Endoscopic Lung Volume Reduction: Can Endobronchial Valves Be Safely Removed?

Abstract

Endoscopic lung volume reduction (ELVR) with endobronchial valves (EBV) has been shown to improve pulmonary function, quality of life, and exercise capacity in a wide range of COPD patients [1-5]. Nevertheless, some patients show severe complications after valve insertion or cannot sufficiently benefit from ELVR. In those patients, reversibility of ELVR with EBV is an important advantage compared to other techniques of lung volume reduction. Nevertheless, data supporting valve removal as being a safe procedure are still lacking.To answer the question, we retrospectively analyzed patient files of 212 severe COPD patients treated with EBV between October 2011 and July 2015 in three experienced emphysema centers in Germany (Charité Universitätsmedizin Berlin, Hospital Havelhöhe Berlin, University Hospital Bonn).Out of 212 patients treated with ELVR, 74 subsequently had the valves removed (Table 1). The major cause for early valve removal was pneumothorax (n = 12, 5.6%). Out of the 12 pneumothorax cases, 8 occurred within the first week after valve insertion. Other indications for valve removal were lack of clinical improvement (n = 30, 14.1%), recurrent exacerbations or pneumonia (n = 30, 14.1%), recurrent hemoptysis (n = 1, 0.5%), and uncontrolled dry coughing (n = 1, 0.5%). Lack of clinical improvement as well as pulmonary infection were the most frequent indications for late valve removal.All removals comprising on average 3.7 ± 1.3 valves per patient treated in the RUL (n = 14), RLL (n = 15), LUL (n = 17), and LLL (n = 28) were complete and successful. In 12 patients, valves were removed in an outpatient, in 62 patients in an inpatient setting. The hospital stay was 8.4 ± 10.9 days. The valve removal was performed in one (n = 53), two (n = 20), or in a maximum of three (n = 1) bronchoscopic sessions. Almost all valves were removed with a flexible bronchoscope (n = 73) using an air tube (n = 62; 7,5 Bronchoflex®, Rüsch, Germany) to keep the upper airways open. The time point for valve removal was on average 360 ± 356 (range 1–1,306) days after the insertion. The complications following valve removal were COPD exacerbations (n = 24; 32.4%) within 48 h after the procedure and postprocedural pneumonia (n = 11, 14.9%). Exacerbations could be well controlled by administering systemic steroids. Postprocedural pneumonia could be likewise controlled with additional antibiotics.Nine patients (12.1%) presented a mild bronchoscopic bleeding not requiring any intervention. One death was recorded within 7 days after valve removal: a patient developed a cardiac arrest after 48 h due to a pneumothorax with air leak, which was the indication of valve removal. The removal procedure was without complications, and we think that the patient died irrespective of the removal procedure. Another patient who already received noninvasive ventilation for chronic respiratory failure before valve implantation showed increasing rate of dynamic hyperinflation with hypercapnia requiring longer intervals of noninvasive ventilation after valve removal. There were no other severe complications, such as pneumothorax or severe bleeding related to the valve removal procedure.In summary, these data suggest that valve removal is a safe and easy procedure. Considering the high percentage of valve removals in our study cohort, the reversibility of ELVR is an important advantage compared to other techniques of lung volume reduction. Because of the potential for postprocedural exacerbations, pneumonias, and bleedings, we recommend close observation of the patient for several days after EBV removal.All study participants provided informed consent, and the study was approved by the appropriate ethics review board.R.-H.H., C.G., and D.S. received fees for lectures, consulting, and research support to the institution from PulmonX. The other authors have not conflicts of interest to declare. PulmonX was not involved at any stage during the study.No funding.All authors recruited patients, had complete access to the data, and reviewed and approved the manuscript.

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