Background: Both bronchoscopic lung volume reduction with endobronchial valves (BLVR-EBV) and pulmonary rehabilitation (PR) are effective treatments for improving exercise capacity and patient-reported outcomes in patients with severe Chronic Obstructive Pulmonary Disease (COPD). Aim To study the impact and timing of PR in patients who underwent BLVR-EBV. Methods: We included patients with severe COPD who were eligible for BLVR-EBV and PR. Participants were randomized into three groups: PR before BLVR-EBV, PR after BLVR-EBV, or BLVR-EBV without PR. The primary outcome was change in constant work rate cycle test (CWRT) endurance time at 6-month follow-up between the PR groups and BLVR-EBV only group. Secondary endpoints included changes in six-minute walking test, daily step count, and patient-reported outcomes. Results: Ninety-seven participants were included. At 6-month follow-up, there was no difference in change in CWRT endurance time between the PR groups and BLVR-EBV alone (median: 376 [IQR: 26; 906] vs. 601 [73; 1003] seconds, p=0.416) or any of the secondary endpoints. Similarly, we found no differences in change in CWRT endurance time between the groups that underwent PR before and after BLVR-EBV (421 [44; 1304] vs. 292 [17; 630] seconds, p=0.210) or in the secondary endpoints. Conclusion: The combination of PR and BLVR-EBV did not result in increased exercise capacity, daily step count, or improved patients-reported outcomes compared to BLVR-EBV alone. The timing of PR in relation to BLVR-EBV did not affect treatment efficacy.
Introduction: Endobronchial valves (EBV) are an effective treatment in highly selected COPD patients with advanced emphysema. Aims: To evaluate a spectrum of treatable traits (TTs) in COPD patients eligible for EBV, stratified for higher or lower health-related quality of life (HRQL). Methods: The SoLVE study (NCT03474471) was a prospective multicenter RCT on the systemic effects of EBV. At baseline, a comprehensive assessment was performed including lung function, exercise capacity, muscle strength, physical activity and patient reported outcome measures. Subjects were divided into higher or lower HRQL based on the St. George's Respiratory Questionnaire total score (SGRQ < or ≥60 points). TTs were calculated on pre-defined thresholds. Logistic regression assessed the odds ratio (OR) of having a SGRQ of ≥60 points per TT. Results: In total, 97 subjects were included: 62±7 yrs, 37% male, mean FEV1 27±7% pred, RV 251±45% pred and a mean SGRQ score of 60±12 points, with 53% scoring ≥60 points. The mean number of TTs per patient was 4.5±1.8, 3.1±1.4 in SGRQ <60 points and 5.4±1.3 in SGRQ ≥60 points (P<0.05). Severe fatigue, measured with Checklist Individual Strength, had the highest OR (6.48). Conclusions: A high prevalence and co-occurrence of multiple TTs could be identified in emphysema patients eligible for EBV. These results justify to study the efficacy of the combination of EBV treatment and pulmonary rehabilitation.
Rationale: Pulmonary hyperinflation in patients with chronic obstructive pulmonary disease has been related to smaller cardiac chamber sizes and impaired cardiac function. Currently, bronchoscopic lung volume reduction (BLVR) with endobronchial valves is a treatment option to reduce pulmonary hyperinflation in patients with severe emphysema. Objectives: We hypothesized that reduction of hyperinflation would improve cardiac preload in this patient group. In addition, we investigated whether the treatment would result in elevated pulmonary artery pressures because of pulmonary vascular bed reduction. Methods: We included patients with emphysema and severe hyperinflation (defined by a baseline residual volume >175% of predicted) who were eligible for BLVR with endobronchial valves. Cardiac magnetic resonance imaging was obtained one day before treatment and at 8-week follow-up. Primary endpoint was cardiac preload, as measured by the right ventricle end-diastolic volume index. As secondary endpoints, we measured indexed end-diastolic and end-systolic volumes of the right ventricle, left atrium, and left ventricle; pulmonary artery pressures; cardiac output; ejection fraction; and strain. Measurements and Main Results: Twenty-four patients were included. At 8-week follow-up, right ventricle end-diastolic volume index was significantly improved (+7.9 ml/m2; SD, 10.0; P = 0.001). In addition to increased stroke volumes, we found significantly higher ejection fractions and strain measurements. Although cardiac output was significantly increased (+0.9 L/min; SD, 1.5; P = 0.007), there were no changes in pulmonary artery pressures. Conclusions: We found that reduction of hyperinflation using BLVR with endobronchial valves significantly improved cardiac preload, myocardial contractility, and cardiac output, without changes in pulmonary artery pressures. Clinical trial registered with www.clinicaltrials.gov (NCT03474471).
Introduction Patients with advanced emphysema eligible for bronchoscopic lung volume reduction (BLVR) using endobronchial valves (EBV) are characterized by severe static lung hyperinflation, which can be considered a treatable trait. Other treatable traits (TTs), which are assumed to be present in this highly selected patient group, have not been studied in detail nor how they may affect health-related quality of life (HRQL). Aims We aimed to evaluate a spectrum of TTs in COPD patients eligible for EBV treatment and their association with HRQL. Methods The SoLVE study (NCT03474471) was a prospective multicenter randomized controlled trial to examine the impact of pulmonary rehabilitation in COPD patients receiving EBV. The presence/absence of 16 TTs was based on pre-defined thresholds. HRQL was assessed with the St. George's Respiratory Questionnaire (SGRQ). Subjects were stratified into two groups, using the median split method, into higher or lower SGRQ total score. Logistic regression assessed the odds ratio (OR) of having a higher SGRQ total score per TT. Results Ninety-seven subjects were included, the mean number of TTs per patient was 8.1 ± 2.5. Low physical activity (95%), poor exercise capacity (94%) and severe fatigue (75%) were the most prevalent TTs. The sum of TTs present in a subject was associated with the SGRQ total score (r = 0.53; p < 0.001). Severe fatigue, depression, and anxiety were predictors of having a higher SGRQ total score. Conclusions A high prevalence and co-occurrence of multiple TTs were identified in emphysema patients eligible for EBV. Patients with a higher number of TTs were more likely to have worse HRQL.
New advanced bronchoscopic treatment options for patients with severe chronic obstructive pulmonary disease (COPD) have led to increased interest for COPD phenotyping, including fissure completeness.
Background Bronchoscopic lung volume reduction using one-way endobronchial valves (BLVR-EBV) improves exercise capacity and quality of life in patients with severe emphysema. However, its effect on symptoms of fatigue, anxiety and depression is unclear. Furthermore, if the combination of pulmonary rehabilitation (PR) and BLVR-EBV yields additional impact on these symptoms remains unknown. We hypothesized that BLVR-EBV would reduce symptoms of fatigue, anxiety and depression and that the combination of BLVR-EBV with PR would lead to additional reduction when compared to BLVR-EBV alone. Methods The SoLVE study ( NCT03474471 ) was a prospective multicentre randomised controlled trial to examine the impact and optimal timing of PR on exercise physiology and patient reported outcomes in patients receiving BLVR-EBV treatment. Subjects were randomised into three groups: PR before BLVR-EBV, PR after BLVR-EBV and BLVR-EBV alone. Fatigue severity was assessed using the Checklist Individual Strength fatigue subscale (CIS-fatigue). The Hospital Anxiety and Depression Scale evaluated symptoms of anxiety (HADS-A) and depression (HADS-D). Results Ninety-seven participants were included. After 6-months follow-up the overall mean change after BLVR-EBV with or without PR was −8.2±10.6 points on CIS-fatigue score, −2.2±2.9 points on HADS-A and −2.3±3.0 points on HADS-D (p<0.001). No significant differences were observed between groups for changes in CIS-fatigue, HADS-A and HADS-D. Conclusion BLVR-EBV is an effective intervention to improve symptoms of fatigue, anxiety and depression. The combination of PR and BLVR-EBV did not result in additional improvement when compared to BLVR-EBV alone.
<b><i>Background:</i></b> Currently, patients with COPD who are evaluated for bronchoscopic treatments are routinely screened for pulmonary hypertension (PH) and systolic left ventricle dysfunction by echocardiography. <b><i>Objectives:</i></b> We evaluated the prevalence of PH and systolic left ventricle dysfunction in this patient group and investigated if the previously proposed CT-derived pulmonary artery to aorta (PA:A) ratio >1 and PA diameter measurements can be used as alternative screening tools for PH. <b><i>Methods:</i></b> Two hundred fifty-five patients were included in this retrospective analysis (FEV<sub>1</sub> 25%pred, RV 237%pred). All patients received transthoracic echocardiography and chest CT scans on which diameters of the aorta and pulmonary artery were measured at the bifurcation and proximal to the bifurcation. <b><i>Results:</i></b> Following echocardiography, 3 patients (1.2%) had PH and 1 (0.4%) had systolic left ventricle dysfunction. Using a PA:A ratio >1, only 10.3% of the patients with a right ventricular systolic pressure (RVSP) ≥35 mm Hg were detected and none of the patients with an RVSP >50 mm Hg were detected. Patients with an RVSP ≥35 mm Hg had significantly higher PA diameters (29.5 vs. 27.5 mm; <i>p</i> = 0.02) but no significantly different PA:A ratios. All patients with an RVSP >50 mm Hg had PA diameters >30 mm. <b><i>Conclusions:</i></b> The prevalence of PH and systolic left ventricle dysfunction is low in this preselected cohort of patients with severe COPD. In this population, a PA:A ratio >1 is not a useful cardiac screening tool for PH. A PA diameter >30 mm could substitute for routinely performed echocardiography in the screening for PH in this patient group.
Introduction The relation between the degree of diaphragm flattening and lung function impairment in COPD remains largely unknown. We aim to develop a CT-based diaphragm analysis tool to investigate the association between diaphragm configuration and pulmonary function in COPD. Methods We developed a CT-based diaphragm analysis tool based on: 1) identification of the pulmonary lobes using an AI-based lung quantification platform (LungQ, Thirona, Nijmegen, The Netherlands), 2) extraction of a 3D-shape map of the lung-diaphragm intersection (Figure 1A), and 3) calculation of a diaphragm index (ratio of diaphragm surface area/projected surface area). Inspiratory CT scans from the first phase of the COPDGene study (n=9567) were used to evaluate the relation between the automatically extracted diaphragm index and FEV1 %-predicted, GOLD stages, and CT quantified emphysema (LAA<-950) (Figure 1). Results We found a significant association between the diaphragm index and emphysema (Figure 1C), FEV1 %- predicted (Figure 1D), and the COPD GOLD stages (Figure 1B). Conclusions With an in-house developed, automatic CT-based diaphragm analysis tool, we showed significant differences in diaphragm configuration relative to pulmonary function in COPD.
Abstract Background and Objective Both bronchoscopic lung volume reduction with endobronchial valves (BLVR‐EBV) and pulmonary rehabilitation (PR) are effective treatments for improving exercise capacity and patient‐reported outcomes in patients with severe Chronic Obstructive Pulmonary Disease (COPD). According to current recommendations, all BLVR‐EBV patients should have undergone PR first. Our aim was to study the effects of PR both before and after BLVR‐EBV compared to BLVR‐EBV alone. Methods We included patients with severe COPD who were eligible for BLVR‐EBV and PR. Participants were randomized into three groups: PR before BLVR‐EBV, PR after BLVR‐EBV or BLVR‐EBV without PR. The primary outcome was change in constant work rate cycle test (CWRT) endurance time at 6‐month follow‐up of the PR groups compared to BLVR‐EBV alone. Secondary endpoints included changes in 6‐minute walking test, daily step count, dyspnoea and health‐related quality of life. Results Ninety‐seven participants were included. At 6‐month follow‐up, there was no difference in change in CWRT endurance time between the PR before BLVR‐EBV and BLVR‐EBV alone groups (median: 421 [IQR: 44; 1304] vs. 787 [123; 1024] seconds, p = 0.82) or in any of the secondary endpoints, but the PR after BLVR‐EBV group exhibited a smaller improvement in CWRT endurance time (median: 107 [IQR: 2; 573], p = 0.04) and health‐related quality of life compared to BLVR‐EBV alone. Conclusion The addition of PR to BLVR‐EBV did not result in increased exercise capacity, daily step count or improved patient‐reported outcomes compared to BLVR‐EBV alone, neither when PR was administered before BLVR‐EBV nor when PR was administered after BLVR‐EBV.
