Publications by authors named "Daniela Gompelmann"

66 Publications

ERS International Congress 2020: highlights from the Clinical Techniques, Imaging and Endoscopy assembly.

ERJ Open Res 2021 Apr 31;7(2). Epub 2021 May 31.

Dept of Internal Medicine II, Division of Pulmonology, Medical University of Vienna, Vienna, Austria.

The European Respiratory Society congress in the year 2020, a year dominated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, was the first virtual congress planned with an innovative and interactive congress programme upfront. It was a large, novel platform for scientific discussion and presentations of cutting-edge innovative developments. This article summarises a selection of the scientific highlights from the Clinical Techniques, Imaging and Endoscopy assembly (assembly 14). In addition to presentations on the important role of bronchoscopy, imaging and ultrasound techniques in the field of SARS-CoV-2 infection, novel diagnostic approaches and innovative therapeutic strategies in patients with lung cancer, interstitial lung disease, obstructive airway disorders and infectious diseases were discussed.
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http://dx.doi.org/10.1183/23120541.00118-2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165368PMC
April 2021

Expert Statement: Pneumothorax Associated with One-Way Valve Therapy for Emphysema: 2020 Update.

Respiration 2021 Jun 1:1-10. Epub 2021 Jun 1.

Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

For selected patients with advanced emphysema, bronchoscopic lung volume reduction with one-way valves can lead to clinically relevant improvements of airflow obstruction, hyperinflation, exercise capacity, and quality of life. The most common complication of this procedure is pneumothorax with a prevalence of up to ±34% of the treated patients. Patients who develop a pneumothorax also experience meaningful clinical benefits once the pneumothorax is resolved. Timely resolution of a post-valve treatment pneumothorax requires skilled and adequate pneumothorax management. This expert panel statement is an updated recommendation of the 2014 statement developed to help guide pneumothorax management after valve placement. Additionally, mechanisms for pneumothorax development, risk assessment, prevention of pneumothorax, and outcomes after pneumothorax are addressed. This recommendation is based on a combination of the current scientific literature and expert opinion, which was obtained through a modified Delphi method.
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http://dx.doi.org/10.1159/000516326DOI Listing
June 2021

Technical Innovations in Pneumology: E-Health, Screening, Diagnostics, and Therapy.

Respiration 2021 May 7:1-7. Epub 2021 May 7.

Institute of Pneumology at the University of Cologne, Clinic of Pneumology and Allergology, Bethanien Hospital, Solingen, Germany.

At the 2020 "Luftschlösser" (castles in the air) conference, experts from a wide range of pneumological fields discussed technical innovations in pneumology, which can be seen in many different areas of the field, including e-health, screening, diagnostics, and therapy. They contribute to substantial advancements ranging from the innovative use of diagnostic tools to novel treatments for chronic lung diseases. Artificial intelligence enables broader screening, which can be expected to have beneficial effects on disease progression and overall prognosis. There is still a high demand for clinical trials to investigate the usefulness and risk-benefit ratio. Open questions remain especially about the quality and utility of medical apps in an inadequately regulated market. This article weighs the pros and cons of technical innovations in specific subspecialties of pneumology based on the lively exchange of ideas among various pneumological experts.
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http://dx.doi.org/10.1159/000516335DOI Listing
May 2021

Angioedema as a predominant symptom of infection.

BMJ Case Rep 2021 Mar 2;14(3). Epub 2021 Mar 2.

Division of Pulmonology, Department of Medicine II, Vienna General Hospital of the Medical University of Vienna, Vienna, Austria.

A 41-year-old woman was referred to our hospital with a 6-week history of severe angioedema, dyspnoea and coughing. Initial investigations focused on common causes of angioedema. Clinical presentation and resistance to treatment with antihistamines and steroids made histamine-mediated angioedema unlikely. Bradykinin-mediated angioedema, such as hereditary or drug-induced angioedema, was excluded by a thorough history investigation and laboratory testing for C1-esterase and C4.In rare cases, exogen pathogens cause angioedema. After profound testing for respiratory pathogens, toxins IgA and IgG were found to be positive, indicating recent infection. Pertussis toxin may be responsible for increased vascular permeability causing angioedema. With adequate antibiotic treatment, the symptoms resolved quickly.This case is an example of an atypical presentation of infection in an unvaccinated adult. The recent resurgence of pertussis makes early diagnosis and disease prevention by vaccination crucial.
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http://dx.doi.org/10.1136/bcr-2020-239243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929862PMC
March 2021

A sneak peek into the Early Career Members' session at the ERS International Congress and the experience of organising an ERS Research Seminar.

Breathe (Sheff) 2020 Jun;16(2):200012

REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium.

http://bit.ly/39yncgO.
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http://dx.doi.org/10.1183/20734735.0012-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714541PMC
June 2020

Endobronchial Ultrasound Elastography for Differentiating Benign and Malignant Lymph Nodes.

Respiration 2020;99(9):779-783. Epub 2020 Oct 7.

Pneumology and Critical Care medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Endobronchial ultrasound elastography that provides information on tissue stiffness may help distinguish malignant from benign mediastinal and hilar lymph nodes.

Objectives: In this prospective trial, we assessed the diagnostic value of elastographic images and the interobserver agreement in its evaluation.

Method: Elastographic images from 77 lymph nodes in 65 patients were reviewed by 3 pneumologists. The elastographic image was classified based on the predominant colour: predominantly green, intermediary, and predominantly blue. With 2 or 3 interobserver matches, the corresponding elastographic image was correlated with the pathological result obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and/or other invasive procedures.

Results: All 3 reviewers had agreement in classifying elastographic images in 45% (35/77). Overall, the interobserver agreement among the 3 readers for classifying elastographic pattern was found to be moderate (Fleiss Kappa index = 0.519; 95% CI = [0.427; 0.611]). On cytological/histological evaluation, 55 lymph nodes were malignant and 22 were benign. In classifying "green" as benign and "blue" as malignant, the sensitivity and specificity were 71% (95% CI = [54%; 85%]) and 67% (95%-CI = [35%; 90%]), respectively.

Conclusions: Elastography will not replace invasive EBUS-TBNA due to a moderate interobserver agreement and insufficient sensitivity and specificity. However, elastography will, maybe, present an additional feature to identify malignant lymph nodes in the context of clinical, radiological, and cytological results.
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http://dx.doi.org/10.1159/000509297DOI Listing
October 2020

Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure.

Ann Thorac Surg 2021 06 28;111(6):1858-1865. Epub 2020 Sep 28.

Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany.

Background: Bronchoscopic valve placement constitutes an effective endoscopic lung volume reduction (ELVR) therapy in patients with severe emphysema and low collateral ventilation. After the most destroyed lobe is occluded with valves, significant target lobe volume reduction leads to improvements in lung function, exercise capacity, and quality of life. The effects are not consistent in some patients, leading to long-term therapy failure. We hypothesized that surgical lung volume reduction (LVRS) would reestablish ELVR short-term clinical improvements after ELVR long-term failure.

Methods: This retrospective single-center analysis included all patients who underwent consolidating LVRS by lobectomy after long-term failure of valve therapy between 2010 and 2015. Changes in forced expiratory volume in 1 second, residual volume, 6-minute walking distance, and Modified Medical Research Council dyspnea score 90 days after ELVR and LVRS were analyzed, and the outcomes of both procedures were compared.

Results: LVRS was performed in 20 patients after ELVR failure. A lower lobectomy was performed in 90%. The 30-day mortality of the cohort was 0% and 90-day mortality was 5% (1 of 20). The remaining 19 patients showed a significant increase in forced expiratory volume in 1 second (+27.5% ± 19.4%) and a reduction in residual volume (-21.0% ± 17.4%) and total lung capacity (-11.1% ± 11.1%). This resulted in significant improvements in exercise tolerance (6-minute walking distance: +56 ± 60 m) and relief of dyspnea (ΔModified Medical Research Council: -1.8 ± 1.4 points.).

Conclusions: Consolidating LVRS by lobectomy after failure of a previously successful ELVR is feasible and results in significant symptom relief and improvement of lung function.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.148DOI Listing
June 2021

ERS International Congress, Madrid, 2019: highlights from the Clinical Techniques, Imaging and Endoscopy Assembly.

ERJ Open Res 2020 Apr 20;6(2). Epub 2020 Jul 20.

Dept of Pneumology and Critical Care Medicine, Thoraxklink University Heidelberg, Heidelberg, Germany.

This manuscript summarises the highlights from Assembly 14, "Clinical techniques, imaging and endoscopy", which were presented at the 2019 European Respiratory Society (ERS) International Congress in Madrid, Spain. Novel diagnostic approaches and innovative therapeutic strategies in patients with lung cancer, interstitial lung disease, obstructive airway disorders and infectious diseases are discussed. The authors from the different Assembly 14 subgroups focus on the key take-home messages given new study results, and place them in the context of current knowledge in these areas. At the 2019 ERS International Congress, encouraging results of numerous trials in the field of interventional pulmonology, imaging and ultrasound were presented. Key topics included novel diagnostic and therapeutic approaches in patients with lung cancer, interstitial lung disease, obstructive airway disorders and infectious diseases.
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http://dx.doi.org/10.1183/23120541.00116-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369474PMC
April 2020

Efficacy and Safety of the 9-mm Intrabronchial Valve in Patients with Advanced Emphysema.

Respiration 2020;99(4):333-343. Epub 2020 Apr 20.

Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Endoscopic valve therapy aims at lung volume reduction that is associated with improved lung function, exercise tolerance and quality of life in emphysema patients. The size of intrabronchial valves of the Spiration® Valve System (SVS) selected to achieve lobar occlusion may have an influence on treatment outcomes.

Methods: 49 severe emphysema patients (M/F: 24/25, age: 64 ± 7 years), with complete interlobar fissures on the side intended to be treated, underwent treatment with at least one 9-mm intrabronchial valve implantation at 3 centers and were followed up at 30, 90 and 180 days after intervention. Changes in pulmonary function tests (PFT), 6-min walk test (6MWT), modified Medical Research Council (mMRC) dyspnea scale and chronic obstructive pulmonary disease assessment test scores as well as possible complications were recorded.

Results: Forced expiratory volume in 1 s (FEV1) improved significantly over the 6-month period of the study, and the proportion of patients achieving a minimal clinically important difference (MCID) for FEV1 was 46.4% at 6 months. Regarding the remaining PFT values, the changes were not statistically significant at 6 months, but when looking at the MCIDs, 44.4% of the patients achieved the MCID decrease for residual volume. The 6MWT distance also improved statistically significantly, and an MCID increase of ≥26 m was reached by 41.7% of the patients. Furthermore, there was a statistically significant improvement in the mMRC score. The incidence of pneumothoraxes requiring drainage was 26.5% while a valve dislocation rate of 24% was observed but only in the lower lobes.

Conclusions: Endoscopic lung volume reduction with the 9-mm SVS valves was associated with statistically significant but modest improvement of FEV1, mMRC and 6MWT up to 6 months after intervention. These results were accompanied by an anticipated and acceptable risk profile. The relative increased incidence of device dislocation observed needs to be further elucidated.
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http://dx.doi.org/10.1159/000506521DOI Listing
April 2021

Interventional Bronchoscopy.

Am J Respir Crit Care Med 2020 07;202(1):29-50

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.
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http://dx.doi.org/10.1164/rccm.201907-1292SODOI Listing
July 2020

Quantitative CT detects progression in COPD patients with severe emphysema in a 3-month interval.

Eur Radiol 2020 May 21;30(5):2502-2512. Epub 2020 Jan 21.

Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.

Objectives: Chronic obstructive pulmonary disease (COPD) is characterized by variable contributions of emphysema and airway disease on computed tomography (CT), and still little is known on their temporal evolution. We hypothesized that quantitative CT (QCT) is able to detect short-time changes in a cohort of patients with very severe COPD.

Methods: Two paired in- and expiratory CT each from 70 patients with avg. GOLD stage of 3.6 (mean age = 66 ± 7.5, mean FEV1/FVC = 35.28 ± 7.75) were taken 3 months apart and analyzed by fully automatic software computing emphysema (emphysema index (EI), mean lung density (MLD)), air-trapping (ratio expiration to inspiration of mean lung attenuation (E/I MLA), relative volume change between - 856 HU and - 950 HU (RVC)), and parametric response mapping (PRM) parameters for each lobe separately and the whole lung. Airway metrics measured were wall thickness (WT) and lumen area (LA) for each airway generation and the whole lung.

Results: The average of the emphysema parameters (EI, MLD) increased significantly by 1.5% (p < 0.001) for the whole lung, whereas air-trapping parameters (E/I MLA, RVC) were stable. PRM increased from 34.3 to 35.7% (p < 0.001), whereas PRM decrased from 23.6% to 22.8% (p = 0.012). WT decreased significantly from 1.17 ± 0.18 to 1.14 ± 0.19 mm (p = 0.036) and LA increased significantly from 25.08 ± 4.49 to 25.84 ± 4.87 mm (p = 0.041) for the whole lung. The generation-based analysis showed heterogeneous results.

Conclusion: QCT detects short-time progression of emphysema in severe COPD. The changes were partly different among lung lobes and airway generations, indicating that QCT is useful to address the heterogeneity of COPD progression.

Key Points: • QCT detects short-time progression of emphysema in severe COPD in a 3-month period. • QCT is able to quantify even slight parenchymal changes, which were not detected by spirometry. • QCT is able to address the heterogeneity of COPD, revealing inconsistent changes individual lung lobes and airway generations.
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http://dx.doi.org/10.1007/s00330-019-06577-yDOI Listing
May 2020

Anchored Transponder Guided Lung Radiation Therapy.

Pract Radiat Oncol 2020 Jan - Feb;10(1):e37-e44. Epub 2019 Aug 31.

Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama. Electronic address:

Purpose: The Calypso Beacon transponder has been modified by the addition of a nitinol anchor feature to allow for positional stability when implanted bronchoscopically into the lung. The purpose of this study was to confirm the feasibility and safety of anchored transponder placement and feasibility of lung target localization and tracking.

Methods And Materials: This study enrolled patients with histologically confirmed cancer in the lung (primary or metastatic) who were scheduled to receive external beam radiation therapy. Three anchored transponders were implanted via flexible bronchoscopy into small (approximately 2- to 2.5-mm diameter) airways. Patient alignment at each radiation fraction was performed with the Calypso system, and anchored transponder position was tracked during radiation delivery. The primary endpoint was defined as the ability to localize at least 85% of the patients during the first week of treatment. Four follow-up visits were specified including a posttreatment assessment and every 3 months up to 1 year.

Results: A total of 69 patients underwent anchored transponder placement, and all 207 implanted anchored transponders were visible on the treatment-planning simulation computed tomography scan. Sixty-seven patients underwent radiation therapy, and localization was successful in 66 cases (98.5%). With 1 failure in 67 cases, the P value for rejecting the null hypothesis was <.001 and the primary objective of the study met. Five adverse events in 5 patients were potentially attributed to the study device or implantation procedure, consisting of pneumonia (2 cases), pleural abscess (1 case), and pneumothorax (2 cases). Two serious events (cardiac arrest and acute hypotension) were attributed to anesthesia during the implantation procedure.

Conclusions: This study strongly supports that anchored transponders are safe, positionally stable, and useful for lung tumor localization and monitoring.
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http://dx.doi.org/10.1016/j.prro.2019.08.009DOI Listing
June 2020

Long-term follow up after endoscopic valve therapy in patients with severe emphysema.

Ther Adv Respir Dis 2019 Jan-Dec;13:1753466619866101

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany Translational Lung Research Center Heidelberg (TLRCH), German Center for Lung Research, Heidelberg, Germany.

Background And Objective: Endoscopic valve therapy is a treatment modality in patients with advanced emphysema and absent interlobar collateral ventilation (CV). So far, long-term outcome following valve implantation has been insufficiently evaluated. The aim of this study was to investigate the real-world efficacy of this interventional therapy over 3 years.

Methods: From 2006 to 2013, 256 patients with severe emphysema in whom absent CV was confirmed underwent valve therapy. The 3-year effectiveness was evaluated by pulmonary function testing (VC, FEV, RV, TLC), 6-minute-walk test (6-MWT) and dyspnea questionnaire (mMRC). Long-term outcome was also assessed according to the radiological outcome following valve placement.

Results: Of 256 patients treated with valves, 220, 200, 187, 100 and 66 patients completed the 3-month, 6-month, 1-year, 2-year and 3-year follow-up (FU) visit, respectively. All lung function parameters, 6-MWT and mMRC were significantly improved at 3- and 6-month FU. At 1-year FU, patients still experienced a significant improvement of all outcome parameters expect VC (L) and TLC (%). At 2 years, RV (L and %) and TLC (L and %) remained significantly improved compared to baseline. Three years after valve therapy, sustained significant improvement in mMRC was observed and the proportion of patients achieving a minimal clinically important difference from baseline in RV and 6-MWT was still 71% and 46%, respectively. Overall, patients with complete lobar atelectasis exhibited superior treatment outcome with 3-year responder rates to FEV, RV and 6-MWT of 10%, 79% and 53%, respectively.

Conclusions: Patients treated by valves experienced clinical improvement over 1 year following valve therapy. Afterwards, clinical benefit gradually declines more likely due to COPD progression.
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http://dx.doi.org/10.1177/1753466619866101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681249PMC
March 2020

Interventional therapy in patients with severe emphysema: evaluation of contraindications and their incidence.

Ther Adv Respir Dis 2019 Jan-Dec;13:1753466619835494

Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany, and Translational Lung Research Center Heidelberg (TLRCH, German Center for Lung Research), Heidelberg, Germany.

Background: Endoscopic and surgical interventions may be beneficial for selected patients with emphysema. Rates of treatment failure decrease when the predictors for successful therapy are known. The aim of the study was to evaluate the number of patients with severe emphysema who were not eligible for any intervention, and the reasons for their exclusion.

Methods: The study was a retrospective analysis of 231 consecutive patients with advanced emphysema who were considered for interventional therapy in 2016 at the Thoraxklinik, Heidelberg, Germany. The reasons for not receiving valve or coil therapy were assessed for all patients who did not receive any therapy.

Results: Of the 231 patients, 50% received an interventional therapy for lung volume reduction (LVR) (82% valve therapy, 6% coil therapy, 4.3% polymeric LVR or bronchial thermal vapour ablation, 4.3% total lung denervation, and 3.4% lung volume reduction surgery [LVRS]). A total of 115 patients did not undergo LVR. Out of these, valve or coil therapy was not performed due to one or more of the following reasons: incomplete fissure in 37% and 0%; missing target lobe in 31% and 30%; personal decision in 18% and 28%; pulmonary function test results in 8% and 15%; ventilatory failure in 4% and 4%; missing optimal standard medical care and/or continued nicotine abuse in 4% and 3%; general condition too good in less than 1% and 3%; cardiovascular comorbidities in 0% and 3%; age of patient in 0% and less than 1%. Both techniques were not performed due to one or more of the following reasons: solitary pulmonary nodule(s)/consolidation in 27%; bronchopathy in 7%; neoplasia in 2%; destroyed lung in 2%; prior LVRS in less than 1%.

Conclusions: The main reason for not placing valves was an incomplete fissure and for coils a missing target lobe. Numerous additional contraindications that may exclude a patient from interventional emphysema therapy should be respected.
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http://dx.doi.org/10.1177/1753466619835494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6421604PMC
August 2019

Computed Tomography Imaging for Novel Therapies of Chronic Obstructive Pulmonary Disease.

J Thorac Imaging 2019 May;34(3):202-213

Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg.

Novel therapeutic options in chronic obstructive pulmonary disease (COPD) require delicate patient selection and thus demand for expert radiologists visually and quantitatively evaluating high-resolution computed tomography (CT) with additional functional acquisitions such as paired inspiratory-expiratory scans or dynamic airway CT. The differentiation between emphysema-dominant and airway-dominant COPD phenotypes by imaging has immediate clinical value for patient management. Assessment of emphysema severity, distribution patterns, and fissure integrity are essential for stratifying patients for different surgical and endoscopic lung volume reduction procedures. This is supported by quantitative software-based postprocessing of CT data sets, which delivers objective emphysema and airway remodelling metrics. However, the significant impact of scanning and reconstruction parameters, as well as intersoftware variability still hamper comparability between sites and studies. In earlier stage COPD imaging, it is less clear as to what extent quantitative CT might impact decision making and therapy follow-up, as emphysema progression is too slow to realistically be useful as a mid-term outcome measure in an individual, and longitudinal data on airway remodelling are still very limited.
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http://dx.doi.org/10.1097/RTI.0000000000000378DOI Listing
May 2019

Hope for Patients with Homogeneous Emphysema?

Chronic Obstr Pulm Dis 2018 Apr 1;5(2):84-86. Epub 2018 Apr 1.

Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany.

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http://dx.doi.org/10.15326/jcopdf.5.2.2018.0135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6190521PMC
April 2018

Preview of highlighted presentations from the European Respiratory Society' clinical assembly.

J Thorac Dis 2018 Sep;10(Suppl 25):S3034-S3042

Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University Hospital, Heidelberg, Germany.

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http://dx.doi.org/10.21037/jtd.2018.09.17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174136PMC
September 2018

Survival after Endoscopic Valve Therapy in Patients with Severe Emphysema.

Respiration 2019;97(2):145-152. Epub 2018 Sep 18.

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Endoscopic valve therapy leads to an improvement of lung function, exercise tolerance, and quality of life in a selected cohort of patients with advanced emphysema. So far, only few data exist on the long-term outcome.

Objectives: This analysis evaluated the impact of valve therapy on the survival of emphysema patients.

Methods: Survival rates of emphysema patients who underwent valve therapy were assessed according to their radiological outcome following valve placement.

Results: From 2005 to 2013, 449 emphysema patients (mean age 64 ± 7 years) underwent valve therapy and were followed for a mean time of 37.3 ± 21.3 months. A total of 128 patients (29%) developed complete lobar atelectasis, 34 out of these also experienced a pneumothorax; 50 patients (11%) developed pneumothorax without lobar atelectasis, and 261 patients (58%) target lobe volume reduction or no volume change. Patients with atelectasis showed significantly better baseline forced expiratory volume in 1 second (%), residual volume (L), total lung capacity (L), and transfer factor for carbon monoxide (%; all p < 0.05), but there was no significant difference in the BODE score (p = 0.195). Patients with valve-induced lobar atelectasis had a significant survival benefit compared to patients without atelectasis (p = 0.009; 5-year survival rate 65.3 vs. 43.9%). The advent of pneumothorax in 84 patients did not influence survival (p = 0.52).

Conclusions: Lobar atelectasis following endoscopic valve therapy is associated with a survival benefit.
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http://dx.doi.org/10.1159/000492274DOI Listing
April 2020

Thermic and chemical procedures for bronchoscopic lung volume reduction.

J Thorac Dis 2018 Aug;10(Suppl 23):S2806-S2810

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany.

In the last 14 years several endoscopic procedures have been developed to offer patients with advanced chronic obstructive pulmonary disease (COPD) and emphysema further therapeutic options, complementary to a medical treatment. In addition to the established valve implantation, new approaches have been available since 2009. These procedures include bronchoscopic thermal vapor ablation (BTVA) and polymeric lung volume reduction. Both therapies are independent of collateral ventilation (CV), are irreversible and can be used on segmental (BTVA) and sub-segmental level [polymeric lung volume reduction (PLVR)], in contrast to valve therapy. The intention is to induce a local inflammation with a following fibrosis and shrinkage and thus a volume reduction in the treated lung areas. Currently, only patients with predominant upper-lobe emphysema are treated. An improvement of lung function, exercise capacity and quality of life could be proved in RCTs for BTVA as well as for PLVR. However, the data for PLVR is very limited and has recently been available only in studies. Furthermore, the risk profile is unfavourable with a high number of adverse respiratory events. While BTVA is an established new approach, the PLVR requires re-evaluation regarding materials, predictive factors, safety profile and dosage.
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http://dx.doi.org/10.21037/jtd.2018.05.123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129803PMC
August 2018

[Interventional Bronchoscopy: What is Possible and What Makes Sense?]

Dtsch Med Wochenschr 2018 08 30;143(15):1097-1102. Epub 2018 Jul 30.

Pneumologie und Beatmungsmedizin, Thoraxklinik am Universitätsklinikum Heidelberg.

Interventional bronchoscopy plays a significant role in the treatment of various pulmonary diseases. Different endoscopic therapeutic modalities are available for the management of central airway obstruction (CAO) that represent a common indication for interventional bronchoscopy. The latest development in the field of CAO management are biodegradable stents, that would maintain the airway patency over time, then gradually degrade and vanish from the airway. Other indications for interventional bronchoscopy are chronic obstructive pulmonary disease (COPD), emphysema, asthma and chronic bronchitis. Thereby, various techniques of endoscopic lung volume reduction (ELVR) that address at hyperinflation reduction extend the therapeutic spectrum of patients with severe emphysema. Targeted lung denervation that aims a persistent bronchodilation present an area of current research in the field of COPD and asthma. In patients with chronic bronchitis, cryospray therapy that is performed within clinical trials may reduce the amount of secretion.
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http://dx.doi.org/10.1055/a-0551-2626DOI Listing
August 2018

Clinical and quantitative computed tomography predictors of response to endobronchial lung volume reduction therapy using coils.

Int J Chron Obstruct Pulmon Dis 2018 20;13:2215-2223. Epub 2018 Jul 20.

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik at the University of Heidelberg, Heidelberg, Germany,

Objectives: Bronchoscopic lung volume reduction using coils (LVRC) is a well-known treatment option for severe emphysema. The purpose of this study was to identify quantitative computed tomography (QCT) and clinical parameters associated with positive treatment outcome.

Patients And Methods: The CT scans, pulmonary function tests (PFT), and 6-minute walk test (6-MWT) data were collected from 72 patients with advanced emphysema prior to and at 3 months after LVRC treatment. The procedure involved placing 10 coils unilaterally. Various QCT parameters were derived using Apollo imaging software (VIDA). Independent predictors of clinically relevant outcome (Δ6-MWT ≥ 26 m, ΔFEV ≥ 12%, ΔRV ≥ 10%) were identified through stepwise linear regression analysis.

Results: The response outcome for Δ6-MWT, for ΔFEV and for ΔRV was met by 55%, 32% and 42%, respectively. For Δ6-MWT ≥ 26 m a lower baseline 6-MWT ( = 0.0003) and a larger standard deviation (SD) of low attenuation cluster (LAC) sizes in peripheral regions of treated lung ( = 0.0037) were significantly associated with positive outcome. For ΔFEV ≥ 12%, lower baseline FEV ( = 0.02) and larger median LAC sizes in the central regions of treated lobe ( = 0.0018) were significant predictors of good response. For ΔRV ≥ 10% a greater baseline TLC ( = 0.0014) and a larger SD of LAC sizes in peripheral regions of treated lung ( = 0.007) tended to respond better.

Conclusion: Patients with lower FEV and 6-MWT, with higher TLC and specific QCT characteristics responded more positively to LVRC treatment, suggesting a more targeted CT-based approach to patient selection could lead to greater efficacy in treatment response.
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http://dx.doi.org/10.2147/COPD.S159355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055902PMC
January 2019

Endoscopic Valve Removal >180 Days since Implantation in Patients with Severe Emphysema.

Respiration 2018;96(4):348-354. Epub 2018 Jul 24.

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Background: Valve implantation provides a reversible effective therapy in a selected group of emphysema patients. Knowing predictors for successful therapy, the rate of treatment failure has decreased. Some patients, however, do not benefit, so that the valves may have to be removed.

Objectives: To assess implant-related events, complications during valve removal, and clinical outcome after endoscopic procedure.

Methods: The data of 76 consecutive emphysema patients who underwent valve removal > 6 months since implantation were collected.

Results: Seventy-six patients (mean age 62 years, 54% male) underwent removal of all valves after a mean time of 624 days (193-3,043 days) since implantation. Granulation tissue was observed in 39.5% (30/76) and significant secretion in 34.2% (26/76). In 5.3% (4/76), valve removal was complicated requiring another bronchoscopy in 2 of them. In 5.3% (4/76) of the patients, one valve could not be removed and remained in situ. Bleeding requiring intervention occurred in 3.9% (3/76) during valve removal. Following bronchoscopy, there was a need for antibiotics in 34.2% (26/76), glucocorticosteroids in 1.3% (1/76), and both in 6.6% (5/76) due to productive cough or chronic obstructive pulmonary disease (COPD) exacerbation. Due to respiratory failure, invasive ventilation or noninvasive ventilation was necessary in 2.6% (2/76) and 6.6% (5/76), respectively, following procedure. No statistical significant change in lung function was observed following valve removal.

Conclusions: Valve removal after > 6 months since implantation is feasible and associated with an acceptable safety profile. However, close monitoring of these patients with limited pulmonary reserve is recommended with particular attention to COPD exacerbations and respiratory failure.
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http://dx.doi.org/10.1159/000489887DOI Listing
October 2019

Bronchoscopic Thermal Vapor Ablation: Best Practice Recommendations from an Expert Panel on Endoscopic Lung Volume Reduction.

Respiration 2018;95(6):392-400. Epub 2018 Jun 12.

Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany.

Bronchoscopic thermal vapor ablation (BTVA) represents one of the endoscopic lung volume reduction (ELVR) techniques that aims at hyperinflation reduction in patients with advanced emphysema to improve respiratory mechanics. By targeted segmental vapor ablation, an inflammatory response leads to tissue and volume reduction of the most diseased emphysematous segments. So far, BTVA has been demonstrated in several single-arm trials and 1 multinational randomized controlled trial to improve lung function, exercise capacity, and quality of life in patients with upper lobe-predominant emphysema irrespective of the collateral ventilation. In this review, we emphasize the practical aspects of this ELVR method. Patients with upper lobe-predominant emphysema, forced expiratory volume in 1 second (FEV1) between 20 and 45% of predicted, residual volume (RV) > 175% of predicted, and carbon monoxide diffusing capacity (DLCO) ≥20% of predicted can be considered for BTVA treatment. Prior to the procedure, a special software assists in identifying the target segments with the highest emphysema index, volume and the highest heterogeneity index to the untreated ipsilateral lung lobes. The procedure may be performed under deep sedation or preferably under general anesthesia. After positioning of the BTVA catheter and occlusion of the target segment by the occlusion balloon, heated water vapor is delivered in a predetermined specified time according to the vapor dose. After the procedure, patients should be strictly monitored to proactively detect symptoms of localized inflammatory reaction that may temporarily worsen the clinical status of the patient and to detect complications. As the data are still very limited, BTVA should be performed within clinical trials or comprehensive registries where the product is commercially available.
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http://dx.doi.org/10.1159/000489815DOI Listing
November 2018

New bacterial growth in bronchial secretions after bronchoscopic valve implantation.

Int J Chron Obstruct Pulmon Dis 2018 8;13:565-570. Epub 2018 Feb 8.

Department of Pulmonology and Respiratory Care Medicine, Thoraxklinik, at the University of Heidelberg, Heidelberg.

Background: Bronchoscopic valve implantation is an established treatment in selected patients with severe lung emphysema. There is evidence in literature of increased bacterial colonization of various implants. So far, it is unclear if an increased bacterial colonization can also be observed after endoscopic valve therapy.

Methods: Retrospective analysis of patients with examination of the bronchial secretions for presence or change of bacterial growth before and after valve implantation.

Results: Overall, 144 patients who underwent bronchoscopic follow-up after valve implantation were included in this analysis. Prior to valve placement, only 7 out of 144 consecutive emphysema patients (5%) presented with evidence of bacterial colonization, whereas 137 patients (95%) showed no bacterial growth prior to valve placement. One hundred seven out of the 137 patients (78%) showed new bacterial growth after valve implantation. Almost 38% of the patients who presented with a new bacterial growth had evidence of , and species simultaneously, as bacterial colonization. Pathogenic bacterial growth was recorded for (18%), (13%) and (9%) microorganisms. There was also a significant bacterial growth by (26%) and anaerobic bacteria (23%), especially in patients with complete atelectasis after successful endoscopic lung volume reduction. For all of the 7 patients, the presented initial bacterial colonization showed a change in the flora after bronchoscopy valve implantation.

Conclusion: In this study we observed an increased bacterial colonization in the long term after valve implantation. This finding needs further evaluation regarding its possible clinical relevance but should be taken into consideration in the follow-up of these patients.
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http://dx.doi.org/10.2147/COPD.S148196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810521PMC
September 2018

European Respiratory Society International Congress 2017: highlights from the Clinical Assembly.

ERJ Open Res 2018 Jan 10;4(1). Epub 2018 Jan 10.

Pneumology and Critical Care Medicine, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.

This article contains highlights and a selection of the scientific advances from the European Respiratory Society's Clinical Assembly (Assembly 1 and its six respective groups) that were presented at the 2017 European Respiratory Society International Congress in Milan, Italy. The most relevant topics from each of the groups will be discussed, covering a wide range of areas including clinical problems, rehabilitation and chronic care, thoracic imaging, interventional pulmonology, diffuse and parenchymal lung diseases, and general practice and primary care. In this comprehensive review, the newest research and actual data as well as award-winning abstracts and highlight sessions will be discussed.
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http://dx.doi.org/10.1183/23120541.00134-2017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761713PMC
January 2018

Influence of fissure integrity on quantitative CT and emphysema distribution in emphysema-type COPD using a dedicated COPD software.

Eur J Radiol 2017 Oct 19;95:293-299. Epub 2017 Aug 19.

Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 430, 69120 Heidelberg, Germany; Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik at University of Heidelberg, Amalienstr. 5, 69126 Heidelberg, Germany.

Objectives: Fissure integrity (FI) plays a key role in selecting patients for interventional emphysema therapy. We investigated its interference with automated lobar segmentation in quantitative computed tomography (CT) and emphysema distribution.

Methods: CT was available for 50 patients with chronic obstructive pulmonary disease (COPD). Lobe segmentation was performed fully automated by software and corrected manually. FI was evaluated visually using a %-scale. The influence of FI on emphysema ratio (ER=percentage of lung volume with density values<-950 HU), mean lung density (MLD), emphysema and total volume of adjacent lobes was analyzed. Lobe-based results were compared with respect to FI.

Results: Differences in ER in adjacent lobes for complete vs. incomplete fissures were 12.4% for the right horizontal, 0.2% and 3% for the right oblique and 4.4% for the left oblique fissure (all p>0.05). Results for emphysema comparing automated vs. manually corrected segmentation exceeded clinically acceptable values, but were not significantly affected by FI (p>0.05). The widest limits of agreement for ER and MLD were noted in the right middle lobe ([-14, 17.4%], [-22.4, 32.4 Hounsfield Units]).

Conclusions: Automated lobe segmentation and emphysema distribution are not significantly affected by FI. Manual correction of automated lobar segmentation is still recommended in severe emphysema.
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http://dx.doi.org/10.1016/j.ejrad.2017.08.015DOI Listing
October 2017

Motion monitoring during a course of lung radiotherapy with anchored electromagnetic transponders : Quantification of inter- and intrafraction motion and variability of relative transponder positions.

Strahlenther Onkol 2017 Oct 21;193(10):840-847. Epub 2017 Jul 21.

Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.

Purpose: Anchored electromagnetic transponders for tumor motion monitoring during lung radiotherapy were clinically evaluated. First, intrafractional motion patterns were analyzed as well as their interfractional variations. Second, intra- and interfractional changes of the geometric transponder positions were investigated.

Materials And Methods: Intrafractional motion data from 7 patients with an upper or middle lobe tumor and three implanted transponders each was used to calculate breathing amplitudes, overall motion amount and motion midlines in three mutual perpendicular directions and three-dimensionally (3D) for 162 fractions. For 6 patients intra- and interfractional variations in transponder distances and in the size of the triangle defined by the transponder locations over the treatment course were determined.

Results: Mean 3D values of all fractions were up to 4.0, 4.6 and 3.4 mm per patient for amplitude, overall motion amount and midline deviation, respectively. Intrafractional transponder distances varied with standard deviations up to 3.2 mm, while a maximal triangle shrinkage of 36.5% over 39 days was observed.

Conclusions: Electromagnetic real-time motion monitoring was feasible for all patients. Detected respiratory motion was on average modest in this small cohort without lower lobe tumors, but changes in motion midline were of the same size as the amplitudes and greater midline motion can be observed in some fractions. Intra- and interfractional variations of the geometric transponder positions can be large, so for reliable motion management correlation between transponder and tumor motion needs to be evaluated per patient.
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http://dx.doi.org/10.1007/s00066-017-1183-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614910PMC
October 2017

Flexible 19-Gauge Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Needle: First Experience.

Respiration 2017 17;94(1):52-57. Epub 2017 May 17.

Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada.

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a well-established first-line invasive modality for mediastinal lymph node staging in lung cancer patients and in the diagnostic workup of patients with mediastinal adenopathy. With the current 21- and 22-gauge (G) EBUS-TBNA needles, the procedure can be limited by the degree of flexibility in the needle and the size of the lumen in tissue acquisition.

Objective: We report our initial experience with a first-generation flexible 19-G EBUS-TBNA (Flex 19G; Olympus Respiratory America, Redmond, WA, USA) needle with regards to efficacy and safety.

Methods: The Flex 19G EBUS-TBNA needle was used in 47 selected patients with enlarged hilar and/or mediastinal lymphadenopathy at 3 centers. The standard Olympus EBUS scope with a 2.2-mm working channel was used in all cases.

Results: The diagnostic yield of the Flex 19G needle according to clinical cytopathology reports was 89% (42/47). The diagnosis and their respective diagnostic yield with the Flex 19G EBUS-TBNA needle were malignancy 24/27 (89%), sarcoidosis 13/14 (93%), and reactive lymph node hyperplasia 5/6 (83%). The mean short axis of the sampled lymph nodes was 19 ± 9 mm. No complications occurred except for 1 instance of moderate bleeding, which did not require intervention beyond suctioning and subsequently resolved. All 13 patients diagnosed with adenocarcinoma by the 19-G needle had sufficient tissue for genetic testing.

Conclusion: EBUS-TBNA using the first-generation Flex 19G needle is feasible and safe with promising diagnostic yield while providing a greater degree of flexion with the Olympus EBUS scope. Additional clinical evaluations are warranted.
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http://dx.doi.org/10.1159/000475504DOI Listing
May 2018

Clinical highlights from the 2016 European Respiratory Society International Congress.

ERJ Open Res 2017 Apr 12;3(2). Epub 2017 Apr 12.

Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg, Heidelberg, Germany.

This article contains highlights and a selection of the scientific advances from the European Respiratory Society (ERS) Clinical Assembly (Assembly 1) and its six respective groups (Groups 1.1-1.6) that were presented at the 2016 ERS International Congress in London, UK. The most relevant topics for clinicians will be discussed, covering a wide range of areas including clinical problems, rehabilitation and chronic care, thoracic imaging, interventional pulmonology, diffuse and parenchymal lung diseases, and general practice and primary care. In this comprehensive review, the newest research and actual data will be discussed and put into perspective.
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http://dx.doi.org/10.1183/23120541.00147-2016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406227PMC
April 2017

Interventional pulmonology in chronic obstructive pulmonary disease.

Curr Opin Pulm Med 2017 05;23(3):261-268

aDepartment of Pneumology and Critical Care Medicine, Thoraxklinik at University of Heidelberg bCenter for Lung Research, Heidelberg, Germany.

Purpose Of Review: Chronic obstructive pulmonary disease (COPD) and emphysema are widespread diseases associated with progressive dyspnea because of airflow limitation and hyperinflation. Fundamental therapeutic strategies consist of pulmonary rehabilitation, pharmacotherapy, long-term oxygen therapy, noninvasive ventilation, and surgical therapeutic approaches.

Recent Findings: In the last 14 years, endoscopic therapeutic modalities emerged as a substantial part of severe COPD and emphysema treatment. Techniques of the endoscopic lung volume reduction (ELVR) aim at reduction of hyperinflation. Thereby, the reversible valve implantation of which the efficacy was confirmed in various randomized controlled trials (RCT) results in lobar volume reduction and clinical benefit in emphysema patients with absent interlobar collateral ventilation. Nonblocking ELVR methods that are independent of collateral ventilation include the partially irreversible coil implantation leading to parenchymal compression, the irreversible bronchoscopic thermal vapor ablation and polymeric lung volume reduction both inducing inflammatory reaction. The nonblocking methods have been examined in only a few RCTs. The targeted lung denervation as a novel bronchoscopic therapy for COPD patients aims at sustainable bronchodilation by ablation of parasympathetic pulmonary nerves.

Summary: The review summarizes the various endoscopic treatment approaches for managment of COPD and emphysema, their mechanism of action, their complications and the current available results of the most important RCTs.
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http://dx.doi.org/10.1097/MCP.0000000000000373DOI Listing
May 2017