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Bronchoscopic Lung Volume Reduction Operation and Pulmonary Rehabilitation https://www.scientificarchives.com/journal/journal-of-physical-medicine-and-rehabilitation Journal of Physical Medicine and Rehabilitation Review Article Bronchoscopic Lung Volume Reduction Operation and Pulmonary Rehabilitation Esra Pehlivan* University of Health Sciences Turkey, Faculty of Hamidiye Health Sciences, Department of Physical Therapy and Rehabilitation, İstanbul, Turkey *Correspondence should be addressed to Esra Pehlivan; [email protected] Received date: February 03, 2021, Accepted date: June 16, 2021 Copyright: © 2021 Pehlivan E. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Dyspnea and reduced exercise capacity negatively affect the quality of life in many Chronic Obstructive Pulmonary Disease (COPD) patients with emphysema phenotype. Surgical procedures may be preferred in cases where improvement in respiratory functions cannot be achieved despite pharmacological treatments. These surgical operations are bullectomy, lung transplantation, lung volume reduction surgery (LVRS) or bronchoscopic lung volume reduction (BLVR). Pulmonary rehabilitation (PR) is a well-established and widely accepted standard therapy in order to alleviate symptoms and optimize pulmonary functions. It is stated in the guidelines and reports that receiving of PR before the bronchoscopic interventions is a necessity. Moreover, there are very few studies on this subject. In this review, PR will be discussed in relation to BLVR. Keywords: Coil, Dyspnea, Exercise, Physiotherapy, Valve Emphysema and Hyperinflation trapping, or dynamic hyperinflation, which becomes much more exaggerated with exercise. The lungs, which become The main symptom in Chronic Obstructive Pulmonary excessively swollen with dynamic hyperinflation, cannot Disease (COPD) is shortness of breath. Shortness of stretch anymore. It becomes difficult for the patient breath occurs especially with exercise and progresses to breath deeply, and the work of breathing increases. over the years despite all medical treatments. One of Respiratory muscles are strained due to increased the main mechanisms by which this symptom occurs is air trapping and as a result, respiratory functions are hyperinflation in the lungs [1]. impaired. Respiratory muscle fatigue develops. The clinical reflection of all this is shortness of breath and a Hyperinflation is divided into two as static and decrease in functional capacity [3]. dynamic pulmonary hyperinflation according to its physiopathogenesis. Emphysema is the most common While the dynamic hyperinflation treatment is based cause of static hyperinflation. Lung parenchymal damage on smoking cessation, bronchodilator drug therapy and and loss of elastic recoil cause static lung hyperinflation. PR, these treatments are insufficient in many patients. Loss of elastic fibers in the alveolar wall leads to a decrease Lung transplantation (LTx) and Lung Volume Reduction in elastic recoil strength, loss of alveolar wall support Surgery (LVRS) are currently available for a selected structures, and premature closure of the airways during group of patients. Endoscopic alternatives to LVRS expiration. As a result, end expiratory lung volume, i.e. have progressively gained acceptance and are currently residual volume increases [2]. Emphysema and lung employed in patients with emphysema. hyperinflation mechanism are schematized in Figure 1. Bronchoscopic Lung Volume Reduction During exercise, before the alveolar air is fully exhaled, mechanism the initiation of inhalation causes dynamic lung hyperinflation. The increase in residual volume at rest Due to the high morbidity and mortality rates in both becomes more pronounced with effort. The result is air LTx and LVRS, minimally invasive methods have come J Phys Med Rehabil. 2021 Volume 3, Issue 1 34 Pehlivan E. Bronchoscopic Lung Volume Reduction Operation and Pulmonary Rehabilitation. J Phys Med Rehabil 2021; 3(1): 34-39. Smoking Air pollution Genetic disorders Inflammatory cells, Oxidative stress, Protease-anti-protease release of inflammatory increased apoptosis imbalance mediators Decrease elastic recoil Loss of alveolar wall support Alveolar wall destruction Pulmonary hyperinflation Figure1: Pathogenesis of emphysema and lung hyperinflation. to the fore in order to reduce the lung volume in patients mechanism. They can be evaluated in two groups. The with emphysema. Bronchoscopic lung volume reduction first group is reversible airway interventions. This group (BLVR) may be considered in COPD patients with advance includes endobronchial valves, endobronchial coils and emphysema who are symptomatic and have refractory transbronchial stents. Interventional substances used in hyperinflation despite optimal medical therapy and PR this group could potentially be withdrawn if complications [4]. The pathophysiological principles of the LVRS is to develop. The second group includes irreversible airway removel the worst affected parts of the emphysematous interventions such as thermal vapor ablation and biological lung, which helps to normalize the diaphragmatic and lung volume reducton that act by inducing an inflammatory chest wall mechanics [5]. On the other hand the BLVR / fibrotic response or permanent obstruction of the distal interventions acts based on a different physiological airways [6] (Figure 2). J Phys Med Rehabil. 2021 Volume 3, Issue 1 35 Pehlivan E. Bronchoscopic Lung Volume Reduction Operation and Pulmonary Rehabilitation. J Phys Med Rehabil 2021; 3(1): 34-39. Bronchoscopic Volume Reduction Interventions Reversible Airway Irreversible Airway Interventions Interventions Thermal Vapor Biological Endobronchial Endobronchial Ablation Lung Volume Valves Coils reducton Transbronchial Stents Figure 2: Bronchoscopic Volume Reduction Interventions. Bronchoscopic lung volume reduction reduces air of ≥ 4) [11]. A study examining the NICE criteria reported trapping, corrects elastic recoil, increases expiratory flow, that a thershold value of 140 meters is appropriate [12]. and enables the rib cage and diaphragm to function more Therefore, if exercise capacity increases with PR before effectively by re-establishing the normal relationship undergoing BLVR, there is no need for bronchoscopic between the lungs and the chest wall. Clinically, dyspnea procedures with a high complication rate and high cost, decreases, exercise capacity increases, and improvement and the disease management can only be done with medical in all components of quality of life is achieved [7]. In a treatment. This information has made it a necessity to retrospective study, it was reported that the cases who undergoing PR before BLVR. underwent BLVR had longer surveillance compared to those who did not receive BLVR [8]. Why is There a Need for Pulmonary Rehabilitation in Bronchoscopic Lung BLVR patient selection is important for the success of Volume Reduction? the procedure and patient safety. FEV1 and DLCO are key inclusion and exclusion parameters used to determine The 2016 Expert Panel Report on Endoscopic Lung eligibility for surgery and/or bronchoscopic intervention. Volume Reduction focused on the patient selection and In patients with high exercise capacity and non-upper discussed available endoscopic techniques [4]. In 2017, lobe emphysema distribution, LVRS was found to be more researchers indicated that patients should receive optimal mortal than medical therapy alone. LVRS should not be medical therapy as defined by the Global Initiative for recommended for these patients [9]. Disease phenotype, Chronic Obstructive Lung Disease [13] and they have exercise capacity, FEV1 and the presence of collateral completed PR or a structured physical therapy program, circulation should be taken into account in the selection of and quit smoking definitively [14]. Despite this report, BLVR patients [10]. UK National Institute for Healthcare there are no studies supporting the importance of PR in Excellence (NICE) guidance states that lung volume volume reduction operations. It is highly probable that reduction treatment option should be considered in COPD the statement in the report was created by considering cases with FEV1 less than 50%, 6-minute walking distance the effect of PR on COPD and LVRS cases. Such patients below 140 meters and shortness of breath worsens the typically have severe ventilatory limitation and disability quality of life (Medical Research Council dyspnoea score and are at high risk of preoperative and postoperative J Phys Med Rehabil. 2021 Volume 3, Issue 1 36 Pehlivan E. Bronchoscopic Lung Volume Reduction Operation and Pulmonary Rehabilitation. J Phys Med Rehabil 2021; 3(1): 34-39. complications. In COPD cases, PR increases exercise training. Exercise intensity was predetermined to be 80% capacity and quality of life and reduces dyspnea [15,16]. of the maximum heart rate, and it was gradually increased It has been revealed that PR in LVRS cases increases taking the severity of dyspnea perception and fatigue ratio exercise tolerance and muscle function [17]. PR in addition as the basis. Strengthening training was recommended to LVRS, improves static lung function, gas exchange, and over resistance targets which were set at loads equivalent quality of life compared with PR alone [18]. to 40% of a 1-repetition maximum (1RM). Home-based group program included education, breathing exercises, Pulmonary rehabilitation
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