Joey Wahler (Host): It's an effective treatment for COPD. So we're discussing Bronchoscopic Lung Volume Reduction. Our guest is Dr. Rakesh Vadde. He's an Interventional Pulmonologist with Mount Carmel Health System. This is Wellness in Reach, a Mount Carmel podcast. Thanks for joining us. I am Joey Wahler. Hi there, Dr. Vadde. Welcome.

Rakesh Vadde, MD, FCCP: Hi, Joey. Thanks for having me today.

Host: Great to have you aboard. We appreciate the time. So first, in a nutshell, what is bronchoscopic lung volume reduction and just how is it used to treat obstructive pulmonary disease, chronic obstructive pulmonary disease, or COPD as it's commonly called?

Rakesh Vadde, MD, FCCP: Awesome. Great question. So before we get to the Bronchoscopic Lung Volume Reduction procedure, just a few lines about the COPD patients is patients who have COPD with emphysema specifically, tend to to lose the elastic recoil of the lung. So pretty much what happens is the air goes inside the lung, but because of the lack of elasticity of the lung, the air gets trapped in the lung, not letting it come out.

So coming to the bronchoscopic lung volume reduction, so it is mainly indicated for patients with severe COPD, with emphysema. So there are currently two FDA approved companies that have been approved for this procedure. The one is Spiration valves, and the other one is a Zephyr valves.

So they kind of both do the same intention. They work differently as a valves, but what they do is they assist with patients to breathe better with COPD.

Host: So what are the main benefits of this procedure, especially compared to more traditional surgical methods for managing COPD?

Rakesh Vadde, MD, FCCP: Absolutely. The way these valves work is, as I said, once they're deployed in the lungs, they help to collapse the part of the lung that is trapped with air, giving more space for the other part of the lungs to expand. In other words, I always use the kind of a, a simple way analogy to explain to the patient as, even though patients have COPD with emphysema, it is not equally distributed in all the lobes equally. In other words, there are some part of the lungs that have very bad emphysema and there are some part of the lungs that do not have a bad emphysema. So I use the bad guy and analogy is the bad lobe, which has bad emphysema, traps air.

And not only it does not do its job, but it does not let the remaining part of the lung do its job. When we go in and place these valves, it tends to pretty much collapse the bad lung, to give more space for the good lung to expand, to help them breathe better. Studies have shown that patients are able to breathe better, they're able to do a lot more activities, they were not able to do before. Because inhalers can only do to a certain extent to help with their breathing. But beyond that, there comes to a situation where their breathing is plateaued with no improvement with inhalers, that's when these procedure come in wherein it gives, offers more hope for them to do more things with their day-to-day activities.

Host: So what can patients expect during the procedure itself?

Rakesh Vadde, MD, FCCP: The procedure is a minimally invasive procedure. It is not a surgery. It's done as an procedure by called as bronchoscopy. It's a small tube with a camera. It'll be done anesthesia, but it's just a limited duration, but 45 minutes to a 60 minutes procedure, once they're assigned as a right candidate for these Zephyr valves, we go with the bronchoscope through the mouth to get that part of the lobe, which has been preselected by the CT scan. And then we deploy these valves. As I said, the procedure by itself takes about 30 to 45 minutes procedure, but it does have a, a 30% risk of lung collapse that can occur after these procedures.

That's why after we complete these procedures, we admit the patients for three nights in the hospital to observe them closely because the risk of lung collapse to occur after this procedure is highest in the first three nights. First three days, basically. So that's where we want them in the hospital after this procedure. So even if they do develop any of these complication of lung collapse, we are there to take care of it.

Host: And if that's the case, what happens there?

Rakesh Vadde, MD, FCCP: When the patients undergo lung collapse, if the collapse is just a minor extent, we just give some supplemental oxygen and let the collapse absorb itself. But if it's a little bit more extensive than what we expect, we have to place a chest tube or a small bore tube from outside to drain the air out, to help to re-expand the lung.

Host: Now you mentioned this is typically done on patients that also have emphysema as well as COPD. So besides that, or in addition to that, any other specific criteria, Doctor, that make a COPD patient a good candidate for this procedure?

Rakesh Vadde, MD, FCCP: Great question, Joey. So, not every COPD patients qualify for these valves. Only patients who have severe COPD, have severe emphysema with air trapping. So how do we know these patients have air trapping? So when they do undergo a pulmonary function test or simply call as PFT, we do see those numbers and make sure that they have adequate air trapping.

So that's one thing. The second thing is, we use their CT scans and then use a software analysis to kind of figure out which lobe is the bad lobe. In other words, with these algorithms that we have, using a CT scan of the lung, we are able to identify them and target those. So not everyone qualifies for it.

We do, once we get referral for any of these procedures, we do a couple of testing before we say that this patient is a candidate or not. Also the patient should have stopped smoking for at least four months. That is one of the requirement, because you don't want to put a valve in patients who continue to smoke because the lungs continue to destroy, on a long-term basis with ongoing smoking.

So those are the things that we generally look for. One is a breathing study and also target lobe to know which exactly, which lobe to target. They should have a stable cardiac history. We don't want to do these procedures who have unstable cardiac issues going on, just because we don't want to risk doing a procedure on them.

Host: Absolutely. So how about the success rate of bronchoscopic lung volume reduction compared to other treatments for COPD?

Rakesh Vadde, MD, FCCP: Absolutely. There are two similar options for these kind of a situation. One is a surgery, one is a bronchoscopic procedure, which is minimally invasive. Studies have shown that the surgical way of treating lung volume reduction surgery had a higher complication risk and higher risk of death, even though it all started off by surgical treating this way, but because of higher complications that kind of got limited access right now. So that's when the next option was something that we can do without doing a surgery, in which case the bronchoscopy is the next safest option. When we compare the other modalities of treatment with COPD, you know, being them on inhalers, undergoing rehab and other kind of therapies for COPD, this procedure is in addition to those current treatment regimens. Once these patients undergo this procedure, they may still need to continue their inhalers. They may still have to undergo rehab. It is not something that's going to replace their current COPD treatment. It may just add them to the next level where they, in spite of being on inhalers, if they're still not able to breathe easier and getting short of breath by even just walking to their mailbox or something simple, activities get making them short of breath; in which case this, is maybe more of an added therapy for these patients.

Host: Gotcha. How about the recovery period after this procedure? You mentioned, Doctor, that there's a, a three day stay in the hospital after it for observation to make sure there are no complications. If all goes smoothly, what should patients expect during the recovery process? How long before they're back to where you'd like to see them be?

Rakesh Vadde, MD, FCCP: Absolutely. So these procedures, even right after doing the procedure, they're off the anesthesia, they're wide awake, they're talking to the family. They're watching TV. . It just that, because the monitoring phase, we keep them in the hospital, but they're as good as going home right after the procedure.

 Most of these patients do benefit or see the improvement within a day or two. But based on the studies, I think they tend to see the best benefit after 44 days based on the studies. So pretty much in about two months phase after the procedure, they should be able to see the full extent of benefit from these valve placement.

Host: And speaking of which, what are the benefits? What is the end result? This can be very tough on people. It could completely cut down their ability to breathe, to function, to move, to live life, really, right. And so what does that look like for them after this is done?

Rakesh Vadde, MD, FCCP: It's a great question. So the main purpose of this procedure or doing this therapy, as treatment option is to able to let them breathe. Because what happens is when these patients have trapped lung, wherein the air gets trapped in the lung, it gets trapped to the point that they can, they do not have any more space in their chest to get that extra breath of air into the lungs.

So what happens is even changing their clothes or, you know, doing any basic activity at home, makes them short of breath, winded. They couldn't breathe anymore because there's no space in the chest to get that extra air into them. So, the benefits of this procedure are mostly going to make an impact in the quality of life.

In other words, able to do more things that they're not able to do. Maybe walk more distance, maybe walk some stairs, which they were not able to. It does not take care of their oxygen that they were on using on before, it may still be the same thing, because we are not transplanting the lung.

We are only reshuffling the air within the lung to, so that they can breathe better. They still have to continue with the inhalers. And studies have also shown that it actually improves the survival as well with these procedures on a long-term basis.

Host: I would imagine, Doc, there's a lot of fear for patients living with COPD because they're often worried, aren't they? Can I get down the stairs? Can I get across the room? Can I make it through the day without help, right? I mean, suddenly breathing, which many of us unfortunately take for granted if we're relatively healthy, for these patients, not the case, and you're really helping alleviate that, right?

Rakesh Vadde, MD, FCCP: Absolutely. Unfortunately there's not much to offer these patients who are struggling every day with breathing. Patients, obviously when they're at end-state COPD, the only option is a lung transplant, and we know that lung transplant, not everyone qualifies, and also there's a long waiting time, so these people suffer every day, not able to breathe while waiting for something to happen, which unfortunately there's not much options available.

I think it's a kind of brim of hope that can, this procedure can come to those patients who are struggling every day to breathe so that at least they have a quality of life.

Host: A couple of other things before we let you go. How about a common misconception or two about bronchoscopic lung volume reduction that you can clear up for patients and for their families here.

Rakesh Vadde, MD, FCCP: One thing I always say is, this is not a surgery. We are not making any incisions. We are not any cutting. It's a procedure that done minimally invasive, with a low risk profile. This is also reversible. Say for example, we place the valve and for whatever reason, if it's not working or the complication seems like are having a major impact, then we can always go back with the scope and remove these valves to get them to the point they were before.

So it's, there's a reversibility process in it. The other aspect of that is, they can continue with their rehab programs as well in addition to this. So, which is a great benefit that I see. So yeah, those are the things that I would suggest.

Host: Having said that, in summary here, what's your main message for those that may be joining us and considering this procedure, but haven't gone ahead and gotten it done? It seems like there's really very little, if any, downside, right?

Rakesh Vadde, MD, FCCP: I mean, every procedure does come with risk and benefits. This procedure, in summary, is a brim of hope for patients who are struggling with COPD, with emphysema. Definitely this is not something that you can overnight with this procedure, make a COPD patient run a marathon.

 That's not a realistic expectation. It is mostly done in patients who are not having any improvement with their inhalers to offer an extra level of benefit or therapeutic options where they can do better with what they have. The risk are low, as I said, but it does come with risk.

 There's no procedure that is a hundred percent safe. It does come with the risk that we go over in details before we do the procedure so that patient and the family completely understands the procedure in detail.

Host: Absolutely. Well folks we trust you are now more familiar with Bronchoscopic Lung Volume Reduction. Dr. Vadde, keep up all your great work and thanks so much again.

Rakesh Vadde, MD, FCCP: Awesome. Thanks Joey. Thanks for having me today.

Host: Absolutely. And for more information, please visit mountcarmelhealth.com. Now, if you found this podcast helpful, please do share it on your social media.

 A thanks so much again for being part of Wellness in Reach, a Mount Carmel podcast.