Less Invasive Emphysema Treatment Matches Lung Volume Reduction Surgery

BARCELONA — Eligible emphysema patients had similar levels of improvement whether treated with lung volume reduction surgery (LVRS) or bronchoscopic lung volume reduction (BLVR) with valve placement, a less-invasive option, the randomized CELEB trial showed.

At 12 months, the average improvement from baseline on the 10-point BODE index — the study’s primary endpoint — was a similar -1.10 (SD 1.44) with LVRS and -0.82 (1.61) with BLVR (P=0.54), Sara Buttery, a research physiotherapist and PhD candidate at Imperial College London, reported here.

“LVRS did not produce substantially superior outcomes,” said Buttery during her presentation at the European Respiratory Society (ERS) annual meeting.

“Both treatments appeared equally safe, with one death in each treatment arm in this severe COPD [chronic obstructive pulmonary disease] cohort,” she said, though noted that the death in the BLVR group was determined to be treatment related following a prolonged air leak.

Changes in the individual components of BODE — body mass index (BMI), airflow obstruction, dyspnea, and exercise capacity — also did not differ significantly between the two treatments.

And improvements in gastrapping scores — measured as residual volume (RV) percent predicted — were similar regardless of treatment method (P=0.81), with both exceeding the clinically important difference:

• LVRS: RV% predicted -36.1 (95% CI -54.1 to -10)
• BLVR: RV% predicted -30.1 (95% CI -53.7 to -9)

The CELEB trial, Buttery explained, is the first study to directly compare the two approaches for emphysema, both of which can improve lung function, exercise capacity, and quality of life in appropriately selected patients.

She said the findings provide important insight for specialists making treatment decisions in this patient population, “and also for patients who are trying to make shared, informed decisions with their clinicians around their treatment options.”

During a Q&A session, Buttery said the only significant between-group difference involved changes in COPD Assessment Test (CAT) scores (a secondary endpoint), which favored LVRS. She also noted that a cost-effectiveness analysis comparing the two methods was currently underway.

With LVRS, thoracic surgeons perform a keyhole operation to access and remove the parts of the lung most affected by emphysema, reducing lung volume and improving airflow and gas exchange in the process.

In the case of BLVR, a fiber optic camera is inserted into the lungs via the mouth or nose and endobronchial valves are placed to block damaged sections of the lungs and allow the healthy parts of the lung to function more normally.

Many years now after the NETT trial, “we can conclude that we have one more time shown that active treatment for emphysema patients improves dyspnea and quality of life,” said ERS discussant Isabelle Opitz, MD, of the University of Zurich in Switzerland. “Let’s hope for broader translation into clinical practice.”

But Opitz said “the choice of the procedure is still not answered,” as many variables — including familiarity with the approach and emphysema type — may play a role in which method is best for a given patient or practitioner.

She concluded that more trials are needed to elucidate the benefits of each procedure, and especially to assess their roles in homogeneous emphysema.

CELEB was a single-blind superiority trial that randomized 88 participants with emphysema (mean 65 years, 42% women, 98% white) to either LVRS or BLVR.

Baseline BODE index scores were 5.9 for each group. For the components of BODE, patients had a BMI of 23.7, forced expiratory volume in the first second (FEV₁) percent predicted of 31.0, a Medical Research Council dyspnea scale score of 4, and poor exercise capacity (210 m on the incremental shuttle walking test). Patients’ fat-free mass index was 30.9 kg/m², and baseline CAT score was 23.1.

Buttery said participants were typical of a cohort undergoing lung volume reduction. Patients were eligible if they had significant airflow obstruction that limited breathing, significant hyperinflation, and were considered to have a heterogeneous emphysema pattern with intact interlobar fissures.

Among others, exclusion criteria included pulmonary fibrosis or any other major comorbidity that could affect survival.