So, it has been a little while since my last blog post. I have been focusing on other issues, specifically my love for writing and recording music. If interested there is a link on my website that takes you to my most recent music project. Anyway, I recently got involved in a Facebook support group page for patients with COPD and emphysema and endobronchial valve treatment for severe emphysema. The Facebook page is called Lung Valves for Friends if interested. Very quickly I received a great deal of support and interest from people all across the nation.
Several years ago, we used to do surgery for lung volume reduction in patients that have predominantly upper lobe significant bullous emphysema in hopes that reducing the air trapping and the abnormal lung and allowing the more normal lower part of the lung more "space to breathe". It was a pretty invasive surgical procedure requiring a big incision, long surgery and prolonged recovery time. Unfortunately, patients had a lot of complications from the surgery itself and difficulty recovering that we have essentially abandoned lung volume reduction major surgical procedures. We have tried many other things including coiling and vapor etc. Recently endobronchial valves have been successfully used for treatment of severe emphysema. I am happy to say that we now have FDA approval for use of endobronchial valves for patients with severe COPD and emphysema. I am even happier to be able to say that endobronchial valve treatment has been listed as receiving Grade-A recommendation from the Global Initiative for Chronic Obstructive Disease (GOLD). They went as far as saying it should be considered as possible standard of care for eligible patients.
The concept of endobronchial valve treatment is simple. The patient receives medicines for sedation and comfort and a bronchoscope is passed through the airway to treat the abnormal emphysematous lung. Using small balloons for sizing it is determined what size is the appropriate valve to place in the airways. On average patient has 4-6 valves placed for treatment. These valves allow air and secretions to escape the emphysematous abnormal lung but block air from getting into the abnormal portion of the lung thereby directing air to the more normal, non-emphysematous lung. Over time, the abnormal emphysematous lung will shrink allowing more space for the non-emphysematous lung to expand and improve functional status.
There are currently 2 different valves available for treatment. The Spiration Valve by Olympus and the Zephyr valve produced by Pulmonx. There are subtle differences between the two but they essentially do the same thing and equally effective. I personally used the Spiration Valves for my patients. I started out using these for treatment of persistent pneumothorax in patients with persistent chest tube leak in order to be able to get the chest tube out and the patient on the hospital. With my comfort level with the valve used that way prior to its FDA approval for treatment of emphysema it was natural that I would lean in that direction. I also particularly like that the Spiration Valve has a dedicated arm that makes it easy to remove later down the line if there are any particular complications requiring manipulation of the valve at a later date. Other than that, there is really not much difference between the 2 valves.
Usually
, it takes time for the treated lobe to shrink down allowing the more normal lung to expand so clinical improvement occurs over several months. If the lung traps too much air in the abnormal lung there is a chance for bleb rupture but that usually not a problem because the valves prevent air from getting into those airways and it is not usually the treated portion of the lung in which there is a concern. Instead, the more normal lung that expands can sometimes expand too quickly and if it has a component of emphysema those weakened airway distal tissues can rupture causing a pneumothorax. The greatest risk for this complication is within the first 48 hours post procedure. For this reason, I always tell my patients to plan for admission after the procedure to the hospital and expect to stay for a minimum of 3 days. I usually reduce their level of activity for 2 days and in the first 24 hours especially. I use nebulized medications and cough suppressants to reduce this risk as well. Some patients treated with the valves have reported immediate relief with less shortness of breath and overall improved breathing but it is difficult to say how much of that initial feeling is placebo effect. It is more expected to show improvement in quality of life and ability to perform daily life tasks in several weeks.
There certainly are risks associated with the procedure and risk vs benefit clear discussions with their doctor is something that anyone considering this would want to have. Predominantly risks are in relation to anesthesia required for the case, pneumothorax and bleeding. This can be done in endoscopy under monitored anesthesia or under general anesthesia in the operating room. Decision regarding anesthesia and location of procedure is on a case by case basis depending on the individual patient’s needs. The likelihood of these risks is not terribly high but not trivial either so talk to your doctor.
Endobronchial valve treatment for severe COPD and emphysema has long been awaited. The valves have been used for several years now for treatment of non-resolving pneumothoraces here in the United States but has been used for emphysema treatment in Europe for many years with significant success and clear evidence of safety. I am very hopeful for this treatment to be able to change the game for many of my patients with severe COPD and emphysema. The GOLD Grade-A recommended guidance is an important achievement in advancing insurance coverage of this procedure for patients.
