Bronchoscopic Lung Volume Reduction With Endobronchial Valve Implantation in One Patient With Severe Emphysema

Abstract

INTRODUCTION: Many patients with advanced emphysema have intolerable breathlessness even receiving medical treatment. Lung-volume reduction surgery (LVRS) can improve lung function and quality of life, but clinical limitation should be considered because of high surgical mortality and morbidity. Bronchoscopic lung volume reduction (BLVR) with endobronchial valve (EBV) implantation is a safer alternative for LVRS. One patient was received the EBV implantation, evaluation after procedure, and mechanism of BLVR was analyzed. CASE PRESENTATION: A 50 year old male patient had a severe dyspnea on exertion for 4 years, with MRC 4 scales, FEV1 0.63L (17.9% pred) , FVC 2.24L (51.14%pred), RV 7.61L (354.1% pred), TLC 7.93L (142.5%pred) and 6 minute walking ( 6MWT) distance 60m. He smoked of 40 pack years and ceased smoking for 2 years. Quantative CT scan and lung ventilation scintigraphy showed heterogeneous emphysema in right upper lobe (RUL) with complete fissure, and emphysema percentage was the highest in all lobes. After 3-week inhaling medicine treatment and physiotherapy, RV decreased to 6.00L (279% pred), 6MWT distance increased to 120m, but FEV1 didn’t improve ( 0.66L, 18.6% pred), and RUL ventilation scintigraphy was still high. Chartis assessment showed absence of collateral ventilation between RUL and other lobes. Three Zephyr EBVs were placed in three bronchus of RUL. RUL atelectasis was confirmed on chest X ray and CT scan on day three and the following day. At 1 week post procedure, FEV1, FVC and TLC increased to 1.14L (32.2% pred), 3.18L (72.60%pred) and 8.43L (123.6%pred) respectively, and RV reduced to 5.12L (238.3% pred). 6MWT distance increased to 410m and MRC increased to 2 scales after 1 month. Meanwhile, CT scan showed emphysema percentage was decreased in right middle lobe and right lower lobe, meanwhile the lung volume increased both of that two lobes. Lung ventilation scintigraphy was improved in bilateral lung. No severe adverse event was reported. DISCUSSION: BLVR was successful by placement of Zephyr endobronchial valves in RUL. The patient achieved an impressive 72.72% improvement in FEV1 and a 14.67% reduction in RV, with 6MWT distance increasing 241.7%. Unilateral lung volume reduction may improve the ventilation and lung volume in other lobes after atelectasis in one lobe. Inhaled bronchial dilator and corticosteroid improve the exercise capacity and decreased the RV, but no effect on FEV1. CONCLUSIONS: BLVR with Zephy EBV implantation induced improvements in lung function, exercise tolerance and symptoms, with relatively less complications. Mechanism may relate to improvement of ventilation in other lobes of bilateral lung.