By Marti Webb Slay
Patients with COPD or emphysema have a new treatment option with the Zephyr® Endobronchial Valve System, a minimally invasive treatment with one-way valves which deflate damaged parts of the lungs and allow the patient to breathe more easily.
Jay Heidecker, MD, of Birmingham Pulmonary Group at Ascension St. Vincent’s, is one of only four doctors in the state who currently perform the procedure. The procedure itself is not particularly new – Heidecker learned a similar approach during his fellowship 18 years ago – but coupled with the Zephyr valve, advances have been made that help physicians better know when the procedure is likely to be successful, resulting in overall better outcomes.
“The candidates for this procedure are people with emphysema as the primary part of their lung disease, people who are having shortness of breath as opposed to people who are coughing up tons of phlegm,” Heidecker said. “That’s step one. Step two is they should already be taking the right medicines and still feel very limited despite being on the right standard medicines. Number three is their lung function tests should show a lot of air trapping.
“When patients blow out air and still have almost two times the air that should remain in their lungs, that indicates they may be candidates for the procedure because that air trapping is causing most of the symptoms.”
Contraindications include uncontrolled heart failure, pulmonary hypertension, and patients who are morbidly obese.
“The procedure involves hospitalization,” Heidecker said. “Patients must know the risks. Approximately one out of three patients experiences a collapsed lung from the procedure. Although the presence of a collapsed lung doesn’t change the overall success rate, it can result in a prolonged hospitalization, so that’s not a trivial risk.
“If a patient is a possible candidate for the procedure and understands the risks, we perform a special CT scan to determine what part of the lung is most diseased and over-inflated. That tells me, if we are to proceed, which lobe of the lung is a good target. It can also show whether there’s a prohibitive risk. The CT scan can also look at fissures between the lobes. If they aren’t intact, the procedure won’t work. The scan and new, special software really increase the safety and the ability to know who is going to benefit from the procedure.”
The minimally invasive procedure, which is not considered surgery because it requires no cutting, is performed under general anesthesia, and takes 60 to 90 minutes. Patients stay in the hospital for four days. “In the initial trial, there were one or two deaths from collapsed lung,” Heidecker said. “If someone has a pneumothorax, it’s much better to know it in the hospital than when the patient is at home. Since 90 percent of the patients who experience a pneumothorax will have it within three days, we keep them where we can see and deal with it.”
The first part of the procedure consists of confirming again that it is likely to be successful. “We prove that those divisions between the lobes are intact, so we prove the procedure will collapse the lobe in the way we want it to,” Heidecker said. “It’s the extra confirmation. Then we put the valves in. We usually have a place we think will be best and a second choice if it seems like the first choice won’t work after all. Each lobe has between two and four main branches, so we put between two and four valves in. Sometimes we put them in two lobes of the lung. We might put in as few as two valves and as many as six.”
The valves can be removed if they don’t help or cause a problem of any kind. “If the lobe collapses very fast and the patient has a bad pneumothorax and the pneumothorax won’t stop, I could take the valves out, and that should make the pneumothorax stop,” Heidecker said. “That’s quite helpful.”
“For some patients, the only way the pneumothorax will stop is to take the valves out. The data says that 50 percent of the time, you have to take the valves out to make the pneumothorax stop. So, if one in three has a pneumothorax and 50 percent have to have the valves removed, then that’s one out of six patients who have an initial unsuccessful procedure. You can offer the patient a repeat attempt. That’s up to them as to whether they want to try again.”
Heidecker has done four procedures so far. One patient wasn’t helped by the valves, and they were removed. “We knew there were significant reasons why it might not work,” he said, “and the patient knew that up front.” None of his patients so far have had a pneumothorax as a result of the procedure.
For physicians considering referral for this procedure, Heidecker summarized the key considerations. “If physicians have patients with COPD and lots of shortness of breath, make sure we do pulmonary function tests where we measure the lung volumes,” he said. “If they have a patient with emphysema and they are still breathless and have lots of air trapping, those are the people to find and refer.
“It’s a lot of work on the front-end from an evaluation standpoint. The physiology is interesting. Why it helps, how it’s working, to me that’s very interesting.”
Heidecker was attracted to the procedure primarily because it offers improved quality of life for many patients. “Of all the interventional things we do, whether it’s new bronchoscopy techniques or other therapeutic techniques, almost all those interventions are palliative,” he said. “This is one of the few pulmonary interventions that helps people with a non-terminal problem improve their quality of life. That was the main reason.”