Chest
Volume 142, Issue 4, October 2012, Pages 900-908
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Original Research
COPD
Complete Unilateral vs Partial Bilateral Endoscopic Lung Volume Reduction in Patients With Bilateral Lung Emphysema

https://doi.org/10.1378/chest.11-2886Get rights and content

Background

Intrabronchial valve placement for endoscopic lung volume reduction is used for patients with severe lung emphysema. Different treatment approaches are unilateral valve placement with the goal of complete occlusion and subsequent atelectasis leading to true volume reduction vs bilateral partial closure aiming for redistribution of ventilation but avoiding atelectasis. In this prospective pilot trial, we compared the efficacy of these treatment approaches.

Methods

Patients with severe bilateral heterogeneous emphysema were randomized to two groups. In the first group, patients received unilateral valves aiming for total occlusion of one lobe. In the other group, valves were placed in two contralateral lobes with incomplete closure. In all cases, one-way valves were placed via a flexible bronchoscope. Patients were followed at 30 and 90 days, end points being change in pulmonary function tests (PFTs), 6-min walk distance (6MWD), and dyspnea score as measured by the modified Medical Research Council (mMRC) dyspnea score, as well as quality of life as measured by the St. George Respiratory Questionnaire (SGRQ).

Results

Twenty-two patients were treated in this study, 11 patients in each arm. At 30 days and 90 days, significant differences were seen in PFT and 6MWD, as well as in mMRC and SGRQ scores, in favor of unilateral treatment. At 90 days, FEV1 was improved by 21.4% ± 10.7% in this group, but not in the bilateral group (−0.03% ± 13.9%, P = .002). One patient in the unilateral group experienced a pneumothorax, and two patients in the bilateral group were treated for transient respiratory failure.

Conclusions

Unilateral intrabronchial valve placement with complete occlusion appears superior to bilateral partial occlusion.

Trial registry

ClinicalTrials.gov; No.: NCT00995852; URL: www.clinicaltrials.gov

Section snippets

Materials and Methods

In this single-center study, we prospectively included patients with severe emphysema after obtaining written consent. The study protocol had been approved by the ethics committee of the University of Heidelberg (S-288/2009).

In all patients, endoscopic lung volume reduction (ELVR) with placement of an IBV was indicated because of their severe emphysema. Heterogeneity and bilateral distribution of the emphysema was proven by native thin-slice CT (HRCT) scan and confirmed by perfusion

Results

We enrolled 23 of 73 screened patients between September 2009 and February 2010 (27.4%). One patient achieved an FEV1 of just above the inclusion criteria on the day of the procedure and, hence, had to be excluded from the study. Of the remaining 22 patients (10 women, 12 men, mean age 63.4 years, range 47-78 years) 11 were randomized into the unilateral and 11 into the bilateral group.

Both groups showed no difference in lung function, exercise tolerance, or mMRC and SGRQ score. However, Paco2

Discussion

The aim of unilateral valve treatment with complete closure of all segments of one lobe is a real volume reduction of the most hyperinflated lobe. The maximum volume effect is achieved by developing a complete lobar atelectasis. In the largest published trial on ELVR (Endobronchial Valve for Emphysema Palliation Trial [VENT]) there was an increase of 4.3% in FEV1 after 6 months in the treatment group, which was significant, but this mean change of 34.5 mL may not be clinically important for the

Conclusion

Unilateral valve placement with complete closure of a single lobe can improve lung function, exercise capacity, and QoL to a clinically relevant degree in patients with severe bilateral pulmonary emphysema. It is significantly superior to bilateral incomplete treatment. The sole improvement in SGRQ cannot justify the risk of an interventional procedure in our opinion, and, hence, a unilateral treatment should be preferred even in bilateral emphysema.

Acknowledgments

Author contributions: Dr Eberhardt is the guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article.

Dr Eberhardt: contributed to patient selection, follow-up, and data sampling; performing the procedures; and writing and editing the manuscript.

Dr Gompelmann: contributed to patient selection, follow-up, and data sampling and writing and editing the manuscript.

Dr Schuhmann: contributed to patient selection, follow-up, and data

References (27)

  • GJ Criner et al.

    Prospective randomized trial comparing bilateral lung volume reduction surgery to pulmonary rehabilitation in severe chronic obstructive pulmonary disease

    Am J Respir Crit Care Med

    (1999)
  • A Fishman et al.

    A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema

    N Engl J Med

    (2003)
  • FC Sciurba et al.

    A randomized study of endobronchial valves for advanced emphysema

    N Engl J Med

    (2010)
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    Funding/Support: The authors' institution has received unrestricted grants from Olympus Europe Holding/Germany for medical education activities. The intrabronchial valves used for this trial and fees associated with the license to use the St. George Respiratory Questionnaire were provided by Olympus Medical Co, Tokyo, Japan.

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