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Review
, 2 (2), CD012158

Bronchoscopic Lung Volume Reduction Procedures for Chronic Obstructive Pulmonary Disease

Affiliations
Review

Bronchoscopic Lung Volume Reduction Procedures for Chronic Obstructive Pulmonary Disease

Joseph Em van Agteren et al. Cochrane Database Syst Rev.

Abstract

Background: In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD).

Objectives: To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique.

Search methods: Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016.

Selection criteria: We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available.

Data collection and analysis: Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software.

Main results: AeriSealOne RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV1) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate. Airway bypass stentsTreatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV1 (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high. Endobronchial coilsThree studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV1 (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high. Endobronchial valvesFive studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV1 (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high. Intrabronchial valvesIn the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV1 (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV1 and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high. Vapour ablationOne study of 69 participants found significant mean between-group differences in FEV1 (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate.

Authors' conclusions: Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.

Conflict of interest statement

Dion Grosser has received payment to attend workshops and to provide education and proctoring for placement of endobronchial valves (Pulmonx) and has received flights and accommodation to attend an education session on implantation of coils (PneumRx). None of the other review authors are aware of any conflict of interest.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figure 4
Figure 4
Forest plot of comparison: 1 BLVR to medical therapy, outcome: 1.1 Mortality (All methods, end of follow‐up).
Figure 5
Figure 5
Forest plot of comparison: 1 BLVR to medical therapy, outcome: 1.2 Adverse Events (all methods, end of follow‐up).
Analysis 1.1
Analysis 1.1
Comparison 1 BVLR (all methods) versus medical therapy, Outcome 1 Mortality (end of follow‐up, all methods).
Analysis 1.2
Analysis 1.2
Comparison 1 BVLR (all methods) versus medical therapy, Outcome 2 Adverse events (end of follow‐up, all methods).
Analysis 2.1
Analysis 2.1
Comparison 2 Endobronchial coils versus medical therapy, Outcome 1 Absolute % change in FEV1 (end of follow‐up, endobronchial coils).
Analysis 2.2
Analysis 2.2
Comparison 2 Endobronchial coils versus medical therapy, Outcome 2 SGRQ change from baseline (end of follow‐up, endobronchial coils).
Analysis 2.3
Analysis 2.3
Comparison 2 Endobronchial coils versus medical therapy, Outcome 3 RV change from baseline (L, end of follow‐up, endobronchial coils).
Analysis 2.4
Analysis 2.4
Comparison 2 Endobronchial coils versus medical therapy, Outcome 4 TLC change from baseline (L, end of follow‐up, endobronchial coils).
Analysis 2.5
Analysis 2.5
Comparison 2 Endobronchial coils versus medical therapy, Outcome 5 RV/TLC change from baseline (end of follow‐up, endobronchial coils).
Analysis 2.6
Analysis 2.6
Comparison 2 Endobronchial coils versus medical therapy, Outcome 6 6MWD change from baseline (end of follow‐up, endobronchial coils).
Analysis 3.1
Analysis 3.1
Comparison 3 Endobronchial valves versus medical therapy, Outcome 1 % change in FEV1 (end of follow‐up, endobronchial valves).
Analysis 3.2
Analysis 3.2
Comparison 3 Endobronchial valves versus medical therapy, Outcome 2 % change in FEV1 (stratified per follow‐up, endobronchial valves).
Analysis 3.3
Analysis 3.3
Comparison 3 Endobronchial valves versus medical therapy, Outcome 3 % change in FEV1 (stratified per disease distribution, endobronchial valves).
Analysis 3.4
Analysis 3.4
Comparison 3 Endobronchial valves versus medical therapy, Outcome 4 % Change in FEV1 (stratified by collateral ventilation, endobronchial valves).
Analysis 3.5
Analysis 3.5
Comparison 3 Endobronchial valves versus medical therapy, Outcome 5 Mortality (stratified per follow‐up, endobronchial valves).
Analysis 3.6
Analysis 3.6
Comparison 3 Endobronchial valves versus medical therapy, Outcome 6 Mortality (stratified by collateral ventilation, endobronchial valves).
Analysis 3.7
Analysis 3.7
Comparison 3 Endobronchial valves versus medical therapy, Outcome 7 SGRQ change from baseline (end of follow‐up, endobronchial valves).
Analysis 3.8
Analysis 3.8
Comparison 3 Endobronchial valves versus medical therapy, Outcome 8 SGRQ change from baseline (stratified by follow‐up time, endobronchial valves).
Analysis 3.9
Analysis 3.9
Comparison 3 Endobronchial valves versus medical therapy, Outcome 9 SGRQ change from baseline (stratified by collateral ventilation, endobronchial valves).
Analysis 3.10
Analysis 3.10
Comparison 3 Endobronchial valves versus medical therapy, Outcome 10 RV change from baseline (L, end of follow‐up, endobronchial valves).
Analysis 3.11
Analysis 3.11
Comparison 3 Endobronchial valves versus medical therapy, Outcome 11 TLC change from baseline (L, end of follow‐up, endobronchial valves).
Analysis 3.12
Analysis 3.12
Comparison 3 Endobronchial valves versus medical therapy, Outcome 12 RV/TLC change from baseline (end of follow‐up, endobronchial valves).
Analysis 3.13
Analysis 3.13
Comparison 3 Endobronchial valves versus medical therapy, Outcome 13 6MWD change from baseline (end of follow‐up, endobronchial valves).
Analysis 3.14
Analysis 3.14
Comparison 3 Endobronchial valves versus medical therapy, Outcome 14 6MWD change from baseline (stratified per collateral ventilation,, endobronchial valves).
Analysis 4.1
Analysis 4.1
Comparison 4 Intrabronchial valves versus medical therapy, Outcome 1 SGRQ change from baseline (end of follow‐up, intrabronchial valves).
Analysis 4.2
Analysis 4.2
Comparison 4 Intrabronchial valves versus medical therapy, Outcome 2 RV change from baseline (L, end of follow‐up, intrabronchial valves).
Analysis 4.3
Analysis 4.3
Comparison 4 Intrabronchial valves versus medical therapy, Outcome 3 TLC change from baseline (L, end of follow‐up, intrabronchial valves).
Analysis 4.4
Analysis 4.4
Comparison 4 Intrabronchial valves versus medical therapy, Outcome 4 PAO2 (end of follow‐up, intrabronchial valves).
Analysis 4.5
Analysis 4.5
Comparison 4 Intrabronchial valves versus medical therapy, Outcome 5 PACO2 (end of follow‐up, intrabronchial valves).
Analysis 4.6
Analysis 4.6
Comparison 4 Intrabronchial valves versus medical therapy, Outcome 6 6MWD change from baseline (intrabronchial valves).

Update of

  • Cochrane Database Syst Rev. doi: 10.1002/14651858.CD012158

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