Tratamento endoscópico do Enfisema: uma atualização / Bronchoscopic Treatment of Emphysema: an Update

O objetivo desta revisão foi apresentar uma atualização das alternativas endoscópicas utilizadas no tratamento do enfisema pulmonar. Os mecanismos bloqueadores de fluxo (válvulas) permanecem como os únicos dispositivos aprovados para uso clínico no tratamento do enfisema pulmonar na América do Sul. A válvula endobrônquica Zephyr® representa o método broncoscópico para o tratamento do enfisema mais bem estudado até o momento, e seu uso clínico está autorizado em diversos países da Europa, Ásia e América do Sul. A válvula IBV® obteve aprovação para uso no tratamento de fuga aérea prolongada nos EUA. Os critérios mais frequentemente analisados na indicação de tratamento endoscópico, além dos aspectos clínicos, incluem o aprisionamento dinâmico, a heterogeneidade e a ventilação colateral, em especial, a passagem de ar através das cissuras interlobares. Atualmente, há softwares que permitem a medida precisa da heterogeneidade e da integridade da cissura.Os resultados obtidos em diversas séries de casos e alguns ensaios randomizados têm trazido nova luz ao entendimento da fisiopatologia dessa doença. No entanto, ainda há necessidade de mais estudos randomizados utilizando o conhecimento adquirido até o momento

The objective of this review is to present an update on endoscopic alternatives for the treatment of emphysema.One-way endobronchial valves continue to be the only devices approved for clinical use in the treatment of emphysema inSouth America. The use of the Zephyr® endobronchial valve is currently the most widely studied bronchoscopic method fortreatment of emphysema and has been approved for clinical use in several countries in Europe, Asia, and South America. Another valve, the IBV® valve, has been approved for use in the treatment of persistent air leaks in the United States. In additionto clinical features, the criteria most often analyzed for indicating endoscopic treatment are dynamic hyperinflation, heterogeneity, and collateral ventilation, especially the passage of air through the interlobar fissures. Currently, there is softwarecapable of accurately measuring heterogeneity and fissure integrity.The results obtained in various case series and certain randomized trials have shed new light on the pathophysiology of emphysema. However, additional randomized trials using the knowledge gained thus far are warranted in order to furtherevaluate this procedure

Tratamento endoscópico do enfisema / Bronchoscopic treatment of emphysema

O objetivo do presente estudo foi apresentar as alternativas endoscópicas para o tratamento do enfisema pulmonar. Os tratamentos incluem o remodelamento com cola biológica e vapor, mecanismos bloqueadores do fluxo aéreo (válvulas) e mecanismos não bloqueadores (coils). A principal diferença entre o remodelamento e os dispositivos (bloqueadores ou não) é que o remodelamento é definitivo, enquanto válvulas e coils podem ser retirados e substituídos. Até o momento, somente válvulas foram aprovadas para uso clínico na América do Sul. Os fatores mais significativos para selecionar pacientes para os diversos tratamentos não cirúrgicos, além dos aspectos clínicos, são o aprisionamento dinâmico, a heterogeneidade e a ventilação colateral. A broncoscopia virtual tem um papel importante no planejamento do tratamento endoscópico do enfisema, diminuindo o tempo do procedimento. Tendo em vista as dúvidas que permanecem acerca dos mecanismos fisiopatológicos de melhora dos pacientes e dos critérios de seleção dos mesmos, é fundamental estabelecer protocolos para o emprego dessas técnicas. Também são necessárias meta-análises para interpretar os resultados já descritos na literatura, assim como estudos randomizados de grande porte que levem em conta os conhecimentos adquiridos até o momento.

The objective of this review is to present endoscopic alternatives for the treatment of emphysema. Treatments include tissue remodeling with biological glue or thermal vapor; airflow blocking mechanisms (valves); and nonblockingmechanisms (coils). The main difference between the remodeling technique and the use of (blocking or non-blocking)devices is that remodeling is definitive, whereas valves and coils can be removed and replaced. In South America, only valve implants have been approved for clinical use. In addition to clinical features, the major criteria for selecting patients for nonsurgical treatment are dynamic hyperinflation, heterogeneity, and collateral ventilation. Virtual bronchoscopy, which reduces the procedure time, plays an important role in the planning of endoscopic treatment for emphysema. Questions remain regarding patient selection criteria and the pathophysiological mechanisms leading to improvement. It is therefore essential to establish guidelines for the use of this technology. Meta-analyses interpreting the results described inthe literature, as well as large randomized trials of the various techniques, should also be conducted to further evaluate this procedure.

Tratamento endoscopico das estenoses funcionais das vias aereas / Bronchoscopic management of functional airway obstruction

O objetivo do presente estudo foi caracterizar a traqueobroncomalacia (TBM) e excessive dynamic airway collapse (EDAC, colapso dinâmico excessivo das vias aereas). Embora a TBM e o EDAC, caracterizados por uma redução de 50% ou mais da luz, sejam descritos com frequencia crescente na forma de relatos de casos clinicos, faltam dados sistematizados que permitam o pronto diagnostico e a distinção entre TBM e EDAC. As tecnicas endoscopicas tem papel fundamental no diagnostico e podem ser uma alternativa para o tratamento de TBM e EDAC. É evidente a necessidade de estudos mais aprofundados acerca de TBM e EDAC que permitam o pronto reconhecimento e o tratamento adequado dessas entidades e das doenças subjacentes, contribuindo para uma melhora na qualidade de vida dos pacientes.

The objective of this review was to characterize tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC). There have been clinical case reports of TBM and EDAC, both of which are characterized by a ¡Ý 50% reduction in the crosssectional area of the tracheobronchial lumen, and the number of such reports is increasing. However, there are no systematicdata that would facilitate prompt diagnosis and allow distinctions to be drawn between TBM and EDAC. Endoscopic techniques play a key role in the diagnosis of both conditions and might represent an alternative means of treating patients with TBM or EDAC.There is a clear need for further studies of TBM and EDAC in order to develop strategies for the prompt recognition andproper treatment of these entities, as well as of the underlying diseases. The use of such strategies could lead to an improvement in the quality of life of patients within this population.

Novel silicone stent to treat tracheobronchial lesions: results of 35 patients.

We describe a case series of 35 patients with either benign (14) or malignant (21) tracheal stenosis who were treated using a novel silicone stent, the HCPA-1, designed to prevent migration. Between March 2001 and September 2008, 13 women and 22 men received 41 HCPA-1 stents. The median duration of stenting in benign cases was 457 days (range, 4-2,961 days). Successful stent removal with curative results was accomplished in 2 patients with tracheomalacia and 1 with post-intubation stenosis. In malignant cases, the median duration of stenting was 162 days (range, 1-1,279 days). Five patients had tumor progression with obstruction requiring repeated laser resection, dilatation, or additional stents. Two patients died due to airway obstruction despite bronchoscopic intervention. Twelve patients with malignant lesions died with the stent in place. At the end of the study, 3 patients with malignant disease remained alive; 2 were lost to follow-up. The HCPA-1 stent proved to be safe, with no severe complications during the study period, and effective in improving quality of life with relief of dyspnea.

Transbronchoscopic pulmonary emphysema treatment: 1-month to 24-month endoscopic follow-up.

OBJECTIVE: Describe the results of a 1- to 24-month follow-up of individuals undergoing transbronchoscopic placement of one-way valves. DESIGN: Longitudinal, noncomparative study. SETTING: University hospital. PATIENTS: Nineteen heterogeneous emphysema patients. MEASUREMENTS AND RESULTS: Pulmonary function testing, imaging examination, and videobronchoscopy were performed at 1, 3, 6, 12, and 24 months after the insertion of one-way valves. Mean age was 67.63 +/- 8.71 years, mean body mass index (BMI) was 24.02 +/- 2.65, and mean exposure to smoking was 65.32 +/- 27.46 pack-years (+/- SD). Baseline BODE index (BMI, degree of airflow obstruction and dyspnea, exercise capacity as measured by the 6-min walk test [6MWT]) was 7 to 10 in 10 patients (estimated 4-year mortality, 80%) and 5 to 6 in 9 patients (estimated 4-year mortality, 40%). Sixty-four valves were inserted. There was no procedure-related mortality. Nonsustained atelectasis was observed within 48 h in 2 of 12 patients with right upper lobe occlusion. Fifty-six bronchoscopic examinations were performed in 24 months. Granulomas not requiring treatment were the main complication. Mucus clogging the valve, mainly at 1 month, was easily cleaned. Eighteen patients completed the 1- and 3-month follow-ups, 14 patients completed the 6-month follow-up, 11 patients completed the 12-month follow-up, and 5 patients completed the 24-month follow-up. Improvement was observed in the 6MWT after 1 month (p = 0.028) and in the BODE index at 3 months (p = 0.002). FEV1 or FVC improvement > or = 12% or > or = 150 mL was observed, respectively, in 4 of 18 patients and 8 of 18 patients at 1 month, 4 of 18 patients and 7 of 18 patients at 3 months, and in 3 of 14 patients and 5 of 14 patients at 6 months. After 24 months, one of five patients and three of five patients, respectively, retained an FEV1 and FVC change > or = 12% or > or = 150 mL. Significant improvement (decrease > or = 4%) in the St. George Respiratory Questionnaire was observed at 3 months and 6 months in three of four domains. CONCLUSION: Endobronchial valves are safe, but the criteria to measure improvement and to select patients should be refined. Atelectasis should be reconsidered as primary treatment goal.

Rejection and indirect revascularization of glycerin-preserved tracheal implant.

The objective of the following study was to evaluate antigenicity, malacia and revascularization in glycerin-preserved canine tracheal allografts. Trachea with six cartilage rings (2.4 to 3.1 cm) were distributed in three study groups: autograft (21), allograft (18) and glycerin-preserved (22). We implanted two segments from different groups in the greater omentum of dogs. After 28 days, latex was injected in the canine aorta before the segments were harvested. We evaluated number of sectors with functional vessels, number of vessels dyed in the submucosa, acute arteritis score, incidence of acute rejection, cartilage lesion score, and malacia. The autograft group had a larger number of dyed vessels than the glycerin-preserved group. The autograft group also had a higher average number of quadrants with functional vessels than the allograft group and the glycerin-preserved group. The allograft group had a higher mean score for acute arteritis than the autograft group and more acute rejection than the glycerin-preserved group. The cartilage lesion score did not show any significant difference between groups. Malacia was not observed in any tracheal segment. Overall, the glycerin-preserved tracheal implant had low antigenicity and good rigidity, but showed incomplete revascularization.