A new functional method to choose the target lobe for lung volume reduction in emphysema – comparison with the conventional densitometric method

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A new functional method to choose the target lobe for lung volume reduction in emphysema – comparison with the conventional densitometric method

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Author(s): Juergen Hetzel ¹ , Michael Boeckeler ¹ , Marius Horger ² , Ahmed Ehab ¹ , Christopher Kloth ² , Robert Wagner ³ , Lutz Freitag ⁴ , Dirk-Jan Slebos ⁵ , Richard Alexander Lewis ⁶ , Maik Haentschel ¹

Publication date (Electronic): 30 August 2017

Journal: International Journal of Chronic Obstructive Pulmonary Disease

Publisher: Dove Medical Press

Keywords: emphysema, chronic obstructive pulmonary disease, high-resolution computed tomography, lung volume reduction

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Abstract

Background

Lung volume reduction (LVR) improves breathing mechanics by reducing hyperinflation. Lobar selection usually focuses on choosing the most destroyed emphysematous lobes as seen on an inspiratory CT scan. However, it has never been shown to what extent these densitometric CT parameters predict the least deflation of an individual lobe during expiration. The addition of expiratory CT analysis allows measurement of the extent of lobar air trapping and could therefore provide additional functional information for choice of potential treatment targets.

Objectives

To determine lobar vital capacity/lobar total capacity (LVC/LTC) as a functional parameter for lobar air trapping using on an inspiratory and expiratory CT scan. To compare lobar selection by LVC/LTC with the established morphological CT density parameters.

Methods

36 patients referred for endoscopic LVR were studied. LVC/LTC, defined as delta volume over maximum volume of a lobe, was calculated using inspiratory and expiratory CT scans. The CT morphological parameters of mean lung density (MLD), low attenuation volume (LAV), and 15th percentile of Hounsfield units (15%P) were determined on an inspiratory CT scan for each lobe. We compared and correlated LVC/LTC with MLD, LAV, and 15%P.

Results

There was a weak correlation between the functional parameter LVC/LTC and all inspiratory densitometric parameters. Target lobe selection using lowest lobar deflation (lowest LVC/LTC) correlated with target lobe selection based on lowest MLD in 18 patients (50.0%), with the highest LAV in 13 patients (36.1%), and with the lowest 15%P in 12 patients (33.3%).

Conclusion

CT-based measurement of deflation (LVC/LTC) as a functional parameter correlates weakly with all densitometric CT parameters on a lobar level. Therefore, morphological criteria based on inspiratory CT densitometry partially reflect the deflation of particular lung lobes, and may be of limited value as a sole predictor for target lobe selection in LVR.

Most cited references 12

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A randomized study of endobronchial valves for advanced emphysema.

Kevin L Kovitz, Geoffrey McLennan, … (2010)

Endobronchial valves that allow air to escape from a pulmonary lobe but not enter it can induce a reduction in lobar volume that may thereby improve lung function and exercise tolerance in patients with pulmonary hyperinflation related to advanced emphysema. We compared the safety and efficacy of endobronchial-valve therapy in patients with heterogeneous emphysema versus standard medical care. Efficacy end points were percent changes in the forced expiratory volume in 1 second (FEV1) and the 6-minute walk test on intention-to-treat analysis. We assessed safety on the basis of the rate of a composite of six major complications. Of 321 enrolled patients, 220 were randomly assigned to receive endobronchial valves (EBV group) and 101 to receive standard medical care (control group). At 6 months, there was an increase of 4.3% in the FEV1 in the EBV group (an increase of 1.0 percentage point in the percent of the predicted value), as compared with a decrease of 2.5% in the control group (a decrease of 0.9 percentage point in the percent of the predicted value). Thus, there was a mean between-group difference of 6.8% in the FEV1 (P=0.005). Roughly similar between-group differences were observed for the 6-minute walk test. At 12 months, the rate of the complications composite was 10.3% in the EBV group versus 4.6% in the control group (P=0.17). At 90 days, in the EBV group, as compared with the control group, there were increased rates of exacerbation of chronic obstructive pulmonary disease (COPD) requiring hospitalization (7.9% vs. 1.1%, P=0.03) and hemoptysis (6.1% vs. 0%, P=0.01). The rate of pneumonia in the target lobe in the EBV group was 4.2% at 12 months. Greater radiographic evidence of emphysema heterogeneity and fissure completeness was associated with an enhanced response to treatment. Endobronchial-valve treatment for advanced heterogeneous emphysema induced modest improvements in lung function, exercise tolerance, and symptoms at the cost of more frequent exacerbations of COPD, pneumonia, and hemoptysis after implantation. (Funded by Pulmonx; ClinicalTrials.gov number, NCT00129584.)

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Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial.

Claire Davey, Zaid Zoumot, Simon Jordan … (2015)

Lung volume reduction surgery improves survival in selected patients with emphysema, and has generated interest in bronchoscopic approaches that might achieve the same effect with less morbidity and mortality. Previous trials with endobronchial valves have yielded modest group benefits because when collateral ventilation is present it prevents lobar atelectasis.

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Efficacy predictors of lung volume reduction with Zephyr valves in a European cohort.

Sarah S LeRoy, Timothy J. Egan, J Ficker … (2012)

The Endobronchial Valve for Emphysema Palliation Trial (VENT) was a multi-centre, prospective, randomised, controlled trial conducted to evaluate the safety and effectiveness of unilateral endobronchial valve (EBV) treatment. The purpose of this analysis was to assess outcomes in the previously unreported European VENT study cohort. Patients with advanced emphysema were randomly assigned (2:1) to receive Zephyr® (Pulmonx Inc., Redwood City, CA, USA) EBV treatment (n = 111) or medical management (n = 60). At 6 months, EBV patients demonstrated a significant improvement compared with the controls for mean ± SD change in forced expiratory volume in 1 s (7 ± 20% versus 0.5 ± 19%; p = 0.067), cycle ergometry (2 ± 14 W versus -3 ± 10 W; p = 0.04) and St George's Respiratory Questionnaire (-5 ± 14 points versus 0.3 ± 13 points; p = 0.047). At 12 months, the magnitude of the difference between groups for change from baseline was of similar magnitude to the differences seen at 6 months. Rates for complications did not differ significantly. EBV patients with computed tomography (CT) scans suggestive of complete fissure and lobar occlusion had a mean ± SD lobar volume reduction of -80 ± 30% and >50% met minimal clinical difference thresholds. The degree of emphysema heterogeneity did not preclude excellent outcomes. Unilateral lobar volume reduction using EBV treatment is safe and superior clinical results correlated with CT suggestive of complete fissures and successful lobar occlusion. Emphysema heterogeneity was not critical for determining positive outcomes.

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Author and article information

Journal

Journal ID (nlm-ta): Int J Chron Obstruct Pulmon Dis

Journal ID (iso-abbrev): Int J Chron Obstruct Pulmon Dis

Journal ID (publisher-id): International Journal of COPD

Title: International Journal of Chronic Obstructive Pulmonary Disease

Publisher: Dove Medical Press

ISSN (Print): 1176-9106

ISSN (Electronic): 1178-2005

Publication date Collection: 2017

Publication date (Electronic): 30 August 2017

Volume: 12

Pages: 2621-2628

Affiliations

[1 ]Division of Haematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine

[2 ]Department of Diagnostic and Interventional Radiology

[3 ]Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry, Department of Internal Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany

[4 ]Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland

[5 ]Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands

[6 ]National Pollen and Aerobiology Research Unit, Institute of Science and the Environment, University of Worcester, Worcester, UK

Author notes

Correspondence: Maik Haentschel, Division of Hematology, Oncology, Rheumatology, Immunology and Pulmonology, Department of Internal Medicine, Eberhard Karls University Tuebingen, Otfried-Müller-Straße10, D-72076 Tuebingen, Germany, Tel +49 7071 29 82711, Fax +49 7071 29 4598, Email maik.haentschel@ 123456med.uni-tuebingen.de

Article

Publisher ID: copd-12-2621

DOI: 10.2147/COPD.S139304

PMC ID: 5586979

SO-VID: 7b2d1fe9-1c5e-442a-aab1-d649088734d0

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A new functional method to choose the target lobe for lung volume reduction in emphysema – comparison with the conventional densitometric method

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Abstract

Background

Objectives

Methods

Results

Conclusion

Most cited references 12

A randomized study of endobronchial valves for advanced emphysema.

Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial.

Efficacy predictors of lung volume reduction with Zephyr valves in a European cohort.

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