Severe Emphysema treatment
RB&HH Consultants offer the very latest in treatment options to help patients suffering from chronic emphysema find the solution that best suits them.
Emphysema is a long-term progressive disease of the lungs that causes difficulty in breathing. It is included in a group of diseases called chronic obstructive pulmonary disease, or COPD. In emphysema, there is damage to the lung tissue which can lead to the lungs becoming over inflated. Common symptoms of emphysema are difficulty breathing, coughing, fatigue and weight loss.
Treatment may include pulmonary rehabilitation advice (guidance on smoking cessation, patient and carer education, exercise training and breathing retraining) and use of inhaled or oral bronchodilators and glucocorticoids. In advanced disease, lung volume reduction surgery or lung transplantation may be indicated; however recent advancements in treatment of emphysema have brought to the forefront minimally invasive alternatives to thoracic surgery.
The endobronchial valve is an implantable device designed to obstruct bronchi in diseased regions of the lung and to allow for the expiration of air from the treated lobe of the lung. When used for the appropriate patients Endobronchial valves reduce hyperinflation which manifests in clinical improvement.
During the insertion of endobronchial valves, a small flexible camera is moved down the windpipe and small one way valves are inserted into elected airways (3 or 4 valves are usually inserted). The valve is designed to prevent air inflow during inspiration but to allow air and mucus to exit during expiration. The aim of the procedure is to prevent air entering the diseased parts of the lung which then collapse.
Before the procedure, it is usual practice to assess the presence of collateral ventilation (when air enters a lobe of the lung through a passage that bypasses the normal airways). A surrogate for this is CT scanning to assess the completeness of fissures. A functional approach, specially developed for use before insertion of airway valves, involves a specially designed balloon catheter with a flow sensor.
Insertion of endobronchial valves is done with the patient under sedation or general anaesthesia. Using a delivery catheter passed through a bronchoscope, a synthetic valve is placed in the target location and fixed to the bronchial wall. Patients may sometimes be given antibiotics and/or steroids after the procedure. A successful procedure has been shown to improve patient survival as well as symptoms.
Lung volume Reduction Coils
Early this year a new innovative service was launched at the Royal Brompton and Harefield Hospitals in London, to treat severe emphysema patients. Lung volume reduction coils are implanted into the diseased parts of the patient’s lung during a minimally invasive procedure, typically taking only 30–45 minutes per procedure. Treatment involves two separate procedures, for each lung, 4–6 weeks apart. This treatment helps to reduce over-inflation of the lungs in severe emphysema patients, resulting in a reduction in difficult or laboured breathing.
During the procedure PneumRx® coils are used, which are made of a shapememory material called Nitinol, common in medical implants such as heart stents. The PneumRx® coils are implanted into the airways via a catheter, and once in place are designed to gently regain their shape, gathering up loose, inelastic lung tissue and holding open surrounding airways. Ten or more coils are placed at each procedure to tighten the entire airway network and achieve the optimal effects.
The coils improve a patient’s lung function in three ways. Firstly, they compress diseased tissue, which provides room for healthier tissue to function; secondly, they re-tension portions of the lung involved in gas transfer, helping to increase the lung’s elasticity, which may enable the lung to more efficiently contract during the breathing cycle; finally, the coil tethers open small airways, preventing airway collapse during exhalation.
Lung Volume Reduction surgery (LVRS)
LVRS is an operation which removes the worst affected areas of the lung so that the healthier parts of the lung can work better. Also, by removing the ‘swollen’ air spaces, less air is trapped so the chest and diaphragm can relax down to a more normal level and breathing is more comfortable.
A surgeon will make a cut in one side of the chest to use a special tool to cut and staple the lung at the same time. This will seal it and prevent or reduce any air leaks. Patients will be given a general anaesthetic and will stay in hospital for about 7–10 days to recover.
Lung volume reduction surgery can help patients live longer, increase ability to exercise and improve quality of life, compared with people who don’t have the operation.
This is a significant operation and it does carry a risk of complications that could be life-threatening. This is why people will only be selected as suitable for this operation if they meet certain criteria. It can also mean a long stay in hospital to recover from the operation.
LVRS is only a suitable treatment for a minority of people who have COPD. It is only effective for emphysema and you may not be suitable if you have other lung conditions such as bronchiectasis and asthma.
This may be offered if:
- The patient has a particular pattern of emphysema, and
- The patient has a suitable pattern of lung function, and
- The patient is well enough to cope with the operation.
To assess a patient’s suitability for emphysema treatment, the following will be arranged:
- A CT scan, which is a special X-ray to get a picture of a cross-section of your body.
- lung function tests to measure
- How good the lungs are taking in oxygen
- How much air is left in the lungs after a maxiumum breath in and out
- A test to measure the ability to exercise. If the patient is unable to walk 140 metres in six minutes, it may not be safe to go ahead with the operation.
- A lung perfusion scan sometimes called a VQ scan may also be arranged. The scan works by injecting the patient with a special material that shows up areas of the lung that do not have much blood supply when they are scanned. These areas are not helping your breathing, so the test will help to decide when to operate.
Dr Samuel Kemp
Consultant Respiratory Physician
Professor Pallav Shah
Consultant in Respiratory Medicine
Mr Simon Jordan
Consultant Thoracic Surgeon