Pehlivan, J Rehabil Res Pract 2021; Journal of Rehabilitation Research and 2(1):10-12. Practice Commentary

Pulmonary rehabilitation in candidates for bronchoscopic volume reduction

Esra Pehlivan*

Faculty of Hamidiye Health Sciences, Bronchoscopic lung volume reduction (BLVR) may be considered in Chronic Obstructive Department of Physical and Pulmonary Disease (COPD) patients with advance emphysema who are symptomatic and have Rehabilitation, University of Health refractory hyperinflation despite optimal medical therapy and pulmonary rehabilitation (PR) [1]. Sciences, Istanbul, Turkey The 2016 Expert Panel Report on Endoscopic Lung Volume Reduction focused on the patient *Author for correspondence: selection and discussed available endoscopic techniques [1]. In 2017, researchers indicated that Email: [email protected] patients should receive optimal medical therapy as defined by the Global Initiative for Chronic Obstructive Lung Disease [2] and they have completed PR or a structured physical therapy program and quit smoking definitively [3]. Received date: January 09, 2021 Different techniques are used in BLVR and it basically shows treatment efficiency with four main Accepted date: January 21, 2021 mechanisms. These mechanisms include nonsurgical volume reduction effect, restoration of lung Copyright: © 2021 Pehlivan E. This is an elasticity, rearrangement of airflow by creating new airways, and reduction of bronchoconstriction open-access article distributed under by ablation of the parasympathetic nerve [4]. The endoscopic methods used are summarized in the terms of the Creative Commons Table 1. There are studies showing that exercise capacity increases after the application of the valve Attribution License, which permits and coil technique [5,6]. Most of the studies on this subject are related to valve cases [6] and there unrestricted use, distribution, and is a need to present the results of coil case series. In addition, there are studies showing that exercise reproduction in any medium, provided capacity increases in patients who undergo PR after the bronchoscopic procedure [7]. The effect of the original author and source are PR before the procedure on the post-procedure clinical status is not fully known. credited.

I. Bronchial blocking tools 1. Valve a. Endobronchial valve (EBV); Zephyr valve b. Intrabronchial valve (IBV); Spiration valve 2. Spigots

II. Parenchymal tools 1. Coil (spiral wires) 2. Biological fillers (Sealant) 3. Thermal vapor ablation

III. Extra anatomical by-pass tools 1. Airway by-pass stents Citation: Pehlivan E. Pulmonary rehabilitation in candidates for bronchoscopic lung volume reduction. IV. Target lung denervation J Rehabil Res Pract 2021; 2(1):10-12. Table 1: Techniques used in lung volume reduction.

This article is originally published by ProBiologist LLC., and is freely available at probiologists.com

J Rehabil Res Pract 2021; 2(1):10-12. 10 Citation: Pehlivan E. Pulmonary rehabilitation in candidates for bronchoscopic lung volume reduction. J Rehabil Res Pract 2021; 2(1):10-12.

The content of PR that should be applied in BLVR is not a The important result here was the greater increase in exercise clear. The COPD PR program content applied to patients with capacity in the hospital-based PR group. One of the factors that we bronchoscopic intervention. This program includes chest hygiene think may affect the achievement of this result may be the differences techniques, breathing exercises, aerobic and strengthening training. in success rates in achieving targeted exercise intensities in home In the guide published by European Respiratory Society and and hospital-based PR organization types. The success of reaching American Thoracic Society, the effectiveness of PR in Lung Volume the target workload in unattended programs and performing all Reduction (LVRS) is emphasized [8]. It should not be exercises within the discipline is a matter of patient initiative. In a forgotten that complications such as COPD exacerbation, chest pain, clinical study we previously conducted with a similar methodology mild bleeding, pneumonia, pneumothorax (px), and respiratory in COPD patients, exercise capacity was increased only in the failure may develop after BLVR [9]. In a study, it was reported that hospital-based group [13]. In another study with online support in emphysema cases with an FEV1 of less than 20%, px developed in and using face-to-face PR, the online-supported PR was noninferior 20% of the cases who underwent BLVR [10]. Possible complications to conventional model delivered in face-to-face sessions in terms of should be taken into consideration especially in the application of effects on 6MWD [14]. respiratory exercises and chest hygiene techniques. Based on the foregoing we can draw the following conclusions: The necessity of applying PR or structured physical therapy • It is a necessity for patients before BLVR to be included in program before BLVR procedure has caused rehabilitation strategies the PR program. to be included in the treatment routines of these cases. In contrast, there are very few clinical studies on PR efficacy before BLVR. On • Symptomatic improvement and increase in exercise the other hand, the small number of PR centers is insufficient to capacity are achieved with PR before BLVR. compensate for the need for existing hospital-based PR programs. • Different PR organization models can be applied to these This situation brings up different types of PR organizations. patients, but according to the available data, hospital-based PR In the Bronchoscopic expert panel [11] published in 2019, programs seem to be more effective in these cases. attention was drawn to the existence of only 2 PR clinical studies on this subject. Of these, SOLVE trial (NCT03474471) is still in Conflict of Interest Statement recruiting status. The other study is ours, completed and published The work has not been published before in any language, is not [12]. being considered for publication elsewhere, and has been read and The mentioned study is a prospective randomized controlled approved by all authors. There are no conflicts of interest around study. Sixty-seven cases with emphysema and found to be suitable this study. for BLVR were included in the study. Most of the patients were References men. The subjects were in the middle age group and their COPD Assessment Test (CAT) score averages 25 and above. In other words, 1. Herth FJ, Slebos DJ, Criner GJ, Shah PL. Endoscopic lung volume the patients were very symptomatic. We randomly divided the cases reduction: an expert panel recommendation-update 2017. Respiration. 2017;94(4):380-8. into 2 groups and applied hospital-based PR to one group and home-based PR to the other group. The program included aerobic 2. Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, training, resistance training and breathing exercises. Hospital-based Bourbeau J, et al. Global strategy for the diagnosis, management, program involved 8 weeks of twice-weekly supervised sessions; it and prevention of chronic obstructive lung disease 2017 report. included education, breathing exercises, treadmill walking, cycle GOLD executive summary. American Journal of Respiratory and Critical Care Medicine. 2017 Mar 1;195(5):557-82. ergometer, arm ergometer training and strengthening training. Exercise intensity was predetermined to be 80% of the maximum 3. van Agteren JE, Hnin K, Grosser D, Carson KV, Smith BJ. heart rate, and it was gradually increased taking the severity of Bronchoscopic lung volume reduction procedures for chronic dyspnea perception and fatigue ratio as the basis. Strengthening obstructive pulmonary disease. Cochrane Database of Systematic training was recommended over resistance targets which were set Reviews. 2017(2). at loads equivalent to 40% of a 1-repetition maximum (1RM). 4. Ömer Özbudak HD. Amfizemde Bronkoskopik Hacim Azaltıcı Home program included education, breathing exercises, upper and Tedaviler (Chapter 21). Tanisal Ve Terapötik Bronkoskopi Uzlaşi lower extremity strengthening exercise with free weights and free Raporu Ed. Prof. Dr. Levent DALAR, Doç. Dr. Aydın YILMAZ. 2017:241- walking for at least four days weekly during the eight weeks. It was 257. recommended that resistance targets were set at loads equivalent to 5. Turan D, Doğan D, Çörtük M, EG UC, Tanrıverdi E, Yıldırım BZ, 40% of a 1RM. We recommended daily free walking for all patients. et al. Real life results of coil treatment for bronchoscopic lung The method of the calculating number of free walking laps based on volume reduction in emphysema. Tuberkuloz ve Toraks. 2020 Mar the six-minute walk test. 1;68(1):17-24. Study outcome measures were 6-minute walking distance 6. Wang Y, Lai TW, Xu F, Zhou JS, Li ZY, Xu XC, et al. Efficacy and safety (6MWD), modified Medical Research Council (mMRC) dyspnea of bronchoscopic lung volume reduction therapy in patients with score, CAT and pulmonary function test parameters. After 8 weeks severe emphysema: a meta-analysis of randomized controlled of exercise, both groups had a significant improvement in dyspnea trials. Oncotarget. 2017 Sep 29;8(44):78031. and the CAT score, which is a symptomatic follow-up material. 7. Bianchi L, Bezzi M, Berlendis M, Marino S, Montini A, Paneroni M, et The parameter that different between the groups was the walking al. Additive effect on pulmonary function and disability of intensive distance. pulmonary rehabilitation following lung volume

J Rehabil Res Pract 2021; 2(1):10-12. 11 Citation: Pehlivan E. Pulmonary rehabilitation in candidates for bronchoscopic lung volume reduction. J Rehabil Res Pract 2021; 2(1):10-12.

reduction (BLVR) for severe emphysema. Respiratory Medicine. PL. Endoscopic lung volume reduction: an expert panel 2018 Oct 1;143:116-22. recommendation–update 2019. Respiration. 2019;97(6):548-57.

8. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. 12. Pehlivan E, Yazar E, Balcı A, Turan D, Demirkol B, Çetinkaya E. An official American Thoracic Society/European Respiratory Society A comparative study of the effectiveness of hospital-based statement: key concepts and advances in pulmonary rehabilitation. versus home-based pulmonary rehabilitation in candidates for American Journal of Respiratory and Critical Care Medicine. 2013 bronchoscopic lung volume reduction. Heart & Lung. 2020 Nov Oct 15;188(8):e13-64. 1;49(6):959-64.

9. Gulsen A. Bronchoscopic lung volume reduction using coil 13. Pehlivan E, Yazar E, Balcı A, Kılıç L. Comparison of Compliance Rates therapy: complications and management. Advances in Respiratory and Treatment Efficiency in Home-Based with Hospital-Based Medicine. 2020;88(5):433-42. Pulmonary Rehabilitation in COPD. Turkish Thoracic Journal. 2019 10. Darwiche K, Karpf-Wissel R, Eisenmann S, Aigner C, Welter S, Jul;20(3):192. Zarogoulidis P, et al. Bronchoscopic lung volume reduction 14. Bourne S, DeVos R, North M, Chauhan A, Green B, Brown T, et al. with endobronchial valves in low-FEV1 patients. Respiration. Online versus face-to-face pulmonary rehabilitation for patients 2016;92(6):414-9. with chronic obstructive pulmonary disease: randomised 11. Herth FJ, Slebos DJ, Criner GJ, Valipour A, Sciurba F, Shah controlled trial. BMJ Open. 2017 Jul 1;7(7):e014580.

J Rehabil Res Pract 2021; 2(1):10-12. 12