Bronchoscopic Lung Volume Reduction: A Window for the Future?

Lung volume reduction (LVR) surgery (LVRS) is an interesting therapeutic option which has been developed over the last decade in patients with end-stage emphysema. Initially cohort studies [1–3] and then randomized trials versus medical treatment [4] have demonstrated that lung function, exercise capacity, and quality of life are improved after LVRS. However, many questions remain unanswered. Recent reports showed that the mortality rate after LVRS remains increased (5%) [4, 5] in patients with a FEV1 !20% predicted or either a very low diffusing capacity of CO or a homogeneous emphysema as compared with a medically treated group [5]. In patients who survived the procedure, the quality of life was not better than after medical treatment, and a limited benefit with regard to lung function and exercise testing was noted [5]. It is unclear whether bilateral LVRS has better results than the single one. Another question is whether classical surgical procedures are doing better versus the thoracoscopic LVR [6]. Also, the technique to be applied, laser or staple method, is questionable, since the laser technique was found to result in a higher mortality rate [7]. Does sternotomy offer better results and better patient comfort than lateral thoracotomy [7]? Finally, the NETT [8], OBEST [9], and Canadian LVR [10] trials may fail to answer important questions such as risks and benefits of LVRS, as the patients’ enrollment failed to be as predicted. Also the question which patients should be referred for LVRS is still pending, since the patients’ profile in trials is different [11]. Nowadays, flexible fiberoptic bronchoscopy (FFB) has been largely applied for diagnosis and therapy of lung diseases. Its simplicity together with the wide application and better physician knowledge made this procedure a major tool in pneumonology [12, 13]. There are recent reports using FFB for LVR [14, 15]. Experiments performed in sheep showed that LVR was possible by FFB using a biocompatible fibrin-based glue system [14]. The success rate was 55% in healthy animals [14] and 91% in animals with a papain-induced experimental emphysema [16]. The lung function parameters showed improvement in this animal emphysema model [16]. Lately, a second team performed bronchoscopic LVR (BLVR) by using a valve implant in a unilateral setting [15]. This phase II pilot study was done in 8 patients with a severe emphysema (median FEV1 23.7% predicted). They placed the valves in all segmental airways leading to the upper lobe most affected by bullae. The procedure was performed under a combined propofol-remifentanil anes-