The minimal important difference of the constant work rate cycle test in severe COPD.

BACKGROUND: The Constant Work Rate Cycle Test (CWRT) is a commonly used and sensitive test to detect treatment success in patients with Chronic Obstructive Pulmonary Disease (COPD). Earlier, the Minimal Important Difference (MID) of the CWRT was estimated at 101 s (or 34%) change from baseline based on one well executed study. However, this study was performed in a population of patients with mild-to-moderate COPD, and we have learned that MIDs might be quite different in patients with severe COPD. Therefore, we aimed to establish the MID of the CWRT in patients with severe COPD. METHODS: We included 141 patients with severe COPD, who underwent either pulmonary rehabilitation, bronchoscopic lung volume reduction with endobronchial valves, or a sham bronchoscopy as a control group. CWRT workload was set at 75% of the peak work capacity, as determined by an incremental cycle test. We used the change in 6-min walking test (6-MWT), forced expiratory volume in 1s (FEV1), residual volume (RV), and St. George's Respiratory Questionnaire (SGRQ) total score as anchors to calculate the MID. RESULTS: All anchors had an association of ≥0.41 with change in CWRT. The MID estimates for the different anchors were: 6-MWT 278 s (95%), FEV1 273 s (90%), RV 240 s (84%), and SGRQ 208 s (71%). The average of these four MID estimates resulted in an MID of 250 s (or 85%). CONCLUSION: We established the MID for CWRT at 250 s (or 85%) change from baseline in patients with severe COPD.

Survival in COPD patients treated with bronchoscopic lung volume reduction.

BACKGROUND AND OBJECTIVE: Severe COPD patients can significantly benefit from bronchoscopic lung volume reduction (BLVR) treatments with coils or endobronchial valves. However, the potential impact of BLVR on survival is less understood. Therefore, our aim was to investigate the survival rate in patients who are evaluated for BLVR treatment and whether there is a difference in survival rate between patients who undergo BLVR treatment and patients who do not. METHODS: We included patients with COPD who visited our hospital for a consultation evaluating their eligibility for BLVR treatment and who performed pulmonary function tests during this visit. Furthermore, vital status was verified. RESULTS: In total 1471 patients were included (63% female, mean age 61 years). A total of 531 patients (35%) died during follow-up and the median survival time of the total population was 2694 days (95% confidence interval(CI) 2462-2926) which is approximately 7.4 years. The median survival time of patients who were treated with BLVR was significantly longer compared to patients who were not treated with BLVR (3133 days versus 2503 days, p < 0.001), and BLVR was found to be an independent predictor of survival when adjusting for other survival-influencing factors such as age, gender or severity of disease. CONCLUSIONS: Our results suggest that bronchoscopically reducing lung volume in patients with severe hyperinflation may lead to a survival benefit for a population with a severely reduced life expectancy.

Identifying Responders and Exploring Mechanisms of Action of the Endobronchial Coil Treatment for Emphysema.

BACKGROUND: So far, 3 randomized controlled trials have shown that the endobronchial treatment using coils is safe and effective. However, the more exact underlying mechanism of the treatment and best predictors of response are unknown. OBJECTIVES: The aim of the study was to gain more knowledge about the underlying physiological mechanism of the lung volume reduction coil treatment and to identify potential predictors of response to this treatment. METHODS: This was a prospective nonrandomized single-center study which included patients who were bilaterally treated with coils. Patients underwent an extensive number of physical tests at baseline and 3 months after treatment. RESULTS: Twenty-four patients (29% male, mean age 62 years, forced expiratory volume in 1 s [FEV1] 26% pred, residual volume (RV) 231% pred) were included. Three months after treatment, significant improvements were found in spirometry, static hyperinflation, air trapping, airway resistance, treated lobe RV and treated lobes air trapping measured on CT scan, exercise capacity, and quality of life. The change in RV and airway resistance was significantly associated with a change in FEV1, forced vital capacity, air trapping, maximal expiratory pressure, dynamic compliance, and dynamic hyperinflation. Predictors of treatment response at baseline were a higher RV, larger air trapping, higher emphysema score in the treated lobes, and a lower physical activity level. CONCLUSIONS: Our results confirm that emphysema patients benefit from endobronchial coil treatment. The primary mechanism of action is decreasing static hyperinflation with improvement of airway resistance which consequently changes dynamic lung mechanics. However, the right patient population needs to be selected for the treatment to be beneficial which should include patients with severe lung hyperinflation, severe air trapping, and significant emphysema in target lobes.

Comparison of Multiple Diagnostic Tests to Measure Dynamic Hyperinflation in Patients with Severe Emphysema Treated with Endobronchial Coils.

PURPOSE: For this study, we aimed to compare dynamic hyperinflation measured by cardiopulmonary exercise testing (CPET), a six-minute walking test (6-MWT), and a manually paced tachypnea test (MPT) in patients with severe emphysema who were treated with endobronchial coils. Additionally, we investigated whether dynamic hyperinflation changed after treatment with endobronchial coils. METHODS: Dynamic hyperinflation was measured with CPET, 6-MWT, and an MPT in 29 patients before and after coil treatment. RESULTS: There was no significant change in dynamic hyperinflation after treatment with coils. Comparison of CPET and MPT showed a strong association (rho 0.660, p < 0.001) and a moderate agreement (BA-plot, 202 ml difference in favor of MPT). There was only a moderate association of the 6-MWT with CPET (rho 0.361, p 0.024). CONCLUSION: MPT can be a suitable alternative to CPET to measure dynamic hyperinflation in severe emphysema but may overestimate dynamic hyperinflation possibly due to a higher breathing frequency.

Patient Selection for Bronchoscopic Lung Volume Reduction.

Purpose: Bronchoscopic lung volume reduction (BLVR) is a valuable treatment option for carefully selected patients with severe COPD. There is limited knowledge about the characteristics and outcomes of patients referred to a specialized center for BLVR. The study objectives were to investigate the selection rate for BLVR treatment in patients referred for this treatment and to investigate the differences between patients that were selected for BLVR and patients that were not. Patients and Methods: We performed a retrospective analysis of patients with severe COPD who were referred to our hospital to assess eligibility for BLVR treatment. Our parameters included demographics, comorbidity, chest computed tomography characteristics, reasons for rejection from BLVR treatment and patient survival. Results: In total, 1500 patients were included (mean age 62 years, 50% female and forced expiratory volume in 1 s 33% of predicted). Out of this group, 282 (19%) patients were selected for BLVR treatment. The absence of a suitable target lobe for treatment, an unsuitable disease phenotype and insufficient lung hyperinflation were the most important factors for not being selected. Patients that were selected for any BLVR option lived significantly longer than the group of patients that were not selected for BLVR (median 3060 versus 2079 days, P<0.001). Conclusion: We found that only a small proportion of patients that are referred for BLVR treatment is eligible for a BLVR treatment, indicating a need for both better referral tools and for the development of new therapies for this group of patients. Furthermore, our data suggest that selection for BLVR is associated with a significant survival benefit.

Significant Differences in Body Plethysmography Measurements Between Hospitals in Patients Referred for Bronchoscopic Lung Volume Reduction.

During the evaluation of potential bronchoscopic lung volume reduction (BLVR) candidates in our hospital, we frequently observe patients with a lower residual volume (RV) value compared to the value measured in their referring hospital, although both measured by body plethysmography. We explored to what degree RV and other pulmonary function measurements match between referring hospitals and our hospital. We retrospectively analyzed a total of 300 patients with severe emphysema [38% male, median age 62 years (range 38-81), median forced expiratory volume in 1 s 29% (range 14-65) of predicted, and a median of 40 packyears (range 2-125)]. We measured a median RV of 4.47 l (range 1.70-7.57), which was a median 310 ml lower than in the referring hospitals (range - 3.04 to + 1.94), P < 0.001). In conclusion, this retrospective analysis demonstrated differences in RV measurements between different hospitals in patients with severe emphysema. Overestimation of RV can lead to unnecessary referrals for BLVR and potential treatment failures. To avoid disappointment and unnecessary hospital visits, it is important that body plethysmography measurements are accurately performed by applying preferably the unlinked method in these patients.