As part of the Pulmonology On Air 2022 Global Event, Gerard Criner, MD, FACP, FACCP, Director of the Temple Lung Center, demonstrates a LIVE endobronchial valve placement on a patient with advanced homogenous emphysema.
So cherry, How are you? Yeah, we have seen in the video now you are alive with us. So the podium is yours? Great. Thanks Felix. Thanks for having me. Thanks Jonas. So the case we're going to present to you today is a patient who's gonna undergo bronchus ka pik lung reduction or endoscopic lung reduction of the right lower lobe. Next slide. So this patient's a 78 year old caucasian male with severe progressive breathlessness despite optimal medical treatment, has had some cardiac issues in the past, has had a cabbage in the past. He had a cardiac stent years ago and had a history of pulmonary crypto cognos. IsSE that's involving the left, lower alone for the last 20 years and has been on a range of different pharmacologic therapy including pulmonary rehab and supplemental oxygen but still remains breathless. Next slide this is the patient's pulmonary function study. He has severe gold grade for airflow obstruction. His FTV one's 20% of predicted his hyper inflated. His total lung capacity is 130% of predicted an air trap. His residual volume is 221% with an RV to TLC ratio 69% diffusion capacity is normal is 02 and PCO two are slightly abnormal but within a good range is P. 0 to 73 his PCO two is 46. Next slide is the patient's cat scan. If you could advance it please, you can see in this actual view. The patient pretty much has a homogeneous emphysema is a site pre plural blood at the right apex. But as you go down with the ct scan you'll see that he has predominance of emphysema or lower lobes. Right greater than left will be done in one second. Okay dance. The next slide. This is a patient status report which you can see from this that it identifies that he has a fairly homogeneous emphysema throughout the lungs equal volumes except the right middle lobe. You can see that his major fissures on both sides are fairly complete 100%. Next slide this is his C. T. Scan. Looking at the corona and sagittal views and you can see something that you can't really identify quite well on the strategy report. But you can see this patient's right middle lobe is smaller compressed than normal because of hyper oration of both the right lower lobe as well as somewhat the right upper lobe. Next slide this is a nuclear medicine spec C. T. And a patient with homogeneous emphysema to try to find the lobe with the highest dead space to treat. And as you can see here what's outlined in the red triangle. The patient's dead space is highest in the right lower lobe which is more allergenic than any of the other lobes. Next slide So our patients gold grade for patient with significant hyperinflation optimal medical treatment, he still remains breathless, homogeneous distribution of emphysema. Major fissures are 100% intact. But he has heterogeneous profusion with the right lower lobe be Mosul. A gimmick with the highest dead space as an additional feature. Right middle lobe is somewhat compressed by the right lower lobe. It has the most viable tissue. So we're banking that this will be recruited viable tissue. So that's why we chose to do E. L. V. R. The right lower lobe. So we'll go ahead and get started, do a quick airway inspection. Put the suction on. We're good to go starting Sydney, the mucus. Hopefully someday when we have bronchus coptic treatments for mucus hyper secretion we would do that kind of procedure first. But this isn't that uncommon with your left side 1st bronchial obstruction of mucus. We'll send this for culture too. So we know what's a predominant, predominant four is if we have to treat the facial antibiotics. Some routinely treat with antibiotics and steroids pre post procedure but we tend to only treat on demand. So this gives us a quick look here. You can see the just O. B. I. His B. Six is somewhat low. So it allows us enough space to be able to do a chartist assessment. The lobes for treatment look to be fairly Road except for this one. The concern is that there'll be some slippage here. If I just treat with one valve might have to do a two bill treatment there. We'll take a look at our b. 10 and that also has an accessory branch but that has a good shelf there. We could probably put in there. Good. Alright. We'll go ahead and clean the scope and start our chartist assessment. You ready? So for those who don't haven't done a lot of chartist assessments or don't do that. We do that routinely in all patients. Even though the fisher is 100% attacked by uh C. T. Assessment, we find about 5% of people. Even with uh complete fishers will have collateral ventilation flow. We will not treat those patients will consider some other form of treatment for them for a C. V. Positive status. We tend to deflate the balloon and dip it with water easier to pass that way. Sometimes it's a little bit stiff and what we usually do is place it that we have the word, the balloon comes off, we have it right at the end so we have good optical coupling. So we can see, go ahead with the Charter's assessment. Get out, taking the style it out now and uh inflating the balloon, checking the chartists. I think you can see that to make sure we have flow and we have a good position here where I can see with optical coupling I can C. B. Six and I can see the lower low levels immediately with the charters you see we have a lower flow state, you'll see that sometimes with a lot of effort. Even the lower lobe we have some clicking of the valve that you could see the kind of average aggregated flow curve is descending into slow fashion which looks like it's moving towards a T. V. Negative assessment which would really confirm what we saw by fisher integrity by the C. T. Scan. Not much flow and it's lower low because of kind of uh a poor flow state that right lower lobe. So we have a cessation of flow at this time will deflate ready so that we can reestablish flow. Although this isn't a typical kind of curve with enough usual volume that we see which is a 25% of the lobe. I'm gonna accept this as evidence of receiving negative status. So we'll go ahead and treat the way we're gonna treat will treat more distal and then come more proximal. So lb 10 will be the first lobe to try to estimate if I can calculate with my scope. It's usually gonna be a 55 and we try to oversize for the most part the lower lobe so there's less likely of distal migration. I could probably use a 55 stick that will check you cherry. There is a question. Do you always use the charges when you have 100% fisher integrity in the Q. C. T. Yeah Felix. I do for this reason because I want to make sure that I'm not missing the 5% that would be positive and if I don't get a treatment effect then it's either I mail position the valve or the basic, the patient has pleural adhesions so it helps me later on diagnostically, if I don't get the treatment effect in my mind that I expect. That's why I do it. And as you can stay as you know, it only takes minutes to be able to do it. Okay, We'll just get here. This is our probe and look for length. So this is our osteo. I have to use my scope a little bit to hold it open. But you can see we have more than enough for a regular length. Now, in terms of the sizing, You can see the small tabs are touching the airway wall. So probably using a 55 in this case would probably be an oversized. So we're gonna go to a four regular stick. Let's measure it with that. Sometimes if you oversized, the valve will stay stuck open, which won't give you the response that you want. So you can oversize too. So we'll check it to be sure with a borough smaller with deployment stick, see what we have. Right? This is a better size fit as you can see the small tabs, don't touch the airway, what the large tabs do. So we're gonna go for four regular on a straight stick for R. b. 10. We'll do a controlled deployment on this, which means can I have a little bit of air, I give you a better view so that we can look at the crime as we partially open up the valve before we fully open it so we can make sure that we're proximal to the airway. There's also an accessory airway maybe here. You know, it's the fault. Good for lotus. Is that one of 11 and 24? That's what it would be approximately. They're going to stay above their, they'll do a controlled deployment event. Please usually hold the ventilator right before I deploy. Open the valve like this that you can see the tertiary critter as you're deployed. And as I opened fully I'll push to make sure it's well seated is a well seated valve. You can see all the struts are, well the crowd within the Austrian, take a picture of it, So you have traction on that. Okay, so we'll now move to L. R. b. 10. I'll take us five here with the small one there too. They're a little bit concerned that if I put one here, it's gonna come off of that over time. If I put one here it will come off of that one at 6:00 over time. Probably the best position is to put one there for more durable treatment effect over time. It's one thing when you think about placing your valves, it's not only to get an immediate treatment effect, but can you get long term durability? This is a pretty deep nine in this case, I'm gonna go with a 55 regular length and I'm gonna pre distantly here in this uh sort of Mercedes like tertiary karina distribution to be able to treat all this. Well the lower lobe for more adorable treatment effect. Then I'll come back and I'll put usually four with a. J. And that one and also in this one. So fully treat nine so probably three valves and nine here to be able to treat it with a durable treatment effect. Always always place the valves obviously more distal and proximal and anticipate that you won't have your pathway blocked by your subsequent treatment. This is bloated. Right okay. Who are they? Sure. Okay hold that. Okay well placed to remember where the other one is. They'll take the 400 J. Yeah that's nine proper nine A. And then I'll give you nine B. Is the next one. Yeah. J. Stick with a four regular loaded up. So jay stick for those who haven't used. I'll take the scope out to show you it will give me back some of the bend that I'll lose. And I have a valve that's a little bit more horizontal place and allows for easier placement and that kind of position. Is it loaded or? No. Yeah go ahead and load it first regular life meantime while steve's loading that up. Well just look at This should be good for a 55. And let's look at secure segment And this is probably gonna be a 55 low profile just by looking at things. Okay, so take the scope out and show you for those who aren't familiar with the J. You see the catheter Ben Comes about 30° of flexion gives you a little bit more maneuverability than what you have with the device without it in place, come back and just put this out of tags so it's easier to advance but not too far out. So you don't scrape the airway wall little bit of why am I that? So we're starting to call for, they just wipe this off. Okay. Right. Oh okay. Snake it around the veil like so come up to where I can see the Corrina as well as the mark. I don't wanna be too deep. The right about there would be good steve whole vet more smooth kind of deployment And that's where we want to put it. All the crowns are below that. Then we'll come up that's and treat nine R. B nine C. Okay, another four. Oh Please. Regular load it on a jet. Uh you know, you can give me a straight, you gave me a J. For that. Yeah, these things are J cause it just travels the airway wall a little bit smoother for me anyhow. Mhm. So what we'll do is after we place the four before we place the final valve, we usually cut the title line by 25% to decrease maybe some over inflation of the remaining lobes, it along, then we'll get a chest x ray on the table or if we're in a floor a room, we'll do it with Farro and then we'll check an X ray in the recovery room at an hour and if the patient's fine, They'll go up to our pulmonary floor and get subsequent three more x rays within the next 24 hours. And we keep patients overall for four nights in our institution. It's recommended at least three nights but we find that The 4th night helps us a little bit with patient management. I think this is an important message that you keep the patients long enough in the hospital to to avoid attention no more and all the related problems to that correct? Absolutely. Okay, so there's our two valves, this will be our third And nine. Hold that. Okay. And that's the way we want to see it. That looks good. They'll take a 55 stick for unloaded the check. 78 good. It'll that for 55. It's great take it. Okay. And there we go. Simple Steve Load 5 5. Okay. Yeah. Regular 5 5. So we're gonna put this 5,5 velvet Regular length. This will go in 78. Very good. All right, very good. Okay, hold that again, control deployment. We're gonna open this up a little bit, make sure it's above the Carina 78 push down a little bit but not too much. It's fine. Good job, good valve placement there. We're gonna go up to look at sticks. Uh This is the one that we think will probably be a low profile. So let's check the width first to make sure it's okay. The width looks good and for a low profile looks just about right. So I think we're good with a low profile 55 and R. B. Six. Very good. These look like they're all in good position. They're ventilating well fairly happy with the deployment. Looks like it went well there. And I think we have so far durable treatment response that we can achieve with this patient. Right? All right. All right. This will be our last valve. We'll cut the title line by 25% guys. Good thank you. Okay then it's just got a little bit control deployment, flexing a little bit. Try to get it centered as well as you can. Make sure it's in foss try to make these in line with the airway walls. So you don't get as much granulated tissue. The foreign body. Yeah that looks good. Low profile. Just makes it. So that's the end of our procedure part of it. We'll order get our X ray in here now and that's a complete case. Any questions there are questions how you handle that in um philadelphia when you have patients which are hyper kept nick and on noninvasive ventilation. Yeah I don't do those. I sent them the transplant if they could go to transplant. But we don't do anyone with a PCO two greater than 50. We don't do people on non invasive ventilation that are using it for treatment or respiratory failure. There might be a uh an extreme exception where PCO two would be accepted to be more palatable. Like 55 56 range if they have a finite amount of dead space with a significant degree of hyperinflation. But if there's someone like this with homogeneous disease and this patient is hyper inflated but not like in a 3 400 range of RV then we would send those patients to transplant. So in in Germany in europe you have had seen two publications, smaller series where we used the valves in patient or non invasive ventilation due to high park apnea. It seems to work. But I think especially when you start with the technologies don't go for those patients because you maybe have a higher complication rate. Um You want to know Felix with your multidisciplinary teams. The procedure is simple but the management of some patients can be difficult. So you have to think what are your capabilities of where you are in terms of your team or anesthesia, respiratory physical therapy etcetera nursing. So jerry thanks a lot