Position statement on endoscopic lung volume reduction in South Africa: 2022 update.

Chronic obstructive pulmonary disease (COPD) remains one of the most common causes of morbidity and mortality in South Africa. Endoscopic lung volume reduction (ELVR) was first proposed by the South African Thoracic Society (SATS) for the treatment of advanced emphysema in 2015. Since the original statement was published, there has been a growing body of evidence that a certain well-defined sub-group of patients with advanced emphysema may benefit from ELVR, to the point where the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines and the United Kingdom National Institute for Health and Care Excellence (NICE) advocate the use of endoscopic valves based on level A evidence. Patients aged 40 - 75 years with severe dyspnoea (COPD Assessment Test score ≥10) despite maximal medical therapy and pulmonary rehabilitation, with forced expiratory volume in one second (FEV1) 20 - 50%, hyperinflation with residual volume (RV) >175% or RV/total lung capacity (TLC) >55% and a six-minute walking distance (6MWD) of 100 - 450 m (post-rehabilitation) should be referred for evaluation for ELVR, provided no contraindications (e.g. severe pulmonary hypertension) are present. Further evaluation should focus on the extent of parenchymal tissue destruction on high-resolution computed tomography (HRCT) of the lungs and interlobar collateral ventilation (CV) to identify a potential target lobe. Commercially available radiology software packages and/or an endobronchial catheter system can aid in this assessment. The aim of this statement is to provide the South African medical practitioner and healthcare funders with an overview of the practical aspects and current evidence for the judicious use of the valves and other ELVR modalities which may become available in the country.

[Spontaneous clinical improvement in a COPD patient]. / Spontane klinische verbetering bij een COPD-patiënt.

BACKGROUND: Bullous lung emphysema is a progressive disease, which may be partly explained by gradual expansion of bullae. These air-spaces arise after destruction of alveolar lung tissue. In some patients, bullae can merge into a giant bulla comprising more than 30% of the hemithorax. This bulla compresses surrounding relatively healthy lung parenchyma and regression results in improvement of pulmonary function, exertional tolerance and quality of life. This can be achieved with medication, surgery and with new experimental bronchoscopic lung volume reduction therapy. CASE DESCRIPTION: A 58-year-old man presented at the outpatient clinic because of exertion-induced dyspnoea. Additional diagnostics revealed bullous lung emphysema in which the left lower lobe had been transformed into a single large bulla over the course of 7 years of monitoring. His exertional tolerance continued to decrease gradually until there was an unexpected spectacular improvement of his lung function. This improvement proved to be caused by spontaneous resorption of the bulla. CONCLUSION: Patients with severe bullous lung emphysema may benefit from resorption of large bullae. This mostly requires treatment, but resorption sometimes can be a spontaneous occurrence.