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Patient selection for bronchoscopic lung volume reduction with endobronchial valves*

Patient selection for bronchoscopic lung volume reduction with endobronchial valves*
Inclusion criteria
Medical history and physical examination

Clinical presentation consistent with emphysema

Symptomatic despite optimal medical therapy (mMRC ≥2)

Clinically stable on ≤20 mg prednisone (or equivalent)/day

Nonsmoking for ≥4 months

BMI <35 kg/m2
Pulmonary function tests

FEV1 ≥15% predicted but ≤45% predicted

TLC ≥100% predicted

RV ≥175% predicted

6MWD ≥100 m and <500 m
Imaging Emphysema on HRCT
Anesthesia Able to tolerate procedural sedation
Collateral ventilation Lobe targeted for EBV placement must have little to no collateral ventilation assessed by Chartis and/or StratXΔ
Exclusion criteria
Prior lung transplant, LVRS, median sternotomy, lobectomy
Heart failure (LVEF <45%), unstable cardiac arrhythmia, myocardial infarction, stroke
Severe hypercapnia: PaCO2 >60 mmHg (8 kPa)
Severe hypoxemia: PaO2 <45 mmHg (6 kPa)
Active pulmonary infection
Allergy to nitinol, nickel, titanium, or silicone
Large bullae >30% either lung
Contraindications to bronchoscopy or high risk postoperative morbidity or mortality
mMRC: modified Medical Research Council dyspnea scale; BMI: body mass index; FEV1: forced expiratory volume in one second; TLC: total lung capacity; RV: residual volume; 6MWD: six-minute walk distance; HRCT: high resolution computed tomography; EBV: endobronchial valve; LVRS: lung volume reduction surgery; LVEF: left ventricular ejection fraction; PaCO2: carbon dioxide tension; PaO2: arterial oxygen tension.
* Endobronchial valves are implanted bronchoscopically in regions of the lung with little to no collateral ventilation to treat adult patients with hyperinflation due to severe emphysema.
¶ Chartis: A specialized catheter for bronchoscopic assessment of localized pressure and flow to assess collateral ventilation. Absence of collateral ventilation improves the likelihood of resorption atelectasis following endobronchial valve placement.
Δ StratX: Quantitative analysis of high resolution computed tomography images to assess amount of emphysematous destruction and fissure completeness. Greater fissure completeness predicts less collateral ventilation and a greater likelihood of success with endobronchial valve placement.
References:
  1. Herth FJ, Eberhardt R, Gompelmann D, et al. Radiological and clinical outcomes of using Chartis™ to plan endobronchial valve treatment. Eur Respir J 2013; 41:302.
  2. Koster TD, van Rikxoort EM, Huebner RH, et al. Predicting Lung Volume Reduction after Endobronchial Valve Therapy Is Maximized Using a Combination of Diagnostic Tools. Respiration 2016; 92:150.
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