Innovative bronchoscopic treatments for respiratory patients

Innovative bronchoscopic treatments for respiratory patients are continuing to evolve and can bring significant additional benefits for appropriate patients, the 2021 ITS Annual Scientific Meeting was told. Prof Dirk-Jan Slebos, Professor of Interventional Pulmonology, University Medical Centre Groningen, Netherlands, who has extensive knowledge and research in the area, gave a comprehensive overview of bronchoscopic interventions for chronic obstructive pulmonary disease (COPD), emphysema, and chronic bronchitis.

He quoted data showing a median survival of 5.7 years versus 8.4 years in COPD patients not offered bronchoscopic lung volume reduction; “so we know that reducing hyperinflation works”. Endobronchial valves are increasingly being used to treat hyperinflation in COPD, but about 20 per cent of patients are not eligible; “so there is a big need for additional treatments,” which include coils and lung volume reduction surgery. Disadvantages of valves include the risk of a pneumothorax (10-33 per cent), and the fact that revision bronchoscopies can be needed to prolong the effect of treatment or address longterm complications.

Moreover, it is a complex treatment with respect to patient selection, intervention and follow-up, and should be performed in specialised centres only, Prof Slebos told the meeting. Targeted lung denervation (TLD) is a 60-minute outpatient procedure performed under general anaesthesia, and fluoroscopy guided, which aims to decrease the release of acetylcholine, which regulates smooth muscle tone and mucus production, by ablating the parasympathetic nerves running alongside the main bronchi.

It leads to sustained airway dilation, with studies showing a decrease in COPD exacerbations following the procedure, he said. In COPD, TLD is intended for symptomatic and at-risk patients, ie, persistent exacerbation history, and persistent high symptom burden (CAT). There is an unmet need in patients with maximal guideline based pharmacotherapy (COPD Gold D), Prof Slebos said.

Looking at emphysema, he cited numerous studies showing that prompt treatment with valves in carefully selected patients achieves good outcomes. “Outcomes depicted over a year are an increase in six minute walk distance, improvement in the St George’s Respiratory Questionnaire, which is a quality-of-life measurement, on top of maximum medical management and pulmonary rehabilitation, so this is really additional benefit.”

New developments for emphysema include new types of coils, airway bypass, and fissure closing. Moving on to chronic bronchitis, Prof Slebos noted that in the past decade there has been significant developments in bronchoscopic treatments. These include liquid nitrogen metered cryospray (RejuvenAir), bronchial rheoplasty and balloon desobstruction, which all aim to destroy the hyperplastic goblet cells and excess submucous glands using different strategies.

Explaining the RejuvenAir technology, where the metered cryospray is delivered via a bronchoscope through a radial spray catheter, he said it is a well-tolerated outpatient procedure, with early signals of a quality-of-life improvement, stable lung function parameters, but durability and effect on exacerbations are not yet known (trial ongoing).

TLD is another option; however, confirmation of the benefit in improvement in chronic bronchitis symptoms is still needed as this treatment is not specifically aimed at chronic bronchitis, but at COPD in general. Concluding, Prof Slebos said that bronchoscopic interventions for COPD and chronic bronchitis are additional to standard treatment (COPD), “bronchoscopic lung volume reduction is a guideline treatment,” phenotyping patients is key, and new developments are ongoing.