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Clinical Application Of Airway Bypass, A New Bronchoscopic Procedure For Severe Emphysema

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Objective: The feasibility, safety and functional outcome of airway bypass, a new bronchoscopic procedure for patients with severe emphysema, was evaluated in a multi-center study. Airway bypass is the process of creating extra-anatomic ventilatory passages between the pulmonary parenchyma and large airways to allow trapped gas to exit from the lung. Decreasing the volume of trapped gas improves respiratory mechanics, which leads to improvement in dyspnea and quality of life.
Methods: Patients with severe emphysema and hyperinflation were considered potential candidates for Airway Bypass; those with a homogeneous pattern of destruction were believed to benefit the most. The procedure was performed using a flexible bronchoscope. A Doppler probe was used to identify a blood vessel-free location at the level of a segmental bronchus; a passage was made through the bronchial wall and dilated using a needle/dilation balloon catheter; paclitaxel-eluting stent was placed in the passage and balloon expanded to a diameter of 3mm. Spirometry, lung volumes, dyspnea (modified Medical Research Council grade-mMRC) and quality of life (St.George's Respiratory Questionnaire-SGRQ) were recorded at 6 months and compared to baseline values.
Results: A total of 28 patients at 7 centers were treated from July04 to March05. The average age was 60years. Mean baseline FEV1, RV and TLC were 27%,257%, and 131% predicted, respectively. Four to 12 (mean =9) extra-anatomic stented passages were made per patient. To date 6-month follow up data are available on 19 of the 28 patients. There was a mean reduction in RV of 478mL for the full cohort. The mean reduction in the mMRC score was 0.6units. 15 of the 19 patients were judged to have a homogeneous pattern of destruction. In these patients, the mean reduction in RV was 630mL. The mean reduction in the mMRC was 0.7units. The best results were observed with a combination of homogeneous emphysema and severe hyperinflation (baseline TLC>133%predicted;n=8) causing a mean reduction in RV of 1120mL. The mean reduction in the mMRC score was 1unit. One death occurred following intraoperative bleeding. As a result the Doppler procedure is now repeated after creating the fenestration but prior to placing the stent in the extra-anatomic passage.
Conclusions: The clinical results suggest that airway bypass can benefit selected patients with emphysema, especially those with a combination of homogeneous distribution and severe hyperinflation.
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