NON-SURGICAL TREATMENT OF PULMONARY ENPHYSEMA

1. NON-SURGICAL TREATMENT OF PULMONARY ENPHYSEMA Erino A.Rendina University “La Sapienza” Roma Sant’Andrea Hospital Division of Thoracic Surgery

2. PATHOPHYSIOLOGY OF EMPHYSEMA • Loss of elastic recoil • Resting volume • Collapse of small airways • Expansion of rib cage • Flattening of diaphragm • Inefficient respiratory muscles • Work of breathing D Y S P N E A

3. SURGICAL LUNG VOLUME REDUCTION Resection of “TARGET” less functioning areas Improve function of the residual lung Reduce hyperinflation Increase diaphragmatic function IMPROVE ELASTIC RECOIL LUNG REMODELING

4. BRONCHOSCOPIC LVR • The resection of non – functioning, hyperinflated target areas improves mechanics and function of the residual parechima • Less invasive approaches • Similar results could be achieved with deflation and even atelectasis of the target areas OPEN THORACOSCOPIC BRONCHOSCOPIC

5. BRONCHOSCOPIC LVRHistorical Notes • Sabanathan (2000): Occlusive stents • Pulmonx Trial (2001): Occlusive stents • Closure Med Trial (2001): Syntetic sealants • Cooper JD: Airway Bypass (2003) • Toma T: Bronchoscopic LVR (2003) • Wood D: Spiration Umbrella (2003) • Yim – Venuta: Emphasys Valves (2004-5)

6. EmphysemaExpiratory Collapse of Small Bronchi Normal Emphysema Inspiration EXPIRATION !

7. COLLATERAL VENTILATION Collateral Ventilation exists in normal lungs but ıs ırrelevant Collateral Ventilation becomes relevant in emphysematous lungs

8. COLLATERAL VENTILATION

9. COLLATERAL VENTILATION • MACKLEM proposed that creation of extraanatomic pathways might bypass the expiratory airflow obstruction. • He suggested the use of “spiracles” opening directly through the chest wall into the lung parenchyma.

11. VENTILATION CHAMBER 12 Emphysematous Lungs Resected for Lung Transplantation

12. FEV1 IN EMPHYSEMATOUS LUNGS

13. CLINICAL STUDY IN EMPHYSEMATOUS PATIENTS • Homogeneous emphysema • FEV1 < 20% • O2 therapy (1.5 – 2.0 L at rest) • RV > 180% • 5 Treatments in 4 patients • 4 – 8 Bilateral Airway Bypass per session

14. AIRWAY BYPASS WITH STENT

15. CLINICAL STUDY WITH STENTS IN EMPHYSEMA PATIENTS Results

16. AIRWAY BYPASS FOR EMPHYSEMA • Experimental and clinical evidence of the value of the theoretical basis • Probes and stent improvement • Prevention of granulation • Needle – Balloon technique • Antiproliferative drugs

17. AIRWAY BYPASS FOR EMPHYSEMA Choong et al JTCVS 2006

18. Airway Bypass Results Cardoso etAl AATS 2006 • 33 patients; July 2004 - March 2005 • 18 males, 15 females; 45-81years (61years) • 4 excluded (technical reasons) • 1 death related (bleeding into the airway) • 3% of patients treated (0.3% all passages made) • 28 patients treated successfully • 242 stents placed (average 8 per patient) • 26 patients w/ 6-month follow-up data • 11 (42%) severe hyperinflation (TLC ≥ 133%)

19. * * *p<0.05 * * Airway Bypass Results Cardoso etAl AATS 2006 • Residual Volume (L)

20. BRONCHOSCOPIC LVRHistorical Notes • Occlusive stents • Synthetic sealants • One – way valves

21. BRONCHOSCOPIC LVREndobronchial Devices • SPIRATION: Umbrella • EMPHASYS: One – way valve

22. BRONCHOSCOPIC LVRSpiration Umbrella

24. BRONCHOSCOPIC LVRStudy Protocol • INCLUSION CRITERIA • Heterogeneous emphysema • FEV1 < 35 % • RV > 180 % • Age between 40 and 75 y • EXCLUSION CRITERIA • Homogeneous emphysema • Currently smoking • Isolated bulla • PaCO2 > 50 mmHg • DLCO < 20 % • Active infection • Productive cough • Small airway disease

25. BRONCHOSCOPIC LVRClinical study • 13 patients with heterogeneous emphysema • Mean age 56 ± 13 years • Pre-op. mean FEV1 0.8 ± 0.4 L • Pre-op mean RV 5.3 ± 0.9 L • 11 unilateral treatments • 2 staged bilateral treatments

26. BRONCHOSCOPIC LVRPreoperative Data Suppl. O2 (L/m) 1.4 ± 0.9 Sat O2(%) 93 ± 2.7 PaO2 (mmHg) 77 ± 12 PaCO2 (mmHg) 41 ± 6 FEV1 (L/s) 0.8 ± 0.4 26 ± 9 % FVC (L) 1.9 ± 0.5 48 ± 9 % DLCO 33 ± 12 % TLC (L) 7.7 ± 1.3 118 ± 14 % RV (L) 5.3 ± 0.9 241 ± 41 % ITGV (L) 6 ± 1 167 ± 35 % 6 min WT(m) 274 ± 113 MRC 3 ± 1.6

27. BRONCHOSCOPICLUNG VOLUME REDUCTION

28. BRONCHOSCOPIC LUNG VOLUME REDUCTION

29. BRONCHOSCOPICLUNG VOLUME REDUCTION POST - OP PRE - OP

30. BRONCHOSCOPIC LVRComplications 6 Complications in 3 Patients • Contralateral pneumothorax 1 • Bilateral pneumothorax 2 • Pneumonia 1 • Diffuse bronchospasm 2

31. BRONCHOSCOPIC LVRFunctional Results

32. BRONCHOSCOPIC LVRFunctional Results

33. BRONCHOSCOPIC LVRSO2 requirement (L/min) L/min p= 0,001 13* 5* 5* * Pts with O2 requirement

34. BRONCHOSCOPIC LVR

35. BRONCHOSCOPIC LVR

38. Target for treatment left upper lobe

39. pre treatment main fissure main fissure diaphragm day 1 diaphragm day 4

40. Post treatment(valves in B4+5, B1+2 and B3) day 4 Pre treatment

41. Post treatment day 4 Pre treatment

42. Left upper lobe Left lower lobe pre treatment day 4

43. pre treatment day 1

44. One-Way Endobronchial ValvesClinical Study Treatments 22 Right/Left 13/9 Valves 92 Valv./Treat. 3.93 Valv./Pz 4.2 (range 3 - 8) Oper. time(min) 45 ± 22 NO COMPLICATIONS Right Upper 8 (40 %) Right Upper + Middle 2 (7 %) Right Lower 3 (20 %) Left Upper 7 (30 %) Left Lower 2 (13 %)

45. Broncoscopic LVRFunctional Results

46. Broncoscopic LVRFunctional Results

47. fissure A 30 gg VOLUME REDUCTION OF THE TREATED LOBE post PRE

48. One-Way Endobronchial Valves Multicentric Study 12/2004 - 2006 • 31 Centers • 321 patients enrolled • 101 medical therapy vs. 220 treated • 193 pts treated at 6 months • 93 pts not treated at 6 months

49. Bronchoscopic Lung Volume Reduction • Complete Lobar exclusion • Complete Fissures

50. SURGERY FOR EMPHYSEMAConclusions • Experimental bronchoscopic techniques show promising results • Potential association of different bronchoscopic techniques • Devices seem dependable • Randomized trials