CASE REPORT

The Clinical Respiratory Journal

Bronchoscopic bullectomy with a one-way endobronchial valve to treat a giant bulla in an emphysematic lung: a case report Gang Hou, Wei Wang, Qiu-yue Wang and Jian Kang Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, China

Abstract The conventional treatment for giant bullae in patients with chronic obstructive pulmonary disease is surgical bullectomy, but it is not possible in some patients with poor lung function. Bronchoscopic bullectomy involving implantation of an endobronchial valve (EBV) has emerged as a potential alternative. Here we describe how EBV implantation in a bullous emphysema with a giant bulla in the right middle lobe led to elimination of the bulla and improvements in pulmonary function, 6-min walking distance during the 1-year follow-up. Our case suggests that bronchoscopic bullectomy with an EBV can be a safe and effective alternative to surgical bullectomy. Please cite this paper as: Hou G, Wang W, Wang Q-y and Kang J. Bronchoscopic bullectomy with a one-way endobronchial valve to treat a giant bulla in an emphysematic lung: a case report. Clin Respir J 2015; ••: ••–••. DOI:10.1111/ crj.12257.

Key words bronchoscopic lung volume reduction – bullectomy – chronic obstructive pulmonary disease – emphysema – endobronchial valve Correspondence Jian Kang, MD, Department of Respiratory Medicine, The First Hospital of China Medical University, No. 155 Nanjing North Street, Shenyang City, 110001 Liaoning Province, China. Tel: +86 24 83282019 Fax: +86 24 83282002 email: [email protected] Received: 01 July 2014 Revision requested: 19 October 2014 Accepted: 07 December 2014 DOI:10.1111/crj.12257 Authorship and contributorship Gang Hou performed patient selection, bronchoscopic bullectomy and wrote the manuscript. Wei Wang helped to follow up the patient and to collect data. Qiu-yue Wang helped with patient selection, evaluation and writing the manuscript. Jian Kang contributed to the analyses and interpretation of the data. Ethics The patient gave written informed consent. It was approved by the Institutional Ethical Review Board of The First Hospital, China Medical University, Shenyang, China. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.

Introduction The defining pathology of chronic obstructive pulmonary disease (COPD) is emphysema and bronchitis. In fact, COPD can be subdivided according to the type of emphysema and bronchitis. Emphysema causes lung tissue hyperinflation, reducing its stretchiness and

The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd

decreasing diaphragm activity, ultimately leading to dyspnea. These pathological effects usually respond poorly to drug therapy (1). One complication of emphysema are air pockets (bullae) that develop in the lung and can grow quite large (becoming so-called giant bullae), preventing the lung tissue from expanding properly.

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Bronchoscopic bullectomy with endobronchial valve

The first choice for treating COPD patients with a giant bulla is surgical bullectomy. However, COPD patients whose forced expiratory volume in the first second (FEV1) are less than 40% of predicted or less than 500 mL are poor candidates for surgery because of high operative risk and mortality ranging between 7% and 12.5% (2). Bronchoscopic lung volume reduction (BLVR) using an endobronchial valve (EBV) has emerged as an alternative to surgery lung volume reduction. This technique has already been used in COPD patients with heterogeneous emphysema and has been reported to relieve the ‘restrictive’ effects of hyperexpansion, improving lung function and endurance during exercise (3). Despite the promise of this approach, few studies have explored the safety and efficacy of EBV in bronchoscopic bullectomy (4, 5). Here we report, for the first time to our knowledge, the successful application of bronchoscopic bullectomy with EBV to treat a bullous emphysema with a giant bulla in the right middle lobe. We describe the preoperative evaluations that led us to conclude that this technique was suitable for the patient, and we discuss the efficacy and safety of the procedure over a 1-year follow up.

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Case report A 65-year-old Chinese female COPD patient was admitted to our hospital in March 2012. She presented with a 20-year history of chronic cough and progressive dyspnea; she had a smoking history of 15 packyears. She had been taking salmeterol/fluticasone (50/ 500 μg) twice daily for 1 year. Pulmonary function tests conducted in June 2012 showed the following lung function parameters: a ratio of FEV1 to forced vital capacity of 37%; FEV1, 0.74 L; percent of predicted FEV1 (FEV1%pred), 36%; residual volume (RV), 3.54 L; measured RV as a percent of the predicted value, 182%; total lung capacity (TLC), 5.72 L; measured TLC as a percent of the predicted value, 120%; 6-min walking distance (6MWD), 230 m; and Saint George respiratory questionnaire (SGRQ) score, 64. Analysis of blood gases (ABG) indicated a pH of 7.44; PaO2, 65.3 mmHg; and PaCO2, 44.2 mmHg. High-resolution computed tomography (CT) indicated panlobular emphysema in both lungs with a severe destruction of right middle lobe with a presence of a giant bulla, which had grown slightly since November 2011 based on follow ups of CT scans (Fig. 1A, B). The adjacent lung parenchyma is compressed. The maximum dimensions of the bulla were 12.7 × 10.1 cm

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Figure 1. (A) Chest computed tomography (CT) scan (15 months before the bronchoscopic bullectomy) indicated panlobular emphysema in both lungs with a severe destruction of right middle lobe with a presence of a giant bulla. (B) Chest CT scan (3 days before the bronchoscopic bullectomy) indicated that the giant bulla in the middle lobe had progressed slowly compared with Fig. 1A. (C and D) Chest high-resolution CT (3 months after bronchoscopic bullectomy) showed shrinking and disappearance of the giant bulla in the middle lobe and re-expansion of adjacent lobes.

The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd

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Bronchoscopic bullectomy with endobronchial valve

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Figure 2. (A and C) The perfusion image of the ventilationperfusion scanning. The right middle lobe was not well perfused presenting as the sparse displaying of the 99mTc-MAA. (B and D) The ventilation image of ventilation-perfusion scanning. The right middle lobe was also not well ventilated, but the retention of the inhaled radiotracer could be seen in the bulla (region of the retention of the inhaled radiotracer was showed by the hollow arrow), which indicated that the bulla was fed by bronchus.

in horizontal section. A ventilation-perfusion scanning showed retention of the inhaled radiotracer in the bulla (Fig. 2). The patient refused surgical bullectomy because of the risk, so we decided to try bronchoscopic bullectomy with an EBV. At 30 min before bronchoscopy, we administered 0.5 mg atropine to minimize

bronchial secretion and 50 mg pethidine to reduce coughing. Bronchoscopy was performed using 25 mL lidocaine for local anesthesia and 2 mg midazolam for sedation. To improve our chances of detecting the bulla, we monitored collateral ventilation using the Chartis system (Pulmonx International SARL, 2034 Peseux, Switzerland). We blocked the right middle bronchus with a balloon catheter and measured expiratory airflow, and we did not detect collateral ventilation (Fig. 3). We verified that the target bronchus was within the size range of Zephyr EBVs (Pulmonx) using the sizing gauge located on the proximal end of the delivery housing. We selected the Zephyr EBV 5.5, the size of which ranges from 5.5 to 8.0 mm, and implanted it in the right middle bronchus. The patient was followed up 1 day after bronchoscopic bullectomy, and subsequently 1 month later, 3 months later and 1 year later. High-resolution CT at 1 month later showed disappearance of the bulla, atelectasis of the middle lobe and re-expansion of the lower lobe (Fig. 1C, D). Pulmonary function tests conducted 1 month after the procedure showed that FEV1 had increased to 0.80 L, 6MWD to 250 m and SGRQ score had decreased to 50. ABG indicated a pH of 7.42; PaO2, 68.8 mmHg; and PaCO2, 41.5 mmHg. The same test performed 3 months after the procedure showed that FEV1 had increased to 0.87 L and 6MWD to 275 m, while RV had decreased to 2.87 L; TLC, to 5.57 L; and SGRQ score, to 41. Six months after the procedure, the patient suffered an exacerbation of COPD due to respiratory tract infection; she was cured using antibiotics and corticosteroid treatment on an outpatient basis. At 12 months after the bullectomy, FEV1 was 0.86 L; RV, 2.89 L; TLC, 5.60 L; 6MWD, 300 m; and SGRQ score, 40. No complications, such as pneumonia postobstruction, pneumothorax or EBV migration were observed during the 1 year follow up.

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Figure 3. Chartis output while assessing the right middle lobe demonstrated a good expiratory flow signal that gradually decreased and reached zero in 2 min 3 s. It showed that the collateral ventilation of right middle lobe was negative.

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The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd

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Discussion BLVR involving implantation of a one-way EBV has already proven effective for patients with severe COPD involving heterogeneous emphysema (3). We show in this case report that bronchoscopic bullectomy involving implantation of a one-way EBV can also be effective for treating giant bullae. As with BLVR, patients should be carefully selected for EBV implantation in order to ensure bulla elimination and satisfactory clinical outcomes. In our case, we confirmed not only that there was no collateral ventilation between the target lobe and adjacent lobe, which can cause EBV treatment to fail. The Chartis system can detect collateral ventilation with high sensitivity and specificity, and it can accurately predict whether the significant target lung volume reduction will be reached (6, 7). High-resolution CT can help determine whether the bulla is supplied by the bronchus. In our case, we identified the bulla supplied by the bronchus by finding the progression of the size of the bulla on serial CT scans. If serial CT scans are unavailable, ventilation-perfusion analysis may indicate the bulla is fed by airway if the bulla is well ventilated. Our patient showed clinical improvement in FEV1, RV, SGRQ and 6MWD following EBV implantation. These findings are similar to those reported by Santini et al. with nine COPD patients with giant bullae in the upper or lower lobes after EBV bronchoscopic bullectomy (5). Although the bulla in our patient was located in the middle lobe, which is not common among patients selected for BLVR, we observed satisfactory clinical improvement. The patient showed striking improvement in pulmonary lung function parameters by 3 months after bronchoscopic bullectomy, and the improved parameters remained stable over a follow up of 1 year. Our results, together with those of Santini et al., suggest that EBV implantation is a valuable alternative to surgery for COPD patients with giant bullae.

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We speculate the pathophysiologic mechanism why patient condition improved so much after valve treatment including that: decompression of the adjacent lung parenchyma that these areas could be ventilated better, reduction of hyperinflation leading to a more efficient movement of diaphragm, improvement of dynamic lung compliance and improvement of imbalance between pulmonary ventilation and perfusion. This case report suggests that bronchoscopic bullectomy with EBV is a valuable alternative to surgical bullectomy for COPD patients with giant bullae. Future studies should evaluate the long-term efficacy and safety of this technique.

References 1. Lee JH, Lee YK, Kim EK, et al. Responses to inhaled long-acting beta-agonist and corticosteroid according to COPD subtype. Respir Med. 2010;104: 542–9. 2. Shah SS, Goldstraw P. Surgical treatment of bullous emphysema: experience with the Brompton technique. Ann Thorac Surg. 1994;58: 1452–6. 3. Sciurba FC, Ernst A, Herth FJ, et al. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med. 2010;363: 1233–44. 4. Noppen M, Tellings JC, Dekeukeleire T, Dieriks B, Hanon S, D’Haese J, Meysman M, Vincken W. Successful treatment of a giant emphysematous bulla by bronchoscopic placement of endobronchial valves. Chest. 2006;130: 1563–5. 5. Santini M, Fiorelli A, Vicidomini G, Di Crescenzo VG, Messina G, Laperuta P. Endobronchial treatment of giant emphysematous bullae with one-way valves: a new approach for surgically unfit patients. Eur J Cardiothorac Surg. 2011;40: 1425–31. 6. Mantri S, Macaraeg C, Shetty S, Aljuri N, Freitag L, Herth F, Eberhardt R, Ernst A. Technical advances: measurement of collateral flow in the lung with a dedicated endobronchial catheter system. J Bronchology Interv Pulmonol. 2009;16: 141–4. 7. Herth FJ, Eberhardt R, Gompelmann D, Ficker JH, Wagner M, Ek L, Schmidt B, Slebos DJ. Radiological and clinical outcomes of using Chartis (TM) to plan endobronchial valve treatment. Eur Respir J. 2013;41: 302–8.

The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2014 John Wiley & Sons Ltd

Bronchoscopic bullectomy with a one-way endobronchial valve to treat a giant bulla in an emphysematic lung: a case report.

The conventional treatment for giant bullae in patients with chronic obstructive pulmonary disease is surgical bullectomy, but it is not possible in s...
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