Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States. Despite optimal pharmacological treatment, many patients with chronic obstructive pulmonary disease remain very disabled. Bronchoscopic lung volume reduction, which involves the insertion of valves into the airways with the intension of improving operating lung volume, could be a valuable treatment option for some patients with advanced emphysema. In this program, participants will learn procedural tips and tricks regarding valve placement from internationally renowned EBV expert Gerard Criner, MD
Okay I want to thank everybody for taking the time to attend this discussion regarding bronchus topic. One bomb reduction. We're gonna be going over some of the procedural details and offering tips and tricks for the more difficult cases. My name is not Marquette, E. Professor of forensic medicine surgery at Temple University, Lewis Katz School of Medicine in philadelphia pennsylvania. And the point of my discussion here is just to really introduce the topic. So we all know that in patients with advanced emphysema and COPD that hyper inflation leads to really severe consequences. And those consequences include limitations and exercise tolerance and display. Um This occurs because the patient's Teitelbaum is limited. When this occurs there's a dramatic increase in their story rate and this serves only one purpose which is results in more dynamic hyperinflation. In more limitation, severe hyperinflation will affect the work of breathing by negatively affecting the respiratory muscles, particularly the diaphragm. Seeing this X ray here of a very flattened hyper inflated, flattened diaphragm and hyper inflated patients Also, as more hyperinflation occurs, the intra thoracic pressure increases and this has a negative effect on the cart. And there are multiple studies of cardiac MRI patients with severe emphysema showing that all the cardiac chambers are decreased in size. So this hyperinflation leads not only to respiratory problems but also cardiac compare. And of course, last but not least, hyperinflation is associated with increased mortality. So the therapy for COPD is predominantly medical therapy. But once you maximize medical therapy, patients will still be symptomatic, those with very secure disease that are very hyper inflated. So there are other options besides medical therapy. These include lumbar reduction surgery, but many patients understandably are reluctant undergo a surgical procedure on their chest when they were so distant and short of breath. And another limitation to L. V. R. S. Is that for whatever reason, after the neck trial, CMS and Medicare decided that they were going to limit the centers have participated in. Net is the ones that they would approve to do the procedure. L. V. R. S. Is not helpful and diffuse disease, in fact is harmful and of course it's expensive. One transplant on the other hand has a much higher morbidity and mortality. It's even further limited in the number of centers that offer this complex therapy and there's very limitations and organ availability. The selection criteria for transplant is even more striking and it's obviously very expensive, probably the most expensive therapy and the most complex therapy that we do as technologists. So broncos coptic lung reduction or L. V. R. Is an attractive option. It's less invasive although there's hospitalization associated with it, it tends to be relatively short hospitalization, but the L. V. R. Is not always easy. Example, here is in the left pane. This is an area of the patients were recently treated in the left upper lobe and you can see that getting around this bend and getting into L. B. One and two is very difficult with a large channel scope and the catheter inserted through the working channel. Dr chrono will go over some tricks that he's learned over the years to make this successful for you. And of course complications are part of the B. L. V. R. As well. Pneumothorax is common about 25 to 30% of the patients experiencing pneumothorax and this will be discussed tonight as well. Temple has a rich history and lung volume reduction surgery research. The first randomized clinical controlled trial for Alvarez was actually conducted at Temple and led by Dr Criner. We were one of the leading and rollers in the national treatment trial and we've had a pivotal role in the development of the L. V. R. Over the last 10 to 15 years having participated in nearly every major clinical trial that's been conducted in this field. So it gives me great pleasure to introduce Dr Criner who is the leader here at Temple in the lung center and he's going to discuss the LBR and offer some tricks to make you more successful for you. So enjoy the talk that we have five minute discussion where you can ask questions following the slide show. Hello and thank you for allowing me to present regarding Blvd. Are procedural details and provide you with some tips and tricks with treatment of patients with bronchus coptic lung reduction. My name is Gerard Criner and professor and founding chair of the department of forensic Medicine and Surgery at the Luz Cat School of Medicine at Temple University philadelphia pennsylvania. These are my disclosures have worked with various companies and clinical trials examining bronchus coptic lung reduction and have received some consultation fees and research fees. So what I'm going to talk to you about some of the procedural challenges that may be encountered when performing bronchus coptic lung reduction. These include Kanye waiting, more articulated orifice is to size and place into bronchial valves, deciding the sequence of al placement and tight areas of the lung, optimizing sustained low bar, add electricity to maximize the durability of treatment effect and how to manage a pneumothorax while managing patients treatment effect. So let's talk first about airways that are more challenging for initial and the bronco valve placement. These are usually more highly articulate segments, such as the typical segments of the right up below than left upper lobe or to superior segments of both lower lobes. So let me give you a case. This is a 67 year old female who presented with severe lower lobe predominant emphysema. She reported an increase in her breathlessness in the past year. Her mm RC. Was four. She is short of breath with walking 100 ft. She has a history of left side of breast cancer and his status post lumpectomy and radiation. She reports the history of Mitral Valve prolapse and she's a former smoker of two packs a day for 15-20 years and quit about 30 years ago. These are her pulmonary function data. Her FCC is 74% of predicted. F. E. V. 1 to 0.94 or 41% of predicted in a ratio of F. E. V. One. The FCC is 43%. Her total lung capacity is 5.64 L or 115% of predicted and residual is 3.18 L or 153% of predicted. With the diffusion capacity of 9.8 or 43% of predicted. This is a sagittal and coronal image of R. C. T. Sections and you can see that she had upper low predominant emphysema from a qualitative inspection. This is her select report again that shows that she has upper low predominant emphysema. She has more profound emphysema in the right upper lobe at 68% compared to the left upper lobe at 59%. However, her fishers, both her right minor and right major fisher are fairly incomplete at 49 and 84% respectively. But her left major fisher is 97%, indicating that perhaps the left upper lobe, maybe an area of treatment based on emphysema Uh involvement, the fisher integrity and she has good heterogeneity in terms of target lobe emphysema compared to its bilateral non targeted lobe emphysema of greater than 10%. In this case is close to 43% head originated. This is her nuclear medicine Spect cT that shows that the patient has bilateral upper lobe Talagi mia and high dead space. Her left upper lobe receives 11% profusion and 20% 7% of the ventilatory volume. So the left upper lobe, which is um approachable by the select report in terms of emphysema and fisher integrity, also is an area of high dead space indicating that that's appropriate area to continue to consider for treatment. So this is an example of a difficult to Kanye late left upper lobe, a pickle segment. This is the video that shows that you can see to try to put the sizing balloon in. It's always important to show that you can calculate with the sizing balloon with SVS before you go to the deployment device, can't calculate the size and you won't be able to calculate the treat in any event. What you have to do is take your time, place the device slowly and gently against the airway wall and then use that to walk your scope down the shaft to maintain the optimal articulation. Sometimes it helps to retract the endotracheal tube to have more flexibility, the bronchoscopes or to perform the calculation and conspiratorial exploratory pause, manipulating different lung volumes to highlight your ability to manipulate the scope and device to calculate the, the Orpheus and sometimes head rotation may help. So this is an example of how to do that. So that's the left upper lobe. How about the right upper lobe? Well, this was a difficult to calculate right up below a pickle segment In a 62 year old female with the history of COPD emphysema. This predominant phenotype. GERD hypertension and you can see the rest, high cholesterol hypothyroidism. She had an M. R. C. Scale of three dismiss score. She gets short of breath while laying down, sometimes walking on level ground, smoked for a half pack per day for 30 years quit in 2000 and two. Sure FTC is 67% of predicted. F. E. V. 1 32% of predicted TLC is 126% of predicted and residual volume is 190% of predicted and R. D. L. Is about 46% of predicted. This is her um uh strategies report. That shows that her right upper lobe and right middle lobe are the optimal targets. As you can see on the status report to the left of the slide, The patient has More significant right upper lobe and right middle lobe emphysema. They're all both of them are 70% of involved, 64% emphysema or right lower lobe. Her right minor fisher is not intact, but a right major major fisher is 96% intact On her left side. She has 64% emphysema and upper lobe and 45% in the left lower lobe. And as you can see from the nuclear medicine spect ct shown to the right, She has about 19% profusion to the right upper lobe and right middle lobe. But that occupies about 26% of the volume of that side. So indicating an area of high dead space. And the only targets in this patient's case based on the degree of involvement and and fisher integrity is going to be the right upper lobe and right middle lobe. You not consider the right, the left upper lobe because you wouldn't want to treat the lobe of the least disease blonde. Um this is um an example of a patient who had a short, very short trunk writer below Bronchus and she had a very typically displaced RB. one. So how would you approach treating this patient? Well, one thing that's important to recognize is know your tools that are available to treat these short and angular hated segments. Um And zephyr Valls give you a multiple kind of tools to be able to use. First. You can see that you know, you can improve the articulation with using a. J. Catheter is shown here And as Jay Catheter can have you regained about 30% of the lost articulation that occurs with a bronchoscopes. When you place a tool through the working channel and as you can see that there's different sizes of veils, both in with a four versus a 5.5, but also in length of 4.0. L. P. Or 5.5 L. P. Compared to the regular length four and 5.5 L. P. S. So this is a difference about 1.7 millimeters in length for four and approximately a 2.2 millimeters in length for a 5.5. So if you have a very articulated uh short trunk, then you're really going to look for a 4.0. L. P. And the bronco valve on A. J. Catheter to help to calculate those very articulated segments. It's also important to kind of map out how you're going to use these valves to treat the patient. So you can place in segments that doesn't obviate your pathway to the treatment lobe. So as you can see in this short trunk, a pickle segment, you're going to treat that last. Because if you treat it first, It's going to block your ability to treat our b. two or r. v. three. In this case we treated our B. Two, then RB. Three. And then we went to RB one. We placed a low profile four point oh zephyr vale with a J. Stick into that area. And this is showing the video of that Our B. two and RB three already place we're measuring it. We're gonna put a low profile on that thin band Into that RB one segment and have that just distal to proximal portion of that band to the valve. As you can see when you look back a little bit blurred video. But you'll be able to see that the struts are all into the Orpheus of that sub segment of of R. B. Um What? So this is the patients X ray report or x ray image on the left before blvd are the right upper lobe. Uh And this is her uh image shown after treatment of the right upper lobe, right middle lobe. And you can see that she had significant volume loss on the right side with near total at Alexis, the right upper lobe, right middle lobe. And she had a very good physiologic outcome. So there's also airways that are more challenging not only for the initial placement but to maintain sustained inclusion and low bar and electricity. And you know that that's the holy grail of E. B. V. Is to not only collapse alot but to keep it collapsed so patients can have sustained improvement. And in my opinion these are the lobes that are most challenging to keep the treatment effect there. It's our B. And L. B. 10. As well as L. B. 12 and three. I'll show you some examples of that. So here's a case of 69 year old male with emphysema cabbage times to hypertension diabetes. This patient underwent E. B. V. In the left lower lobe had four valves. Place all 5.53 of them regular length one, a low profile in lb six. So they had four zephyr valves. Place in the left lower lobe. Can see the strategies report here. To the right strategies report shows, I'm sorry that the patient has predominant left lower lobe. Uh emphysema has a left lower, low volume of about 1.8 L, 96% complete. Left Fisher, emphysema and that left lower lobe. Um Pretty much homogeneous disease on that. Left aside the iPSa lateral treated non treated lobe were less than 10% emphysema difference. You can see that we were effective in getting low bar inclusion. It was immediate. And when our post patient has a pretty sizable pneumothorax and we place a chest tube in patients left the hospital one week post discharge with a good treatment effect on that left side. But six weeks later the patient really didn't really have any physiologic or clinical improvement. As you can see by his physiology. It was the same as F. E. V. One Fbc, air trapping and hyperinflation were the same. And if you look at the sagittal image blown up of his, of his left lower lobe, you can see that the L. B. 10 valve is somewhat male rotated and not including both the accessory segment that's present of the um lb. 10. That is per perpendicular to the mean uh segment, uh segmental uh sub segmental orifice of L. B. 10. So this is what it looks like. Endoscopic lee. We have placed develop on that sub karina of lb 10 to include both the accessory branch as well as the main airway, but it might not be effective and sustained fashion because there's some rotation it occurs with valves with collapse. And you can see that patient had total low bar collapse and then had a chest to place with three expansion in the left upper lobe. So with that decrease in volume rotation of lobe, that valve that was sit on that uh sub karina, tertiary criminal between the accessory segment and the main uh segmental airway of the um lb 10 kind of was displaced and mel rotated off that karina. So this is how we fixed it, We went back in, we removed that valve, we place the 5.5 regular length zephyr valve into that large segmental Orpheus shown by that top arrow and remaining accessory orifice. We treated it with a subsequent or an additional four point oh um uh low profile valve on a four point a regular uh valve zephyr valve on a. J. Catheter. And this is how we did it. That's after the 5.5 has already placed. We're looking for the accessory airway which is identified here at this six o'clock position. We try to move to stick against the airway wall gently away from the valve and sneak it in there. Sometimes we use error. We use saline. Try to make the proximal portion of that uh green thick border right below the segmental sub segmental orifice. Mhm. You can see their place now side by side with good torque on the valve enclosure. This is the patients pre and post procedure at six weeks now and you can see that the patient has loss of the descending aorta and the left hemi diaphragm and has good volume loss that return. And the patient had good subsequent clinical benefit. Um The third kind of tip and trick try to present to you is how to manage a chest tube placement with pneumothorax present. This is a case of a 71 year old male history of GERD, both coronary heart disease and peripheral vascular disease treated with stents in both locations. Bph diabetes, hypertension, emphysema. This final type of COPD worsening dysthymia. He tells me in history has been dismissed for the past few years, has gotten worse in the last year. He was hospitalized a couple years ago for exacerbation. He did rehab felt no improvement short of breath. He works as a band equipment carrier for local band and he smoked a lot but quit five years ago. And here's his baseline imaging. He has fairly predominant upper lobe emphysema And this is his pft data. His nephew ones, 40% of predicted his TLC is 112% of predicted an r. s. 154% of predicted, which doesn't look too bad. But I don't think I show you hear his c pet study but he trapped about an additional 809 100 mls of gas during a incremental maximum symptom, limited maximum exercise tests. So a large element of dynamic hyperinflation. Also, This is a select report that shows upper, low predominant emphysema and you can see that he has um 44% emphysema. In the write up below 47% left upper lobe. He has greater fissure integrity of the left. Major fisher compared to the right major fisher and slightly more percent emphysema, left upper lobe. And if you look at looking for dead space, he has slightly more dead space in the left upper lobe. With on this nuclear medicine spec C. T. Um more ali G. Mia related to a dealer volume 24% profusion compared to 27% volume in the left upper lobe, Compared to 22% volume, 22% profusion and 22% volume matched profusion and volume of the right upper lobe. So we chose the left upper lobe is a target for treatment. So this is immediately post SVS uh placement in the left upper lobe. You can see the valves in place has relatively uh more cephalopod displacement of diagram indicating early volume loss. Post excavation complained of shortness of breath, you can see as a pretty sizable pneumothorax had a chest tube place had a pigtail place, second intercostal space which we prefer to do. So it's more comfortable for the patient in case they go home with it, it's easier for them to manage. And four hours later he still had an air leak in complete opposition of the visceral pleura or lung to the chest wall. So we increase the suction to 40 cm of water. That helped but still didn't accomplish what we wanted. So we up size that uh 16 French pigtail to a 20 French and then we increase The suction to 40 cm of water. And then we had opposition of the lung to the chest wall. The air leak. Stop, replaced the numa stat with a Heimlich valve. The patient was discharged home and we saw him back and follow up. In a week. We removed the chest tube and he had good volume loss, good response to procedure that had good physiologic and functional improvement. So in summary, hopefully some of these tips and tricks can tell you how to difficult uh how to manage difficult to articulate airways and regions of lobes that could be accessed with some simple maneuvers. In some patients always plays valves in adjacent airways and sequence with the more discernible distal segments treated distal sub segments treated first and always go in that kind of order. That doesn't obviate your pathway to the next subsequent valve. You have to place so go distal to more proximal to try to achieve that. And the goal is sustained inclusion to achieve low bar and electricity. So in some cases that may require more valves place more distantly to ensure continued occlusion. So try to anticipate how many valves you need based on, not what the lung may look like in front of you at that time, but also what you would imagine, what would happen with volume loss and slight rotation that may move a valve office sub crying is so that you can place fails more more permanently to achieve low bar and electricity. And then finally some new authorities can be handled conservatively to maintain treatment effect and limit the patient's hospital stay by a combination of Heimlich valve with chest to placement and follow up the patient clinic. So thanks very much for this opportunity to present to you guys and I hope that this was of some help to you take care. Mhm. Okay. So um my name's not marquette E. And I think you can hear me hopefully and um if you have any questions feel free to raise your hand or type them into Q. And a session and I'll make sure that they get addressed. Um While we're waiting for questions, I'm going to pose a couple of questions for dr kleiner to discuss um as we wait for others to try men with other questions. So uh Gary a question that we often get regarding valves is when you have an airway your size and it's a borderline size versus a smaller valve or larger valve. Is it better you think the upsides the valve or is it better to place two smaller valves in the more distal sub sub segment if you know what I mean? Yeah, I think that's a good question. I think it's pretty much all of them um As you well know um you like to place the appropriate size valve in some cases uh It's better to put a slightly wider valve in an area than a smaller valve but in some cases to white a valve will allow the valve not to function normally. So proper proper sizing is always, I think the key variable in some cases to get that proper sizing rather than doing one delve going a little bit more distantly to get the proper valve. Sizing might be required to do it. So, you know, I don't think one answer fits all in that case is you know, I think you have to really selected for the case. We only get a couple of questions. Um Here's one from uh john suing. The question is how do you, how do you deal with graduation tissue that builds up at the valves? And uh I imagine what um specific when you remove the valve, if you remove it, you have to treat the Ukrainian grain relations issue. and then how do you do that mm. That's also a good question. For the most part, most of degranulation tissue is soft Paula point tissue. It's easily removable in some cases just removing the velvet self. We'll remove degranulation tissue with it. There's not usually much bleeding that occurs in some cases that have more exuberant graduation tissue. Then we'll use either a cryo probe or will use some focal a PC to treat it, damp it down and then try to dilate with the small dilation balloon to like smooth it out before we place another gal our replace it on the same case. We usually are able to revise the valve, treat degranulation tissue and replace available at the same setting. In rare cases we might bring the patient back for a subsequent visit if there's a lot of graduation tissue or a lot of Hiroshima or if there's any evidence of Purell infection will treat the patient with antibiotics, systemic steroids, topical steroids and then bring them back. Okay. Another question that we uh that I saw pop up in the chat here is what are you doing about homogeneous disease? If the patient has a homogeneous disease in general for any long reduction procedure, the magnitude of benefit and the durability is less than better genius disease. But if you have homogeneous patients whose major trigger for their dysosmia and there impairment is related to hyperinflation and then those patients do better with treatment um than they do with just um continuation of optimal medical therapy. There's a couple of providers of that. If one looks at the papers have treated patients with homogeneous disease within the bronco valve placement. The best and the only prospective randomized control trial is our sean gallup pores and there's a couple homogeneous patients and and Karen cluster and dark john Sloboda study in Stelvio trial. There are patients that were significantly hyper inflated the mean RV and um Our Sean developers impact trial was about 250% RV predicted. So these are very hyper inflated uh, patients also, it's paramount to use profusion scanning to really pick the load the treat. That's um, that's the most allegheny because there if it's homogeneous disease are equally impaired by homogeneous by epidemics destruction. Um, are there any other questions guys can start type type some in uh, but a couple of questions for you regarding management of pneumothorax and so, you know, based on our experience here and you highlighted a case here where we had the upsides and tubes, we tend to put in a larger tube upfront. Impossible. But what's going to trigger yet to start contemplating taking valves out to quiet down or to treat the pneumothorax versus waiting it out. Um Wait it out for a couple of weeks. But what would make you change and take out the house? Mhm. Yeah, we've done that rarely taking out Bell's mm authorities are pneumothorax rate overall about 100 and 80 patients now is about 24% little bit let it's within the range of all the randomized controlled trials. But the number of patients that we've taken Taken into bronchial valves out is about a handful, maybe 4-6, somewhere around that range. And it's mainly related to patient instability, which is rare. Either a large ehrlich is causing um really gas exchange abnormalities or someone with a large air leak that required mechanical ventilation, positive pressure ventilation for management of respiratory insufficiency, then it's difficult to manage those patients with the large, fairly fortunately, that's been very rare in most cases like the case we showed were able to manage it with chest to management and then be patient and take the the chest tube out in clinic couple weeks later, usually one week post discharge. We're for most of most of the patients that we've had this phone was they were willing to wait it out for the for the benefit down the road and go home with a just to it's worked out pretty well. Another question that that we commonly get that maybe we can discuss for a few minutes is um when when patients experienced a pneumothorax, sometimes they're asymptomatic and it could be an X factor and pneumothorax. Can you give a couple of tips or pointers on who should get a chest tube? And I'm not talking about people that are obviously symptomatic. But what what's a situation read wait and watch versus have interventional radiology places just to. Mhm. Yeah, that's a good question. Overall in the liberate study the X vacuum pneumothorax percentage was 15%. So it's the minority of patients who developed a pneumothorax have x vacuum and and um by definition they're usually small under a symptomatic and non progressive. So it's the minority of the name authorities that occur and pretty much it signifies the patient who doesn't have a progressive niMA forex and is asymptomatic. There is another question that received in the chat again from john Sue. And when would you get a post valve quantitative ct scan of the chest to assess for a sustained volume reduction in your targeted lobe? Yeah. So it's a good question, john we re image our patients at six weeks and we do that to see with their total targeted lung volume reduction effect. Is we also also look at valve position and placement and identify if there is any area if the patient doesn't meet our target For low bar reduction where there might be a potential to revise the procedure to maintain or enhance the patient's benefit. So we do it in six weeks and then we do it manually and annually we're looking for lung reduction. But most of these patients, a number of them are meeting the criteria for a lung cancer screening. And you know I just had a patient today that we treated a year ago at a follow up CT scan for um for looking at target of lung reduction in lung cancer screening was found to have a contra lateral lung new nodule that wasn't there before that ended up being non small cell cancer. So you know these patients that you're treating for lung reduction because of their history and prevalence of smoking, as well as age, as well as presence of air flow chart production and presence of emphysema are all important risk factors for people at risk for lung cancer. So don't forget that, mm hmm. It looks like we're pretty much out of time. Um, so I want to thank everybody for uh, listening in and uh, thank you dr crane for the talk regarding the tips and tricks for this procedure.