Other Methods of ELVR

Bronchoscopic Thermal Vapor Ablation (Update Medical Inc.; Seattle, WA) has been studied as yet another method of ELVR. Conceptually akin to the polymer treatment, thermal ablation seeks to create in ammation and subsequent atelectasis of a treated diseased lobe thereby promoting lung volume reduction. A small multicenter trial enrolling 44 patients with upper lobe predominant emphysema reported sustained benefts in quality of life, lung function, and exercise tolerance at 1 year [48]. However, serious adverse events occurred in 53% of patients, chief among them COPD exacerbations. The STEP-UP trial which enrolled 70 patients reported a mean relative improvement in FEV1 favoring the treatment group was +14.7% [49]. Mean SGRQ scores were also improved in the treatment arm by 9.7 points. COPD exacerbations were once again common in the treatment arm occurring in 24% as compared with 4% of the control group, accounting for one death possibly related to treatment. The study investigators claimed that targeted thermal vapor ablation offers clinically

meaningful and statistically signifcant improvements in lung function and quality of life at 6 months, with an acceptable safety profle.

A few small clinical series or trials have reported a beneft from autologous blood instillation as a method of ELVR in bullous disease [50]. This low-cost technique requires adequately powered randomized trials to fnd its place as a novel ELVR alternative.

Summary and Recommendations

A growing body of evidence suggests that ELVR is reasonably safe and can offer modest regional or total lung volume reduction and signifcant improvements in quality of life in carefully selected patients with severe emphysema. Unfortunately, clinically relevant effcacy is underwhelming for most procedures and as a general rule randomized trial data show marginal benefts in key outcomes, while highlighting the risks associated with some methods of ELVR, including serious adverse events. We are currently optimizing patient selection and refning

treatment strategies. I believe we should continue to strive for improvements in lung function and survival. Only then will device-related complications or signifcant increases in morbidity become acceptable in this patient population.

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