Dr Rania Habib (Host): The CDC estimates that approximately 16 million Americans are living in the U.S. with COPD. Welcome to AHN MedTalks, an informative resource for physicians across various specialties, as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm your host, Dr. Rania Habib. Joining me today is Dr. Stephanie Baltaji, an interventional pulmonologist and critical care physician with AHN Medicine Institute. She is here to discuss the effects of smoking on COPD patients and explain the complexities of bronchoscopic lung volume reduction. Welcome to the podcast, Dr. Baltaji.

Dr Stephanie Baltaji: Thank you, Dr. Habib. It's very nice to meet you. I'm very happy to be here today.

Host: It's an honor to have you with us today to discuss this very important topic.

Dr Stephanie Baltaji: Yes, I can't wait to talk about it.

Host: I'd love to begin by you giving us a summary of AHN's Interventional Pulmonary Program because we know that it is very comprehensive.

Dr Stephanie Baltaji: Interventional pulmonary is a relatively new field. It requires extra training, because it involves more advanced bronchoscopies and other procedures to treat certain conditions in the lung and the chest. We treat both malignant airway disease as well as benign airway disease. And today, we'll be focusing on bronchoscopic management for COPD.

Host: Wonderful. So, Dr. Baltaji, let's begin by reviewing the effects of smoking on lung function. And I would love for you to highlight the pathophysiology of COPD.

Dr Stephanie Baltaji: So, lung function peaks at the age of 25 and it slowly declines with age. In patients who are smokers, that lung function decline becomes a lot steeper. And what I mean about that is, basically, COPD patients will eventually develop obstructive lung disease. And this is translated on their pulmonary function testing where they would have an obstruction with decrease in their FEV1 over FVC ratio and decline in their FEV1. They will also develop hyperinflation, which is increase in their total lung capacity, as well as air trapping, which is increase in their residual volume.

Host: Now, for patients who are still symptomatic once they've reached that maximum therapy, what would be the next steps?

Dr Stephanie Baltaji: I would just like to go over why these patients are symptomatic. So, COPD patients tend to develop, as I mentioned, hyperinflation and air trapping. Whenever this happens, the total lung capacity increases and it causes pressure on the diaphragm. And the diaphragm is the main muscle that contributes to breathing. So if the diaphragm has a lot of pressure on it, this translates to the patients becoming more and more dyspneic.

Host: Dr. Baltaji, what is the main treatment then for these COPD patients?

Dr Stephanie Baltaji: So, treatment for COPD patients, it involves both non-invasive and invasive treatment options. So for the non-invasive part, which is most of our COPD population, basically patients will be on inhaler. These involve basically bronchodilators as well as inhaled corticosteroids, as well as these patients are referred to pulmonary rehab because that helps them with their functional status. And smoking cessation, obviously, is one of the big ones.

Host: And for patients who are still symptomatic, let's say they've maxed out all the therapy, the bronchodilators, the corticosteroids, the respiratory therapy, what are the next steps?

Dr Stephanie Baltaji: In the past, patients with emphysema, they used to undergo surgical lung volume reduction, where a portion of the emphysematous portion of the lung would be taken out surgically. But these patients developed a lot of complications from these surgeries, and this is when the minimally invasive procedures started to come to play. And what we are doing these days is bronchoscopic lung volume reduction.

Host: I'd love to learn more about that. What is bronchoscopic lung volume reduction?

Dr Stephanie Baltaji: It is an exciting procedure, actually. The bronchoscopic lung volume reduction, basically, we place endobronchial valves inside the airway to make the lobe where the endobronchial valves are placed atelectatic. And so, instead of basically taking that part of the lung out, that part of the lung becomes more atelectatic. And that way, you decrease the volume in that area of the lung, and you're basically collapsing the lung that does not function. So, it's like you're doing a lung volume reduction without actually having to do surgery.

Host: Now, we know that lots of primary care physicians are managing these COPD patients. So, when should a patient be referred to a pulmonologist and specifically an interventional pulmonologist to be considered for bronchoscopic lung volume reduction?

Dr Stephanie Baltaji: Patients with COPD who have quit smoking and have evidence of air trapping and hyperinflation on their pulmonary function tests should be referred to us, for further, evaluation and testing.

Host: What is involved in your workup for BLVR?

Dr Stephanie Baltaji: It's actually a very extensive workup to identify who would benefit from this procedure, because we obviously don't want to put valves in someone who would not benefit from them. So, the workup includes the PFTs, which is usually obtained prior to the patient coming to us and seeing us in the clinic. Because we review the PFTs and, once the PFTs are reviewed and the patient qualifies for further management, then we would bring them into the clinic to talk to them more about this.

The other tests that we would do is a six-minute walk test because we want to know the distance that the patient is able to walk within six minutes. We also do an ABG to make sure that these patients are not hypercapnic. We get an echocardiogram to make sure there's no heart condition that is contributing to the patient's dyspnea. And then, we would obtain a high-resolution CT scan. And the high-resolution CT scan, we upload this to a software, which gives us a report that tells me how much there is evidence of emphysema in each lobe of the lung. It also tells me how much volume there is in each lobe of the lung, and then if the fissures are complete or not, and that's important, and we can talk about that later when we talk about the procedure.

Host: Now, you've described the workup in detail, which is very intense, and I love that you guys are really looking at the patient from a holistic standpoint. Could you describe the contraindications for BLVR?

Dr Stephanie Baltaji: So, patients who are actively smoking cannot undergo BLVR. Patients in whom a bronchoscopy is contraindicated, we can't do it for these patients. And then, any active pulmonary infection, and large bullous disease where the bullae would occupy around 30% of the lung, these patients are contraindicated to have a bronchoscopic lung volume reduction or BLVR.

Host: So now, we've got a patient worked up for you, they meet all the specific criteria to have the BLVR. Dr. Baltaji, what does the procedure actually entail?

Dr Stephanie Baltaji: Once we know that the patient will qualify, this procedure is done under general anesthesia. Once we identify, based on the report that we have, which lobe to target, let's say we're going to target the right upper lobe, then we would do the bronchoscopy. On the same day of the bronchoscopy, we do a second test to make sure that the fissures are complete. So, we introduce the bronchoscope first into the airway, and then we introduce a catheter that has a balloon at the end of it, and that balloon detects flow. Let's say the right upper lobe is the target, we inflate the balloon in the right lower lobe. And if there's cessation of flow, this means that the fissures are complete.

The reason why we want the fissures to be complete is based on the collateral ventilation. Whenever we're trying to make one lobe of the lung atelectatic, we want to make sure that there's no communication between the upper lobe and the lower lobe. Because if there is a communication there, then the lobe is not going to become atelectatic and patients won't benefit from this procedure. So once we do this test and the patient does not have evidence of collateral ventilation, then we're able to place the valve. The way we place the valve is we introduce a sizing catheter and we measure each segment of the lobe. After we measure each segment, we deploy the valves accordingly. So, some patients may get three valves, some patients may get seven valves. It all depends on how many segments there are that we're going to be placing valves in.

Host: And how do you determine how many segments the patient needs in terms of knowing how many valves they actually need?

Dr Stephanie Baltaji: That's a great question. It actually depends on the patient's anatomy.

Host: That makes total sense. So, a patient's had BLVR, what is involved in the actual recovery and post-procedure followup for that patient?

Dr Stephanie Baltaji: These patients are at increased risk of pneumothorax post-procedure. For that reason, they get admitted to the hospital for three days just to make sure that that pneumothorax doesn't happen. Based on the studies, the highest risk of that happening is in the first three days. After they get discharged from the hospital, we'll see them back in the clinic in six to eight weeks after discharge. And we'll repeat their x-rays and PFTs to see if they did have atelectasis from the x-ray, and then to make sure that their lung function is improving with the valves that we placed. They can continue to follow with their regular primary care physician or general pulmonologist.

Host: Now, these patients post-procedure for that three-day stay, are they in the ICU, step-down unit, or are they in a floor bed?

Dr Stephanie Baltaji: No. They're on the floor beds. We usually keep a chest tube at bedside just in case a pneumothorax happens and that's just as a precaution.

Host: And how quickly does the patient get back to normal function after one of these procedures?

Dr Stephanie Baltaji: If there's no complication from the procedure, the patients can resume their activities the next day. The only reason why we keep them in the hospital is for that risk of pneumothorax. So if there's no complication, they're good to go.

Host: I mean, that's completely different than the traditional lung volume reduction surgery, so that is quite an improvement. Dr. Baltaji, could you describe the clinical versus patient-reported benefits of this procedure?

Dr Stephanie Baltaji: So, clinical benefit, as I mentioned, we repeat the PFTs six to eight weeks after the procedure. That's because on the PFTs, we see improvement in their FEV1. We see decrease in their residual volume. We also see improvement in their six-minute walk test and an improved quality of life and dyspnea scores. For patient-reported benefit, they do report a decrease in their shortness of breath. They'll tell you that they have more energy to be able to do more stuff around the house. They will say that they feel more confident in leaving the house. And they're able to go back to work with minimal limitations.

Host: Those are all fantastic benefits. Is this procedure covered by insurance?

Dr Stephanie Baltaji: Yeah. So, most patients who qualify for the procedure and meet all the criteria, they will be covered by insurance. Now, some insurance plans do not cover the valve treatment. For these patients, we'll submit a prior auth, which is requested on a case to case basis. in addition to that, Pulmonix is the company that manufactured the Zephyr valves, these are the valves that we place here at AHN. They have a reimbursement support program, and this is available for patients as they navigate the insurance process for this procedure.

Host: Wow. That is really great that there's so many avenues for patients to get this very beneficial procedure done. Dr. Baltaji, you've given us wonderful information about BLVR. If a primary care physician or someone in the community wants to make a referral to you or to the pulmonary program at AHN, how do they do that?

Dr Stephanie Baltaji: So, primary care physician and general pulmonary physician who are following the COPD patients, who see evidence of the hyperinflation and the air trapping on their PFTs, they should be able to refer to us, either they can send us an Epic referral, or send us a fax, or they can call the clinic. And let us know that they want to refer that patient to us. In addition to that, patients can self-refer. There's a lot of advertisement on the valve these days, and patients can just call 412-442-2100.

Host: Dr. Baltaji, you have provided a wonderful overview of the interventional pulmonary program at AHN and helped us really learn the wonderful benefits of bronchoscopic lung volume reduction procedures. Are there any last tidbits that you would like to share with our audience?

Dr Stephanie Baltaji: Just want to highlight how many patients we've helped so far. So, since we started doing the valves here, we have screened over 200 patients so far. And we have placed endobronchial valves in over 40 patients. And I just want to say that COPD patients do struggle a lot with symptom management. And if patients have severe COPD and have evidence of the air trapping on their lung function, on their pulmonary function test, and they're still short of breath despite all the inhalers and the pulmonary rehab that they've done and who have quit smoking, referring them to us to see if we would be able to do bronchoscopic lung volume reduction would be a great benefit from symptomatic standpoint for these patients.

Host: That's wonderful. What an incredible program. Thank you so much for what you do.

Dr Stephanie Baltaji: Thank you for having me today.

Host: That was Dr. Stephanie Baltaji, an interventional pulmonologist and critical care physician with AHN Medicine Institute. I'm your host, Dr. Rania Habib, wishing you well. Thank you for listening to this edition of AHN MedTalks. To learn more or refer a patient, please call 844-MD-REFER. That's 844-M-D-R-E-F-E-R or visit ahn.org.