiratory lung volume have shown improvements in lung function, dyspnea and quality of life. In this review, we review selection criteria, risks, and benefits of surgical and bronchoscopic lung volume reduction (BLVR). Recommendations are provided to guide treatment decisions based on the current literature.

Endobronchial Coils Versus Lung Volume Reduction Surgery or Medical Therapy for Treatment of Advanced Homogenous Emphysema

Rationale: Bronchoscopic lung volume reduction utilizing shape-memory nitinol endobronchial coils (EBC) may be safer and more effective in severely hyperinflated homogeneous emphysema compared to medical therapy or lung volume reduction surgery (LVRS). Methods: The effect of bilateral EBC in patients with homogeneous emphysema on spirometry, lung volumes and survival was compared to patients with homogeneous emphysema randomized in the National Emphysema Treatment Trial (NETT) to LVRS or medical therapy. NETT participants were selected to match EBC participants in age, baseline spirometry, and gender. Outcomes were compared from baseline, at 6 and 12 months. Results: There were no significant baseline differences in gender in the EBC, NETT-LVRS or medical treatment patients. At baseline no differences existed between EBC and NETT-LVRS patients in forced expiratory volume in 1 second ( FEV₁) or total lung capacity (TLC) %-predicted; residual volume (RV) and diffusing capacity of the lung for carbon monoxide (DLco) %-predicted were higher in the EBC group compared to NETT-LVRS (p < 0.001). Compared to the medical treatment group, EBC produced greater improvements in FEV₁ and RV but not TLC at 6 months. FEV₁ and RV in the EBC group remained significantly improved at 12-months compared to the medical treatment group. While all 3 therapies improved quality of life, survival at 12 months with EBC or medical therapy was greater than NETT-LVRS. Conclusion: EBC may be a potential therapeutic option in patients with severe homogeneous emphysema and hyperinflation who are already receiving optimal medical treatment.

Lung volume reduction surgery for diffuse emphysema

BACKGROUND

Lung volume reduction surgery (LVRS) performed to treat patients with severe diffuse emphysema was reintroduced in the nineties. Lung volume reduction surgery aims to resect damaged emphysematous lung tissue, thereby increasing elastic properties of the lung. This treatment is hypothesised to improve long-term daily functioning and quality of life, although it may be costly and may be associated with risks of morbidity and mortality. Ten years have passed since the last version of this review was prepared, prompting us to perform an update.

OBJECTIVES

The objective of this review was to gather all available evidence from randomised controlled trials comparing the effectiveness of lung volume reduction surgery (LVRS) versus non-surgical standard therapy in improving health outcomes for patients with severe diffuse emphysema. Secondary objectives included determining which subgroup of patients benefit from LVRS and for which patients LVRS is contraindicated, to establish the postoperative complications of LVRS and its morbidity and mortality, to determine which surgical approaches for LVRS are most effective and to calculate the cost-effectiveness of LVRS.

SEARCH METHODS

We identified RCTs by using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register, in addition to the online clinical trials registers. Searches are current to April 2016.

SELECTION CRITERIA

We included RCTs that studied the safety and efficacy of LVRS in participants with diffuse emphysema. We excluded studies that investigated giant or bullous emphysema.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed trials for inclusion and extracted data. When possible, we combined data from more than one study in a meta-analysis using RevMan 5 software.

MAIN RESULTS

We identified two new studies (89 participants) in this updated review. A total of 11 studies (1760 participants) met the entry criteria of the review, one of which accounted for 68% of recruited participants. The quality of evidence ranged from low to moderate owing to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes. Eight of the studies compared LVRS versus standard medical care, one compared two closure techniques (stapling vs laser ablation), one looked at the effect of buttressing the staple line on the effectiveness of LVRS and one compared traditional 'resectional' LVRS with a non-resectional surgical approach. Participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced. Short-term mortality was higher for LVRS (odds ratio (OR) 6.16, 95% confidence interval (CI) 3.22 to 11.79; 1489 participants; five studies; moderate-quality evidence) than for control, but long-term mortality favoured LVRS (OR 0.76, 95% CI 0.61 to 0.95; 1280 participants; two studies; moderate-quality evidence). Participants identified post hoc as being at high risk of death from surgery were those with particularly impaired lung function, poor diffusing capacity and/or homogenous emphysema. Participants with upper lobe-predominant emphysema and low baseline exercise capacity showed the most favourable outcomes related to mortality, as investigators reported no significant differences in early mortality between participants treated with LVRS and those in the control group (OR 0.87, 95% CI 0.23 to 3.29; 290 participants; one study), as well as significantly lower mortality at the end of follow-up for LVRS compared with control (OR 0.45, 95% CI 0.26 to 0.78; 290 participants; one study). Trials in this review furthermore provided evidence of low to moderate quality showing that improvements in lung function parameters other than forced expiratory volume in one second (FEV1), quality of life and exercise capacity were more likely with LVRS than with usual follow-up. Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (e.g. pneumonia) and cardiovascular morbidity. Although LVRS leads to an increase in quality-adjusted life-years (QALYs), the procedure is relatively costly overall.

AUTHORS' CONCLUSIONS

Lung volume reduction surgery, an effective treatment for selected patients with severe emphysema, may lead to better health status and lung function outcomes, specifically for patients who have upper lobe-predominant emphysema with low exercise capacity, but the procedure is associated with risks of early mortality and adverse events.

Lung volume reduction for emphysema

Advanced emphysema is a lung disease in which alveolar capillary units are destroyed and supporting tissue is lost. The combined effect of reduced gas exchange and changes in airway dynamics impairs expiratory airflow and leads to progressive air trapping. Pharmacological therapies have limited effects. Surgical resection of the most destroyed sections of the lung can improve pulmonary function and exercise capacity but its benefit is tempered by significant morbidity. This issue stimulated a search for novel approaches to lung volume reduction. Alternative minimally invasive approaches using bronchoscopic techniques including valves, coils, vapour thermal ablation, and sclerosant agents have been at the forefront of these developments. Insertion of endobronchial valves in selected patients could have benefits that are comparable with lung volume reduction surgery. Endobronchial coils might have a role in the treatment of patients with emphysema with severe hyperinflation and less parenchymal destruction. Use of vapour thermal energy or a sclerosant might allow focal treatment but the unpredictability of the inflammatory response limits their current use. In this Review, we aim to summarise clinical trial evidence on lung volume reduction and provide guidance on patient selection for available therapies.

Supported and unsupported arm exercise capacity following lung volume reduction surgery: a pilot study

Study Objectives: Lung volume reduction surgery (LVRS) has been shown to improve lung function, leg exercise capacity and quality of life in subjects with severe COPD. This is the first study to examine the effect of LVRS on supported and unsupported arm exercise capacity. Design: Eight subjects with COPD (% pred FEV1 ±SD = 31.1 ± 9.8%) completed testing. At baseline (TI), after eight weeks pulmonary rehabilitation (T2) and four months after LVRS (T3), each subject had tests of lung function, and performed three symptom-limited exercise tests to peak work capacity:supported arm exercise (SAE), unsupported arm exercise (UAE) and leg exercise (LE).Measurements: The FEV1 (% pred) increased from 27.8 ± 7.4 (mean ± SD) at T2 to 36.3 ± 7.1 at T3 (P <0.05). Peak oxygen consumption (VO2) remained similar from TI to T2 for SAE, UAE and LE (all P=1.0) but increased from T2 to T3 (P <0.05) (SAE: T2 = 0.59 ± 0.2 L/min,T3 = 0.72 ± 0.1 L/min; UAE: T2 = 0.45 ± 0.1 L/min, T3 = 0.54 ± 0.1 L/min; LE:T2-0.68 ± 0.2 L/min, T3 = 0.81 ± 0.2 L/min). The ratio of end-expiratory lung volume to total lung capacity was reduced at peak SAE and LE from T2 to T3 (P < 0.01) (SAE:T2 = 81 ± 4.0%, T3 = 76 ± 2.7%; LE: T2-81 ± 5.1%, T3 = 75 ± 3.6%). Conclusion: There was a significant increase in SAE and UAE capacity following LVRS. Dynamic hyperinflation wras reduced during SAE following LVRS.

Non-pharmacological treatments for COPD

Chronic obstructive pulmonary disease (COPD) affects roughly 10% of the global population and is growing in prevalence annually. COPD is characterized by progressive non-reversible narrowing of airways mainly due to cigarette smoking. Therapeutic interventions aimed at altering this progressive disease course can largely be grouped into pharmacological or non-pharmacological therapies. The focus of this paper is on the non-pharmacological aspects of COPD management, reviewing the current literature to provide an evidence-based management approach. Non-pharmacological therapies reviewed in this article include the implementation of comprehensive care models utilizing a coordinated multidisciplinary team, tele-monitoring and patient-centred approach to optimize COPD care and improve compliance. Preventing progression of COPD via smoking cessation remains of paramount importance, and newer therapeutic options including electronic cigarettes show promise in small studies as cessation aids. COPD has systemic manifestations that can be ameliorated with the enrollment in pulmonary rehabilitation programmes, which focus on exercise endurance to improve dyspnoea and quality of life. Advanced therapeutics for COPD includes lung volume reduction surgery for a pre-specified cohort and minimally invasive bronchoscopic valves that in recent reviews show promise. Lastly, patients on maximal COPD therapy with progressive disease can be referred for lung transplantation; however, this often requires a highly selected and motivated patient and care team. Survival rates for lung transplantation are improving; thus, this procedure remains a viable option as more expertise and experience are gained.

Use of exercise testing in the evaluation of interventional efficacy: an official ERS statement

This document reviews 1) the measurement properties of commonly used exercise tests in patients with chronic respiratory diseases and 2) published studies on their utilty and/or evaluation obtained from MEDLINE and Cochrane Library searches between 1990 and March 2015.

Exercise tests are reliable and consistently responsive to rehabilitative and pharmacological interventions. Thresholds for clinically important changes in performance are available for several tests. In pulmonary arterial hypertension, the 6-min walk test (6MWT), peak oxygen uptake and ventilation/carbon dioxide output indices appear to be the variables most responsive to vasodilators. While bronchodilators do not always show clinically relevant effects in chronic obstructive pulmonary disease, high-intensity constant work-rate (endurance) tests (CWRET) are considerably more responsive than incremental exercise tests and 6MWTs. High-intensity CWRETs need to be standardised to reduce interindividual variability. Additional physiological information and responsiveness can be obtained from isotime measurements, particularly of inspiratory capacity and dyspnoea. Less evidence is available for the endurance shuttle walk test. Although the incremental shuttle walk test and 6MWT are reliable and less expensive than cardiopulmonary exercise testing, two repetitions are needed at baseline. All exercise tests are safe when recommended precautions are followed, with evidence suggesting that no test is safer than others.

Efficacy and safety of endobronchial valves for advanced emphysema: a meta analysis

OBJECTIVE

A meta-analysis was undertaken to evaluate the efficacy and safety of bronchoscopic lung volume reduction with endobronchial valves (EBV) for advanced emphysema.

METHODS

A systematic search was performed from PubMed, EMBASE, CNKI, Cochrane Library database. Randomized control clinical trials on treatment of emphysema for 3-12 months with the EBV compared with standard medications and sham EBV were reviewed. Inclusion criteria were applied to select patients with advanced emphysema treated with EBV. The primary outcome was the percentage of the forced expiratory volume in the first second (FEV1%). Secondary outcomes included St George's Respiratory Questionnaire (SGRQ) score, the distance of the 6-minute walk (6MWD) test, the Modified Medical Research Council (MMRC) dyspnoea score, cycle ergometry workload, and the rate of the six major complications at 3 or 12 months. Fixed- or random-effects models were used and weighted mean differences (WMD), relative risks (RR) and 95% confidence intervals (CI) were calculated.

RESULTS

Three trials (565 patients) were considered in the meta-analysis. EBV patients yielded greater increases in FEV1% than standard medications (WMD =6.71; 95% CI, 3.31 to 10.10; P=0.0001), EBV patients also demonstrated a significant change for SGRQ score (WMD =-3.64; 95% CI, -5.93 to -1.34; P=0.002), MMRC dyspnoea score (WMD =-0.26; 95% CI, -0.44 to -0.08; P=0.004), and cycle ergometry workload (WMD =4.18; 95% CI, 2.14 to 6.22; P<0.0001). A similar level was evident for 6MWD (WMD =11.66; 95% CI, -3.31 to 26.64; P=0.13). EBV may increase the rate of hemoptysis (RR =5.15; 95% CI, 1.16 to 22.86; P=0.03), but didn't increase the adverse events including mortality, respiratory failure, empyema, pneumonia, pneumothrax. The overall rates for complications compared EBV with standard medications and sham EBV was not significant (RR =2.03; 95% CI, 0.98 to 4.21; P=0.06).

CONCLUSIONS

EBV lung volume reduction for advanced emphysema showed superior efficacy and a good safety and tolerability compared with standard medications and sham EBV, further more randomized controlled trial (RCT) studies are needed to pay more attention to the long-term efficacy and safety of bronchoscopic lung volume reduction with EBV in advanced emphysema.

Endoscopic lung volume reduction with endobronchial valves in patients with severe emphysema and established pulmonary hypertension

BACKGROUND

One of the most common forms of pulmonary hypertension (PH) is that associated with chronic obstructive pulmonary disease (COPD). So far, patients with severe emphysema and established PH have been excluded from endoscopic lung volume reduction (ELVR) therapy due to the risk of right heart decompensation.

OBJECTIVE

The aim of this pilot study was to evaluate the feasibility and efficacy of ELVR using one-way endobronchial valves (EBV) in this specific group of patients.

METHODS

We prospectively included 6 patients with COPD, severe heterogeneous emphysema, and established PH who underwent right heart catheterization and clinical assessments before and 90 days after ELVR with unilateral EBV placement.

RESULTS

This study was not powered to measure any statistical differences in endpoints. Ninety days after ELVR, the symptoms, lung function, and hemodynamics improved in 5 out of 6 patients (1 patient normalized and 1 slightly worsened). The mean hemodynamics improved from baseline to 90 days after ELVR as follows: mean pulmonary artery pressure, -2.5 ± 3.5 mm Hg; pulmonary arterial wedge pressure, -4.3 ± 8.3 mm Hg; cardiac index, +0.3 ± 0.6 l/min/m(2), and 6-min walk distance, +59 ± 99 m. ELVR was performed without PH-related complications in all patients.

CONCLUSION

To our knowledge, this is the first prospective, single-center pilot study to evaluate the feasibility and efficacy of ELVR in patients with established PH. ELVR was feasible and resulted in an improvement of clinical and hemodynamic parameters in 5 out of 6 patients. These results have to be further confirmed in larger-scale controlled studies.

Advanced therapies for COPD-What's on the horizon? Progress in lung volume reduction and lung transplantation

Advanced chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity. Treatment options beyond conventional medical therapies are limited to a minority of patients. Lung volume reduction surgery (LVRS) although effective in selected subgroups of patients is not commonly undertaken. Morbidity associated with the procedure has contributed to this low utilisation. In response to this, less invasive bronchoscopic lung volume techniques are being developed to attempt to mitigate some of the risks and costs associated with surgery. Of these, endobronchial valve therapy is the most comprehensively studied although the presence of collateral ventilation in a significant proportion of patients has compromised its widespread utility. Bronchial thermal vapour ablation and lung volume reduction (LVR) coils are not dependent on collateral ventilation. These techniques have shown promise in early clinical trials; ongoing work will establish whether they have a role in the management of advanced COPD. Lung transplantation, although effective in selected patients for palliation of symptoms and improving survival, is limited by donor organ availability and economic constraint. Reconditioning marginal organs previously declined for transplantation with ex vivo lung perfusion (EVLP) is one potential strategy in improving the utilisation of donor organs. By increasing the donor pool, it is hoped lung transplantation might be more accessible for patients with advanced COPD into the future.

Cardiopulmonary correlates of cognition in systemic lupus erythematosus

Objective

We aimed to evaluate the relationship between cognitive dysfunction and lung function, exercise endurance, and self-reported activity levels in patients with systemic lupus erythematosus (SLE).

Background

Cognitive dysfunction is present in 20%–60% of SLE patients. No studies to date have investigated the inter-relationships between cardiopulmonary factors and cognition in this population.

Methods

Thirty-seven SLE patients without overt neuropsychiatric histories and 16 healthy controls completed neuropsychological testing, measures of lung function, exercise capacity (distance walked during a timed walk test,1 maximal oxygen uptake2), and exercise questionnaires.

Results

Thirty-two percent of SLE patients demonstrated cognitive impairment. Cognitive impairment was correlated with Six-Minute Walk Distance (6MWD) ( r = 0.37, p = 0.02) and certain measures of lung function. Also, in SLE patients, self-reported physical activity was correlated with 6MWD ( p = 0.012), but none of the more complex measures of physical activity (VO2max).

Conclusions

Patients with mild SLE disease activity have cognitive dysfunction associated with certain objective markers of exercise capacity and activity levels. The lack of associations between self-report activity and VO2max suggests the possibility that multiple factors mediate the relationships between perceived and actual physical ability. Additional studies are needed to better understand the relationship between cognition and physical activity in patients with SLE.

Noninvasive ventilation and lung volume reduction

As parenchymal lung disease in chronic obstructive pulmonary disease becomes increasingly severe there is a diminishing prospect of drug therapies conferring clinically useful benefit. Lung volume reduction surgery is effective in patients with heterogenous upper zone emphysema and reduced exercise tolerance, and is probably underused. Rapid progress is being made in nonsurgical approaches to lung volume reduction, but use outside specialized centers cannot be recommended presently. Noninvasive ventilation given to patients with acute hypercapnic exacerbation of chronic obstructive pulmonary disease reduces mortality and morbidity, but the place of chronic non-invasive ventilatory support remains more controversial.

Pulmonary rehabilitation. Sociedad Española de Neumología y Cirugía Torácica (SEPAR)

Pulmonary rehabilitation (PR) has been shown to improve dyspnea, exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). PR has also shown benefits in diseases other than COPD but the level of evidence is lower. The fundamental components of PR programs are muscle training, education and chest physiotherapy. Occupational therapy, psychosocial support and nutritional intervention should also be considered. Home programs have been shown to be as effective as hospital therapy. The duration of rehabilitation programs should not be less than 8 weeks or 20 sessions. Early initiation of PR, even during exacerbations, has proven safe and effective. The use of oxygen or noninvasive ventilation during training is controversial and dependent on the patient's situation. At present, the best strategy for maintaining the benefits of PR in the long term is unknown. Longer PR programs or telemedicine could play a key role in extending the results obtained.

Effectiveness of endobronchial coil treatment for lung volume reduction in patients with severe heterogeneous emphysema and bilateral incomplete fissures: a six-month follow-up

BACKGROUND

Treatment with lung volume reduction coils (LVRC) may be effective in patients with severe heterogeneous emphysema and incomplete fissures.

OBJECTIVE

We hypothesized that LVRC placement improves pulmonary function, exercise tolerance and quality of life in these patients.

METHODS

Twenty-six patients with chronic obstructive pulmonary disease (COPD), 13 males and 13 females, aged 66 ± 8 years with heterogeneous emphysema and incomplete fissures were included in this retrospective analysis. The coils were implanted unilaterally in the upper or lower lobe. Patients were followed up at 30, 90 and 180 days after treatment and changes in pulmonary function test and 6-minute-walk-test (6MWT) values as well as scores for the modified Medical Research Council (mMRC) dyspnea scale and the St. George's Respiratory Questionnaire (SGRQ) were recorded.

RESULTS

FEV1 improved significantly at 90 days and tended to decrease at the 180-day follow-up (0.67 ± 0.17 vs. 0.78 ± 0.25 vs. 0.73 ± 0.21 liters, respectively, p < 0.001). The 6MWT score had improved significantly at 90 days and had tended to decrease at the 180-day follow-up (216 ± 107 vs. 262 ± 97 vs. 262 ± 112 m, respectively, p = 0.001). SGRQ was significantly improved at 90 days. Multivariate analysis showed that worse 6MWT performance at baseline was independently associated with a greater improvement in 6MWT at the 90-day follow-up. The total complication rate was 54% (n = 14) and included light hemorrhage in 6 patients, COPD exacerbation in 6, pneumothorax in 1 and both COPD exacerbation and pneumothorax in 1 patient.

CONCLUSIONS

This is the first study to show that LVRC in patients with heterogeneous emphysema and incomplete fissures improves exercise capacity, quality of life and lung function up to 90 days after the intervention. Further studies are needed to assess the long-term effects of LVRC in these patients.

Prediction of lobar collateral ventilation in 25 patients with severe emphysema by fissure analysis with CT

OBJECTIVE

Reducing pulmonary volume through implantation of endobronchial valves is a major interest to improve exercise tolerance and survival in patients with severe emphysema. The primary aim of this study was to evaluate how well CT-determined fissure integrity predicts interlobar collateral ventilation. The secondary objective was to show whether there is a relationship between the size of fissural defects and the presence of collateral ventilation.

MATERIALS AND METHODS

Thirty patients with heterogeneous emphysema (postbronchodilator forced expiratory volume in 1 second [FEV1] = 20-50% predicted and > 50% of emphysema in a lobe) underwent collateral ventilation measurements with a catheter through an occlusive balloon within this target lobe during flexible endoscopy. Two senior thoracic radiologists studied the fissures on thoracic high-resolution CT.

RESULTS

Collateral ventilation was successfully measured in 37 target lobes in 25 patients. The fissures surrounding the 37 target lobes were evaluated on CT. For the detection of collateral ventilation, the presence of a fissural defect on CT has a sensitivity, specificity, positive predictive value, and negative predictive value of 95%, 44%, 69%, and 88%, respectively. There was a statistically significant difference in the area of the defect between patients with collateral ventilation and those without collateral ventilation (p = 0.04).

CONCLUSION

Analysis of pulmonary fissures using CT is useful before endoscopic volume reduction because results are well correlated to endoscopic measurements of collateral ventilation. Further study with clinical outcomes is mandatory to determine if and when one test or the other or both should be used in patient selection.

Long-term survival analysis of the Canadian Lung Volume Reduction Surgery trial

BACKGROUND

The Canadian Lung Volume Reduction Surgery (CLVRS) trial was a multicentered randomized controlled trial that concluded that lung volume reduction surgery improves functional status and health-related quality of life (for at least 2 years) in selected patients with advanced emphysema.

METHODS

This retrospective observational study assessed the long-term survival of patients enrolled in the CLVRS at 8 to 10 years after randomization. Vital statistics were gathered through telephone contact, physician records, and municipal obituaries. Survival analysis was undertaken using Kaplan-Meier and the Cox proportional hazards models.

RESULTS

Fifty-two patients (84% of the initial 62 patients randomized) had a median survival time of 4.11 years. A 16-month survival advantage and a 20% reduction in mortality was observed in the LVRS group as compared with the best medical care group. Although clinically meaningful, these differences were not statistically significant.

CONCLUSIONS

These findings echo those of other published reports and demonstrate the potential long-term benefit of LVRS in the treatment of end-stage emphysema.

Responsiveness of Various Exercise-Testing Protocols to Therapeutic Interventions in COPD

Exercise intolerance is a key element in the pathophysiology and course of Chronic Obstructive Pulmonary Disease (COPD). As such, evaluating exercise tolerance has become an important part of the management of COPD. A wide variety of exercise-testing protocols is currently available, each protocol having its own strengths and weaknesses relative to their discriminative, methodological, and evaluative characteristics. This paper aims to review the responsiveness of several exercise-testing protocols used to evaluate the efficacy of pharmacological and nonpharmacological interventions to improve exercise tolerance in COPD. This will be done taking into account the minimally important difference, an important concept in the interpretation of the findings about responsiveness of exercise testing protocols. Among the currently available exercise-testing protocols (incremental, constant work rate, or self-paced), constant work rate exercise tests (cycle endurance test and endurance shuttle walking test) emerge as the most responsive ones for detecting and quantifying changes in exercise capacity after an intervention in COPD.

Several clinical interests regarding lung volume reduction surgery for severe emphysema: meta-analysis and systematic review of randomized controlled trials

Objectives

We aim to address several clinical interests regarding lung volume reduction surgery (LVRS) for severe emphysema using meta-analysis and systematic review of randomized controlled trials (RCTs).

Methods

Eight RCTs published from 1999 to 2010 were identified and synthesized to compare the efficacy and safety of LVRS vs conservative medical therapy. One RCT was obtained regarding comparison of median sternotomy (MS) and video-assisted thoracoscopic surgery (VATS). And three RCTs were available evaluating clinical efficacy of using bovine pericardium for buttressing, autologous fibrin sealant and BioGlue, respectively.

Results

Odds ratio (95%CI), expressed as the mortality of group A (the group underwent LVRS) versus group B (conservative medical therapies), was 5.16(2.84, 9.35) in 3 months, 3(0.94, 9.57) in 6 months, 1.05(0.82, 1.33) in 12 months, respectively. On the 3^rd, 6^th and 12^th month, all lung function indices of group A were improved more significantly as compared with group B. PaO2 and PaCO2 on the 6^th and 12^th month showed the same trend. 6MWD of group A on the 6^th month and 12^th month were improved significantly than of group B, despite no difference on the 3^rd month. Quality of life (QOL) of group A was better than of group B in 6 and 12 months. VATS is preferred to MS, due to the earlier recovery and lower cost. And autologous fibrin sealant and BioGlue seems to be the efficacious methods to reduce air leak following LVRS.

Conclusions

LVRS offers the more benefits regarding survival, lung function, gas exchange, exercise capacity and QOL, despite the higher mortality in initial three postoperative months. LVRS, with the optimization of surgical approach and material for reinforcement of the staple lines, should be recommended to patients suffering from severe heterogeneous emphysema.

Assessment of a novel lung sealant for performing endoscopic volume reduction therapy in patients with advanced emphysema

AeriSeal Emphysematous Lung Sealant is a novel endoscopic lung-volume reduction therapy designed to reduce hyperinflation and improve pulmonary function and quality of life in patients with advanced emphysema. The device is administered to the subsegmental bronchus via a catheter as a 20 ml volume of liquid-foam. It flows into the peripheral airways and alveoli where it polymerizes and functions as a tissue glue, forming a film of material on the lung surface that seals the target region to cause durable absorption atelectasis. The AeriSeal System received CE mark approval for the treatment of patients with advanced upper lobe predominant and homogeneous emphysema based upon favorable results from clinical studies, and is commercially available in Europe. Patient and treatment site selection algorithms have been developed to simplify product use and optimize outcomes. This manuscript summarizes how the device is used, its mechanism of action and clinical trial results supporting its safety and efficacy.

Lung transplantation and lung volume reduction surgery

Since the publication of the last edition of the Handbook of Physiology, lung transplantation has become widely available, via specialized centers, for a variety of end-stage lung diseases. Lung volume reduction surgery, a procedure for emphysema first conceptualized in the 1950s, electrified the pulmonary medicine community when it was rediscovered in the 1990s. In parallel with their technical and clinical refinement, extensive investigation has explored the unique physiology of these procedures. In the case of lung transplantation, relevant issues include the discrepant mechanical function of the donor lungs and recipient thorax, the effects of surgical denervation, acute and chronic rejection, respiratory, chest wall, and limb muscle function, and response to exercise. For lung volume reduction surgery, there have been new insights into the counterintuitive observation that lung function in severe emphysema can be improved by resecting the most diseased portions of the lungs. For both procedures, insights from physiology have fed back to clinicians to refine patient selection and to scientists to design clinical trials. This section will first provide an overview of the clinical aspects of these procedures, including patient selection, surgical techniques, complications, and outcomes. It then reviews the extensive data on lung and muscle function following transplantation and its complications. Finally, it reviews the insights from the last 15 years on the mechanisms whereby removal of lung from an emphysema patient can improve the function of the lung left behind.

Mechanisms of gas exchange response to lung volume reduction surgery in severe emphysema

Lung volume reduction surgery (LVRS) improves lung function, respiratory symptoms, and exercise tolerance in selected patients with chronic obstructive pulmonary disease, who have heterogeneous emphysema. However, the reported effects of LVRS on gas exchange are variable, even when lung function is improved. To clarify how LVRS affects gas exchange in chronic obstructive pulmonary disease, 23 patients were studied before LVRS, 14 of whom were again studied afterwards. We performed measurements of lung mechanics, pulmonary hemodynamics, and ventilation-perfusion (Va/Q) inequality using the multiple inert-gas elimination technique. LVRS improved arterial Po₂ (Pa(O₂)) by a mean of 6 Torr (P = 0.04), with no significant effect on arterial Pco₂ (Pa(CO₂)), but with great variability in both. Lung mechanical properties improved considerably more than did gas exchange. Post-LVRS Pa(O₂) depended mostly on its pre-LVRS value, whereas improvement in Pa(O(2)) was explained mostly by improved Va/Q inequality, with lesser contributions from both increased ventilation and higher mixed venous Po(2). However, no index of lung mechanical properties correlated with Pa(O₂). Conversely, post-LVRS Pa(CO₂) bore no relationship to its pre-LVRS value, whereas changes in Pa(CO₂) were tightly related (r² = 0.96) to variables, reflecting decrease in static lung hyperinflation (intrinsic positive end-expiratory pressure and residual volume/total lung capacity) and increase in airflow potential (tidal volume and maximal inspiratory pressure), but not to Va/Q distribution changes. Individual gas exchange responses to LVRS vary greatly, but can be explained by changes in combinations of determining variables that are different for oxygen and carbon dioxide.

A randomized study of endobronchial valves for advanced emphysema

BACKGROUND

Endobronchial valves that allow air to escape from a pulmonary lobe but not enter it can induce a reduction in lobar volume that may thereby improve lung function and exercise tolerance in patients with pulmonary hyperinflation related to advanced emphysema.

METHODS

We compared the safety and efficacy of endobronchial-valve therapy in patients with heterogeneous emphysema versus standard medical care. Efficacy end points were percent changes in the forced expiratory volume in 1 second (FEV1) and the 6-minute walk test on intention-to-treat analysis. We assessed safety on the basis of the rate of a composite of six major complications.

RESULTS

Of 321 enrolled patients, 220 were randomly assigned to receive endobronchial valves (EBV group) and 101 to receive standard medical care (control group). At 6 months, there was an increase of 4.3% in the FEV1 in the EBV group (an increase of 1.0 percentage point in the percent of the predicted value), as compared with a decrease of 2.5% in the control group (a decrease of 0.9 percentage point in the percent of the predicted value). Thus, there was a mean between-group difference of 6.8% in the FEV1 (P=0.005). Roughly similar between-group differences were observed for the 6-minute walk test. At 12 months, the rate of the complications composite was 10.3% in the EBV group versus 4.6% in the control group (P=0.17). At 90 days, in the EBV group, as compared with the control group, there were increased rates of exacerbation of chronic obstructive pulmonary disease (COPD) requiring hospitalization (7.9% vs. 1.1%, P=0.03) and hemoptysis (6.1% vs. 0%, P=0.01). The rate of pneumonia in the target lobe in the EBV group was 4.2% at 12 months. Greater radiographic evidence of emphysema heterogeneity and fissure completeness was associated with an enhanced response to treatment.

CONCLUSIONS

Endobronchial-valve treatment for advanced heterogeneous emphysema induced modest improvements in lung function, exercise tolerance, and symptoms at the cost of more frequent exacerbations of COPD, pneumonia, and hemoptysis after implantation. (Funded by Pulmonx; ClinicalTrials.gov number, NCT00129584.)

National Emphysema Treatment Trial redux: accentuating the positive

OBJECTIVE

Under the Freedom of Information Act, we obtained the follow-up data of the National Emphysema Treatment Trial (NETT) to determine the long-term outcome for "a heterogeneous distribution of emphysema with upper lobe predominance," postulated by the NETT hypothesis to be optimal candidates for lung volume reduction surgery.

METHODS

Using the NETT database, we identified patients with heterogeneous distribution of emphysema with upper lobe predominance and analyzed for the first time follow-up data for those receiving lung volume reduction surgery and those receiving medical management. Furthermore, we compared the results of the NETT reduction surgery group with a previously reported consecutive case series of 250 patients undergoing bilateral lung volume reduction surgery using similar selection criteria.

RESULTS

Of the 1218 patients enrolled, 511 (42%) conformed to the NETT hypothesis selection criteria and received the randomly assigned surgical or medical treatment (surgical = 261; medical = 250). Lung volume reduction surgery resulted in a 5-year survival benefit (70% vs 60%; P = .02). Results at 3 years compared with baseline data favored surgical reduction in terms of residual volume reduction (25% vs 2%; P < .001), University of California San Diego dyspnea score (16 vs 0 points; P < .001), and improved St George Respiratory Questionnaire quality of life score (12 points vs 0 points; P < .001). For the 513 patients with a homogeneous pattern of emphysema randomized to surgical or medical treatment, lung volume reduction surgery produced no survival advantage and very limited functional benefit.

CONCLUSIONS

Patients most likely to benefit from lung volume reduction surgery have heterogeneously distributed emphysema involving the upper lung zones predominantly. Such patients in the NETT trial had results nearly identical to those previously reported in a nonrandomized series of similar patients undergoing lung volume reduction surgery.

Quality of life following lung cancer surgery: what about before?

Lung cancer is the major malignancy worldwide with cigarette smoking being the main risk-factor. In lung cancer patients, quality of life is considered the strongest prognostic factor for survival irrespective of initial performance status, weight loss, stage of disease, number of metastatic sites, and type of treatment. The study evaluates the health-related quality of life of patients after surgical intervention using a generic questionnaire, the Medical Outcome Study Questionnaire Short Form, and compares this outcome with a normal healthy population, lung cancer patients, and coronary artery bypass grafting patients. Compared with healthy controls and coronary bypass patients, lung cancer patients had significantly higher impaired physical functioning scores, comparable with mean scores for anxiety and depression. However, health-related quality of life in lung cancer remains an issue which needs further assessment.

Interventional bronchoscopy from bench to bedside: new techniques for central and peripheral airway obstruction

This article discusses how basic scientific concepts, based on a greater understanding of airway physiology, support the development and dissemination of multidimensional classification systems for tracheal stenosis, expiratory central airway collapse, and innovative interventional bronchoscopic procedures for patients with asthma and chronic obstructive pulmonary disease.

Interventional treatment options for advanced emphysema: imaging manifestations

Chronic obstructive pulmonary disease is a preventable and treatable disease characterized by progressive and debilitating limitations of airflow. Despite aggressive medical therapy, many patients with advanced emphysema continue to decline and exhibit disabling symptoms. Lung volume reduction surgery and lung transplantation can offer improved quality of life, enhanced exercise tolerance, and improvement in mortality rates in selected patients with advanced disease. In addition, newer bronchoscopic techniques to reduce lung volume in patients with emphysema are under development in an effort to duplicate the results of lung volume reduction surgery without significant morbidity. This article discusses the results of a variety of surgical and bronchoscopic interventions, with an emphasis upon the role of imaging.

[Surgical management of COPD distension]

INTRODUCTION

The impressive results seen when giant and compressing lung bullae are resected has inspired pneumonologists and thoracic surgeons to consider the possibility of applying a similar approach to the treatment of respiratory failure due to chronic obstructive pulmonary disease (COPD).

STATE OF THE ART

The major problem with this surgical indication lies in our ability to understand fully the pathophysiology of lesions and thus identify which emphysematous patients will have a response most similar to that achieved in purely bullous disease.

PERSPECTIVES

At the present time consideration should be given as to whether surgery is the only means of reducing pulmonary distension. Indeed, as endoscopic alternatives develop could they reproduce its beneficial effects and what would be their place compared to the surgery?

CONCLUSIONS

While waiting the development of these innovations, if the selection of the candidates is correct, the surgical treatment of lung hyperinflation can temporarily improve the quality of life of these patients by decreasing their dyspnea and increasing their exercise tolerance.