Analysis of body composition with bioelectrical impedance analysis in patients with severe COPD and pulmonary emphysema

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often suffer from cachexia and malnutrition. Less is known about body composition and nutritional behaviour in patients with advanced COPD and pulmonary emphysema.

METHODS

We performed a single-center prospective analysis of patients with COPD GOLD III/IV. Metabolic parameters, dietary and exercise behavior, lung function, exercise capacity and body composition by bioelectrical impedance analysis (BIA) were analyzed. Patients with severe emphysema (emphysema index [EI] >20%) were compared to patients with mild emphysema (EI ≤ 20%).

RESULTS

A total of 121 patients (45.5% female, mean age 64.8 ± 8.1 years, mean FEV1 31.0 ± 8.6%, mean RV 234.7 ± 50.6%) were analyzed, of whom 14.1% were underweight. Only 5% of the patients substituted protein and only about 1/3 performed regular exercise training. BIA showed an unfavourable body composition: body fat ↑, ECM/BCM-index ↑, phase angle ↓ (5.0 ± 0.9°), cell percentage ↓, FFMI (fat-free mass index) ↓. The 94 patients with severe emphysema (mean EI 36.6 ± 8.5%) had lower body-mass-index (22.8 ± 4.3 vs. 31.1 ± 5.8 kg/m2, p < 0.001), FFMI, body weight and body fat, but did not differ significantly in the quality of body composition (e.g. phase angle). Their lipid and glucose metabolism were even better than in mild emphysema patients.

CONCLUSION

The finding of significantly lower BMI but similar body composition and better metabolic status in severe emphysema patients needs further investigation. However, it should not distract from the necessity to implement dietary and exercise recommendations for advanced COPD patients.

Endoscopic Lung Volume Reduction with One-Way Valves in Patients with Severe Chronic Obstructive Pulmonary Disease with Hypercapnia

BACKGROUND

Robust clinical evidence on the efficacy and safety of endoscopic lung volume reduction (ELVR) with one-way valves in patients with severe lung emphysema with chronic hypercapnic respiratory failure is lacking.

OBJECTIVE

The aim of this study was to compare patient characteristics, clinical outcome measures, and incidences of adverse events between patients with severe COPD undergoing ELVR with one-way valves and with either a partial pressure of carbon dioxide (pCO2) of ≤45 mm Hg or with pCO2 >45 mm Hg.

METHODS

This was a multicentre prospective study of patients with severe lung disease who were evaluated based on lung function, exercise capacity (6-min walk test [6-MWT]), and quality-of-life tests.

RESULTS

Patients with pCO2 ≤45 mm Hg (n = 157) and pCO2 >45 mm Hg (n = 40) showed similar baseline characteristics. Patients with pCO2 ≤45 mm Hg demonstrated a significant increase in forced expiratory volume in 1 s (p < 0.001), a significant decrease in residual volume (RV) (p < 0.001), and significant improvements in the quality of life and 6-MWT at the 3-month follow-up. Patients with pCO2 >45 mm Hg had significant improvements in RV only (p < 0.05). There was a significant decrease in pCO2 between baseline and follow-up in hypercapnic patients, relative to the decrease in patients with pCO2 ≤45 mm Hg (p = 0.008). Patients who were more hypercapnic at baseline showed a greater reduction in pCO2 after valve placement (r = -0.38, p < 0.001). Pneumothorax was the most common adverse event in both groups.

CONCLUSIONS

ELVR with one-way valves seems clinically beneficial with a remarkably good safety profile for patients with chronic hypercapnic respiratory failure.

[Interventional bronchoscopy-an overview]

Die Bronchoskopie stellt neben der Lungenfunktion und der radiologischen Bildgebung das wichtigste Diagnostikum bei Patienten mit Atemwegs- und Lungenerkrankungen dar. Aufgrund des kombinierten Einsatzes flexibler und starrer Bronchoskope kommt sie heutzutage aber auch zunehmend als endoskopisches Therapieverfahren bei pulmonalen Erkrankungen in Frage. Bei thorakalen Tumoren kann die interventionelle Bronchoskopie sowohl in palliativer als auch kurativer Intention zum Einsatz kommen. Neben der bronchoskopischen Tumorbehandlung rückten in den letzten Jahren zunehmend die Techniken der endoskopischen Lungenvolumenreduktion in den Fokus. Darüber hinaus bieten sich Therapiemöglichkeiten für Asthma und chronische Bronchitis sowie bei Atemwegsstenosen und -fisteln.

Endoscopic lung volume reduction coils for patients with severe emphysema-a single-centre retrospective analysis

OBJECTIVES

Patients with chronic obstructive pulmonary disease and lung emphysema may benefit from surgical or endoscopic lung volume reduction (ELVR). Previously reported outcomes of nitinol coil-based ELVR techniques have been ambiguous. The analysis was done to analyse outcomes of ELVR with nitinol coils in patients with severe pulmonary emphysema.

METHODS

From September 2013 to November 2014, our centre performed a total of 41 coil implantations on 29 patients with severe emphysema. Coils were bronchoscopically placed during general anaesthesia. Twelve out of 29 patients received staged contralateral treatments up to 112 days later to avoid bilateral pneumothorax. Lung function and 6-min walking distance were assessed 1 week prior, 1 week after as well as 6-12 months after the procedure. Patients were followed up to 48 months after ELVR and overall mortality was compared to a historic cohort.

RESULTS

While coil-based ELVR led to significant short-term improvement of vital capacity (VC, +0.14 ± 0.39 l, P = 0.032) and hyperinflation (Δ residual volume/total lung capacity -2.32% ± 6.24%, P = 0.022), no significant changes were observed in 6-min walking distance or forced expiratory volume in 1 s. Benefits were short-lived, with only 15.4% and 14.3% of patients showing sustained improvements in forced expiratory volume in 1 s or residual volume after 6 months. Adverse events included haemoptysis (40%) and pneumothorax (3.4%), major complications occurred in 6.9% of cases. Overall survival without lung transplant was 63.8% after 48 months following ELVR, differing insignificantly from what BODE indices of patients would have predicted as median 4-year survival (57%) at the time of ELVR treatment.

CONCLUSIONS

ELVR with coils can achieve small and short-lived benefits in lung function at the cost of major complications in a highly morbid cohort. Treatment failed to improve 4-year overall survival. ELVR coils are not worthwhile the risk for most patients with severe emphysema.

Endobronchial Coils for Endoscopic Lung Volume Reduction: Best Practice Recommendations from an Expert Panel

Endobronchial coils are an additional treatment option for lung volume reduction in patients with severe emphysema. Patient selection should be focused on patients with severe emphysema on optimal medical therapy and with evidence of severe hyperinflation. The technique is suitable in a broad range of patients with emphysema; however, patients with paraseptal emphysema, large focal (giant) bullae, significant co-morbidity and airway-predominant disease should be avoided. Treatment involves placing between 10 and 14 coils by bronchoscopy in the selected treatment lobe, with 2 lobes being treated sequentially. Lobe selection for treatment should be based on quantitative computed tomography, and the lobes with the greatest destruction should be targeted (excluding the right middle lobe). The treatment results in an improvement in pulmonary function, exercise performance and quality of life, particularly in patients with severe hyperinflation (residual volume > 200% predicted) and upper-lobe heterogeneous emphysema, but will also be of benefit in lower-lobe predominant and homogeneous emphysema. Finally, it has an acceptable safety profile, although special attention has to be paid to coil-associated opacity which is an inflammatory response that occurs in some patients treated with endobronchial coils.

Novel Technologies in Endoscopic Lung Volume Reduction

Endoscopic lung volume reduction (ELVR) presents an effective therapy in patients with advanced emphysema. Different ELVR techniques are available differing in mechanism of action, degree of reversibility and safety. Precise patient selection with respect to pulmonary function test, emphysema distribution, and collateral ventilation are prerequisites for a successful use of the various ELVR techniques. To date, there are only a few randomized controlled trials for bronchoscopic therapy in patients with chronic obstructive pulmonary disease, so the various techniques should be performed within clinical trials or registry studies.

Early Trends in Bronchoscopic Lung Volume Reduction: A Systematic Review and Meta-analysis of Efficacy Parameters

INTRODUCTION

The goal of our systematic review and meta-analysis is to examine the therapeutic effectiveness of bronchoscopic lung volume reduction (BLVR), and to compare it with medical management and lung volume reduction surgery.

METHODS

Variables of interest were absolute change in FEV1, 6MWT, and SGRQ. Meta-analysis was performed for the BLVR modalities with ≥3 trials. Of the 18 shortlisted publications, only valves (four trials; n = 159) and coils (six trials; n = 194) qualified for meta-analysis. To avoid redundant reporting for valves, only the data for intact fissure subjects were analyzed. Outcome data are presented as the mean difference from baseline with 95% confidence interval at 6-months follow-up.

RESULTS

For BLVR using valves, the pooled mean difference (PMD) for FEV1 was 0.146 L (95% CI 0.111-0.181; p < 0.001), 6MWT was 45.225 meters (95% CI 26.954-63.495; p < 0.001), and SGRQ was -8.825 points (95% CI -14.824 to -2.825; p = 0.004). All the PMDs were statistically significant and higher than their respective minimal clinically important difference (MCID). For BLVR using coils, the PMD for FEV1 was 0.080 L (95% CI 0.057-0.104; p < 0.001), 6MWT was 45.320 meters (95% CI 28.040-62.600; p < 0.001), and SGRQ was -10.570 points (95% CI -13.299 to -7.841; p < 0.001). All three variables showed statistically significant PMDs but that for FEV1 was smaller than the MCID. Data from BLVR modalities with <3 major publications are reviewed in the discussion section.

CONCLUSIONS

BLVR offers early promise in the palliation of advanced emphysema. Better characterization of patients to identify phenotypes that will derive sustained benefit is needed.