An 85-year-old male was admitted to our clinic (April 2019) with diagnosis of COPD (GOLD D). He had a history of arterial blood hypertension and hyperuricemia. A family history of lung tumor (brother), nor of drug allergies. He was a former smoker of 60 pack years (stop smoking 20 years prior). He had important dyspnea at rest (mMRC > 3) despite optimal pharmacotherapy (aclidinium bromide and salmeterolo/fluticasone) two times daily, teofilline, prednisone as needed and continuous 6 L/min of oxygen.
Pulmonary function test (PFT): ratio of forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) was 51%, FEV1 was 1.29 L (percentage of predicted FEV1, 56%), residual volume (RV) was 3.96 L (percentage of predicted RV, 140%); the total lung capacity (TLC) was 7.50 L (percentage of predicted TLC, 118%), and the percentage of predicted diffusing capacity of carbon monoxide (DLCO) was 21%. Arterial blood gas analysis revealed a pH of 7.37, PaCO2 of 46.4 mmHg and PaO2 of 61.8 mmHg, SaO2 92.4% in room air. At 6MWT he walked greater than 140 mt (about 160 mt). St George Respiratory questionnaire (SGRQ) was calculated. Echocardiography shows an ejection fraction of > 55%, with normal left and right ventricular size, normal PAPS.
CT performed in July 2019 indicated severe and heterogeneous pan-lobular emphysema with higher prevalence in upper lobes (UL) (Figs. 1).
In order to perform BLVR, the CT scan was analyzed by a dedicated software (VIDA Diagnostics, Coralville, IA, USA) measuring disease severity of each segment for identify the target area. The software showed a difference in lung density between targeted UL segment and its respective lower lobe and absence of IF. For this reason, LVRS and EBV weren’t taken into consideration and BTVA was proposed as an alternative.
After placing an endoscopic catheter, a balloon was inflated in order to occlude the target segment and water heated vapor was delivered, 8.5 cal/g dose, first in LB1 + 2a for 6.1 s. Afterwards the balloon was deflated and the catheter was inserted into the other sub-segmentary bronchus LB1 + 2b for 3.6 s to complete the treatment of LB 1 + 2 a - b (Figs. 2).
The total procedure time was about 10 min. The treatment was performed in rigid bronchoscopy under general anesthesia, in order to suppress the cough that could displaced the balloon.
After the procedure an increase in the inflammatory markers (PCR 5.48 mg/dl vs 0.5 mg/dl at admission, PCT 0.13 µg/L vs 0.02 µg/L) was found.
The CT scan performed after BTVA (Figs. 3) showed a parenchymal pulmonary inflammatory response of the apicodorsal segment of the left UL, with consequent reduction of lung volume (10). No adverse events were recorded (11). The patient was discharged at home in post operative day 8.
PFT was performed at 3 months after BTVA (October 2019). FEV1/FVC increased from 51 to 73%, FEV1 increased by 560 mL from 1.29 L (percentage of predicted FEV 56%) to 1.86 L (82%), RV decreased from 3.96 L (percentage of predicted RV, 140%) to 3.22 L (113%), TLC decreased from 7.50 L (percentage of predicted TLC, 118%) to 6.76 L (107%). The symptoms and quality of life improved markedly (SGRQ-C ≤-8 points). The oxygen therapy was reduced to 1 L/min.
During the follow-up (November 2019) he performed CT scan that identified a subpleural lung nodule in the posterior segment of the RUL (SUV 2.3).
On January 2019 a lung biopsy-CT guided was performed. The histological examination showed a carcinoma (CK7+, TTF1-, P40-.) The patient was candidate to thermoablation because of the concomitant pathologies.