Nonsurgical valve treatment provides relief for patients with severe emphysema
June 2, 2021
Patients who suffer from severe emphysema usually have tried just about everything to breathe easier: inhalers, oxygen, medications, and pulmonary rehabilitation.
Some have even considered lung volume reduction surgery and lung transplant to cope with the severe and progressive condition, which is often categorized as chronic obstructive pulmonary disease (COPD).
Now, thanks to a nonsurgical procedure and innovative devices that were developed through serial clinical studies at UT Southwestern and centers nationwide, those patients have another option.
Bronchoscopic Lung Volume Reduction (BLVR) is a minimally invasive procedure – no incisions, no stitches – that employs tiny one-way valves to prevent air from entering the diseased areas of the lungs. The procedure and devices were approved in 2018 by the U.S. Food and Drug Administration (FDA) following two landmark clinical trials, one of which I was the principal investigator for at UTSW.
In a relatively short time, BLVR has become a vital piece of UT Southwestern’s nationally recognized pulmonary care for patients with COPD. We have performed more than 80 BLVR procedures since June 2019, and the results have been overwhelmingly positive. Our patients have reported less shortness of breath, better lung function, higher tolerance of exercise, and they are experiencing better overall quality of life.
Who is a candidate for BLVR?
An average healthy adult takes about 12 to 16 breaths per minute. Patients with severe COPD, such as emphysema or bronchitis, usually double that number. They are constantly short of breath, even while doing simple daily tasks such as getting dressed.
Bronchoscopic lung volume reduction was designed to help patients with severe emphysema, who typically have damaged lung tissue and a loss of elasticity in their airways and air sacs (alveoli). Emphysema is usually caused by long-term exposure to irritants that damage the lungs and airways, such as cigarette smoke, secondhand smoke, air pollution, and chemical fumes.
Severe emphysema patients who qualify for the procedure must be on maximum medical therapy and inhalers, which reduce inflammation in their lungs and open up the airways to ease symptoms such as coughing, wheezing, and shortness of breath. They must also have permanently stopped smoking several months before BLVR and participate in pulmonary rehabilitation, a specialized physical therapy for patients with lung conditions.
Our evaluation for BLVR also includes:
- Computed tomography (CT) scan, a specialized X-ray of the chest that takes cross-sectional 3D images of the lungs to locate diseased areas
- Echocardiogram to evaluate heart function
- Pulmonary function tests, which measure airflow in and out of the lungs, how well the lungs move oxygen into the bloodstream, and lung size
- Arterial blood gas (AGB), a specialized blood test that measures oxygen and carbon dioxide levels directly from the arterial blood
- Perfusion lung scan, which examines how blood is flowing within the lungs and help determine regional lung function
We also review the patient’s history and go over the risks and benefits of BLVR. Not every patient with severe emphysema will be a candidate. For example, if you have major heart conditions, had major lung surgery, or have had a recent lung infection, we might recommend an alternate treatment.
How BLVR was born
In the late 1950s, this surgery was developed by Drs. Otto C. Brantigan and Eugene Mueller but the morbidity in this patient population was high. In the 1990s, the concept was revitalized and surgery to reduce lung volume became more common for some emphysema patients. A thoracic surgeon would remove the most diseased portions of a patient’s lung to relieve compression against the more normal lung regions. The surgery was associated with mostly good outcomes, but many patients were too sick to tolerate this major surgery, which required a long hospital stay and several months of recovery at home.
In the early 2000s, researchers began thinking about ways to reproduce the results of lung volume reduction surgery with a less-invasive approach. The designs of one-way valves were born.
The one-way valves would allow air and secretions to escape the diseased lung but prevent the air from entering those target areas.
We began testing the device in multicenter clinical trials in the early 2000s and learned much about patients’ selection and outcomes. The FDA approval process is usually long, averaging 15 to 20 years for new technology or devices, but in June 2018 the first valve was granted a “breakthrough device designation” and in December 2018, the second valve design was approved. UT Southwestern was the first hospital in Dallas to offer BLVR.
How BLVR works
Our interventional pulmonologists perform BLVR with a bronchoscope, which is a flexible tube that gets inserted into the nose or mouth or through an anesthesia tube. There are no surgical incisions involved with bronchoscopic lung volume reduction (BLVR).
The entire procedure is performed in our interventional pulmonology suite at William P. Clements Jr. University Hospital, and patients receive either a sedative to help them relax or general anesthesia to put them to sleep during the relatively short procedure. They also receive numbing medications in the nostril or mouth and throat to prevent irritation from the scope, which has a camera on it so we can visualize the inside of the patient’s airways. The scope also has a working channel so the doctor can suction secretions and use certain tools to place the valves in the airways and study the patient’s lung ventilation. On average, we insert 2-5 valves, which limit airflow into the diseased areas while still allowing trapped air and secretions to escape. By directing air to the healthier sections of the lung, patients will be able to breathe easier and enjoy more normal lung function.
The entire procedure usually takes less than 30 minutes. Patients typically stay in the hospital for two to three days so we can observe them and ensure they are not experiencing any air leaks in their lungs, which is called pneumothorax. That is the main complication with BLVR affecting 15 to 30 percent of patients, but it is usually managed and corrected while the patient is hospitalized. The complication is anticipated due to the lung volume reduction nature of this procedure.
Benefits of BLVR
By the time many patients consider BLVR, they have exhausted other standard treatments for severe emphysema such as medication, oxygen, and rehabilitation.
BLVR benefits the patient by:
- Reducing lung volume without removing sections of lung tissue
- Expanding relatively healthier sections of the lungs, which improves breathing overall
- Improving objective measures of lung function
- Increasing the ability to exercise and do everyday activities
- Avoiding surgery, and staying in the hospital for less time
- Giving physicians the option to remove airway valves if there are complications or if the procedure is not effective.
- Providing better quality of life and more years before having to consider lung transplant
The benefits of comprehensive lung care
BLVR doesn’t just improve lung function for people with severe emphysema – it can give them a big psychological boost as well and a more positive outlook about their disease.
Many of our patients have told us they were able to resume their daily routines, get out of the house more, and reclaim their lives because they feel better physically and mentally.
Our pulmonary care team at UT Southwestern is dedicated to helping patients manage their COPD with the most advanced treatments as soon as they’re available, and we’re proud to have played a role in making bronchoscopic lung volume reduction a reality for patients all over the world. We are also proud to be part of clinical trials dealing with other new treatment modalities for COPD.