Running head: TREATMENT OF ADVANCED EMPHYSEMA
Emphysematous Lung Sealant (ELS) for Treatment of Advanced Emphysema:
A Clinical Appraisal Topic (CAT)
Jaydee M. Unruh
University of Mary
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TREATMENT OF ADVANCED EMPHYSEMA
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Emphysematous Lung Sealant for Treatment of Advanced Emphysema:
A Clinical Appraisal Topic (CAT)
Appraised by Jaydee M. Unruh, RN, BSN, FNP-S
May 29, 2015
Emphysema is recognized far and wide as a chronic obstructive pulmonary disease
(COPD) phenotype. Emphysema is an incurable, widespread, and under-diagnosed condition,
which has become the third leading cause of death in the United States (Armstrong, et al., 2015;
Pompeo, 2014). It is termed as an atypical irreversible enlargement of air spaces distal to the
terminal bronchiole linked to destruction of their walls.
Within the last couple decades lung volume reduction surgery (LVRS) has transpired as
an valuable surgical option that can undo harmful effects for a subgroup of patients with
emphysema, leading to significant and ongoing improvements in respiratory function, exercise
tolerance, quality of life, and overall survival (Armstrong, et al., 2015; Pompeo, 2014).
However, the common LVRS-related morbidity has lead to the development of emphysematous
lung sealant (ELS). ESL (AeriSeal System therapy) is an innovative, minimally invasive
alternative to LVRS for treatment of patients with advanced emphysema. AeriSeal is injected
into the peripheral airways and alveoli where it polymerizes and acts as tissue glue on the surface
of the lung in order to seal the target area to cause durable permanent absorption atelectasis
(Falkenstern, Ingerl, & Kohlhäuf, 2013).
Clinical Scenario
M.T. is a 65-year old male who presents to your clinic with worsening shortness of
breath. M.T. was diagnosed with emphysema approximately 2 years ago; since diagnosis he has
quit smoking. Past CT images demonstrate that M.T. has predominantly upper lobe emphysema.
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He reports having minimal exercise tolerance that has seemed to worsen over the past month or
so. Aside from emphysema, M.T. has an unremarkable history and has no co-existing
conditions. M.T.’s emphysema has notably exacerbated despite his diligent compliance with
medical therapy. He asks you about “new options and surgeries that he keeps hearing about” for
people with emphysema.
PICO Question
Among people with advanced emphysema, is treatment with emphysematous lung sealant
more effective in reducing lung volume, compared to surgical lung volume reduction surgery?
Summary and Appraisal of Key Evidence
Falkenstern, Ingerl and Kohlhäuf (2013) identified that emphysematous lung sealant
(ELS) treatment minimizes air trapping, which results in improved pulmonary function, exercise
tolerance and quality of life. In the study, ELS treatment was accompanied with a ‘flulike’
reaction beginning 8–24 hours post-treatment in all study patients. The most common side
effects included: elevated inflammatory markers, dyspnea, fever, leukocytosis, chest infiltrates
on x-ray, and chest pain. The symptoms tended to be self-limited and resolved within 24–96
hours. To further support Falkenstern, Ingerl and Kohlhäuf ‘s (2013) study, Herth, et al. (2011)
yielded results that indicated ELS treatment was a safe option for patients with advanced
emphysema, and can reduce gas trapping and enhance quality of life for up to six months in ELS
appropriate patients (Herth, et al., 2011).
Another clinical study was conducted to assess the safety and efficacy of bilateral
AeriSeal Emphysematous Lung Sealant System (ELS) treatment in patients with advanced
emphysema out to one year. In this study twenty patients received treatment and were evaluated
at 3, 6, and 12 months to assess the effectiveness. The ELS treatment was deemed to have a
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short procedure time and length of hospital stay. The follow-up evaluations at 3, 6, and 12
months demonstrated that physiologic and functional improvement was noted at one year
(Kramer, Refaely, Maimon, Rosengarten & Fruchter, 2012).
In light of lung volume reduction surgery (LVRS), Brown, et al. (2012) completed a
literature review, which deemed LVRS to be a highly effective palliative treatment modality for
patients with severe emphysema, predominantly for those who have CT verification of
heterogeneous upper-lobe predominant disease associated with impaired exercise capacity. By
the application of different strategies of treatment including one-stage bilateral, unilateral and
staged surgical approaches, there were considerable and long-lasting improvements, including
respiratory function, exercise capacity, and quality of life (Pompeo, 2014).
LVRS has been a highly debated topic due to the potential benefit being outweighed by
harms. Tiong (2008) examined eight trials involving 1663 participants and found that people
who underwent LVRS ran an increased risk of death at three months post-operatively. However,
by the end of follow up in the studies, there was no significant difference in mortality between
surgery and non-surgically managed participants. The mortality rates suggested that the number
of deaths in each treatment group were similar after two to three years, but LVRS led to an
increase in the odds of death in the first 90 days post-operatively (Tiong, 2008).
Clinical Bottom Line
In conclusion, ELS therapy is an effective, novel approach to reducing lung volume in
patients with advanced emphysema. Although current studies involve small populations in
which drawing definitive conclusions can be made difficult, the safety and effectiveness of ELS
therapy has promising indications and further testing is supported. In contrast, the research that
has accrued over the past couple decades examining the efficacy of LVRS has ultimately
TREATMENT OF ADVANCED EMPHYSEMA
demonstrated to be a favorably effective method of improving respiratory function, exercise
tolerance, and quality of life in patients with advanced emphysema (Pompeo, 2014). LVRS
remains a promising solution to reducing lung volume, but study findings are still needed from
large trials with lengthy follow-up research to help identify the most effective treatment option
for patients with advanced emphysema. This is mainly due to the mortality statistics associated
with LVRS.
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References
Armstrong, H. F., Dussault, N. E., Thirapatarapong, W., Lemieux, R. S., Thomashow, B. M., &
Bartels, M. N. (2015). Ventilatory efficiency before and after lung volume reduction
surgery. Respiratory Care, 60(1), 63-71. doi:10.4187/respcare.03233
Brown, M. S., Kim, H. J., Abtin, F. G., Strange, C., Galperin-Aizenberg, M., Pais, R., & ...
Goldin, J. G. (2012). Emphysema lung lobe volume reduction: Effects on the ipsilateral
and contralateral lobes. European Radiology, 22(7), 1547-1555. doi:10.1007/s00330-0122393-6
Falkenstern-Ge, R. F., Ingerl, H., & Kohlhäuf, M. (2013). Severe emphysema treated by
endoscopic bronchial volume reduction with lung sealant (AeriSeal). Case Reports In
Pulmonology, 1-4. doi:10.1155/2013/361391
Herth, F. F., Gompelmann, D., Stanzel, F., Bonnet, R., Behr, J., Schmidt, B., & ... Eberhardt, R.
(2011). Treatment of advanced emphysema with emphysematous lung sealant
(AeriSeal®). Respiration; International Review Of Thoracic Diseases, 82(1), 36-45.
doi:10.1159/000322649
Kramer, M.R., Refaely, Y., Maimon, N., Rosengarten, D., & Fruchter, O. (2012). Bilateral
endoscopic sealant lung volume reduction therapy for advanced emphysema. Chest,
142(5), 1111-1117. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22722233
Pompeo, E. (2014). Lung volume reduction surgery for emphysema treatment: State-of-the-art
and perspectives. ISRN Otolaryngology, 1-17. doi:10.1155/2014/418092
Tiong, L. U. (2008). Lung volume reduction surgery for diffuse emphysema. Cochrane
Database Of Systematic Reviews, (1), doi:10.1002/14651858.CD001001.pub2