MINISTRY OF
MINISTRY OF
EDUCATION AND TRANING
NATIONAL DEFENCE
VIETNAM MILITARY MEDICAL UNIVERSITY
DAO NGOC BANG
A STUDY ON THE EFFICIENCY
OF BRONCHOSCOPIC LUNG VOLUME
REDUCTION WITH ONE-WAY VALVES IN PATIENTS
WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Speciality: Internal medicine
Code: 9.72.01.07
ABSTRACT OF MEDICAL DOCTORAL THESIS
HANOI – 2018
Training instutation:
VIETNAM MILITARY MEDICAL UNIVERSITY
Supervisors:
1. Dong Khac Hung, PhD, Prof.
2. Ta Ba Thang. PhD. Ass Prof.
The 1st opponent: Vu Van Giap. PhD. Ass Prof.
The 2nd opponent: Tran Van Ngoc. PhD. Ass Prof.
The 3rd opponent: Nguyen Viet Nhung. PhD. Ass Prof.
This thesis was presented at the commission for theses of
Vietnam Military Medical University
at:…………………, on:……………….
This thesis maybe found at:
1. National Library
2. Library of Vietnam Military Medical University
3. ………………………….
1
BACKGROUND
Lung volume reduction (LVR) brings good benefits to patients
with chronic obstructive phumonary disease (COPD) with severe
emphysema. Bronchospic LVR (BLVR) with one-way brochial valve
proved to have good effects, with low proportion of complications.
In Vietnam, this technique was applied in treatment of COPD
firstly in the Respiratory Center, Military Hospital 103. Therefore,
the topic: “A study on the efficiency of bronchoscopic lung volume
reduction with one-way valves in patients with chronic obstructive
pulmonary disease” was carried out with 2 purposes:
1. To assess some clinical characteristics, chest computed
tomography images and respiratory function disorders in patients
with stable chronic obstructive pulmonary with severe emphysema.
2. To assess the efficacy of bronchoscopic lung volume
reduction with one-way valves in patients with stable chronic
obstructive pulmonary disease with severe emphysema.
* New contributions of the research:
- Definition of clinical characteristics, chest computer
tomography (CT) images and respiratory function disorders of stable
COPD patients with severe emphysema.
- Definition of correlations: The emphysema score has a
medium negative correlation with VC, MVV (p < 0.01) and FEV1 (p
< 0.05) and a relatively strong positive correlation with RV (r =
0.537, p < 0.01) and TLC (r = 0.479, p < 0.01).
- Assessment of the efficacy of BLVR with one-way valve:
+ Efficacies: The average CAT and 6-minute walk distance (6MWD) of group 1, underwent the valve technique, improved more
than group 2 of control patients. The emphysema score had a trend to
decrease after the therapy, with the most clearly after 3 months. FVC
increased clearly after valve placement. 15 patients (45.45%)
increased FEV1 after 3 months in comparison with before treatment.
RV and TLC decreased after the technique. The reduced levels of RV
and TLC of group 1 more than group 2 after 3 months (p < 0.05).
2
Patients with one valve had a high rate of reduced RV. After 1
month, the percentages of patients witnessed the RV and TLC
reduction more than 20% were 65.21% and 30.43%.
+ Complications: COPD exacerbations, pneumothorax and
blocked valve by mucus followed by 9.09%, 3.03% and 9.09%.
Hemoptysis and granulation were similar (6.06%).There were no
death or valve removement.
* The structure of thesis: including 129 pages, of which the
Introduction with 2, Chapter 1 (Overview) with 31, Chapter 2
(Research subjects and research methods) with 25, Chapter 3
(Results) with 33, Chapter 4 (Discussions) with 35, Conclusions with
2 and Recommendations with 1 pages. The thesis has 37 tables, 8
charts, 1 diagram, 11 images and 129 references with 21 Vietnamese
and 108 English ones.
Chapter 1: OVERVIEW
1.1. Characteristics of epidermiology, pathophysiology and
pathology of COPD
1.1.1. Epidermiology of COPD
Nowadays, studies about epidemiology of COPD are
concentrated in the prevalence of COPD types. In Vietnam, there was
no research of COPD with severe emphysema.
1.1.2. Pathophysiology of of chronic obstructive pulmonary
disease with severe emphysema
Lung hyperinflation or air-trapping is hallmark of COPD with
severe emphysema pathophysiology. The increase of the volume by
the end of expiration also increases the burden on the inhaled
muscles. The early and rapid closure of airways makes the pressure
in the alveoli is still positive when the effect of inhalation begins,
leading to decreased FEV1. RV increases because of the closure of
airways and air-trapping in the pulmonary cysts and bullaes. TLC
also increases but not much as RV does.
1.1.3. Pathology of emphysema
3
Emphysema is characreized by destruction of gas-exchanging
air spaces. Alveolar walls are destroyed and air spaces enlarge. Small
airways become narrow, thin and meandering and reduce in numbers.
1.2. Characteristics of clinical symptoms, chest X-ray images and
respiratory function disorders in COPD with severe emphysema
1.2.1. Characteristics of clinical symptoms
Chronic progressive cough and sputum, dyspnea and barell
chest. While the echo of lungs increases, alveolotheosis and alveolar
hypertrophy decrease.
1.2.2. Characteristics of chest X-ray images
1.2.2.1. Standard chest X-ray: to orient to diagnosis.
1.2.2.2. Chest computed tomography scan images of emphysema
On CT-scan images, emphysema zones have the density <
-950 HU.
Emphysema types include: Centribular, panacinar and
paraseptal emphysema and pulmonary bullae.
1.2.2.3. Assessment of emphysema severity on chest CT-scan
images
Following to Makita H. et al. (2007), assessment of
emphysema severity on chest CT-scan images at three slices: the
aortic arch, carina and 1 - 2 cm above the highest hemi diaphragm.
- In every slice, it is divided into 100 small squares,
corresponding 1% for each one. Each square is measured its density.
- Calculate the emphysema percentage in relation to its slice.
- The scale to assess emphysema severity has the score from 0
to 4. Each image was classified as normal (score 0), 5% affected
(score 0.5), 25% affected (score 1), ≤ 50% affected (score 2), ≤ 75%
affected (score 3) and >75% affected (score 4).
- Total scores are devided into 3. Classification of emphysema
severity includes : 0 score: No emphysema, < 1 point: emphysema at
degree 1, from 1 to < 2 points: emphysema at degree 2, from 2 to < 3
points: emphysema at degree 3, from 3 to 4 points: emphysema at
degree 4.
4
1.2.3. Characteristics of respiratory function disorders
1.2.3.1. Disorders of spirometry: obstructive ventilatory disorder.
1.2.3.2. Changes of lung volumes and capacities: TLC and RV
increase.
1.2.3.3. Changes of lung mechanical patterns: Raw and CV
increase while C reduces.
1.2.3.4. Disorder of lung diffusion: The diffusion and co-efficient of
kCO decrease.
1.2.3.5. Arterial blood gas: the gas exchange reduces.
1.3. Treatment of lung volume reduction
1.3.1. History of lung volume reduction
Lung volume reduction surgery was initially developed by
Brantigan et al. in the 1950s. Nowadays, endoscopic LVR (ELVR)
was developed. In Vietnam, LVR was firstly applied in the Military
Hospital 103 in 2014.
1.3.2. Physiologic basis of lung volume reduction
LVR treatment reduces injuried lung areas because of
emphysema and let the lung areas which are less injuried recover
their orgirinal size. The length of respiratory muscles become
normal.
1.3.3. Improvement of lung function after lung volume reduction
Increase of lung elastic recoil and decrease of Raw. VC
increases, RV and TLC reduce, leading to FEV 1 and FVC increase.
Improvement of respiratory muscle: increases the inspiratory power.
1.3.4. Bronchoscopic lung volume reduction
1.3.4.1. Principles of techniques
- Causing atelectasis by: Reversible EB blocker with one-way
valves or irreversible EB blocker with sealant, metal coils...
- Airway bypass stents reduce pressures of emphysema areas.
1.3.4.2. Bronchopic lung volume reduction techniques: LVR with
endobronchial blockers, coil implantation, polymeric LVR, bronchoscopic
thermal vapour ablation or LVR with airway by-pass stents.
1.4. BLVR with one-way bronchial valves
5
1.4.1. Operation mechanisms of one-way bronchial valves
One-way valves allow the air to exit the target areas during
expiration by opening valves and close during inspiration. Thanks to this
action, the lung parts of bronchi, located one-way valve, will be collapsed.
1.4.2. Types of one-way bronchial valves
Two types of valves, including endobronchial and intrabronchial
ones, have similar operation mechanisms but different structures.
1.4.6. Studies about BLVR with one-way bronchial valve in
treatment of COPD patients in the world and Vietnam
1.4.6.1. In the world
The VENT trial by Sciurba F.C. et al. included 220 COPD patients,
inserted 3.8 valves per patient, with the rate of valves in the right upper lobe
(52.3%). After 6 months, FEV1 increased 4.3% (p = 0.005). 6-minute walk
distance (6-MWD) increased 2.5% (p=0.04). Complications were unusually
seen, including: dyspnea, chest pain and hypoxemia. Later adverse events:
pneumonia (4.2%), increase of COPD exacerbations (7.9%), hemoptysis
(6.1%). 31 patients (14.1%) had to be removed valves.
In Euro-VENT study by Herth F.J. et al. (2012), 111 patients were
placed about 3 valves per patient, with the proportion in the right upper lobe
(46%). After 6 months, RV decreased 80 ± 0.3% predicted. 6-MWD and
FEV1 improved insignificantly. The proportion of pneumothorax was
higher than in control group. The rate of valve imigration was 7.2%.
The studies by Hopkinson N.S. et al. (2011), Venuta F. et al. (2012)
and Park T.S. et al. (2014) had similar results.
1.4.6.2. In Vietnam
From Jannuary 2013, the first COPD patient underwent BLVR in the
Respiratory Center, Military Hospital 103. This project was accepted with
the first results of the efficacy of bronchial one-way valve in LVR treatment.
Chapter 2: RESEARCH SUBJECTS AND RESEARCH METHODS
2.1. RESEARCH SUBJECTS
66 patients were diagnosed stable COPD with severe
emphysema and treated in the Respiratory Center, Military Hospital
6
103 and Tuberculosis and Lung Diseases Department, Central
Military Hospital 108 from January 2014 to Jun 2017.
For the first purpose: all of selected patients.
For the second one: 66 patients were divided into 2 groups:
- Group 1: 33 patients, underwent BLVR with one-way valve
in combination of internal treatment.
- Group 2: 33 patients, only underwent internal treatment.
2.1.1. Selection criteria
2.1.1.1. General criteria
Diagnostic criteria of COPD based on GOLD (2013).
Diagnostic criteria of COPD with severe emphysema:
- To diagnose emphysema: based on GOLD (2013).
- To diagnose severe emphysema: according to Grippi (2015).
To diagnose stable COPD: according to GOLD (2013).
2.1.1.2. Selection criteria of BLVR: According to “Technical
processes of Ministry of Health” (2014), selecting patients:
- Stable COPD. Older than 18 years old and giving up smoking
more than 6 months. 6-MWD > 140 meters.
- Severe heterogeneous emphysema or large pulmonary bullae.
- RV ≥ 150 %pred., TLC ≥ 100 %pred., measured
plethymosgraphy.
- No colateral ventilation under the location of valve.
2.1.2. Exclusion criteria
2.1.2.1. General exclusion criteria
- Having other respiratory diseases: tuberculosis, asthma…
- Contraindications of lung function measurement: pneumothorax,
…
- Patients do not cooperate.
2.1.2.2. Exclusion criteria of BLVR with one-way valve
- Having COPD exacerbation.
- Having homogeneous emphysema or giant pulmonary bullae
with the size > 1/3 of lung’s volume.
- Having allergy with anesthesia, nikel, titanium or silicone.
7
- Having contraindications of bronchoscopy.
2.2. Contents and methods
2.2.1. Contents
2.2.1.1. Assessment of some clinical characteristics, chest computed
tomography images and respiratory function disorders of patients
with stable chronic obstructive pulmonary with severe emphysema.
- Clinical characteristics: Age, gender, risk factors. Duration of
disease, number of exacerbations per year. Systemic, respiratory
subjective and physical symptoms. CAT and SMWD. Classification
of disease groups.
- Characteristics of chest CT-scan image: Locations, types and
severity of emphysema.
- Characteristics of respiratory function disorders: Changes of
spirometry, pthemography and arterial blood gas parameters.
- Definition of the correlation of the emphysema severity on chest
CT-scan images with respiratory function parameters.
2.2.1.2. Assessment of the efficacy of bronchoscopic lung volume
reduction with one-way valves for patients patients with stable
chronic obstructive pulmonary disease with severe emphysema
- Quantity, size and location of valves.
- Assessment of the results of valve placement:
+ Changes of clinical symptoms, chest CT-scan images and
lung function.
+ Complications and adverse events of the technique.
2.2.2. Methods
2.2.2.1. Study design and patient selection
- Purpose 1: Case study, cross sectional description.
- Purpose 2: Non-randomized controlled trial and vertical follow-up.
Methods for patient selection:
- For purpose 1: COPD patients with severe emphysema, diagnosed
by measurement of lung function, underwent HRCT.
8
- For purpose 2: From 185 COPD patients, selected 66 COPD
patients with severe emphysema, having indications of BLVR with
one-way bronchial valve. They were advised about the technique.
+ Patients agreed with valve therapy: selected in group 1.
+ Patients disagreed with valve therapy: selected in group 2.
2.2.2.2. Clinical study
2.2.2.3. Standard chest X-ray and chest CT-scan
2.2.2.4. Measurement of repiratory function
2.2.2.5. Arterial blood gas test
2.2.2.6. Other tests
2.2.2.7. Technique of BLVR with one-way bronchial valve:
Following to “Technical processes of Ministry of Health” (2014).
Preparation of patients and equipments
- Patients: similar to preparing for bronchoscopy.
- Equipments:
+ Flexible bronchoscope with the size of active tube of 2.8
mm, Chartis system, valve catheter for measurement of bronchial
diameters and bronchial one-way valve Zephyr of Pulmonx, USA.
+ Others: similar to preparing for bronchoscopy.
- Medication: similar to preparing for bronchoscopy.
Procedure
- Performing of bronchoscopy to control bronchial system.
- Definition of the location of valve placement.
- Checking of collateral ventilation by Chartis system.
- Choosing of the bronchial lobe without collateral ventilation.
- Using 4 wings catheter to measure the bronchial diameter.
- Choosing of suitable sizes and inserting it into the valve catheter.
- Flowing of catether to target bronchi via bronchoscopic active tube.
- Realesing of the valve and withdrawing delivery catheter from the
brochoscope.
- Controlling of the location and acting of the valve.
- Assessment and solving of early complications of the procedure.
- These patients underwent bronchoscopy next examinations.
9
2.2.2.8. Assessment of the eficacy of one-way bronchial valve
2.2.3. Internal treatment of stable COPD: following to Guidelines
of Ministry of Health (2014).
2.2.4. Methods of assessment of study characteristics
2.2.4.1. Assessment of clinical characteristics:
- Assessment of BMI: Based on IDI&WPRO (2011).
- Dyspnea severity (mMRC): Following to GOLD (2013).
- The affection of COPD: by calculation of CAT points’ total.
- Assessment of SMWD.
2.2.4.2. Assessment of results of chest CT-scan
- Location of emphysema: follows by every lobe and lung.
- Emphysema types: based on Thurlbeck W.M. et al. (1994).
- Emphysema severity: based on Makita H. et al.(2007).
2.2.4.3. Assessment of obstructive severity
- Classification of obstructive severity: followed by GOLD (2013).
- Classification of COPD groups: followed by GOLD (2013).
2.2.4.4. Assessment of respiratory function parameters
- Assessment of plethymosgrapphy parameters:
+ Increased Raw severity: followed by Grippi et al. (2015).
+ Emphysema severity: followed by Grippi et al.(2015).
- Assessment of arterial blood gas: followed by Weinberger et al.
(2013).
2.2.5. Data processing and analysis
Translations in the study: Calculate the mean ( X ) and
standard rate (SD); Compare the difference between groups,
proportions and average numbers in pairs by Paired-Samples T-test,
test χ2. The difference was statistical when p < 0.05. Calculate the
Pearson correlation. Management and analysis of the data by the
SPSS 20.0 program.
2.2.6. Ethics in the research
This research was carried out in accordance with the principles
of ethics in medicine.
10
DIAGRAM OF STUDY
PURPOSE
185 COPD patients
Clinical examination, lung function
mesuament and chest HRCT
66 ones with severe emphysema
33 ones in group 1
Characteristics
of clinical
examination,
lung function
mesuament and
chest HRCT
1
Purpose
1
33 ones in group 2
23 ones at 1 months after valve placement
33 ones at 3 months after valve placement
16 ones at 6 months after valve placement
23 ones after 3 months
Changes of clinical examination, lung
function mesuament and chest HRCT
Complications, adverse events
Changes of clinical
examination, lung function
Purpose 2
11
Chapter 3: RESULTS
3.1. Characteristics of clinical symptoms, chest CT-scan images
and respiratory function disorders of the studied patients
3.1.1. Characteristics of clinical symptoms of the studied patients
All patients were male, with average age of 65.80 ± 6.96 years
old.
Duration of disease was 7.61 ± 4.72 years.
Patients smoked much, with the pack-year index of 26.71 ±
11.81.
Low BMI (18.26 ± 2.46 kg/m2) with the rate of underweight of
66.60%. SMWD was short (302.82 ± 59.33 meters).
High CAT was 19.38 ± 3.26 and average mMRC score was
2.38 ± 0.84.
3.1.2. Characteristics of chest computer tomography images
Severe emphysema concentrated mainly in lower lobes
(78.79%).
80.30% had only panacinar emphysema and 9.09% of patients
had panacinar emphysema plus paraseptal emphysema.
Mean of emphysema score was 2.76 ± 0.48. The rates of
emphysema with degree 3 and 4 on chest CT-scan images were
45.45% and 51.52%.
3.1.3. Characteristics of respiratory function disorders
VC and FVC decreased significantly. FEV 1 decreased
severely (35.02 ± 13.22 %predicted).
RV (252 ± 72.81 %predicted) and Raw (9.28 ± 4.14
cmH2O/l/s) corresponded with severe increase. TLC increased
moderately (140.67 ± 26.17 %predicted).
PaO2 reduced (76.36 ± 12.13), with the lowest of 39 mmHg.
The proportion of patients having decreased O 2 in blood was
65.15%.9.09% of patients had respiratory failure.
3.1.4. The correlation between emphysema severity on chest CTscan image and respiratory function parameters
12
Emphysema score had a moderate negative correlation with
VC and MVV (p < 0.01) and FEV1 (p < 0.05).
Table 3.13. The correlation between emphysema severity and
plethymosgraphy parameters
Correlation
r
p
RV
Emphysema score
0.537
0.001
TLC
Emphysema score
0.479
0.001
Raw
Emphysema score
0.105
0.440
Emphysema score had a relatively strong positive correlation
with RV (r = 0.537, p < 0.01) and TLC (r = 0.479, p < 0.01).
3.2. Results of one-way valve placement
3.2.1. Characteristics of clinical and para-clinical symptoms of 2
groups of patients before valve procedure
The average age of patients in group 1 was 65.70 years old,
with high CAT, mMRC and short 6-MWD. There was no difference
between 2 groups in most parameters.
Patients in group 1 had highly increased RV, TLC, Raw and
emphysema score, while VC, FVC, FEV1, MVV and PaO2 decreased.
Most parameters in 2 groups had no difference.
3.2.2. Quantity, size and location of valve
The rate of valve with the size 5.5 mm used was 75.00%. 31
patients (94.94%) were treated with only one valve. The proportion
of valve located in the right lung was 88.88%, in which in the right
lower lobe (55.55%).
3.2.3. Changes of clinical characteristics of patients after therapy
Table 3.18. Changes of clinical characteristics of patients after 3
months
Parameters
Group 1
Group 2
Before
After 3 months
Before
After 3 months
therapy (1)
(2)
treatment (3)
(4)
(n=33)
(n=33)
(n=23)
(n=23)
BMI (kg/m2)
- X
p
± SD
18.61 ± 2.44
18.58 ± 2.55
17.61 ± 2.70
17.58 ± 2.70
p2,1 > 0.05; p2,4 > 0.05; p3,1 > 0.05; p4,3 > 0.05
13
- Changes
CAT (points):
- X ± SD
p
- Changes
p
-Reduced ≥ 2 (n) (%)
p
6-MWD (meters):
-0.03 ± 0.38
20.12 ± 3.42
17.79 ± 3.39
-0.03 ± 0.10
18.78 ± 3.10
17.65 ± 3.71
p2,1 < 0.01; p2,4 > 0.05; p3,1 > 0.05; p4,3 < 0.01
-2.33 ± 1.27
-1.13 ± 1.36
< 0.05
25 (75.76)
11 (47.82)
< 0.05
302.0 ± 59.53 333.48 ± 62.69 307.39 ± 67.89 326.74 ± 88.72
- X ± SD
p
p2,1 < 0.01; p2,4 > 0,05; p3,1 > 0.05; p4,3 < 0.05
- Changes
31.48 ± 26.30
19.35 ± 36.03
p
> 0.05
- Increased ≥26 m(n) (%)
16 (48.48)
5 (21.74)
p
< 0.05
mMRC (poits):
2.52 ± 0.80
2.03 ± 1.05
2.26 ± 0.92
2.09 ± 0.79
- X ± SD
p
p2,1 < 0.01; p2,4 > 0.05; p3,1 > 0.05; p4,3 < 0.01
- Changes
- 0.48 ± 0.57
- 0.17 ± 0.49
p
< 0.05
Patients in group 1 witnessed the significant increase of 6MWD (p < 0.01), with statistical decrease of CAT, mMRC (p <
0.01). In comparison with group 2, group 1 had the significant
improvement of 6-MWD, CAT and mMRC (p < 0.05).
With 1 valve, patients had a clear improvement of CAT,
mMRC and 6-MWD in comparison with before treatment (p < 0.01).
3.2.4. Changes of emphysema on chest CT-scan image
Table 3.20. Changes of emphysema score and severity after being
inserted 1 valve in comparison with before treatment
Characteristics
of emphysema
Emphysema
score ( X ±
SD)
Before
therapy
(n = 23) (1)
After 1
month
(n = 23)(2)
After3
months
(n = 23)(3)
2.59 ± 0.49
2.42 ± 0.52
2.36 ± 0.52
p
p2,1 < 0.01
p3,1 < 0.01
p3,2 > 0.05
14
Degree 2
1 (4.35%)
2 (8.70%)
4 (17.39%)
Degree 3
16 (69.57%)
15 (65.22%)
15 (65.22%)
Degree 4
6 (26.08%)
6 (26.08%)
4 (17.39%)
Patients in group 1 had mainly emphysema with degree 3
(69.57%). After valve placement, the emphysema score decreased at
both times follow-up statistically (p < 0.01). The decrease of
emphysema score was seen clearly at 3 months later.
3.2.5. Changes of spirometry and plethymosgraphy parameters of
patients after valve therapy
After 3 months, FVC and FEV1 rose. Especially, 3 patients
(9.09%) in group 1 increased FEV1 > 10% predicted. FVC improved
clearly in comparison with group 2 and before treatment (p < 0.05).
Table 3.23. Changes of plethymosgraphy parameters after 3
months
Group 1
Group 2
Before therapy After 3 months
Before
After 3 months
(1)
(2)
treatment (3)
(4)
(n=33)
(n=33)
(n=23)
(n=23)
RV (%predicted):
250.27 ± 73.88 215.00 ± 60.70 251.43 ± 64.93 275.9 ± 88.56
- X ± SD
p
p2,1 < 0.01; p2,4 < 0.01; p3,1 > 0.05; p4,3 > 0.05
- Changes
-35.27 ± 62.00
23.65 ± 60.72
p
< 0.01
TLC (%predicted):
138.12 ± 24.01 126.15 ± 22.25 144.70 ± 24.84 154.39 ± 35.47
- X ± SD
p
p2,1 < 0.05; p2,4 < 0.01; p3,1 > 0.05; p4,3 > 0.05
- Changes
-11.97 ± 27.43
9.70 ± 24.45
p
< 0.05
Raw(cmH2O/l/s)
9.04 ± 4.31
10.07 ± 4.50
9.72 ± 4.41
11.13 ± 4.77
- X ± SD
p
p2,1 > 0.05; p2,4 > 0.05; p3,1 > 0.05; p4,3 > 0.05
- Changes
1.03 ± 3.97
1.41 ± 5.44
p
> 0.05
Parameters
15
After 3 months, RV and TLC of patients in group 1 reduced (p
< 0.05), with RV more than TLC. To compare with group 2, the
decrease of RV and TLC was more statistical (p < 0.05).
3.2.5.2. Changes of respiratory function parameters of patients
placed 1 valve
After locating 1 valve, patients witnessed the improvement of
FVC, FEV1 and MVV, while VC decreased. However, the difference
was not statistical (p > 0.05).
After locating 1 valve, patients decreased RV and TLC, in
which RV went down significantly after 3 months (p < 0.05).
In group of patient with 1 valve, the number of patients with
increased FEV1 1 month after procedure was higher than 3 months
later. 8.7% of patients increased FEV1 > 10% 3 months later.
After placement of 1 valve, the highest proportion of patients
with decreased RV was met 1 month after procedure (65.22%). The
proportion of patients with decreased RV > 20% was the highest at
everytime of follow-up.
After placement of 1 valve, the rate of patients with decreased
TLC was 73.97% after 1 month and 56.52% after 3 months. The
proportion of patients with decreased RV > 20% was high (30.43%).
3.2.5.3. Changes of respiratory function parameters after 6 months
Table 3.30. Changes of spirometry and plethymosgraphy
parameters at 6 months later in comparison with before treatment
Parameters
Before therapy
(n = 16)
After 6 months
(n = 16)
p
(
± SD)
VC (%predicted)
75.11 ± 16.62
71.43 ± 21.59
p > 0.05
FVC (%predicted)
63.63 ± 16.09
67.75 ± 21.68
p > 0.05
X
FEV1 (%predicted)
37.88 ± 15.30
36.5 ± 12.81
p > 0.05
RV (%predicted)
244.19 ± 63.16
197.37 ± 56.55
p < 0.01
TLC (%predicted)
137.75 ± 19.20
117.25 ± 18.60
p = 0.01
Raw (cmH2O/l/s)
8.49 ± 4.41
11.53 ± 5.21
p < 0.01
16
RV and TLC decreased clearly in comparison with those
before treatment (p ≤ 0.01).
3.2.6. Changes of arterial bood gas parameters after valve
placement
3.2.6.1. Changes of arterial bood gas parameters after 3 months
After 3 months, PaO2 of patients in group 1 increased (p <
0.01) and in group 2 decreased. This difference was statistical (p <
0.01).
After 3 months, the proportion of patients in group 1, having
improvement of PaO2, was significant higher in comparison with
group 2 (68.75% and 40.91%).
3.2.6.2. Changes of arterial bood gas parameters in patients with 1
valve
After insertion of 1 valve, PaO 2 increased and PaCO2 decreased
in both times of follow-up, with the clearest improvement after 3
months, with PaO2 increasing statistically (p < 0.05).
3.2.6.3. Changes of arterial bood gas parameters after 6 months in
comparison with before treatment
At 6 months after the therapy, PaO2 went up and PaCO2 went
down not very clearly (p > 0.05). SaO 2 changed insignificantly and
stayed in normal limitation.
3.2.7. Complications after vale therapy
Table 3.36. Early complications after vale therapy
Complications
n
%
COPD exacerbations
3
9.09
Pneumothorax
1
3.03
Respiratory failure
0
0
Valve imigration
0
0
Total
4
12.12
The proportion of COPD exacerbations was 9.09% (3/33
patients). Pneumothorax was seen in 1 patient after 1 week (3.03%).
Table 3.37. Later complications after vale therapy
Complications
n
%
17
Hemoptysis
2
6.06
Blocked valve by mucus
3
9.09
Covered valve by granulation
2
6.06
Valve imigration
0
0
Valve removement
0
0
Total
7
21.21
Blocked valve by mucus was seen of 9.09%. Hemoptysis
was witnessed in 2 patients (6.06%) and granulation nearby the
location of valve was seen 6.06%.
Chapter 4: DISCUSSIONS
4.1. Characteristics of clinical symptoms, chest computer
tomography images and respiratory function disorders of the
studied patients
4.1.1. Characteristics of clinical symptoms of the studied patients
4.1.1.1. Characteristics of age and gender
Characteristics of age, gender was suitable with results of other
studies in Vietnam and in over the world. However, the proportion of
female in the studies in Europe and in the USA is ussually higher.
This could be related to the rate of higher smoking female.
4.1.1.2. Duration of disease
To compare with other previous studies by Pham Kim Lien
(2012)… patients in this study had a different duration of disease.
This related to the method to choose studied patients.
4.1.1.3. Risk factors
Characteristics of risk factors were similar to results of
previous studies, with most COPD patients having prehistory of
smoking and high pack-year index.
4.1.1.4. Characteristics of clinical symptoms
Characteristics of BMI index was likely the results of COPD
studies in Vietnam, including by Pham Kim Lien (2012)…In studies
in the world, BMI usually higher than that in Vietnam. This
difference could be caused by the socioeconomic conditions as well
18
as healthy care services and affected much to the results of new
methods of treatment.
Results of characteristics of dyspnea, mMRC points were
suitble with selection criteria of previous studies for LVR. Results of
CAT index, 6-MWD showed that severe COPD patients decreased
physical activities and quality of life: Sciurba F.C. et al (2010)…
The number of COPD exacerbations per year was high, similar
to some studies by Pham Kim Lien (2012)…, but more than in the
studies by Burgel P-R. et al (2010)... This has shown the level of
awareness as well as the quality of medical care in every area.
4.1.1.5. Classification of COPD group
The characteristics of COPD group showed that the
hospitalizied patients usually are severe, need to be treated
completely and controll carefully after leaving the hospital.
4.1.2. Characteristics of emphysema on CT-scan images
4.1.2.1. Locations of severe emphysema
The characteristics of emphysema location were also suitable
with the emphysema types of selected patients, with most patients
having panacinar emphysema (80.3%). This result was similar to that
in the study by Pham Kim Lien (2011).
4.1.2.2. Classification of emphysema types
The characteristics of emphysema types was similar to Pham
Kim Lien (2011), but different from Benjamin M.S. et al. (2014).
This difference might be caused by selection patients, preparing for
LVR, with mix or severe emphysema.
4.1.2.3. Severity of emphysema
In comparison with previous studies, the rate of severe
emphysema patients in this study was higher, such as Pham Kim Lien
(2011), Makita H. et al. (2007),...This difference could relate to
selection criteria, being severe emphysema patients.
4.1.3. Characteristics of respiratory function disorders
4.1.3.1. Changes of VC, FVC and FEV1
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