Skip to main content

Main menu

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Peer reviewer login
  • Journal club
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Peer reviewer login
  • Journal club
  • Alerts
  • Subscriptions

Response to exclusive right middle lobe treatment with endobronchial valves: a case report

Thomas Villeneuve, Romane Fumat, Valentin Héluain, Pierre Pascal, Gavin Plat, Nicolas Guibert
Breathe 2021 17: 210108; DOI: 10.1183/20734735.0108-2021
Thomas Villeneuve
1Pulmonology Dept, Larrey University Hospital, Toulouse, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Thomas Villeneuve
Romane Fumat
1Pulmonology Dept, Larrey University Hospital, Toulouse, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Valentin Héluain
1Pulmonology Dept, Larrey University Hospital, Toulouse, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Pierre Pascal
2Radiology and Nuclear Medecine Dept, Rangueil University Hospital, Toulouse, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Gavin Plat
1Pulmonology Dept, Larrey University Hospital, Toulouse, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Gavin Plat
Nicolas Guibert
1Pulmonology Dept, Larrey University Hospital, Toulouse, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: guibert.n@chu-toulouse.fr
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Isolated right middle lobe (RML) lung volume reduction using endobronchial valves can lead to significant improvements in appropriately selected patients, with highly hyperinflated RML and preserved upper and lower lobes https://bit.ly/3rICgTn

Introduction

Emphysema is a condition of the lung mainly due to tobacco smoking characterised by abnormal, permanent enlargement of airspaces distal to the terminal bronchiole, accompanied by the destruction of their walls. Symptoms may include coughing, wheezing and shortness of breath. Treatment options may include bronchodilators, supplemental oxygen, vaccination, pulmonary rehabilitation and nutrition therapy. Depending on the severity of the emphysema, other invasive or minimally invasive options can be offered such as lung transplantation for end-stage disease, lung volume reduction surgery (LVRS) for heterogeneous, upper lobe-predominant emphysema and giant bullae, and bronchoscopic lung volume reduction (BLVR) in selected patients. Based on the positive results of multiple randomised controlled trials demonstrating improvements in pulmonary function, exercise capacity and quality of life [1–4], BLVR using Zephyr endobronchial valves (EBVs; PulmonX, Redwood City, CA, USA) has been approved for the treatment of patients with severe emphysema and little to no collateral ventilation.

Case presentation

A 57-year-old male, former smoker (50 pack-years), with no other medical history than severe COPD, was referred to our institution to discuss the management of his chronic respiratory failure. His body mass index (BMI) was 21 kg·m−2. Dyspnoea was reported as modified Medical Research Council (mMRC) scale 4 despite optimal treatment including inhaled therapeutics and formal rehabilitation programmes. Physical examination revealed chest hyperinflation and reduced breath sounds on chest auscultation. St George's Respiratory Questionnaire (SGRQ) score was 78.4 (score between 0 and 100, designed to measure the impact on general health, daily life and perceived well-being in patients with COPD).

Pulmonary function tests showed:

  • forced vital capacity (FVC) of 2.3 L (49% predicted),

  • forced expiratory volume in 1 s (FEV 1) of 0.8 L (23% predicted),

  • FEV1/FVC ratio of 0.35, and

  • residual volume (RV) of 8.0 L (340% predicted).

Diffusing capacity of the lung for carbon monoxide (DLCO) was 21% of predicted. The 6-min walk distance (6MWD) was 250 m under 4 L·min−1 oxygen. BODE (BMI, airflow obstruction, dyspnoea, exercise capacity) index was 8.

Chest computed tomography (CT) scan revealed severe emphysema which was homogeneous except for a surprisingly hyperinflated and destroyed right middle lobe (RML) whose volume was measured at 2350 mL (figure 1a). Quantitative tomoscintigraphy showed homogeneous distribution of perfusion between all “major” lobes, with a relatively preserved perfusion in the right upper and lower lobes, but an abolished perfusion in the RML (figure 1b).

Figure 1
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1

a) Pre-treatment CT scan. b) Pre-treatment sagittal ventilation/perfusion tomoscintigraphy showing abolished perfusion in the right middle lobe contrasting with preserved right upper and lower lobe perfusions.

Task 1

What are the treatment options?

Answer 1

  • Pursue medical treatment and respiratory rehabilitation.

  • LVRS of RML to reduce the size of the over-inflated lung.

  • Lung transplantation for this patient with end-​stage COPD.

  • BLVR using EBVs [1–4].

Task 2

What additional analysis would you suggest if you decide to perform BLVR with valves?

Answer 2

The StratX software (PulmonX, Redwood City, CA, USA) analyses the density and volume of each lobe, as well as the fissures integrity. It represents a valuable noninvasive screening tool for candidates for BLVR and helps choosing the target lobe.

It confirmed the homogeneity of the emphysema (5% and 2% destruction gradients between the upper and lower lobes for the right and left lungs, respectively), but a highly destroyed (85% and 70% of parenchyma below 910 and 950 Hounsfield units (HU) density, respectively) and hyperinflated (2350 mL) RML. Large and small fissures integrity scores were 100% and 94%, respectively.

Task 3

What treatment option would you take?

Answer 3

We decided to perform our first isolated treatment by BLVR of the RML due to its unusual volume, the preserved perfusion on all major lobes and low diffusing capacity.

Ongoing management

Two EBVs were placed in the RML (one 4.0 in RB4, one 5.0 in RB5) through a flexible bronchoscope under general anaesthesia after confirmation of the absence of collateral ventilation using the Chartis system (PulmonX, Redwood City, CA, USA). The patient was discharged from the hospital after 3 days. 6 weeks after the procedure, the CT scan showed complete atelectasis of the RML (figure 2b).

Figure 2
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2

CT scan a) before and b) after EBV treatment showing the right middle lobe atelectasis and expansions of the right upper and lower lobes. Before EBV treatment: RV 8000 mL, FVC 2300 mL, FEV1 800 mL, mMRC scale 4, 6MWD 250 m, SGRQ 78.4 and BODE index 8. After EBV treatment: RV 5900 mL (−2100 mL), FVC 3500 mL (+52%), FEV1 1200 mL (+50%), mMRC scale 2, 6MWD 360 m, SGRQ 37.8 and BODE index 5.

This significant target lung volume reduction (TLVR) resulted in expansions of both the right upper and lower lobes (figure 2b) and a deep reduction in RV (−2100 mL).

This translated into significant improvements in:

  • FVC (from 2300 to 3500 mL, +52%),

  • FEV1 (from 800 to 1200 mL, +50%),

  • dyspnoea which dropped to mMRC scale 2,

  • quality of life with SGRQ score decreased from 78.4 to 37.8,

  • 6MWD (from 250 m to 360 m under 4 L·min−1 oxygen), and

  • BODE index which decreased from 8 to 5.

Discussion

The most destructed lobes with intact fissures among the major lobes (upper and lower) are usually chosen as targets for a BLVR approach; the RML is treated only in addition to the right upper lobe when the small fissure is not complete. Very few data are available regarding isolated treatment of the RML. We report herein successful treatment of RML alone in a patient with the perfect RML as a target lobe and review the existing BLVR literature regarding this unusual presentation.

No data are available from the main randomised controlled trials regarding isolated BLVR of the RML [1–4]. The STELVIO trial was the only one where isolated RMLs were treated, but results were not shown per treatment-target groups [1]. Exclusive RML treatment is commonly considered inappropriate for two main reasons: 1) RML is rarely the most destroyed in emphysema, and 2) the expected benefit may be considered negligible due to a smaller physiological volume. Our patient met all the clinical criteria for BLVR [5], but was initially thought to have contraindications due to the absence of a clear target, in particular on tomoscintigraphy. However, we decided to target the RML alone based on its unusual hyperinflation, the relatively preserved right upper lobe and right lower lobe, and the absence of collateral ventilation on the RML Chartis evaluation. Usually, the RML is only treated in combination with the right upper lobe, but in cases of a severely hyperinflated and destructed RML with intact fissures, treatment might be considered, EBV therapy being a good example of personalised medicine.

After EBV implantation, we observed noteworthy clinical and functional improvements (figure 2). All items improved well above minimal clinically important differences, with in particular an unexpected 2100 mL RV decrease for an exclusive RML treatment.

To the best of our knowledge, this is only the sixth reported case of isolated BLVR of the RML (table 1) [6–8]. In other reports, BLVR has been used to treat giant bullae in the RML with clinical improvement in four out of five patients (650 to 1700 mL RV decreases; 170 mL median FEV1 increase (120 mL (+16%) to 600 mL (+60%)) (table 1) [6–8]. The outcomes observed in our case agree with what was observed in these previous cases [5, 9, 10], providing further evidence that the RML is “targetable” by BLVR.

View this table:
  • View inline
  • View popup
Table 1

Characteristics of patients with bronchoscopic RML reduction with EBVs

In conclusion, the RML can be chosen as the sole target for BLVR in appropriately selected patients, with highly hyperinflated RML and preserved upper and lower lobes.

Footnotes

  • Conflict of interest: None declared.

  • Received July 20, 2021.
  • Accepted July 25, 2021.
  • Copyright ©ERS 2021
http://creativecommons.org/licenses/by-nc/4.0/

Breathe articles are open access and distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

References

  1. ↵
    1. Klooster K,
    2. ten Hacken NHT,
    3. Hartman JE, et al.
    Endobronchial valves for emphysema without interlobar collateral ventilation. N Engl J Med 2015; 373: 2325–2335. doi:10.1056/NEJMoa1507807
    OpenUrlCrossRefPubMed
    1. Kemp SV,
    2. Slebos D-J,
    3. 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: 1535–1543. doi:10.1164/rccm.201707-1327OC
    OpenUrlCrossRefPubMed
    1. Valipour A,
    2. Slebos D-J,
    3. 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: 1073–1082. doi:10.1164/rccm.201607-1383OC
    OpenUrlCrossRef
  2. ↵
    1. Davey C,
    2. Zoumot Z,
    3. 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: 1066–1073. doi:10.1016/S0140-6736(15)60001-0
    OpenUrlCrossRefPubMed
  3. ↵
    1. Slebos D-J,
    2. Shah PL,
    3. Herth FJF, et al.
    Endobronchial valves for endoscopic lung volume reduction: best practice recommendations from expert panel on endoscopic lung volume reduction. Respiration 2017; 93: 138–150. doi:10.1159/000453588
    OpenUrl
  4. ↵
    1. Hou G,
    2. Wang W,
    3. Wang Q, et al.
    Bronchoscopic bullectomy with a one-way endobronchial valve to treat a giant bulla in an emphysematic lung: a case report. Clin Respir J 2016; 10: 657–660. doi:10.1111/crj.12257
    OpenUrl
    1. Gu Lee E,
    2. Rhee CK
    . Bronchoscopic lung volume reduction using an endobronchial valve to treat a huge emphysematous bullae: a case report. BMC Pulm Med 2019; 19: 92. doi:10.1186/s12890-019-0849-z
    OpenUrl
  5. ↵
    1. Tian Q,
    2. An Y,
    3. Xiao B-B, et al.
    Endobronchial valve to treat large bulla at right middle lobe in chronic obstructive pulmonary disease patients. J Thorac Dis 2015; 7: E374–E377.
    OpenUrl
  6. ↵
    1. Deslée G,
    2. Mal H,
    3. Dutau H, et al.
     Lung volume reduction coil treatment vs usual care in patients with severe emphysema: the REVOLENS randomized clinical trial. JAMA 2016; 315: 175. doi:10.1001/jama.2015.17821
    OpenUrlCrossRefPubMed
  7. ↵
    1. Sciurba FC,
    2. Criner GJ,
    3. Strange C, et al.
    Effect of endobronchial coils vs usual care on exercise tolerance in patients with severe emphysema: the RENEW randomized clinical trial. JAMA 2016; 315: 2178. doi:10.1001/jama.2016.6261
    OpenUrlCrossRef
PreviousNext
Back to top
Vol 17 Issue 3 Table of Contents
Breathe: 17 (3)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Response to exclusive right middle lobe treatment with endobronchial valves: a case report
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Response to exclusive right middle lobe treatment with endobronchial valves: a case report
Thomas Villeneuve, Romane Fumat, Valentin Héluain, Pierre Pascal, Gavin Plat, Nicolas Guibert
Breathe Sep 2021, 17 (3) 210108; DOI: 10.1183/20734735.0108-2021

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Response to exclusive right middle lobe treatment with endobronchial valves: a case report
Thomas Villeneuve, Romane Fumat, Valentin Héluain, Pierre Pascal, Gavin Plat, Nicolas Guibert
Breathe Sep 2021, 17 (3) 210108; DOI: 10.1183/20734735.0108-2021
Reddit logo Technorati logo Twitter logo Connotea logo Facebook logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Introduction
    • Case presentation
    • Ongoing management
    • Discussion
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Subjects

  • Respiratory clinical practice
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Expert opinion

  • Lung cancer screening by volume CT
  • In pursuit of the primary
  • A rare complication in a case of nonsmall cell lung carcinoma
Show more Expert opinion

Case report

  • Bilateral mediastinal lymphadenopathy with cough and shortness of breath
  • Recurrent bilateral lung infiltrates in a patient with UC
  • Persistent pleuritic chest pain in a patient with CF
Show more Case report

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About Breathe

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Intructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN: 1810-6838
Online ISSN: 2073-4735

Copyright © 2023 by the European Respiratory Society