The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema

Theodoor David Koster, Dirk-Jan Slebos, Theodoor David Koster, Dirk-Jan Slebos

Abstract

In patients with severe emphysema, bronchoscopic lung volume reduction using one-way valves is a promising therapeutic option to improve lung function and quality of life. The goal of this treatment is to achieve a complete lobar atelectasis. In a significant proportion of patients, this atelectasis cannot be achieved due to interlobar collateral ventilation. This collateral ventilation is generated through incomplete lobar fissures. Therefore, only patients with complete fissures and no collateral ventilation can be selected for endobronchial therapy with one-way valves. Incomplete fissures are very common and exhibit a great variation in anatomy. The reported prevalence is 17%-85% for the right major fissure, 19%-74% for the left major fissure, and 20%-90% for the minor fissure. There are several methods of measuring or predicting the presence of collateral ventilation, with computed tomography (CT)-fissure analysis and the Chartis measurement being the most important. CT-fissure analysis is an indirect method to measure the completeness of fissures as a surrogate for collateral ventilation. The Chartis system is an endobronchial method to directly measure the presence of collateral ventilation. Both methods have unique value, and the combination of both can accurately predict the treatment response to the bronchoscopic placement of endobronchial valves. This review provides an in-depth view of lung fissure and collateral ventilation to help understand its importance in selecting the appropriate patients for new emphysema treatments and thus avoid useless treatment in unsuitable patients.

Keywords: BLVR; COPD; ELVR; HRCT; bronchoscopy; collateral respiration; one-way valve.

Figures

Figure 1
Figure 1
Three different pathways for collateral ventilation. Notes: Interalveolar ventilation through the pores of Kohn. Bronchiole–alveolar ventilation through channels of Lambert. Interbronchiolar ventilation through channels of Martin.
Figure 2
Figure 2
Collateral ventilation. Notes: Schematic figure illustrating the role of intra- and interlobar collateral ventilation, and the implications for bronchoscopic lung volume reduction using one-way endobronchial valves. The interlobar collateral ventilation from the left upper to the left lower lobe, impedes the desired atelectasis of the lower lobe. Because all segments of the left lower lobe have endobronchial valves, intralobar collateral ventilation does not influence the development of atelectasis.
Figure 3
Figure 3
Chartis measurement. Notes: (A) The Chartis balloon at the distal tip of the catheter. (B) Bronchoscopic view of the Chartis balloon blocking the entrance to the right lower lobe to measure collateral ventilation to this lobe. (C) Example of a negative Chartis measurement with absence of collateral ventilation, measured in spontaneous breathing patient. The orange pattern shows the expired flow (mL/min). The decrease of the flow pattern indicates there is no collateral flow. The blue pattern shows the negative intrapleural pressure (cmH2O) and indicates the quality of the occlusion by the balloon. (D) Example of a positive Chartis measurement with collateral ventilation, as there is no decline in the expired flow. (E) Example of a negative Chartis measurement with absence of collateral ventilation, measured in a sedated patient with positive pressure ventilation. Therefore, only the decreasing flow pattern is shown, indicating there is no collateral flow. Abbreviations: F, flow; P, pressure.
Figure 4
Figure 4
Implanted one-way endobronchial valve. Notes: (A) Open valve, allowing trapped air and fluids to escape. (B) Closed valve, no air or fluids can enter the valve.

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