Search

Introduction: The recent STEP-UP trial showed clinically relevant improvements in lung function and quality of life associated with segmental upper lobe vapor ablation. Objective: To correlate changes in segmental volumes of treated and untreated segments with FEV1. Methods: In the STEP-UP study patients with bilateral, upper-lobe predominant emphysema underwent vapor ablation of 1-2 segments of each upper lobe. Quantitative software (VIDA, Coralville, IA) was used to assess relative segmental volume changes from baseline to 6-month follow-up CT scans. Results: Data from 40 treated patients (21f/19m, FEV1 34±8%, RV 236±41%) with complete data sets were included. Vapor ablation resulted in a statistically significant 36±17% segmental volume reduction at emphysematous treatment sites and an 8±9% volume increase of untreated preserved lung segments (p < 0.01) Volume reduction of treated segments correlated positively with the absolute improvement in FEV 1 at 6 months (r=0.47) Conclusions: Targeted segmental vapor ablation and subsequent volume reduction of the most diseased upper lobe segments induced expansion of preserved, relatively healthy upper lobe segments.

Background: RENEW is a multicenter, randomized controlled study comparing endobronchial coil treatment to medical management in 315 patients (52% female, mean 64 years, FEV 1 25% pred, RV 240% pred) with advanced heterogeneous (23%) and homogenous (77%) emphysema. One year overall primary results showed modest exercise and lung function improvement with meaningful quality of life improvements 1 . Objective: To investigate whether responder subgroups in RENEW would demonstrate predictive characteristics to enhance patient selection for coil therapy. Methods: Analyses of key outcome measures between prespecified and exploratory subgroups was performed on the RENEW patient population 1 . Results: Statistically significant baseline differences between high (RV>225%, n=235) and low (RV 225% showed greater treatment response for FEV 1 , RV, 6MWT, and SGRQ. Analysis of treatment interaction of baseline factors for change in 6MWT showed that number of comorbidities had a greater influence than RV. Over 1/3 of reported pneumonia events were reclassified as non-infectious coil-associated opacities. These coil induced mechanistic events predicted significantly greater treatment response in affected patients across all endpoints. Conclusion: Baseline RV is a sensitive predictor of response to coil therapy in severe emphysema patients. Patients with a high comorbidity burden have worse 6MWT outcomes. Coil associated opacities, although not a baseline variable, may predict superior response and should be further studied. 1) JAMA 2016;315:2178-89.

Introduction: Endobronchial Ultrasound guided Trans-bronchial Needle Aspiration, (EBUS-TBNA) is used for the diagnosis and/or staging of cancer and other disorders. A novel 19G EBUS-TBNA needle ([Olympus Respiratory America], Redmond, WA, USA) with a larger diameter was developed to collect larger samples. Aims and Objectives: Evaluations were done in patients to assess the performance of the new 19G EBUS-TBNA needle. Methods: Product performance evaluations were conducted in 4 countries by 13 physicians experienced with EBUS-TBNA from Sept 2015 to Nov 2015. Physicians in each country were provided with 20 needles and asked to evaluate their performance in patients by completing evaluation forms. The forms asked physicians to rate the needles9 absolute (stand-alone) and relative performance (with respect to their experience of using current commercially available 21G and 22G needles) in the areas of penetration, visibility, and sample collection. Eighty completed evaluation forms were returned and analyzed. Results: For relative performance, physicians rated the 19G needle as comparable or better on 97.5% of the forms for sample collection, 92.5% for penetration, and 95% for visibility. For absolute performance, physicians rated the ability of the device to collect samples, its penetration, and its visibility as acceptable 98.75%, 97.5%, and 97.5% of the time respectively. One subject in Poland experienced bleeding after puncturing of the right hilum. Conclusions: Product performance evaluations of the 19G needle suggest that its performance is equivalent to or better than currently commercially available needles. However, additional clinical evaluations are warranted.

Introduction: In emphysema hyperinflation within a lobe occurs heterogeneously at the segmental level, meaning that certain segments are more hyperinflated than their neighboring segments. Volume reduction leading to CMI has formerly only been achievable on a lobar basis, resulting in indiscriminate treatment of all segments irrespective of disease severity. We hypothesized that targeting the most hyperinflated segments would result in clinically meaningful reduction of residual volume (RV) while preserving lung parenchyma. Objective: Whether targeted reduction of most hyperinflated upper lobe segments results in reduced RV and CMI in FEV 1 Methods: In the STEP-UP RCT, 45 patients received bilateral vapor ablation in 1 or 2 of the more hyperinflated upper lobe segments over 2 procedures. Difference in RV and FEV 1 was calculated using baseline and 6-month follow up patient data for the control and treatment arm. Results: Change in RV at 6 months showed a correlation with FEV 1 change (r=0.39) Conclusions: Targeted reduction of the most hyperinflated upper lobe segments with vapor ablation results in RV reduction, which correlates with improvement in FEV 1 . This targeted method of bronchoscopic lung volume reduction preserves functional lung parenchyma. In the event of future disease progression, remaining segments may be targeted for volume reduction to yield sustained benefit.

Background: Bronchoscopic lung volume reduction (BLVR), using endobronchial valves to target unilateral lobar occlusion can improve lung function and exercise capacity in appropriately selected patients with emphysema 1 . Few data exist on the long term outcome following BLVR. Methods: 19 patients (16 male), FEV 1 28.4(11.9)%, RV 260.5(68.4)%TLco 35.9 (10.9)% underwent BLVR between July 2002 and February 2004. The occurrence of atelectasis, representing successful BLVR, was defined on CT appearances one month after the procedure. Survival data to November 2015 were compared between those with (n=5) and without (n=14) atelectasis. Results: Survival was significantly greater in the atelectasis group p=0.017 (Figure 1). In the atelectasis group 2/5 (40%) were still alive compared to 2/14 (14%) of the non-atelectasis group. The two groups did not differ at baseline in lung function, quality of life, exacerbation rate, exercise capacity (shuttle walk test or cycle ergometry) or CT appearances. Conclusions: Successful BLVR is associated with a substantial, persisting survival benefit. 1. Davey C, Zoumot Z, Jordan S, et al. Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial. The Lancet 2015;386:1066-73.

Introduction: Emphysema is a progressive disease, and the lobes of severe emphysema patients typically contain segments with substantially more disease than other segments within the lobe. Objective: Prove thermal vapor treatment of the most diseased segments in a step-wise manner, results in clinically meaningful improvement in FEV1 % predicted, SGRQ and 6MWD. Methods: 69 patient, multi-national, 2:1 RCT comparing segmental ablation vs. medical management. Treat 1 upper lobe segment followed by treatment of 1 – 2 segments of an upper lobe in Gold stage III/IV patients. Results: Exacerbation and pneumonia rates were in the range of expectation for bronchoscopic lung volume reduction therapies and were 24% and 18% at 6 months post treatment respectively. ![Figure][1] Conclusions: Treating the most diseased segments results in clinically meaningful improvement in FEV1, SGRQ, and 6MWD while sparing healthier segments. Thermal Vapor is safe with no chest tube insertion or surgery. Finally, treating in a step-wise manner leaves additional segments for possible treatment over time. [1]: pending:yes