Endobronchial Valves for the Treatment of Advanced Emphysema
2020; Elsevier BV; Volume: 159; Issue: 5 Linguagem: Inglês
10.1016/j.chest.2020.12.007
ISSN1931-3543
AutoresKarin Klooster, Dirk‐Jan Slebos,
Tópico(s)Respiratory Support and Mechanisms
ResumoBronchoscopic lung volume reduction with one-way endobronchial valves is a guideline treatment option for patients with advanced emphysema that is supported by extensive scientific data. Patients limited by severe hyperinflation, with a suitable emphysema treatment target lobe and with absence of collateral ventilation, are the responders to this treatment. Detailed patient selection, a professional treatment performance, and dedicated follow up of the valve treatment, including management of complications, are key ingredients to success. This treatment does not stand alone; it especially requires extensive knowledge of COPD for which the most appropriate treatment is discussed in a multidisciplinary approach. We discuss the endobronchial valve treatment for emphysema and provide a guideline for patient selection, treatment guidance, and practice tools, based on our own experience and literature. Bronchoscopic lung volume reduction with one-way endobronchial valves is a guideline treatment option for patients with advanced emphysema that is supported by extensive scientific data. Patients limited by severe hyperinflation, with a suitable emphysema treatment target lobe and with absence of collateral ventilation, are the responders to this treatment. Detailed patient selection, a professional treatment performance, and dedicated follow up of the valve treatment, including management of complications, are key ingredients to success. This treatment does not stand alone; it especially requires extensive knowledge of COPD for which the most appropriate treatment is discussed in a multidisciplinary approach. We discuss the endobronchial valve treatment for emphysema and provide a guideline for patient selection, treatment guidance, and practice tools, based on our own experience and literature. Bronchoscopic lung volume reduction (BLVR) with one-way endobronchial valve (EBV) is a minimally invasive treatment that has been shown to improve clinical outcomes in patients with advanced emphysema and severe hyperinflation.1Klooster K. ten Hacken N.H. Hartman J.E. Kerstjens H.A. van Rikxoort E.M. Slebos D.J. Endobronchial valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (278) Google Scholar,2Shah P.L. Slebos D.J. Bronchoscopic interventions for severe emphysema: where are we now?.Respirology. 2020; 25: 972-980Crossref PubMed Scopus (4) Google Scholar Bronchoscopic placement of EBVs in a suitable target lobe, with proven absence of collateral ventilation with the use of the Chartis Pulmonary Assessment System (Pulmonx Corporation, Redwood City, CA),3Welling J.B.A. Klooster K. Hartman J.E. et al.Collateral ventilation measurement using chartis: procedural sedation vs general anesthesia.Chest. 2019; 156: 984-990Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar induces a (partial) atelectasis of the target lobe.4Slebos D.J. Shah P.L. Herth F.J. Valipour A. Endobronchial valves for endoscopic lung volume reduction: best practice recommendations from expert panel on endoscopic lung volume reduction.Respiration. 2017; 93: 138-150Crossref PubMed Scopus (82) Google Scholar This atelectasis ensures reduction in residual volume (RV) and results in an improvement in lung function, a greater exercise performance, and a better quality of life (Table 1).1Klooster K. ten Hacken N.H. Hartman J.E. Kerstjens H.A. van Rikxoort E.M. Slebos D.J. Endobronchial valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (278) Google Scholar,5Criner G.J. Sue R. Wright S. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (LIBERATE).Am J Respir Crit Care Med. 2018; 198: 1151-1164Crossref PubMed Scopus (129) Google Scholar, 6Kemp S.V. Slebos D.J. Kirk A. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (TRANSFORM).Am J Respir Crit Care Med. 2017; 196: 1535-1543Crossref PubMed Scopus (135) Google Scholar, 7Valipour A. Slebos D.J. Herth F. et al.Endobronchial valve therapy in patients with homogeneous emphysema: results from the IMPACT study.Am J Respir Crit Care Med. 2016; 194: 1073-1082Crossref PubMed Scopus (173) Google ScholarTable 1Results of the Randomized Controlled Trials Investigating Zephyr Endobronchial ValveaPulmonx Corporation, Redwood City, CA. Treatment in Patients With Severe Emphysema With Proven Absence of Collateral Ventilation With the Use Chartis Assessment SystemaPulmonx Corporation, Redwood City, CA.VariableTrialSTELVIO1Klooster K. ten Hacken N.H. Hartman J.E. Kerstjens H.A. van Rikxoort E.M. Slebos D.J. Endobronchial valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (278) Google ScholarIMPACT7Valipour A. Slebos D.J. Herth F. et al.Endobronchial valve therapy in patients with homogeneous emphysema: results from the IMPACT study.Am J Respir Crit Care Med. 2016; 194: 1073-1082Crossref PubMed Scopus (173) Google ScholarTRANSFORM6Kemp S.V. Slebos D.J. Kirk A. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (TRANSFORM).Am J Respir Crit Care Med. 2017; 196: 1535-1543Crossref PubMed Scopus (135) Google ScholarLIBERATE5Criner G.J. Sue R. Wright S. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (LIBERATE).Am J Respir Crit Care Med. 2018; 198: 1151-1164Crossref PubMed Scopus (129) Google ScholarPatients, No./No.EBV34/SoC34EBV43/SoC50EBV65/SoC32EBV128/SoC62Follow up, mo63612Target lobar volume reduction, mL−1366−1195−1090−1142Between group difference FEV1, %+18+17+29+18 Residual volume, mL−831−480−700−522 6-Minute walk distance, m+74+40+79+39 St. George's Respiratory Questionnaire, points−14.7−9.7−6.5−7.1EBV = Zephyr endobronchial valve; SoC = Standard of care.a Pulmonx Corporation, Redwood City, CA. Open table in a new tab EBV = Zephyr endobronchial valve; SoC = Standard of care. Almost two decades ago, the very first EBV case series were published.8Snell G.I. Holsworth L. Borrill Z.L. et al.The potential for bronchoscopic lung volume reduction using bronchial prostheses: a pilot study.Chest. 2003; 124: 1073-1080Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar,9Toma T.P. Hopkinson N.S. Hillier J. et al.Bronchoscopic volume reduction with valve implants in patients with severe emphysema.Lancet. 2003; 361: 931-933Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar Based on a large number of subsequent randomized controlled trials,1Klooster K. ten Hacken N.H. Hartman J.E. Kerstjens H.A. van Rikxoort E.M. Slebos D.J. Endobronchial valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (278) Google Scholar,5Criner G.J. Sue R. Wright S. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (LIBERATE).Am J Respir Crit Care Med. 2018; 198: 1151-1164Crossref PubMed Scopus (129) Google Scholar, 6Kemp S.V. Slebos D.J. Kirk A. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (TRANSFORM).Am J Respir Crit Care Med. 2017; 196: 1535-1543Crossref PubMed Scopus (135) Google Scholar, 7Valipour A. Slebos D.J. Herth F. et al.Endobronchial valve therapy in patients with homogeneous emphysema: results from the IMPACT study.Am J Respir Crit Care Med. 2016; 194: 1073-1082Crossref PubMed Scopus (173) Google Scholar,10Davey C. Zoumot Z. Jordan S. et al.Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial.Lancet. 2015; 386: 1066-1073Abstract Full Text Full Text PDF PubMed Scopus (226) Google Scholar,11Sciurba F.C. Ernst A. Herth F.J. et al.A randomized study of endobronchial valves for advanced emphysema.N Engl J Med. 2010; 363: 1233-1244Crossref PubMed Scopus (608) Google Scholar EBV treatment has regulatory approval (CE-Mark; in the United States, Food and Drug Administration12Zephyr EBV FDA approval letter. 2018.https://www.accessdata.fda.gov/cdrh_docs/pdf18/P180002a.pdfDate accessed: October 2, 2020Google Scholar) and is now a GOLD-COPD13Singh D. Agusti A. Anzueto A. et al.Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019.Eur Respir J. 2019; 53: 1900164Crossref PubMed Scopus (606) Google Scholar and United Kingdom-NICE14Hopkinson N.S. Molyneux A. Pink J. Harrisingh M.C. Chronic obstructive pulmonary disease: diagnosis and management: summary of updated NICE guidance.BMJ. 2019; 366: l4486Crossref PubMed Scopus (30) Google Scholar guideline treatment in patients with advanced emphysema.15Hartman J.E. Vanfleteren L. van Rikxoort E.M. Klooster K. Slebos D.J. Endobronchial valves for severe emphysema.Eur Respir Rev. 2019; 28: 180121Crossref PubMed Scopus (16) Google Scholar Because EBV treatment is a treatment for a very difficult to treat highly prevalent disease, there is an increasing worldwide demand to offer this treatment to patients with severe COPD. In this "How I do it" review, we provide a deeper insight by sharing our in-house expertise to new and also more experienced programs to ensure continued success with this exciting treatment. A 58-year-old woman with COPD (FEV1, 30% of predicted; RV, 239% of predicted), ex-smoker, is receiving optimal medication and recently performed a pulmonary rehabilitation program. Despite all this, the patient still experiences severe dyspnea, a limited exercise capacity, and a poor quality of life. Chest imaging showed that the left lower lobe is a good treatment target lobe for BLVR with the use of valves (Fig 1). Chartis assessment confirmed the absence of collateral ventilation in the target lobe, and a total of 5 EBVs were placed into the left lower lobe. Total procedure time was 30 minutes; no complications occurred. The patient was discharged three nights after the procedure. At 1 year after treatment, she continued to perceive less dyspnea, increased her 6-minute walk distance by 30%, and experienced a better quality of life without side-effects. The high-resolution CT (HRCT) scan showed a complete atelectasis of the left lower lobe with a decrease in RV of 1044 mL and FEV1 improvement of 41% compared from baseline. Selecting patients for lung volume reduction (LVR) therapies is all about COPD phenotyping16Herth F.J.F. Slebos D.J. Criner G.J. Valipour A. Sciurba F. Shah P.L. Endoscopic lung volume reduction: an expert panel recommendation: update 2019.Respiration. 2019; 97: 548-557Crossref PubMed Scopus (39) Google Scholar and is kind of the "art of balancing." Balancing between reducing hyperinflation and maintaining sufficient gas-exchange, balancing between the volume of the lobe to be treated vs the ipsilateral nontreated lobe, and balancing between the expected potential benefit and the risks involved. Thus the question is "how do I know if my patient is a suitable candidate for EBV treatment?" Potential patients who have advanced COPD remain highly symptomatic despite receiving optimal medical treatment.13Singh D. Agusti A. Anzueto A. et al.Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019.Eur Respir J. 2019; 53: 1900164Crossref PubMed Scopus (606) Google Scholar,14Hopkinson N.S. Molyneux A. Pink J. Harrisingh M.C. Chronic obstructive pulmonary disease: diagnosis and management: summary of updated NICE guidance.BMJ. 2019; 366: l4486Crossref PubMed Scopus (30) Google Scholar To facilitate this question a structured step-wise evaluation approach can be very helpful. Symptoms can be assessed with validated questionnaires. Symptomatic patients with COPD Assessment Test17Jones P.W. Harding G. Berry P. Wiklund I. Chen W.H. Kline Leidy N. Development and first validation of the COPD Assessment Test.Eur Respir J. 2009; 34: 648-654Crossref PubMed Scopus (1652) Google Scholar scores ≥10 and modified Medical Research Council dyspnea scale dyspnea score18Vogelmeier C.F. Alter P. Assessing symptom burden.Clin Chest Med. 2020; 41: 367-373Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ≥2, and limited exercise performance (6-minute walk distance between 100 and 450 m) are candidates. LVR candidates should be limited significantly because of lung hyperinflation. Assessment of symptoms and physical limitations is, however, very subjective and also largely dependent on individual patient preferences.19Hartman J.E. Klooster K. Ten Hacken N.H.T. van Dijk M. Slebos D.J. Patient satisfaction and attainment of patient-specific goals after endobronchial valve treatment.Ann Am Thorac Soc. 2020; (2021;18(1):68-74.)Google Scholar It is important to understand and discuss a patient's treatment outcome expectations and goals and to explain the pros and cons of not performing a treatment or alternative options. Patient preference is an important topic of any LVR program, because the treatments performed are often timed in an end-of-life situation of the patient with COPD and often will result in the desired outcome but can also end in disappointment.19Hartman J.E. Klooster K. Ten Hacken N.H.T. van Dijk M. Slebos D.J. Patient satisfaction and attainment of patient-specific goals after endobronchial valve treatment.Ann Am Thorac Soc. 2020; (2021;18(1):68-74.)Google Scholar,20Mansfield C. Sutphin J. Shriner K. Criner G.J. Celli B.R. Patient preferences for endobronchial valve treatment of severe emphysema.Chronic Obstr Pulm Dis. 2018; 6: 51-63PubMed Google Scholar Smoking cessation, receiving guideline pharmacologic therapy, completed pulmonary rehabilitation, and/or are participating in a structured physical therapy program, nutrition support, long-term oxygen therapy, and noninvasive ventilation should all have been evaluated and optimized as appropriate.13Singh D. Agusti A. Anzueto A. et al.Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019.Eur Respir J. 2019; 53: 1900164Crossref PubMed Scopus (606) Google Scholar,21van Dijk M. Gan C.T. Koster T.D. et al.Treatment of severe stable COPD: the multidimensional approach of treatable traits.ERJ Open Res. 2020; 6: 00322-2019Crossref PubMed Scopus (3) Google Scholar Postbronchodilator FEV1/FVC < 70% and FEV1 between 15% and 50% of predicted are suggestions. Good outcomes have been published in selected cases with very optimal treatment targets that had both lower and higher FEV1 values.1Klooster K. ten Hacken N.H. Hartman J.E. Kerstjens H.A. van Rikxoort E.M. Slebos D.J. Endobronchial valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (278) Google Scholar,22Darwiche K. Karpf-Wissel R. Eisenmann S. et al.Bronchoscopic lung volume reduction with endobronchial valves in low-FEV1 patients.Respiration. 2016; 92: 414-419Crossref PubMed Scopus (18) Google Scholar The bottom line is that patients need to have severe COPD that is proven to be the limiting factor of their dyspnea. Postbronchodilator RV ≥175% of predicted and RV/total lung capacity ≥55%, measured by body plethysmography are suggestions. Good outcomes have been published in selected cases with very optimal treatment targets that had a lower RV or RV/TLC ratio.23Klooster K. Hartman J.E. van Dijk M. Koster T.D. Slebos D.J. Response to endobronchial valve treatment in emphysema patients with moderate hyperinflation. J Bronchology Interv Pulmonol.Eur Respir J. 2021; (28(1):e14-e17)Google Scholar As long as an individual patient is significantly limited by hyperinflation, the patient can be evaluated for LVR options. Patients are less likely to be eligible if they have one of more of the following occurrences:•Severe hypercapnia (Paco2 >8 kPa/>60 mm Hg) or severe hypoxia (Pao2 45 mm Hg) at room air (sea level), both for safety reasons•Significant congestive heart failure (left ventricular ejection fraction 50 mm Hg)•Use of coumadins/antiplatelets, which cannot be stopped around the procedure•Maintenance immunosuppressive agents or prednisolone ≥10 mg daily (to avoid severe local microbiologic colonization of the device)•Previous lobectomy, lung transplantation, or LVR surgery•Frequent infectious exacerbations (bronchitis phenotype) and/or symptomatic bronchiectasis•Diffusing capacity for carbon monoxide (Dlco) 60% of predicted A Dlco >60% means that there is still well lung tissue preserved, which is another COPD phenotype. Another COPD phenotype like small airways disease, chronic bronchitis, or asthma COPD overlap syndrome can also cause hyperinflation and symptoms. Assessment of a low diffusing capacity in LVR candidates requires a lot of nuances, and a Dlco of <20% of the predicted value cannot be regarded as a definite exclusion criterion. Good outcomes have been published in patients with a low ( 30% (or >50% at −910 Hounsfield Units).29Gevenois P.A. De Vuyst P. de Maertelaer V. et al.Comparison of computed density and microscopic morphometry in pulmonary emphysema.Am J Respir Crit Care Med. 1996; 154: 187-192Crossref PubMed Scopus (460) Google Scholar,30Gierada D.S. Bierhals A.J. Choong C.K. et al.Effects of CT section thickness and reconstruction kernel on emphysema quantification relationship to the magnitude of the CT emphysema index.Acad Radiol. 2010; 17: 146-156Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar If there is not enough emphysematous tissue present in the target lobe, too much functional lung tissue will become atelactatic and cause V/Q mismatch (shunting) with resultant chest discomfort and dyspnea and likely no benefit of the procedure. Lobar volumes also have to be considered in guiding treatment decisions. As an example, when considering a target lobe with a 2500 mL volume against the ipsilateral lobe with a volume of 750 mL, serious problems could occur if the ipsilateral lobe with a small volume has no healthy lung tissue (eg, destruction scores >30% at −950 Hounsfield Units). No clear cut-off values exist for these volumes, but a judgment would have to be made on whether the smaller remaining lobe is capable of occupying the entire hemithorax again after treatment. Fissure integrity is a surrogate for the absence or presence of collateral ventilation.31Klooster K. Koster T.D. Ruwwe-Glösenkamp C. et al.An integrative approach of the fissure completeness score and chartis assessment in endobronchial valve treatment for emphysema.Int J Chron Obstruct Pulmon Dis. 2020; 15: 1325-1334Crossref PubMed Scopus (7) Google Scholar, 32Koster T.D. Slebos D.J. The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema.Int J Chron Obstruct Pulmon Dis. 2016; 11: 765-773Crossref PubMed Scopus (49) Google Scholar, 33Koster T.D. van Rikxoort E.M. Huebner R.H. et al.Predicting lung volume reduction after endobronchial valve therapy is maximized using a combination of diagnostic tools.Respiration. 2016; 92: 150-157Crossref PubMed Scopus (58) Google Scholar EBV treatment is effective only if there is absence of collateral ventilation in the target lobe.1Klooster K. ten Hacken N.H. Hartman J.E. Kerstjens H.A. van Rikxoort E.M. Slebos D.J. Endobronchial valves for emphysema without interlobar collateral ventilation.N Engl J Med. 2015; 373: 2325-2335Crossref PubMed Scopus (278) Google Scholar,5Criner G.J. Sue R. Wright S. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (LIBERATE).Am J Respir Crit Care Med. 2018; 198: 1151-1164Crossref PubMed Scopus (129) Google Scholar, 6Kemp S.V. Slebos D.J. Kirk A. et al.A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (TRANSFORM).Am J Respir Crit Care Med. 2017; 196: 1535-1543Crossref PubMed Scopus (135) Google Scholar, 7Valipour A. Slebos D.J. Herth F. et al.Endobronchial valve therapy in patients with homogeneous emphysema: results from the IMPACT study.Am J Respir Crit Care Med. 2016; 194: 1073-1082Crossref PubMed Scopus (173) Google Scholar,34Herth F.J. Eberhardt R. Gompelmann D. et al.Radiological and clinical outcomes of using Chartis™ to plan endobronchial valve treatment.Eur Respir J. 2013; 41: 302-308Crossref PubMed Scopus (191) Google Scholar Recent studies have shown that patients with an incomplete fissure based on a fissure completeness score (FCS; with the use of QCT analysis) of 80% complete fissures, the FCS is not specific enough for EBV treatment decision. In this case, additional Chartis measurements are always recommended for the right lung fissures.31Klooster K. Koster T.D. Ruwwe-Glösenkamp C. et al.An integrative approach of the fissure completeness score and chartis assessment in endobronchial valve treatment for emphysema.Int J Chron Obstruct Pulmon Dis. 2020; 15: 1325-1334Crossref PubMed Scopus (7) Google Scholar For the left lung, Chartis assessments may be omitted if the FCS is >95%.31Klooster K. Koster T.D. Ruwwe-Glösenkamp C. et al.An integrative approach of the fissure completeness score and chartis assessment in endobronchial valve treatment for emphysema.Int J Chron Obstruct Pulmon Dis. 2020; 15: 1325-1334Crossref PubMed Scopus (7) Google Scholar The advantage of always performing Chartis assessments is to ensure that there can be an expected treatment benefit and that any lack of volume reduction after valve placement is most likely not due to the presence of collateral flow but rather due to a valve misplacement or other factors, such as adhesions limiting lung deflation. Selecting the best EBV treatment target lobe is crucial for a good outcome and to avoid serious complications such as severe hypoxia, respiratory failure, and severe pneumothorax. Only one lobe can be treated in a single procedure for safety reasons. However, the right upper lobe and right middle lobe combination can be regarded as a single lobe in cases in which there is collateral flow across the minor fissure. Selecting the optimal target lobe requires combining diagnostic information, where both absence of collateral ventilation (Chartis or FCS on CT scan) and at least 30% emphysematous destruction at ≤−950 Hounsfield Units (≥50% at ≤−910 Hounsfield Units) with the use of QCT analysis, are important features to assess. The ideal lobe (and lung) targeted for treatment is characterized by the highest level of emphysema heterogeneity, the lowest perfusion present on nuclear perfusion scintigraphy (or alternative perfusion methods), balanced lung volumes, and most air trapping (with the use of expiratory CT scan, especially helpful in homogeneous cases). Local factors such as significant pleural adhesions or pleural thickening,35van Geffen W.H. Klooster K. Hartman J.E. et al.Pleural adhesion assessment as a predictor for pneumothorax after endobronchial valve treatment.Respiration. 2017; 94: 224-231Crossref PubMed Scopus (17) Google Scholar presence of bronchiectasis, fibrotic changes, nodules or a large bulla, or significant paraseptal emphysema just adjacent to the target lobe might make a potential target lobe less suitable for treatment. Based on the emphysema distribution on QCT analysis, combined with a treatable FCS, it is possible to have multiple targets for an individual patient. Again, combining visual CT (and air trapping), QCT analysis, perfusion data, and Chartis assessment will result in deciding on the one preferable lobe. In general, for a more homogeneous emphysema distribution, relatively more hyperinflation, and preserved gas exchange (ie, better Dlco and blood gasses) are needed to get a good outcome after treatment, compared with a heterogeneous (upper or lower lobe) emphysema distribution. Both the Chartis measurement and the placement of the valves can be performed preferably in a single procedure (to avoid additional bronchoscopy-related adverse events36Bellinger C.R. Khan I. Chatterjee A.B. Haponik E.F. Bronchoscopy safety in patients with chronic obstructive lung disease.J Bronchol Interv Pulmonol. 2017; 24: 98-103Crossref PubMed Scopus (16) Google Scholar), with deep conscious sedation or with general anesthesia.3Welling J.B.A. Klooster K. Hartman J.E. et al.Collateral ventilation measurement using chartis: procedural sedation vs general anesthesia.Chest. 2019; 156: 984-990Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,37Welling J.B.A. Hartman J.E. Ten Hacken N.H.T. et al.Chartis measurement of collateral ventilation: conscious sedation versus general anesthesia: a retrospective comparison.Respiration. 2018; 96: 480-487Crossref PubMed Scopus (9) Google Scholar,38Thiruvenkatarajan V. Maycock T. Grosser D. Currie J. Anaesthetic management for endobronchial valve insertion: lessons learned from a single centre retrospective series and a literature review.BMC Anesthesiol. 2018; 18: 206Crossref PubMed Scopus (3) Google Scholar In practice, it turns out that both Chartis and the placement of the valves with general anesthesia is more accurate and easier to perform because there is less coughing, less mucus production, and less mucosal swelling and that the diameter of the airways can be measured more precisely to select the correct valve size for placement.3Welling J.B.A. Klooster K. Hartman J.E. et al.Collateral ventilation measurement using chartis: procedural sedation vs general anesthesia.Chest. 2019; 156: 984-990Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,4Slebos D.J. Shah P.L. Herth F.J. Valipour A. Endobronchial valves for endoscopic lung volume reduction: best practice recommendations from expert panel on endoscopic lung volume reduction.Respiration. 2017; 9
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