A couple of years ago I went on the advanced bronchoscopy course Palav Shah runs at the Brompton. I walked away with ideas of starting up a cryotherapy service, and excited about trying out some of the new lung volume reduction coils. I had a tinker with a cryotherapy machine, and hope to have another go with it at some point. The coils are a different issue – only available in the study, and only in London, initially.
After a couple of months I saw a patient I thought might be suitable for coils. It’s a long way down to London from up here, but the patient was keen to go, and wend down for the study. 18 coils later, he came back to clinic a completely changed man. He left for London in a wheelchair, he walked back into my clinic after his procedure. A dramatic response to therapy, for sure. How long would it last? A year, it turned out. After 12 months he was essentially back to square 1, back in his wheelchair, and back in clinic asking if he could have another referral back to London for more coils. He went back down, but the study was over so no more coils.
My n=1 experience made me interested in the end result of the study, and it’s now in this month’s Thorax. The average result seems to follow my n=1 result – about a year of improvement.
I had thought the best patients for this study would have been those with homogenous disease, rather than those with heterogenous disease who might do better with targeted valve therapy – but the results seem to show similarly good results with homogenous, and heterogenous lung disease.
It works. So should we all be offering it? We do all the normal bronch things, including EBUS, much as everyone will be doing all over the country, I’m sure. We haven’t managed to persuade the bean counters to let us do valves yet, but the complexity of looking for collateral airflow does make it a complicated procedure. Could we manage to get coils into the service? It’s not cheap, but it works, and in some patients it works really well. But can we predict which of those patients will do best? The paper couldn’t really identify which patients would respond best.
The COPD treatment landscape is currently very interesting. Moving away from steroids, a push towards dual bronchodilator therapy, the new technology is gaining an evidence base, the focus on phenotypic medicine can only gain momentum. And not to mention the eCigarette debate. Interesting times.