Bronchoskopische Lungenvolumenreduktion bei fortgeschrittenem Lungenemphysem: Zukunftsmusik oder viel Lärm um nichts?

Zusammenfassung

Die endoskopische Lungenvolumenreduktion (ELVR) entwickelt sich rasch weiter und wird derzeit intensiv untersucht und diskutiert. Der Ansatz, eine Lungenvolumenreduktion zu erreichen, ohne die Risiken eines chirurgischen Eingriffs eingehen zu müssen, ist sehr vielversprechend. Die verschiedenen Techniken der ELVR sind durch geringere Morbidität und Mortalität gekennzeichnet. Allerdings ist der erzielte Effekt meist eher limitiert. Die Blockade von Atemwegen durch Ventile mit dem Ziel einer Reduktion des Lungenvolumens durch Ausbildung einer Absorptionsatelektase ist bislang am intensivsten untersucht und angewandt worden. Den blockierenden Verfahren stehen teilblockierende Verfahren wie die Einlage von Coils und nicht blockierende irreversible Verfahren wie die polymerische Lungenvolumenreduktion oder die thermische Ablation gegenüber. Die Schaffung von Atemwegsbypässen, die vorwiegend beim homogenen Emphysem eingesetzt wird, führt vorübergehend zur Verbesserung von Lungenfunktionsparametern und zur Reduktion von Dyspnoe. Letztlich ist die erzielte Verbesserung aber von kurzer Dauer und hat sich deshalb nicht durchgesetzt. Diese Arbeit soll einen Überblick über den derzeitigen Stand des Wissens zur ELVR geben.

Abstract

Bronchoscopic lung volume reduction (BLVR) is a rapidly developing area and at present it is being intensively evaluated and discussed. There is a great interest in developing new treatment modalities that can reduce lung volume and air trapping without the risk of a surgical intervention. The different techniques of BLVR are characterised by lower morbidity and mortality, but by a more limited effect too. The placement of valves leads to blockade of the airway and sometimes to absorption atelectasis. The valves have been most intensively evaluated and are frequently applied. Beside the blocking devices there are partially blocking or deforming devices available as coils that are introduced in heterogeneous emphysema. Irreversible procedures such as polymeric lung volume reduction or thermal vapour ablation are used too. The creation of airway bypasses to allow trapped air to escape is mainly employed in homogenous emphysema. Following such by-pass creation there is an increase of lung function tests and a reduction of dyspnea, but only for a limited time. The bypass procedure has disappeared from bronchoscopy units completely. We give a review of the recent developments regarding BLVR and the state of the art.

• Literatur

• 1 Hopkinson NS, Kemp SV, Toma TP et al. Atelectasis and survival after bronchoscopic lung volume reduction for COPD. Eur Respir J 2011; 37: 1346-1351
• 2 Geddes D, Davies M, Koyama H et al. Effect of lung-volume reduction surgery in patients with severe emphysema. N Engl J Med 2000; 343: 239-245
• 3 National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003; 348: 2059-2073
• 4 Ferguson GT, Fernandez E, Zamora MR et al. Improved exercise performance following lung volume reduction surgery for emphysema. Am J Respir Crit Care Med 1998; 157: 1195-1203
• 5 Ramsey SD, Shroyer AL, Sullivan SD et al. Updated evaluation of the costeffectiveness of lung volume reduction surgery. Chest 2007; 131: 823-832
• 6 Naunheim KS, Wood DE, Mohsenifar Z et al. National Emphysema Treatment Trial Research Group. Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group. Ann Thorac Surg 2006; 82: 431-443
• 7 Sciurba FC, Ernst A, Herth FJF et al. A randomized study of endobronchial valves for advanced emphysema. New Engl J Med 2010; 363: 1233-1244
• 8 Hopkinson NS. Bronchoscopic lung volume reduction: indications, effects and prospects. Curr Opin Pulm Med 2007; 13: 125-130
• 9 Herth FJF, Gompelmann D, Stanzel F et al. Treatment of advanced emphysema with emphysematous lung sealant (AeriSeal^®). Respiration 2011; 82: 36-45
• 10 Kuhnigk JM, Dicken V, Zidowitz S et al. New tools for computer assistance in thoracic CT. Part 1. Functional analysis of lungs, lung lobes, and bronchopulmonary segments. RadioGraphics 2005; 25: 525-536
• 11 Toma TP, Polkey MI, Goldstraw PG et al. Methodological aspects of bronchoscopic lung volume reduction with a proprietary system. Respiration 2003; 70: 658-664
• 12 Toma TP, Hopkinson NS, Hillier J et al. Bronchoscopic volume reduction with valve implants in patients with severe emphysema. Lancet 2003; 361: 931-933
• 13 Hopkinson NS, Toma TP, Hansell DM et al. Effect of bronchoscopic lung volume reduction on dynamic hyperinflation and exercise in emphysema. Am J Respir Crit Care Med 2005; 171: 453-460
• 14 Gompelmann D, Eberhardt R, Michaud G et al. Predicting atelectasis by assessment of collateral ventilation prior to endoscopic lung volume reduction: a feasibility study. Respiration 2010; 80: 419-425
• 15 Wood DE, McKenna RJ Jr, Yusen RD et al. A multicenter trial of an intrabronchial valve for treatment of severe emphysema. J Thorac Cardiovasc Surg 2007; 133: 65-73
• 16 Sterman DH, Mehta AC, Wood D et al. IBV valve pilot trial research team. A multicenter pilot study of a bronchial valve for the treatment of severe emphysema. Respiration 2010; 79: 222-233
• 17 Springmeyer SC, Bolliger CT, Waddell TK et al. Treatment of heterogeneous emphysema using the spiration IBV valves. Thorac Surg Clin 2009; 19: 247-253
• 18 Eberhardt R, Gompelmann D, Schuhmann M et al. Unilateral vs. bilateral endoscopic lung volume reduction in patients with severe heterogenous emphysema: A comparative randomised case study. ERS; 2010
• 19 Herth FJF, Eberhardt R, Gompelmann D et al. Bronchoscopic lung volume reduction with a dedicated coil: a clinical pilot study. Ther Adv Respir Dis 2010; 4: 225-231
• 20 Slebos DJ, Kerstjens HAM, Ernst A et al. Bronchoscopic lung volume reduction coil treatment of severe heterogeneous emphysema. ERS; 2010
• 21 Ingenito EP, Berger RL, Henderson AC et al. Bronchoscopic lung volume reduction using tissue engineering principles. Am J Respir Crit Care Med 2003; 167: 771-778
• 22 Criner GJ, Pinot-Plata V, Strange C et al. Biologic lung volume reduction in advanced upper lobe emphysema: Phase 2 results. Am J Respir Crit Care 2009; 179: 791-798
• 23 Refaely Y, Dransfield M, Kramer MR et al. Biologic lung volume reduction therapy for advanced homogeneous emphysema. Eur Respir J 2010; 36: 20-27
• 24 Herth FJF, Schmidt B, Ficker J et al. Germany pilot safety and feasibility study of bronchoscopic thermal vapor ablation (BTVA) for lung volume reduction in patients with heterogenous emphysema with upper lobe predominance. Eur Resp J 2009; 35: 1827
• 25 Snell GI, Hopkins P, Westall G et al. A feasibility and safety study of bronchoscopic thermal vapor ablation: a novel emphysema therapy. Ann Thorac Surg 2009; 88: 1993-1998
• 26 Shah PL, Slebos DJ, Cardoso PFG et al. EASE trial study group. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial. Lancet 2011; 378: 997-1005
• 27 Herth FJF, Gompelmann D, Ernst A et al. Endoscopic lung volume reduction. Respiration 2010; 79: 5-13