Emerging therapies for COPD: Bronchoscopic treatment of emphysema
- Michael S Machuzak, MD
Michael S Machuzak, MD
- Department of Pulmonary, Allergy and Critical Care Medicine
- Cleveland Clinic
- Thomas R Gildea, MD, MS
Thomas R Gildea, MD, MS
- Department of Pulmonary, Allergy and Critical Care Medicine and Transplant Center
- Cleveland Clinic
Emphysema is a form of chronic obstructive pulmonary disease (COPD) that is defined by abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles and is associated with destruction of the alveolar walls. The destruction of alveolar walls causes loss of elastic recoil, early airway closure during exhalation, and air trapping in the distal air spaces. Alveolar wall destruction with formation of emphysematous blebs and bullae leads to loss of gas exchanging surface (also known as increased physiologic dead space). In addition, air trapping and hyperinflation press the diaphragm into a flat configuration, rather than its normal domed shape, and place all the muscles of respiration at a mechanical overstretch disadvantage. In combination, these processes lead to refractory dyspnea.
Lung volume reduction surgery (LVRS, also called reduction pneumoplasty or bilateral pneumectomy) is a surgical treatment for patients with advanced emphysema whose dyspnea is poorly controlled with the usual therapies (eg, short and long acting bronchodilators, inhaled glucocorticoids, supplemental oxygen, and pulmonary rehabilitation) . LVRS entails reducing the lung volume by wedge excisions of emphysematous tissue. However, surgical morbidity is high and non-pulmonary comorbidities may preclude surgery.
Bronchoscopic lung volume reduction (bLVR) refers to techniques developed to treat hyperinflation due to emphysema via a flexible bronchoscope.
The devices and techniques for bLVR will be reviewed here. The general management of COPD, an overview of flexible bronchoscopy, and the roles of lung volume reduction surgery, bullectomy, and lung transplantation in the management of advanced COPD are discussed separately. (See "Management of stable chronic obstructive pulmonary disease" and "Flexible bronchoscopy in adults: Overview" and "Lung volume reduction surgery in COPD" and "Lung transplantation: General guidelines for recipient selection".)
RATIONALE FOR LUNG VOLUME REDUCTION
The mechanisms by which lung volume reduction might provide benefit in patients with emphysema are not known with certainty. However, it is believed that the removal of diseased, hyperinflated areas of lung would have the following benefits:
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