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Background: Lung volume reduction of emphysematous lobes results in clinical improvement for patients with severe emphysema. However, some segments within a lobe are often substantially more diseased than others, thereby warranting a more targeted approach of the emphysematous parts of a lobe. We therefore did a study to assess whether or not selective sequential treatment of the more diseased upper lobe segments with bronchoscopic vapour ablation led to clinical improvement., Methods: For the multicentre, parallel-group, randomised, controlled, open-label Sequential Staged Treatment of Emphysema with Upper Lobe Predominance (STEP-UP) trial, adult patients aged 45-75 years with severe, upper lobe-predominant emphysema with a forced expiratory volume in 1 s (FEV1) between 20% and 45%, substantial hyperinflation, and post-rehabilitation 6-min walk test (6MWT) greater than 140 m were enrolled from 13 hospital sites in Europe (ten sites) and Australia (three sites). A computer-generated blocked randomisation scheme (block size three per site based on a random table from an independent biostatistician) stratified by site was used to randomly assign enrolled patients 2:1 to segmental vapour ablation (treatment group) or standard medical management (control group). Patients and investigators were not masked to group assignment. The primary efficacy endpoints were statistically significant changes in FEV1 and St George's Respiratory Questionnaire (SGRQ-C) scores between trial groups at 6 months, analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01719263., Findings: Between June 30, 2013, and Oct 1, 2014, 134 patients were screened and 70 were enrolled and randomly assigned: 46 to the treatment group and 24 to the control group. One patient in the treatment group did not receive treatment because of physician decision post-randomisation; this patient is excluded from all analyses. The mean relative improvement in FEV1 between the treatment group versus the control group was 14·7% (95% CI 7·8-21·5%; p<0·0001) and in SGRQ-C was -9·7 points (95% CI -15·7 to -3·7; p=0·0021). COPD exacerbation was the most common serious adverse event, occurring in 11 (24%) of 45 patients in the treatment group and one (4%) of 24 in the control group. One exacerbation resulted in a patient death 84 days after treatment; this was judged by the data and safety monitoring board to be possibly related to treatment. No pneumothorax occurred within 30 days of treatment., Interpretation: Compared with standard medical management, targeted thermal vapour ablation of more diseased segments and preservation of less diseased segments resulted in clinically meaningful and statistically significant improvements in lung function and quality of life at 6 months, with an acceptable safety profile., Funding: Uptake Medical., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

One-way endobronchial valves (EBVs) have been shown to relieve symptoms of emphysema, particularly in patients without collateral ventilation (CV) between the target and adjacent lobes. In this study, we investigated the ability of the bronchoscopic Chartis™ Pulmonary Assessment System to predict treatment response by determining the presence of CV. 80 EBV patients underwent a pre-treatment Chartis assessment. Before and 30 days after implantation, high-resolution computed tomography scans were taken to determine target lobe volume reduction (TLVR). A pre- to post-treatment reduction of ≥350 mL was defined as significant. In addition, clinical outcomes (forced expiratory volume in 1 s (FEV(1)), 6-min walk test and St George's Respiratory Questionnaire) were compared over the same time period. Of the 51 patients classified as having an absence of CV according to their Chartis reading, 36 showed a TLVR ≥350 mL. 29 patients were classified as having CV, and of these 24 did not meet this TLVR cut-off. Chartis showed an accuracy level of 75% in predicting whether or not the TLVR cut-off would be reached. Those predicted to respond showed significantly greater TLVR (p<0.0001) and FEV(1) improvement (p=0.0013) than those predicted not to respond. Chartis is a safe and effective method of predicting response to EBV treatment.

Background: We recently demonstrated that continuous positive airway pressure (CPAP) therapy rapidly improves insulin sensitivity within 2 days in non-diabetic patients with obstructive sleep apnea syndrome. In these very patients we investigated whether this improvement of insulin sensitivity is maintained during long-term CPAP therapy., Material/methods: After a mean of 2.9 years (963+/-98 days) of CPAP treatment, these patients were reevaluated and hyperinsulinemic euglycemic clamp studies were performed in those with regular and effective CPAP treatment., Results: From the initial 31 patients 16 could be reevaluated. 4 patients did not use their devices regularly (CPAP usage <2.5 h/night), 2 patients had insufficient CPAP treatment (AHI > or =10/h). One patient had developed type 2 diabetes mellitus. In the remaining 9 patients who used their devices regularly and effective (mean CPAP usage 5.2+/-1.6 h/night, mean AHI 3.3+/-2.6/h), mean insulin sensitivity index (ISI) was significantly higher than the baseline ISI established 2.9 years before (10.6+/-7.0 vs. 6.3+/-5.6 micromol/kg x min; p=0.008). At baseline 7 out of 9 patients had an impaired fasting glucose, after 2.9 years of treatment 3 out of 9 patients still had an impaired fasting glucose. The mean body mass index (BMI) had remained unchanged (31.4+/-7.8 vs. 31.4+/-7.6 kg/m2; mean individual difference -0.02+/-1.9 kg/m2)., Conclusions: OSA is a risk factor for impaired insulin sensitivity. CPAP treatment, when used regularly and with effective pressure, may improve insulin sensitivity over long time.