Endoscopic bronchial valve treatment: patient selection and special considerations

Figures & data

Figure 1 High-resolution computed tomography prior to (A) and after (B) endoscopic valve placement leading to a complete atelectasis in the left upper lobe. The arrow shows an implanted endobronchial valve.

Figure 2 Different types of bronchial valves.

Notes: (A and B) Right – endobronchial valves (Zephyr^®, Redwood City, CA, USA) have been placed in the left lower lobe. Left – intrabronchial valves in the left upper lobe (Spiration^®, Olympus, Tokyo, Japan).

Figure 3 Recommended algorithm for patient selection depending on emphysema distribution as well as on the presence or absence of collateral ventilation.

Abbreviations: FEV₁, forced expiratory volume in 1 second; RV, residual volume; EBV, endobronchial valve; IBV, intrabronchial valve; LVRC, lung volume reduction coil; LVRS, lung volume reduction surgery; BTVA, bronchoscopic thermal vapor ablation; PLVR, polymeric lung volume reduction.

Figure 4 High-resolution computed tomography of a patient with severe emphysema showing an incomplete fissure (↑) on the right and a complete fissure on the left.

Figure 5 Assessment of collateral ventilation using Chartis system (Pulmonx Corp., Redwood City, CA, USA).

Notes: (A) No reduction in flow F(mL/min); orange lines visualized indicating presence of collateral ventilation and incomplete fissure in the right upper lobe. The blue lines show the changes in intralobar pressure P(cmH20) during spontaneous respiration. (B) A reduction in flow (orange lines) can be seen in the left upper lobe over a time period of more than 5 minutes, while the breathing effort (blue lines) does not change. This indicates no collateral ventilation and complete fissure in the left lung making valve placement possible.
Abbreviations: P, pressure; F, flow.

Figure 6 Automated software analysis for fissure integrity and emphysema severity and distribution using Apollo™ software (Vida Diagnostics, Inc., Minneapolis, MN, USA).

Notes: (A) Fissure analysis showing in blue fissure integrity of the right upper lobe of 87% and on the left of 94%. The green areas represent small fissure defects. (B) Lung volume responder with predominant lower lobe disease. The low attenuation cluster (LAC) map is a representation of the overall distribution of emphysema in the different lobes (RUL, red; RML, purple; RLL, yellow; LUL, green; LLL, blue). Each sphere is the aggregate of connected low attenuation areas defined by using the −950 HU threshold, and its size is proportional to the size of connected low density areas. The surface rendering representation provides a visual indication of the lobar volume reduction effect of the treatment, in particular for the target and ipsilateral lobes. Emphysema percentage in the LLL as expressed by the low attenuation area percentage was LAA%−950=53.7%, with a heterogeneity score of 15.4%. The follow-up scan 1 month after the endobronchial valve therapy of the left lower lobe shows a complete atelectasis of the treated lobe (reduction in lobar volume of 2,120.1 cm³) and an expansion of the ipsilateral lobe.
Abbreviations: FLL, fissure left lung; FRUL, fissure right upper lobe; LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.