An expert statement published in Respiration updates best practice recommendations regarding patient selection and use of the most appropriate endoscopic lung volume reduction (ELVR) techniques for the treatment of advanced emphysema.
The use of ELVR procedures in patients with advanced emphysema has been increasing over the past several months, with the goal being to improve respiratory mechanics and alleviate chronic dyspnea.
Baseline assessment of appropriate candidates for ELVR should include cardiac evaluation, high-resolution computed tomography scans and perfusion scintigraphy, full pulmonary function tests, and cardiopulmonary exercise testing. Efficacy of ELVR procedures is based on use of an appropriate diagnostic and treatment algorithm for identification of ideal candidates for each of the different ELVR technologies.
In 2016, an expert panel published a possible treatment algorithm for ELVR, in accordance with peer-reviewed evidence. A number of randomized controlled trials have been published since then that modify the treatment decisions outlined in the 2016 Expert Panel Report. The use of bronchoscopic lung volume reduction techniques has now been incorporated into the 2017 update.
Patients who are potential candidates for endoscopic interventions comprise those who remain highly symptomatic despite receiving optimal medical treatment, including maximal doses of bronchodilator therapy, inhaled corticosteroids, and occasional maintenance of systemic therapies. In addition, patients need to have completed pulmonary rehabilitation and/or currently be participating in a structured physical therapy program. A key contraindication among patients is active smoking.
The ELVR technologies being evaluated include endobronchial valves, nitinol coils, and bronchoscopic thermal vapor ablation. Clinical trials are ongoing for all ELVR methodologies. Clinical experience should focus on the early phases involved in introduction of the various therapies. According to the panel, patients need to be treated in expert, high-volume facilities that participate in clinical trials and registries that include all types of treatment.
Herth FJF, Slebos DJ, Criner GJ, Shah PL. Endoscopic lung volume reduction: an expert panel recommendation – update 2017 [published online August 18, 2017]. Respiration. doi:10.1159/000479379