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Management of Emphysema with Lung Volume Reduction through bronchoscopy.

GP Information Leaflet

Emphysema is a disease characterised by increasing the volume of the lungs due to alveolar destruction. This results in lung hyperinflation. Up to recently, emphysema management was faced with nihilism. Lung hyperinflation causes breathlessness, limitations of activities and occasionally weight loss.

Lung volume reduction is a procedure aimed at removing or reducing the size of the least useful parts of the lungs, thus allowing more useful parts to expand. It also allows the respiratory muscles and the chest wall to function under less pressure. A panel of experts will decide which treatments are most useful based on the CT scan and lung function tests as well as the general wellbeing.

Currently there are 3 recognised procedures – lung volume reduction surgery, insertion of endo-bronchial valves and insertion of endo-bronchial coils through bronchoscopy.

Lung volume reduction surgery: This is aimed to remove parts of the lungs that are most affected by emphysema. This is done through a keyhole (video assisted thoracoscopy VATS) under general anaesthesia. Patients stay for a few days in hospital. If this is decided the best treatment, further information on the benefits and risks will be provided by the thoracic surgeon.

Endo-bronchial valves:

Normally 4-5 one way valve are inserted aiming to occlude all bronchi leading to the target lobe. Once the valves are in place, they start to allow air and secretions to leave the targeted areas of the lungs without allowing it to re-enter them (figure). Gradually, this results in partial or total collapse of these areas. The procedures are done through bronchoscopy under sedation or anaesthesia. The procedures have 2 stages. The first is to assess the integrity of the inter-lobar fissures. This is done using a ballon catheter called Chartis. The second stage is to insert endo-bronchial valves. After the procedure, patients need to stay in hospital for 3 days to monitor complications in particular pneumothorax.

Endobronchial coils:

Coils are wires that are Nitinol inserted through an intra-bronchial catheter through the bronchoscope. Once they are released in the bronchi, they take a pre-determined shape. By doing so, they fold the lung tissue adjacent to the target bronchi thus causing volume reduction. By inserting 8-12 coils (normally 10) in each lobe volume reduction occurs. The set of figures below illustrate the release of the coil in the atmosphere for clarification (panel 1) and inside the lungs ( panel 2).

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Panel 1: The shape of the coil in the catheter and after it is released.

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Panel 2: Folding of the lung tissue adjascent to the bronchi where the coil is inserted. By folding several parts of the lung by several coils the volume of the lungs is reduced and the airways become less floppy.

The procedure is done under general anaesthesia. Ideally two lobes, one in each side, are treated few months apart. In non-complicated procedures, patients stay for 24 hours.

Clinical trials demonstrated that in a properly selected patients, surgery, valves and coils improve breathlessness, quality of life, lung function tests and survival. On the whole the procedures are well tolerated. Mortality rate is around 5%.

Possible complications:

Pneumothorax: This happens in up to 25% of patients for the valve and 3% of patients for coils. It tends to happen within 48-72 hour after the procedure.

Pneumothorax often needs a chest drain inserted and may require removal of valves and another valves re-inserted at another time. Very occasionally, a surgical intervention may be needed.

Chest infections and pneumonia: This is fairly common (30%-40%) after the valves and coils are inserted. Patients are provided with a course of antibiotics and prednisolone after valve insertion. The chest infections are treated in the normal way.

Valve migration: This is rare (less than 5%). Patients either cough the valve up or the valve may go to another area of the lungs. If this happens the valve will be removed through bronchoscopy and a new valve is inserted.

Haemoptysis (less than 5%) : This is rare too and in the majority of people it stops without treatment.

Death: This is rare and occurs in around 3-5%

Benefits of the treatment:

In all methods, benefits from the treatment are variable. Lung function tests, quality of life scores and exercise endurance improve from 5% to 40%.

However, approximately 25% of patients may not get any benefit from the treatment. The reason for this is not clear.

After discharge from hospital, patients will be seen with investigations every 3 months for the following year.

Referrals criteria:

Inclusion Criteria:

• FEV1 Less than 50% Predicted

• MRC Breathlessness >3

• 6 Minute Walk Distance - 100 metres – 450 metres

• Stopped Smoking for 6 Months

• Have Completed Pulmonary Rehabilitation Programme - or willing to do so

Exclusion Criteria:

• Current Smokers

• Sputum Producing Bronchiectasis

• Significant Asthma Component

• Suspected Lung Cancer (Lung Nodules)

• Severe Co-Morbid Conditions

Please refer patients to:

Dr Nabil Jarad, via E-Referral

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