Bronchoscopische interventies bij COPD

Transcription

1 Photo Ron Buist Bronchoscopische interventies bij COPD 2 dagen Bomen over COPD Wolfheze Woensdag 7 november vrijdag 9 november 2018 David Koster, MD en, PhD Bronchoscopic Intervention Center University Medical Center Groningen, The Netherlands

2 To begin with: valve placement

3 ADDITTIONAL COPD TREATMENT COPD Targeted Lung Denervation Chronische bronchitis Targeted Tissue Destruction of a Metered Cryospray Bronchial Rheoplasty Pulsed Electric Field Airway Ablation Emphysema Valves reimbursed (BREATH-NL Registry) Coils ELEVATE study Lung volume reduction

4 Endoscopic lung volume reduction

5 Valve treatment: efficacy STELVIO (2015) IMPACT (2016) TRANSFORM (2017) LIBERATE (2018) PATIENTS, Number EBV:34, SoC:34 EBV:43, SoC:50 EBV:65, SoC:32 EBV:128, SoC: 62 Emphysema distribution Hetero- & Homogeneous Homogeneous Heterogeneous Heterogeneous EFFICACY N=68 N=93 N=97 N=190 Target lobe volume reduction, ml Between group difference 6 months FU 3 month FU 6 months FU 12 months FU Change in Lung function Change in exercise capacity FEV 1, % +17.8%* +17%* +29%* +18%* RV, ml * -700* -522* 6MWD, meter +74* +40* +79* +39* Change in patient-centered outcomes SGRQ, total score * -6.5* -7.1* mmrc, change * -0.6* -0.8* RESPONDER RATES FEV 1 72% 40% 66% 54% RV 71% 44% 68% 66% 6MWD 79% 57% 66% 56% SGRQ 87% 50% 65% 39% Data are presented as median (range) for procedure outcomes or mean change between EBV and SOC groups for efficacy and safety outcomes. *Intention to treat analyses EBV: endobronchial valve group, SoC: standard of care group. MID: FEV1: 12% (STELVIO 10% ), RV: 430 ml (LIBERATE 310 ml), 6MWD 25 meter, SGRQ 4 points).

6 Coil treatment: efficacy RESET 1 3m META ANALYSIS 6m 2-5 META ANALYSI S 12m 2-5 REVOLENS 6 6m REVOLENS 6 12m RENEW 7 12m n T23:C T47:C49 T44:C T1:C1 FEV 1 % relative change RV Liters 6MWD meters SGRQ points % +10% +11% +11% +7.0% (+51 vs -12) (+19 vs -2) +21 (-2 vs -23) +14.6m (+10 vs -7) ) Shah, Lancet Resp Med 2013; 2) Zoumot, Plos One 2015; 3) Slebos, Chest 2012; 4) Klooster, Respiration 2014; 5) Deslee, Thorax 2014; 6) Deslee, JAMA 2016; 7) Sciurba JAMA 2016

7 How to achieve significant benefit It s all about patient selection!

8 How to achieve significant benefit Step-wise-approach 1. Severity of airflow obstruction 2. Symptoms and limitations 3. Optimal medical treatment 4. Hyperinflation 5. Co-morbidity 6. Emphysema phenotype Endoscopic Lung Volume Reduction: An Expert Panel Recommendation. Herth, Slebos, et al. Respiration 2016 Respiration 2016;91(3):241-50

9 1. Severity of airflow obstruction FEV 1 >45% FEV 1 <45% GOLD I/II GOLD III/IV

10 2. Symptoms and limitations OBJECTIVE Patient and physician judgement Severity of limitations Quality of life SUBJECTIVE mmrc 2 and/or CAT 10 limited exercise capacity (6MWD <450m)

11 3. Optimal medical treatment Smoking No optimal medication No fysio or rehabilitation Stopped smoking (>6m) Optimal medication fysio or rehabilitation

12 4. Hyperinflation TLC > 100% RV <175% RV/TLC <55% VC VC TLC > 100% RV >175% RV/TLC >55% Homogeneous distribution of emphysema: RV >200% and RV/TLC 58% RV RV

13 5. Co-morbidity PaCO 2 >8 kpa (>60mmHg) PaO 2 <6.0 kpa (<45mmHg) DLCO <20% Cardiac comorbidity: LVEF<40% Pulmonale hypertension: RVSP >50mgHg Life-threatening disease Use of coumarines/plavix which can not been stopped High dosis prednisolon (>10 mg)

14 6. Phenotype: Emphysema Airway disease Bronchiectasis Paraseptal Emphysema Fibrosis Suspicious nodule Accidental findings

15 6. Phenotype: Emphysema If patient full fit the criteria according to the step wise approach Next step: Identify a target lobe

16 Identify a target RUL

17 Tissue destruction X X X More than 50% UMCG

18 Tissue destruction Quantitative Analysis Report 62% Infographic summarizes key information Fissure completeness 63% (%) 64% Destruction (-910, -950 HU) Inspiratory lobar volume

19 Tissue destruction & volumes

20 Identify a target lobe 64% 62% 42% 44% 64% 63% X??

21 Identy a target lobe StratX Perfusion scan 54% 54% 54% 57% 42% What can be helpful too? Right Left 40% 60%

22 Identify a target lobe No flow Inspiration Expiration RLL

23 Fissure integrity

24 Fissure integrity Fissures PARTIALLY (>80%) intact? Perform always a chartis assessment Koster et al. Respiration UMCG

25 Chartis assessment X? Herth et al. ERJ 2013 and Klooster et al. NEJM 2015

26 Place EBVs in all (sub) segments of the target lobe achieve lobar occlusion

27 Not eligible for valve treatment CV+ or fissure integrity <80% Evaluate if patient is suitable for coil treatment Koster et al. Respiration UMCG

28 Not eligible for valve treatment Independent of collateral flow Coil treatment is a valid treatment for non-valve patients In a selected group of emphysema patients: modest effects on exercise clinical relevant effects on PFT & QOL UMCG

29 Not eligible for valve treatment Having benefit of coil treatment requires: Severe hyperinflation (RV>200% AND RV/TLC >58%) due to emhysema Absence of airway disease / bronchitis component X UMCG

30 Not eligible for valve treatment Be sure that you treat emphysema! and not patients with: Asthmatic/Chronic bronchitis phenotypes Childhood asthma Severe Hyperresponsiveness High number of exacerbations Maintanance antibiotics >3 pulses of AB/steroids/yr >1 hospitalisation X High dose prednisolone maintance (>10mg) Endoscopic Lung Volume Reduction: An Expert Panel Recommendation. Herth, Slebos, et al. Respiration 2016 Respiration 2016;91(3): UMCG

31 PRACTICE

32 CT-exercise case#1 - Emphysema - Distribution - Target lobe - Fissure - Treatment?

33 CT-exercise case#2 - Emphysema - Distribution - Target lobe - Fissure - Treatment?

34 Case report #1

35 Case report #1 Male, 64 years Hypertension, echo cardiography: normal COPD Gold IV, (44py) Recent clinical pulmonary rehab program Optimal medication Severe dyspnea, no exacerbations Depressed Emphysema on CT scan

36 Case report #1 FVC, L 3.05 (60%) FEV 1, L 1.01 (27%) FEV 1 /FVC 33% TLC, L (134%) RV, L 7.71 (290%) RV/TLC 72% 6MWT 212 meter (35%) mmrc 4 PaCO 2 = 5,47 Kpa PaO 2 = 8,22 Kpa

37 Case report #1 Current possibilities Do nothing, accept as-is Screening Lung Transplantation Lung Volume Reduction Surgery Bronchoscopic Lung Volume Reduction

38 Case report #1

39 Case report #1 Valves or coils? TLC, L (134%) RV, L 7.71 (290%) RV/TLC 72%

40 Case report #1 Chartis assessment RUL + LLL RUL X LLL No Collateral Ventilation EBV treatment: 6 EBV in LLL No complications

41 Case report #1 Baseline 2 month FU FVC, L 3.05 (60%) 5,04 (99%) FEV 1, L 1.01 (27%) 1,95 (52%) +85% RV, L 7.71 (290%) 4,74 (179%) ml RV/TLC 72% 49% 6MWT 212 meter 413 meter +201 meter mmrc 4 2

42 Case report #1 Efficacy after 4 years Baseline RV/TLC 72% RV 7,71 L 212 meter 4 year FU RV/TLC 56% RV 5,71 L 330 meter

43 Case report #2

44 Case report #2 Female, 60 y 55 PY, stopped 10 years History COPD, Gold IV Hypothyreoïdism 1993 DVT after surgery (HNP) Medication Combivent, Berodual, Spiriva Resp, Relvar Levothyroxine, Calcichew Can t work anymore. Dyspnea d effort, would like to be able to perform better, is very motivated. 2 stairs is too much. Little coughing, no mucus. Exacerbations: 1-2/yr. Fysiotherapy: 2x/wk

45 Case report #2 Pulmonary Function Test FVC, L 3.02 (81%) FEV 1, L 0.85 (29%) TLC, L 7,79 (135%) RV, L 4,63 (221%) RV/TLC 59% 6MWT 470 m PaCO2 kpa 5.0, PaO2 kpa 11.1

46 Case report #2 BLVR?

47 Case report #1 TLC, L 7,79 (135%) RV, L 4,63 (221%) RV/TLC 59% Additional test?

48 Case report #2 LEFT Right 57% 43%

49 Case report #2 Chartis: CVneg ROK en LOK. 4x EBV RBK+MK

50 Case report #2 Pulmonary Function Test Pre Post FVC, L 3.02 (81%) 3,92 (105%) FEV 1, L 0.85 (29%) 1.11 (38%) TLC, L 7,79 (135%) 7.56 (131%) RV, L 4,63 (221%) 3.61 (170%) RV/TLC 59% 48% 6MWT 470 m 535 m

51 Case report #3

52 Case report #3 Female, 62 yr 56 pack years, stopped in 2016 History COPD, Gold IV 2018: Pulmonary rehabilitation Dekkerswald Medication Beclometason/formoterol, Salbutamol, Tiotropium

53 Case report #3 Pulmonary Function Test FVC, L 1,44 (42%) FEV 1, L 0.43 (14%) TLC, L 7,91 (137%) RV, L 5,85 (287%) RV/TLC 74% 6MWT mmrc meter

54 Case report #3 BLVR? TLC, L 7,11 138% RV, L 4,84 240% RV/TLC 68%

55 Case report #3 Valves? Coils?

56 Case report #3 Valves? Coils?

57 Case report #3 Bi-lateral coil treatment RUL and LUL

58 Case report #3 Pulmonary Function Test Pre Post FVC, L 2,15 67% 2,45 76% FEV 1, L 0,53 21% 0,75 30% +42% TLC, L 7,11 138% 6,94 134% RV, L 4,84 240% 4,15 206% -690ml RV/TLC 68% 60%

59 Case report #4

60 Case report #4 Male 62 Y Pulmonary Function Test History COPD Medication Spiriva FVC 123% FEV1 89% FEV1/FVC 57% RV 90% RV/TLC 35% DCLO 21% PO2 7.5kPa

61 Case report #4 CT-scan Valves? Coils?

62 Case report #4 Pulmonary Function Test FVC 123% FEV1 89% FEV1/FVC 57% RV 90% RV/TLC 35% X DCLO 21% PO2 7.5kPa Evaluate other cause!

63 Case report #5

64 Case report #5 Female, 71 yr History 2008: COPD, Gold III COPD, Gold IV 2012: Pulmonary rehabilitation Medication Alvesco DA 2 dd 1, Spiriva Respimat 1 dd 2, Striverdi Respimat 1 dd 2, Ventolin DA z.n. Approvel 300 mg 1 dd 1 Pulmonary Function Test FVC, L 1,95 (76%) FEV 1, L 0,58 (27%) TLC, L 6,86 (135%) RV, L 4,75 (227%) RV/TLC 69% 6MWD 355 meter PaCO 2 5,82 kpa PaO 2 10,52 kpa Dyspnea on exercise. Progressive. Walking distance: 50 m. No infections or exacerbations. No asthma. Bronchial hyperreactivity: fog, smoke, perfume.

65 Case report #5

66 Case report #5

67 Case report #5

68 Case report #5 Valves? Coils? TLC, L 6,86 (135%) RV, L 4,75 (227%) RV/TLC 69%

69 Case report #5

70 Case report #5

71 Case report #5 Chartis assessment

72 Case report #5 Follow-up Big smile. More air, more exercise capacity. Pulmonary Function Test Pre ( ) Post ( ) FVC, L 1,95 (76%) 2,52 (87%) FEV 1, L 0,58 (27%) 0.72 (32%) TLC, L 6,86 (135%) 6,33 (125%) RV, L 4,75 (227%) 3,70 (176%) RV/TLC 69% 58% FEV 1 +24% RV -1050ml 6MWD +56 meter

73 Case report #5 Follow-up: Complaints: progressive dyspnea and cough Pre Post

74 Case report #5 Follow-up Bronchoscopy: severe granulation tissue and purulent secretion Follow up bronchoscopy needed after course prednisolone to remove valves.

75 Team Bronchoscopic Intervention Centrum (BIC) University Medical Center Groningen, The Netherlands Pulmonologist Dirk-Jan Slebos, MD, PhD Nick ten Hacken, MD, PhD Marlies van Dijk, MD Coordinator & Post-doc Jorine Hartman, PhD, PhD PFT technician Sonja Augustijn MD PhD student Jorrit Welling Marieke van der Molen, MD David Koster, MD Secretary Gea Zwart Photo Ron Buist

76 Verwijsprocedure Wat te doen als een patiënt in aanmerking wil komen voor een aanvullende behandeling? Ga eerst na wat de patiënt zelf kan verbeteren! Optimale medicatie en goede compliance? Goede voeding? Voldoende beweging? (hulpmiddelen zoals een rollator kunnen hierbij helpen) etc. Acceptatie Indien de patiënt zelf niets meer kan verbeteren dan kan hij/zij met de longarts overleggen of hij/zij in aanmerking komt voor een verwijzing naar het UMCG.

77 Verwijsprocedure - Brief met vraagstelling, voorgeschiedenis, revalidatie/fysio, rookstop en medicatie gebruik - CT scan dunne coupes (1 mm coupes Kernel B31f + zonder contrast) - Longfunctie uitslagen (recente body-box meting) + bloedgassen - Indien beschikbaar een brief cardioloog/ uitslag van een echo cor - Indien beschikbaar uitslag perfusiescan (op CD rom) Graag als 1 pakket per post verzenden, na ontvangst zal het een aantal weken duren voordat er een beoordeling verstuurd wordt. Alleen als de patiënt op papier mogelijk geschikt is voor een interventie, dan zullen we de patiënt oproepen voor een second opinion consult in het UMCG. Informatie:

78 Valve N=450 N=51 N=5 N=2 Coils Nervus vagus ablation Cryospray N= N= N=3 N=

79 Case report #6

80 Case report #6 Male, 41 yr History 1988: pneumothorax left COPD, Gold IV 2012: Pulmonary rehabilitation Medication Seretide 2dd500/50mcg, Spiriva 5mcg, O2 3l/min at night and during exercise. Nutridrink 4dd

81 Case report #6 Pulmonary Function Test FVC, L 3.73 (75%) FEV 1, L 1.25 (31%) TLC, L 8,47 (116%) RV, L 4,58 (226%) RV/TLC 54% 6MWT 260 meter mmrc 3 PaCO 2 PaO 2 5,61 kpa 7,92 kpa

82 Case report #6

83 Case report #6 BLVR? TLC, L 8,47 (116%) RV, L 4,58 (226%) RV/TLC 54%

84 Case report #6 Valves? Coils? Target? *

85 Case report #6 Chartis assessment Right upper lobe: Right lower lobe:

86 Case report #6 EBV Treatment RUL & ML Pulmonary Function Test Oct 2012 Dec 2012 FVC, L 3.73 (75%) 4.19 (84%) FEV 1, L 1.25 (31%) 1.88 (46%) TLC, L 8,47 (116%) 8.32 (114%) RV, L 4,58 (226%) 4,01 (197%) RV/TLC 54% 48% mmrc 3 1

87 Case report #6 Follow up

88 Case report #6 Follow up: what to do?

89 Case report #6

90 Case report #6 Lobectomy Left-UL: 0.8cm tumor, adenocarcinoma, pt1n0m0 Pulmonary Function Test Oct 2012 Dec 2012 Sept 2014 FVC, L 3.73 (75%) 4.19 (84%) 4.33 (88%) FEV 1, L 1.25 (31%) 1.88 (46%) 2.12 (53%) TLC, L 8,47 (116%) 8.32 (114%) 7.47 (102%) RV, L 4,58 (226%) 4,01 (197%) 3.15 (152%) RV/TLC 54% 48% 42% mmrc 3 1 1

91 Case report #