Revision Bronchoscopy After Endobronchial Valve Treatment for Emphysema: Indications, Findings and Outcomes

Figures & data

Table 1 Patient Characteristics Prior to Endobronchial Valve Treatment

	Total Cohort (n=179)		No Granulation Tissue (n=140)		Granulation Tissue (n=39)		p-value
	n	Value	n	Value	n	Value
Sex (% female)	179	73%	140	71	39	77	0.55
Age (years)	179	63 ± 8	140	63 ± 8	39	62 ± 8	0.51
BMI (kg/m^2)	179	24 ± 4	140	24 ± 4	39	24 ± 4	0.29
Smoking history (pack-years)	178	43 ± 24	139	44 ± 25	39	42 ± 20	0.61
FEV1 (% of predicted)	179	27 ± 10	140	26 ± 9	39	28 ± 11	0.18
FVC (% of predicted)	179	70 ± 25	140	68 ± 24	39	74 ± 27	0.20
RV (% of predicted)	177	238 ± 58	138	237 ± 54	39	241 ± 71	0.73
TLC (% of predicted)	177	137 ± 14	138	136 ± 15	39	140 ± 13	0.18
Distance on 6-minute walking test (m)	179	316 ± 98	139	312 ± 99	39	329 ± 93	0.34
SGRQ, total score (points)	173	58.7 ± 12.1	136	58.9 ± 12.3	37	58.0 ± 11.2	0.71
mMRC (points)	174	2.7 ± 0.6	136	2.8 ± 0.7	38	2.6 ± 0.5	0.06
CAT (points)	170	22.3 ± 5.2	133	22.5 ± 5.3	37	21.4 ± 4.6	0.25
Target lobe volume (mL)	178	1846 ± 579	140	1787 ± 563	38	2064 ± 590	0.01
Pathogenic bacteria (% present)	175	27%	136	26%	39	31%	0.64
Aspergillus species (% present)	175	14%	136	13%	39	18%	0.44
Bronchitis Index Score of the target lobe^Citation26	104	5.9 ± 2.8	78	6.1 ± 3.0	26	5.2 ± 2.1	0.18
Bronchitis score SGRQ^a	172	4.6 ± 2.4	135	4.6 ± 2.4	37	4.9 ± 2.3	0.46
Bronchitis score CAT^b	170	3.5 ± 2.1	133	3.6 ± 2.1	37	3.2 ± 2.0	0.36

Notes: ^aTotal score of part 1, question 1 and 2 of the SGRQ. Lower scores indicate more symptoms. ^bTotal score of question 1 and 2 of the CAT. Higher scores indicate more symptoms.

Abbreviations: BMI, body mass index; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; RV, residual volume; TLC, total lung capacity; SGRQ, St George’s Respiratory Questionnaire; MMRC, modified Medical Research Council; CAT, COPD assessment test.

Figure 1 Study flow chart.

Figure 2 Time to first revision bronchoscopy. Reverse Kaplan–Meier curve of cumulative percentage of patients who underwent a revision bronchoscopy against time from initial treatment for all patients (N=179). Patients are censored because of reaching maximum follow-up without undergoing a revision bronchoscopy or because of death without a previous revision bronchoscopy.

Table 2 Indication for Revision Bronchoscopy with Corresponding Endoscopic Diagnosis

		Total	Indication for Revision Bronchoscopy
			Loss of Initial Treatment Effect	Lack of Treatment Benefit	Hemoptysis	Hypoxemia	Persistent Cough	Valve Expectoration	Obstruction Pneumonia
Endoscopic diagnosis	Granulation tissue	39 (53%)	21	9	8	1^a	-	-	-
	Clinical significant secretions	8 (11%)	3	2	-	-	1	-	2
	Valve migration	5 (7%)	3	1	-	-	1	-	-
	Possible collateral ventilation	5 (7%)	-	5	-	-	-	-	-
	Missing valve	4 (5%)	-	1	-	-	-	3	-
	Valve size mismatch	4 (5%)	3	1	-	-	-	-	-
	No abnormality	4 (5%)	-	3	1	-	-	-	-
	Untreated subsegment	3 (4%)	2	1	-	-	-	-	-
	Airway kinking	2 (3%)	-	-	-	1	1	-	-

Note: ^aGranulation tissue was thought to be an incidental finding and not the cause for the hypoxemia.

Figure 3 Endoscopic images of implanted valves in one patient. (A) Directly after implantation. (B) During revision bronchoscopy performed due to a loss of initial treatment effect. Granulation tissue has formed around the valves causing dislocation of the lower valve.

Figure 4 Overview of revision bronchoscopies (n=74). (A) Established diagnosis during revision bronchoscopy. (B) Interventions performed during revision bronchoscopy.

Table 3 Changes in Pulmonary Function Test Outcomes in Patients Undergoing a Revision Bronchoscopy for Either No Effect of Treatment or Loss of the Initial Treatment Effect and in Whom Valves Were Retained During the Revision Bronchoscopy

Δ Best After Initial Treatment – Baseline				Δ Last Before Revision – Baseline				Δ Best After Revision – Baseline
N	FEV1 (mL)	N	RV (mL)	N	FEV1 (mL)	N	RV (mL)	N	FEV1 (mL)	N	RV (mL)
38 (100%)	+175 (−20 – 600)	34 (89%)	−685 (−2370 – 450)	38 (100%)	+40 (−150 – 460)	35 (92%)	−130 (−3340 – 570)	30 (79%)	+120 (−210 – 550)	28 (74%)	−495 (−2730 – 1120)

Abbreviations: FEV₁, forced expiratory volume in 1 second; RV, residual volume.

Thompson AB, Huerta G, Robbins RA, et al. The bronchitis index. Chest. 1993;103(5):1482–1488. doi:10.1378/chest.103.5.1482

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