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Konstantina Kontogianni,1,2 Kanoe Russell,3 Ralf Eberhardt,1,2 Maren Schuhmann,1,2 Claus Peter Heussel,2,4 Susan Wood,3 Felix JF Herth,1,2 Daniela Gompelmann1,2 1Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany; 2Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany; 3VIDA Diagnostics, Coralville, IA, USA; 4Diagnostic and Interventional Radiology with Nuclear Medicine, Chest Clinic (Thoraxklinik), University of Heidelberg, Heidelberg, Germany Objectives: Bronchoscopic lung volume reduction using coils (LVRC) is a well-known treatment option for severe emphysema. The purpose of this study was to identify quantitative computed tomography (QCT) and clinical parameters associated with positive treatment outcome.Patients and methods: The CT scans, pulmonary function tests (PFT), and 6-minute walk test (6-MWT) data were collected from 72 patients with advanced emphysema prior to and at 3 months after LVRC treatment. The procedure involved placing 10 coils unilaterally. Various QCT parameters were derived using Apollo imaging software (VIDA). Independent predictors of clinically relevant outcome (∆6-MWT ≥ 26 m, ∆FEV1 ≥ 12%, ∆RV ≥ 10%) were identified through stepwise linear regression analysis.Results: The response outcome for ∆6-MWT, for ∆FEV1 and for ∆RV was met by 55%, 32% and 42%, respectively. For ∆6-MWT ≥ 26 m a lower baseline 6-MWT (p = 0.0003) and a larger standard deviation (SD) of low attenuation cluster (LAC) sizes in peripheral regions of treated lung (p = 0.0037) were significantly associated with positive outcome. For ∆FEV1 ≥ 12%, lower baseline FEV1 (p = 0.02) and larger median LAC sizes in the central regions of treated lobe (p = 0.0018) were significant predictors of good response. For ∆RV ≥ 10% a greater baseline TLC (p = 0.0014) and a larger SD of LAC sizes in peripheral regions of treated lung (p = 0.007) tended to respond better.Conclusion: Patients with lower FEV1 and 6-MWT, with higher TLC and specific QCT characteristics responded more positively to LVRC treatment, suggesting a more targeted CT-based approach to patient selection could lead to greater efficacy in treatment response. Keywords: COPD, emphysema, interventional pulmonology, bronchoscopy, endoscopic lung volume reduction, endobronchial coils

D Gompelmann,1,2 K Kontogianni,1 M Schuhmann,1 R Eberhardt,1,2 CP Heussel,2–4 FJ Herth1,2 1Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, 2Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg (DZL), 3Diagnostic and Interventional Radiology, Thoraxklinik at University of Heidelberg, Heidelberg, 4Diagnostic and Interventional Radiology at University of Heidelberg, Heidelberg, Germany Objective: Endoscopic valve therapy aims at target lobe volume reduction (TLVR) that is associated with improved lung function, exercise tolerance and quality of life in emphysema patients. So far, a TLVR of >350 mL was considered to be indicative of a positive response to treatment. However, it is not really known what amount of TLVR is crucial following valve implantation. Patients and methods: TLVR, forced expiratory volume in 1 second (FEV1), residual volume (RV) and 6-minute walk distance (6-MWD) were assessed before and 3 months after valve implantation in 119 patients. TLVR was calculated based on computed tomography (CT) scan analysis using imaging software (Apollo; VIDA Diagnostics). Minimal important difference estimates were calculated by anchor-based and distribution-based methods. Results: Patients treated with valves experienced a mean change of 0.11 L in FEV1, -0.51 L in RV, 44 m in 6-MWD and a TLVR of 945 mL. Using a linear regression and receiver operating characteristic analysis based on two of three anchors (ΔFEV1, ΔRV), the estimated minimal impor­tant difference for TLVR was between 890 and 1,070 mL (ie, 49%–54% of the baseline TLV). Conclusion: In future, a TLVR between 49% and 54% of the baseline TLV, should be used when interpreting the clinical relevance. Keywords: emphysema, hyperinflation, target lobe volume reduction

Konstantina Kontogianni,1,2 Vasiliki Gerovasili,3 Daniela Gompelmann,1,2 Maren Schuhmann,1,2 Hans Hoffmann,2,4 Claus Peter Heussel,2,5 Felix JF Herth,1,2 Ralf Eberhardt1,2 1Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, 2Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research DZL, Heidelberg, Germany; 3Department of Respiratory Medicine, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, UK; 4Department of Thoracic Surgery, Thoraxklinik at the University of Heidelberg, 5Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany Background: Lung volume reduction coil (LVRC) treatment is established in daily endoscopic lung volume reduction routine. The aim of this study was to evaluate the safety and efficacy of LVRC treatment.Patients and methods: This was a retrospective analysis of 86 patients (male/female: 40/46, mean age: 64±7 years) with severe COPD and bilateral incomplete fissures. A total of 10 coils were unilaterally implanted in a single lobe, and 28 out of 86 patients were treated bilaterally. At 90-, 180-, and 365-day follow-up, changes in pulmonary function test (PFT), 6-minute walk test (6MWT) and modified Medical Research Council (mMRC) dyspnea scale, as well as possible complications, were recorded.Results: At 90 days, the forced expiratory volume in 1 second did improve (P

D Gompelmann,1,2 N Benjamin,1 K Kontogianni,1 FJF Herth,1,2 CP Heussel,2–4 H Hoffmann,2,5 R Eberhardt1,2 1Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, 2German Center for Lung Research, 3Diagnostic and Interventional Radiology, Thoraxklinik at University of Heidelberg, 4Diagnostic and Interventional Radiology, University Hospital Heidelberg, 5Thoracic Surgery, Thoraxklinik at University of Heidelberg, Heidelberg, Germany Introduction: Valve implantation has evolved as a therapy for patients with advanced emphysema. Although it is a minimally invasive treatment, it is associated with complications, the most common being pneumothorax. Pneumothorax occurs due to the rapid target lobe volume reduction and may be a predictor of clinical benefit despite this complication. Objective: The objective of this study was to conduct an exploratory data analysis of patients who developed a pneumothorax following endoscopic valve therapy for emphysema. Materials and methods: This study performed a retrospective evaluation of pneumothorax management and the impact of pneumothorax on clinical outcomes in 70 patients following valve therapy in 381 consecutive patients. Results: Pneumothorax rate following valve therapy was 18%. Pneumothorax management consisted of chest tube insertion, valve removal, and surgical intervention in 87% (61/70), 44% (31/70), and 19% (13/70) of the patients, respectively. Despite pneumothorax, patients experienced modest but significant improvements in lung function parameters (forced expiratory volume in 1 second: 55±148 mL, residual volume: -390±964 mL, total lung capacity: -348±876; all P

Daniela Gompelmann,1,2,* Hyun-ju Lim,3,4,* Ralf Eberhardt,1,2 Vasiliki Gerovasili,5 Felix JF Herth,1,2 Claus Peter Heussel,2–4 Monika Eichinger3,4 1Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, 2Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research, 3Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, 4Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany; 5First Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece *These authors contributed equally to this work Background: Endoscopic valve implantation is an effective treatment for patients with advanced emphysema. Despite the minimally invasive procedure, valve placement is associated with risks, the most common of which is pneumothorax. This study was designed to identify predictors of pneumothorax following endoscopic valve implantation. Methods: Preinterventional clinical measures (vital capacity, forced expiratory volume in 1 second, residual volume, total lung capacity, 6-minute walk test), qualitative computed tomography (CT) parameters (fissure integrity, blebs/bulla, subpleural nodules, pleural adhesions, partial atelectasis, fibrotic bands, emphysema type) and quantitative CT parameters (volume and low attenuation volume of the target lobe and the ipsilateral untreated lobe, target air trapping, ipsilateral lobe volume/hemithorax volume, collapsibility of the target lobe and the ipsilateral untreated lobe) were retrospectively evaluated in patients who underwent endoscopic valve placement (n=129). Regression analysis was performed to compare those who developed pneumothorax following valve therapy (n=46) with those who developed target lobe volume reduction without pneumothorax (n=83). Finding: Low attenuation volume% of ipsilateral untreated lobe (odds ratio [OR] =1.08, P=0.001), ipsilateral untreated lobe volume/hemithorax volume (OR =0.93, P=0.017), emphysema type (OR =0.26, P=0.018), pleural adhesions (OR =0.33, P=0.012) and residual volume (OR =1.58, P=0.012) were found to be significant predictors of pneumothorax. Fissure integrity (OR =1.16, P=0.075) and 6-minute walk test (OR =1.05, P=0.077) were also indicative of pneumothorax. The model including the aforementioned parameters predicted whether a patient would experience a pneumothorax 84% of the time (area under the curve =0.84). Interpretation: Clinical and CT parameters provide a promising tool to effectively identify patients at high risk of pneumothorax following endoscopic valve therapy. Keywords: endoscopic lung volume reduction, COPD, emphysema, pneumothorax, valve therapy