Reply to Jain et al.: Improving Lung Function in Severe Heterogenous Emphysema with the Spiration Valve System: Still a Great Need to "EMPROVE".

From the Authors:

We thank Dr. Jain and colleagues for their comments about our study. We wholeheartedly agree that refining the patient population most likely to benefit from this or any other therapy is the goal of personalized patient care. The cost of care, especially in the case of patients with emphysema, is also of prime importance. However, we would like to emphasize that despite the severity of the patient group studied in EMPROVE (patients with severe and irreversible airflow obstruction [FEV1, 28–30% predicted], hyperinflation [residual volume, 207–213% predicted], and >60% emphysema severity in the targeted lobes), patients with valve treatment were sevenfold more likely to achieve >15% improvement in FEV1 at 1 year compared with the control group receiving optimal medical therapy (1). In addition, as pointed out by Dr. Jain, more than half the subjects exceeded the minimally important changes in dyspnea and quality of life. This was balanced against the complication of pneumothorax, a treatable consequence of endobronchial valve treatment with total lobar occlusion in subjects with fissure integrity. We believe it is also important to consider the alternative therapies used to treat patients at this stage of their disease and their symptom burden: lung volume reduction surgery and lung transplantation (2). Although both these therapies can have significant benefits to patients, they also have significant complications and costs associated with them that far exceed those that have been reported in patients undergoing endobronchial lung volume reduction therapy (2, 3). We also wholeheartedly agree with Dr. Jain that future research should focus on better predictors of patient outcomes, the minimization of risk, and providing improved outcomes in the most cost-effective fashion.