Bronchoscopic Lung Volume Reduction Therapy

2011 By

Mohamed EL gamal Assistant lecture of chest medicine

Bronchoscopic Lung Volume Reduction Therapy

2011 By

Mohamed EL gamal Assistant lecture of chest medicine

Objectives

1- Pathophysiolog of Emphysema

2- Indications , Contraindications, complication OF LVRS

3- Types of Bronchoscopic Lung Volume Reduction Therapy

Objectives

1- Pathophysiolog of Emphysema

2- Indications , Contraindications, complication OF LVRS

3- Types of Bronchoscopic Lung Volume Reduction Therapy

RATIONALE FOR LUNG VOLUME REDUCTION

RATIONALE FOR LUNG VOLUME REDUCTION

Pathophysiolog of Emphysema

The destruction of alveolar walls causes loss of elastic recoil, early airway closure during exhalation air trapping in the distal air spaces

Air trapping reduces inspiratory capacity and

limits ventilation. increase in minute ventilation can then only be achieved by increasing respiratory rate further that in turn results in a vicious cycle of more dynamic air trapping.

Pathophysiolog of Emphysema

The destruction of alveolar walls causes loss of elastic recoil, early airway closure during exhalation air trapping in the distal air spaces

Air trapping reduces inspiratory capacity and

limits ventilation. increase in minute ventilation can then only be achieved by increasing respiratory rate further that in turn results in a vicious cycle of more dynamic air trapping.

• Alveolar wall destruction with formation of emphysematous bullae leads to loss of gas exchanging surface

• air trapping and hyperinflation press the diaphragm into a flat configuration, rather than its normal domed shape

• and place all the muscles of respiration at a mechanical overstretch disadvantage. In combination, these processes lead to refractory dyspnea.

• Alveolar wall destruction with formation of emphysematous bullae leads to loss of gas exchanging surface

• air trapping and hyperinflation press the diaphragm into a flat configuration, rather than its normal domed shape

• and place all the muscles of respiration at a mechanical overstretch disadvantage. In combination, these processes lead to refractory dyspnea.

Emphysema Phenotypes • Heterogeneous" and "homogenous" are

the 2 different types of distribution of emphysema.

• Heterogeneous is when emphysema is more isolated to certain areas of the lungs and the extent of emphysema varies between segments of the lungs.

• Homogenous is when emphysema has a more diffuse pattern and it is distributed more evenly throughout the lungs.

Emphysema Phenotypes • Heterogeneous" and "homogenous" are

the 2 different types of distribution of emphysema.

• Heterogeneous is when emphysema is more isolated to certain areas of the lungs and the extent of emphysema varies between segments of the lungs.

• Homogenous is when emphysema has a more diffuse pattern and it is distributed more evenly throughout the lungs.

What are benefits of LVR in advanced COPD patients?

improvement in forced expiratory volume in the first second (FEV1)

improvement in exercise tolerance,

decrease in regional volume of lung at the targeted lung segment,

less requirement of oxygen,

chest wall shape remodelling,

symptomatic improvement in breathlessness.  

What are benefits of LVR in advanced COPD patients?

improvement in forced expiratory volume in the first second (FEV1)

improvement in exercise tolerance,

decrease in regional volume of lung at the targeted lung segment,

less requirement of oxygen,

chest wall shape remodelling,

symptomatic improvement in breathlessness.  

Indications OF LVRS

Indications OF LVRS

• Age<75years • Ex-smoker(>6months)• Clinical picture consistent with emphysema• Dyspnea despite maximal medical therapy and

pulmonary rehabilitation

• FEV1 after bronchodilator <45 percent predicted

• Hyperinflation (TLC >100 percent predicted, RV >150 percent)

• Post rehabilitation 6-minute walk distance >140 meters

• Low post rehabilitation maximal achieved cycle ergometry wattsΔ

• Chest radiograph - hyperinflation   • HRCT confirming severe emphysema, ideally

with upper lobe predominance

• Age<75years • Ex-smoker(>6months)• Clinical picture consistent with emphysema• Dyspnea despite maximal medical therapy and

pulmonary rehabilitation

• FEV1 after bronchodilator <45 percent predicted

• Hyperinflation (TLC >100 percent predicted, RV >150 percent)

• Post rehabilitation 6-minute walk distance >140 meters

• Low post rehabilitation maximal achieved cycle ergometry wattsΔ

• Chest radiograph - hyperinflation   • HRCT confirming severe emphysema, ideally

with upper lobe predominance

Contraindications of LVRS !!!!

Contraindications of LVRS !!!!

• Age greater than 75 • Cigarette smoking • A comorbid illness (eg, significant

coronary heart disease, heart failure with a left ventricular ejection fraction less than 40 percent)

• Severe cachexia or obesity (eg, 31.1 kg/m2 for men and 32.3 kg/m2 for women)

• Inability to complete a 6 to 10 week program of pulmonary rehabilitation

• Age greater than 75 • Cigarette smoking • A comorbid illness (eg, significant

coronary heart disease, heart failure with a left ventricular ejection fraction less than 40 percent)

• Severe cachexia or obesity (eg, 31.1 kg/m2 for men and 32.3 kg/m2 for women)

• Inability to complete a 6 to 10 week program of pulmonary rehabilitation

A chest wall deformity, previous pleurodesis, or thoracotomy that would preclude surgery

A chest HRCT scan that shows minimal emphysema or shows homogeneously distributed emphysematous changes without areas of preserved lung tissue,

Findings on HRCT that would be considered a contraindication for LVRS (eg, giant bulla, interstitial lung disease, pulmonary nodule)

FEV1 is less than 20 percent predicted

DLCO less than 20 percent of predicted, (PaCO2) > 60 mmHg, (PaO2) < 45 mmHg Pulmonary hypertension (pulmonary artery systolic

pressure greater than 45 mmHg, mean pulmonary artery pressure >35 mmHg)

severe alpha-1 antitrypsin deficiency

A chest wall deformity, previous pleurodesis, or thoracotomy that would preclude surgery

A chest HRCT scan that shows minimal emphysema or shows homogeneously distributed emphysematous changes without areas of preserved lung tissue,

Findings on HRCT that would be considered a contraindication for LVRS (eg, giant bulla, interstitial lung disease, pulmonary nodule)

FEV1 is less than 20 percent predicted

DLCO less than 20 percent of predicted, (PaCO2) > 60 mmHg, (PaO2) < 45 mmHg Pulmonary hypertension (pulmonary artery systolic

pressure greater than 45 mmHg, mean pulmonary artery pressure >35 mmHg)

severe alpha-1 antitrypsin deficiency

Complication of LVRS!!!!!Complication of LVRS!!!!!

• Postoperative mortality 5%• intraoperative complications is 9%• postoperative complications is 58.7%• reintubation (21.8%),• arrthymias (18.6%), • pneumonia (18.2%),• Readmission to the intensive care unit (11.7%)• tracheotomy (8.2%)• Air leaks • hospitalized or living in a nursing

home/rehabilitation facility at 1 month after surgery

(Review Lung volume reduction surgery: technique, operative mortality, and morbidity. Proc Am Thorac Soc. 2008 )

• Postoperative mortality 5%• intraoperative complications is 9%• postoperative complications is 58.7%• reintubation (21.8%),• arrthymias (18.6%), • pneumonia (18.2%),• Readmission to the intensive care unit (11.7%)• tracheotomy (8.2%)• Air leaks • hospitalized or living in a nursing

home/rehabilitation facility at 1 month after surgery

(Review Lung volume reduction surgery: technique, operative mortality, and morbidity. Proc Am Thorac Soc. 2008 )

Types of Bronchoscopic Lung Volume Reduction Therapy

Types of Bronchoscopic Lung Volume Reduction Therapy

1. Endobronchial blockers

Mech : resorption atelectasis by occluding airways Types :1. Initially silicone vascular balloons filled with

radio opaque contrast 2. custom-built stainless steel stents with a central

occlusive sponge . Complication :: Endobronchial blocker migration postobstructive pneumonia

(Bronchoscopic lung volume reduction Cardiovasc Surg Torino. 2003 ).

1. Endobronchial blockers

Mech : resorption atelectasis by occluding airways Types :1. Initially silicone vascular balloons filled with

radio opaque contrast 2. custom-built stainless steel stents with a central

occlusive sponge . Complication :: Endobronchial blocker migration postobstructive pneumonia

(Bronchoscopic lung volume reduction Cardiovasc Surg Torino. 2003 ).

2. Airway Bypass Stents2. Airway Bypass Stents• creation of extra-anatomic bronchial

fenestrations to deflate emphysematous lung parenchyma

• Mech : presence of collateral ventilation which is the ventilation of alveoli through anatomic channels that bypass the airways. These channels include interalveolar pores, accessory bronchiole-alveolar connections, accessory respiratory bronchioles, and interlobar pathways across fissures

• creation of extra-anatomic bronchial fenestrations to deflate emphysematous lung parenchyma

• Mech : presence of collateral ventilation which is the ventilation of alveoli through anatomic channels that bypass the airways. These channels include interalveolar pores, accessory bronchiole-alveolar connections, accessory respiratory bronchioles, and interlobar pathways across fissures

– created low resistance bronchial fenestrations allow trapped air to escape by Distal emphysematous lung segments are drained via collateral ventilation through these fenestrations and lung compliance is improved by reductions in dead space

– without any actual change in pulmonary elastic properties

– created low resistance bronchial fenestrations allow trapped air to escape by Distal emphysematous lung segments are drained via collateral ventilation through these fenestrations and lung compliance is improved by reductions in dead space

– without any actual change in pulmonary elastic properties

– flexible bronchoscopy: identification of an area of the segmental bronchi that is free from blood vessels using a Doppler probe, fenestration of the airways, and placement of a paclitaxel eluting stent. Paclitaxel is a mitotic inhibitor that prevents granulation tissue from obstructing the stent.

• Complication• Hemoptysis most common • COPD exacerbation • pneumomediastinum • respiratory infection• Closure by granulation tissue

– flexible bronchoscopy: identification of an area of the segmental bronchi that is free from blood vessels using a Doppler probe, fenestration of the airways, and placement of a paclitaxel eluting stent. Paclitaxel is a mitotic inhibitor that prevents granulation tissue from obstructing the stent.

• Complication• Hemoptysis most common • COPD exacerbation • pneumomediastinum • respiratory infection• Closure by granulation tissue

3. Endobronchial Valves 3. Endobronchial Valves • Valves allow one-way flow of secretions

and air out of an occluded pulmonary segment during expiration but prevent any distal flow during inspiration .

• There 2 types of Endobronchial Valves

A- The duckbill valves

B- Umbrella-shaped valves

• Valves allow one-way flow of secretions and air out of an occluded pulmonary segment during expiration but prevent any distal flow during inspiration .

• There 2 types of Endobronchial Valves

A- The duckbill valves

B- Umbrella-shaped valves

3000 $ 3000 $

The duckbill valves are supported by a nitinol self-expanding, tubular mesh that is covered with a silicone membrane to form a seal between the valve and the bronchial wall.

Umbrella-shaped valves have a nitinol framework comprising 6 support struts . These struts are covered by a polyurethane membrane that seals the airways

The duckbill valves are supported by a nitinol self-expanding, tubular mesh that is covered with a silicone membrane to form a seal between the valve and the bronchial wall.

Umbrella-shaped valves have a nitinol framework comprising 6 support struts . These struts are covered by a polyurethane membrane that seals the airways

Endobronchial Collateral Ventilation• Lobar atelectasis was not achieved in the

majority of patients due ECV + or -

Evaluation of early generation Chartis Assessment Systems.

• Balloon catheter to occlude a target lobe to measure pressure and flow to determine the presence or absence of collateral ventilation.

• When flow is not measured in the steady-state phase, the patient is determined to be negative for collateral ventilation

Endobronchial Collateral Ventilation• Lobar atelectasis was not achieved in the

majority of patients due ECV + or -

Evaluation of early generation Chartis Assessment Systems.

• Balloon catheter to occlude a target lobe to measure pressure and flow to determine the presence or absence of collateral ventilation.

• When flow is not measured in the steady-state phase, the patient is determined to be negative for collateral ventilation

4. Bronchoscope Biologic lung volume reduction

Direct application of a sealant/remodeling system to collapse areas of emphysema. through resorptive atelectasis .

1-The initial method applied fibrin-thrombin mixtures to selected endobronchial locations

2- called BioLVR, was developed, adding chondroitin sulfate and poly-L-lysine to the fibrin mixture

4. Bronchoscope Biologic lung volume reduction

Direct application of a sealant/remodeling system to collapse areas of emphysema. through resorptive atelectasis .

1-The initial method applied fibrin-thrombin mixtures to selected endobronchial locations

2- called BioLVR, was developed, adding chondroitin sulfate and poly-L-lysine to the fibrin mixture

• An enzymatic primer solution (eg, porcine trypsin) is instilled detachment of epithelial cells from the target region.

• After two minutes, the primer is removed by suction and 10 mL of cell culture media is used to wash out residual primer.

• Next, a dual lumen catheter with the thrombin mixture in one lumen and the fibrin mixture in the other is placed through the wedged bronchoscope.

• The contents of the two lumens are instilled, followed by 60 mL of air to push the solutions distally.

• HYDROGEL• .

• An enzymatic primer solution (eg, porcine trypsin) is instilled detachment of epithelial cells from the target region.

• After two minutes, the primer is removed by suction and 10 mL of cell culture media is used to wash out residual primer.

• Next, a dual lumen catheter with the thrombin mixture in one lumen and the fibrin mixture in the other is placed through the wedged bronchoscope.

• The contents of the two lumens are instilled, followed by 60 mL of air to push the solutions distally.

• HYDROGEL• .

A hydrogel is created when the fibrin and thrombin solutions then collagen synthesis that promotes scarring and prevents future recanalization and ventilation of the treated area.

• It is thought that the hydrogel sealant will block the interalveolar and bronchiolar-alveolar pores and channels, eradicating collateral ventilation, and thus promoting resorptive atelectasis .

• Safe used in homog or het ,,, + or - ECV

A hydrogel is created when the fibrin and thrombin solutions then collagen synthesis that promotes scarring and prevents future recanalization and ventilation of the treated area.

• It is thought that the hydrogel sealant will block the interalveolar and bronchiolar-alveolar pores and channels, eradicating collateral ventilation, and thus promoting resorptive atelectasis .

• Safe used in homog or het ,,, + or - ECV

5. Thermal airway ablation 

specialized catheter via a flexible bronchoscope to administer steam vapor directly to segmental airways.

The procedure utilizes a reusable vapor generator

During the procedure, a vapor occlusion balloon is inflated to protect other airways from the heated vapor.

The goal induce inflammatory response that will result in occlusion and atelectasis of that segment.

It is hoped that the complication rate will be lower than with bronchial valve techniques, as no foreign body is left in place.

The procedure is typically performed under general anesthesia.

COMPL : COPD exacerbation ,,, Pneumonitis

5. Thermal airway ablation 

specialized catheter via a flexible bronchoscope to administer steam vapor directly to segmental airways.

The procedure utilizes a reusable vapor generator

During the procedure, a vapor occlusion balloon is inflated to protect other airways from the heated vapor.

The goal induce inflammatory response that will result in occlusion and atelectasis of that segment.

It is hoped that the complication rate will be lower than with bronchial valve techniques, as no foreign body is left in place.

The procedure is typically performed under general anesthesia.

COMPL : COPD exacerbation ,,, Pneumonitis

6. Airway implantsNitinol coils of 10 to 20cm in length

use in patients with either homogeneous or heterogeneous emphysema.

These implants which are straight when housed in a delivery catheter, coil up on deployment and tether the lung.

Comp: coils by distorting bronchi will cause

bronchiectasis

kinking pulmonary vessels will cause pulmonary infarcts.

6. Airway implantsNitinol coils of 10 to 20cm in length

use in patients with either homogeneous or heterogeneous emphysema.

These implants which are straight when housed in a delivery catheter, coil up on deployment and tether the lung.

Comp: coils by distorting bronchi will cause

bronchiectasis

kinking pulmonary vessels will cause pulmonary infarcts.

CHOOSE THE IDEALCHOOSE THE IDEAL

• valves and thermal vapor ablation target heterogeneous emphysema.

• airway bypass stents targeting homogenous emphysema

• Biological sealants and endoscopic coil implants have been used in both homogenous and heterogeneous emphysema

• valves and thermal vapor ablation target heterogeneous emphysema.

• airway bypass stents targeting homogenous emphysema

• Biological sealants and endoscopic coil implants have been used in both homogenous and heterogeneous emphysema

World wide importance • 3rd International Training Day on

Bronchoscopic Lung Volume Reduction and other Therapies with the IBV Valve System (3rd IBV Training Day 11.11.2011 Heidelberg / Germany)

World wide importance • 3rd International Training Day on

Bronchoscopic Lung Volume Reduction and other Therapies with the IBV Valve System (3rd IBV Training Day 11.11.2011 Heidelberg / Germany)

HOME MESSAGESBronchoscopic Lung volume

reduction surgery the NEW hope for emphysema patients .

SO

Chest depatment Mansoura university hospital must start

HOME MESSAGESBronchoscopic Lung volume

reduction surgery the NEW hope for emphysema patients .

SO

Chest depatment Mansoura university hospital must start

Thank Thank youyou