Valve Treatment of Emphysema Improves Breathlessness

Valve Treatment – A Minimally Invasive Approach For Emphysema

Background:  Emphysema is a type of COPD in which lung tissue is

Valve treatment can be used to reduce hyperinflation

On left: Normal size of lungs.
On right: lungs are larger due to inability to exhale completely. This is called hyperinflation.

destroyed. As a result, the person is unable to completely empty air out of the lungs.  This is called lung hyperinflation which is a major cause of shortness of breath and poor quality of life.

Surgery is one way to remove parts of the lung that are hyperinflated. However, this approach is seldom used because it is invasive and carries some risk.

A safer approach is to place valves into breathing tubes in areas of poorly functioning lungs. These one-way valves allow air to leave the lungs and prevent air entry; this reduces the amount of air trapped in the lung. The valves are placed using a tube (called a bronchoscope) that is passed into the mouth and then advanced into the breathing tubes.

Bronchoscopy used to assesss whether valve treatment is appropriate

Diagram of a scope passed into the mouth and then advanced into the lungs (called bronchoscopy)

Zephyr is a type used for valve treatment of emphysema

One type of endobronchial valve being evaluated is called Zephyr.

An endobronchial valve (called a Zephyr valve) is shown on the left. Until now, only two studies have been completed to evaluate this type of valve placed into breathing tubes. Each study was done at a single medical center. This makes it difficult to know if the results would be similar at other hospitals.

Study: A study evaluated placement of Zephyr endobronchial valves at 17 different medical centers in Europe. All patients had severe emphysema with no passage of air between parts of the lung (no collateral ventilation). The main outcome was the percentage of subjects with a 12% or higher increase in the amount of air exhaled in one second (FEV1) compared to before the procedure. The findings were published in the December 15, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (volume 196; pages 1535-1543).

Results: 65 subjects received placement of one or more valves while 32 subjects continued to receive normal care (the comparison group). At 3 months after valve placements, 55% improved their breathing tests by at least 12%, while only 7% in normal care group showed improvements. At 6 months after treatment, the valve group had an average increase in FEV1 of 21%, while there was 9% decrease in those who received normal care.

In addition, the valve treatment group had significantly better scores for shortness of breath and for quality of life and walked farther on the six minute walk test.

Lung collapse (called pneumothorax) occurred in 29% of those who received valve placement.

Conclusions: The authors concluded that valve treatment resulted in clinically meaningful benefits in lung function, shortness of breath, exercise tolerance, and quality of life. They also considered that there was “an acceptable safety profile.”

My Comments: The findings in this study provide additional support for the benefits of Zephyr valve placements to “deflate” the lungs in those with advanced emphysema. From the individual’s perspective, the most important outcomes were improved shortness of breath, ability to walk farther, and quality of life.

Identifying the “right” individual with emphysema who will benefit from valve placement is important. Before entering the study, all subjects had to qualify by having: 1. low breathing test results; 2. a CT scan of the chest which demonstrated evidence of emphysema that was at least 10% different between the “bad” part of the lung and an adjacent “good” part of the lung; and 3. no evidence of collateral ventilation using a special bronchoscopy test (see my post on December 27, 2015, for measuring collateral ventilation).

Rollators Increase Walking Distance and Reduce Breathlessness

Systematic Review of Rollators In Those With COPD

What Is A Rollator?  Walkers and rollators are equipment used to help people with mobility issues. A walker is usually built with aluminum supports and does not have wheels. The person has to lift the walker as he/she moves forward. In contrast, a rollator has wheels that does not require lifting.

The front wheels swivel to make turning in small spaces easy. It typically is

There are many types of rollators

3-wheel rollator

equipped with a padded seat and brakes. It is faster than a walker because of the wheels.

The rollator comes with either 3 or 4 wheels. The 3-wheel device is smaller and easier to maneuver than one with 4 wheels.

Study: Dr. A.L. Lee and colleagues from West Park Healthcare Centre in Toronto, Ontario, Canada, reviewed studies evaluating the effects of a rollator in those with COPD. Two reviewers assessed all published studies on the effects of rollator use compared to no aid in individuals with COPD. The article was published on-line in the Journal of Cardiopulmonary Rehabilitation and Prevention (November 8, 2017).

4-wheel rollator

4-wheel rollator with padded seat and hand brakes

Results: A total of seven studies were identified that involved 126 subjects. Use of a rollator increased the distance walked in 6-minutes by an average of 43 feet compared with walking without an aid and also lowered the shortness of breath rating at the end of the 6-minute walk by an average of one unit. However, longer term use did not impact exercise capacity or the person’s quality of life.

Conclusions: The authors concluded that when used in short-term, rollators improved walking distance with a reduction in breathing difficulty.

My Comments: A physical therapist typically evaluates individuals for use of a walker or rollator. Three standard tests are generally used to assess someone’s ability to perform basic physical activities: timed up-and-go; five times sit to stand; and assessment of gait and balance.

The timed up-and-go test is:  When I say “Go,” I want you to:
1. Stand up from the chair.
2. Walk to the line (10 feet away) on the floor at your normal pace.
3. Turn.
4. Walk back to the chair at your normal pace.
5. Sit down again.                                                                                                   The time to do this test is recorded with a stop watch.

If you have difficulty getting around due to weakness, recent falls, or struggle with balance, you should ask your health care professional about a rollator.

Maintenance Pulmonary Rehabilitation in COPD is Beneficial for Two Years

Maintenance Pulmonary Rehabilitation Increases Walking Distance

Background: Whether maintenance pulmonary rehabilitation programs help to sustain the short-term benefits is unclear.

Study: Researchers in Spain studied patients with COPD over 3 years after they completed a standard 8-week pulmonary rehabilitation program. Subjects were randomized (divided by chance) into two groups: those who received maintenance therapy and those in a control group (no maintenance).

Cycle ergometer for maintenance pulmonary rehabilitation

Cycle ergometer

What was the maintenance program?  Patients exercised at home three times a week doing: 15 minutes of chest physiotherapy; 30 minutes of lifting weights (which were bought by patients); and 30 minutes of riding a stationary cycle (provided by the hospitals). A physiotherapist called the patients every 15 days; during the alternate week, patients went to the hospital for a supervised training session.

Patients assigned to maintenance pulmonary rehabilitation did arm training with weights

Woman with COPD doing arm curls with hand weights.

What did the control group do? Patients in the control group were advised to exercise at home without any supervision. They were encouraged to walk or buy a stationary cycle for home use.

The study results were published in the March 1, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (pages 622-629).

Results: For the total of 138 patients, average age was 64 years, and the amount of air exhaled in one second (FEV1) was 34% predicted. There were 68 patients in the treatment group, and 70 in the control group. More than 50% of those who started the study failed to complete the 3 years. Main reasons for stopping were a COPD flare-up (exacerbation), other medical problems (called co-morbidities), and death.

Those in the treatment group improved significantly more than the control group for: 1. distance walked in 6 minutes and 2. the BODE index [B = body mass index (weight and height); O = FEV1; D = breathlessness; E = 6-minute walking distance]. However, there were no differences in health-related quality of life between the two groups.

Conclusions:  The authors concluded that the 3-year maintenance pulmonary rehabilitation program provided improvements in walking distance and the BODE index compared with usual care. These improvements lasted for 2-years; after that, there no longer was a beneficial effect.

My Comments: This study is notable because it has the longest follow-up period of any published randomized trial of maintenance pulmonary rehabilitation. The findings support the benefits of continued exercise following completion of a pulmonary rehabilitation program.

One limitation of the study is that it primarily involved men so that it cannot be assumed that women would experience the same benefits.  However, women may be more compliant than men and are likely to live longer.  

I recommend participation in pulmonary rehabilitation to all of my patients with COPD and strongly encourage maintenance after completing our 12-week program.