Lung Disease Treatment Without Major Surgery
不做大手術(shù)，也能治肺??？

Hospitals are testing new procedures to help patients with a devastating lung disease breathe easier without major surgery.

More than 15 million people have been diagnosed with chronic obstructive pulmonary disease, or COPD, according to the Centers for Disease Control and Prevention. Millions more may be unaware they have it. The disease is the third leading cause of death in the U.S., after heart disease and cancer. COPD costs nearly $30 billion in direct health care expenditures.

COPD is mainly caused by smoking, but the condition also has been linked with secondhand smoke, air pollution and workplace dust and chemicals. Genes may play a role in why some smokers develop it and some don't.

Some patients with severe cases of COPD may be referred for surgery, during which the diseased part of the lung is removed. But the risky and costly procedure isn't often used, partly because recovery is long and many patients experience complications after surgery.

More than two dozen U.S. medical centers are currently testing a technique that places metal coils into the lung using special scopes inserted through the mouth or nose. Once in place, the coils compress the diseased tissue and allow the healthier parts of the lung to breathe more freely. Other hospitals are investigating a small-umbrella shaped valve that redirects air from less healthy to more healthy parts of the lung.

'If successful, we will be able to help a significant number of patients have an improved quality of life, and potentially improve survival in a noninvasive manner,' says Atul C. Mehta, an interventional pulmonologist at Cleveland Clinic, one the centers participating in the coils trial.

In Europe, where the coils have been approved for use since 2008, studies have shown the treatment is safe for patients and results in significant improvements in pulmonary function, exercise capacity and quality of life. Current U.S. research is being funded by PneumRx Inc., the Mountainview, Calif., maker of the coils. While smokers can prevent COPD by quitting before it develops, once the lungs are damaged it isn't reversible. Most patients are managed with the use of inhaled medications called bronchodilators, oxygen and pulmonary rehabilitation.

Mary Morgan, a nurse who lives in Parma, Ohio, was diagnosed seven years ago with emphysema, a form of COPD. Still, she continued to smoke for a few more years because the disease 'wasn't bothering me,' she says. Two years ago, the 55-year-old came down with pneumonia and had to call 911 because she couldn't breathe. She quit smoking but needed to be on oxygen all the time. She gasped for breath often and wasn't able to speak more than a few words at a time. 'It gets to the point where you are living in such misery that you just don't want to go on,' Ms. Morgan says.

After completing a pulmonary rehabilitation program, Ms. Morgan was accepted into the coils trial at the Cleveland Clinic last December. Dr. Mehta and another pulmonologist placed 12 of the small devices in her right lower lung. She was discharged from the hospital after just one night and says she felt improvements almost immediately. Tests a month later showed her breathing had improved by 30%. She is still on supplementary oxygen and is scheduled to have additional coils inserted in her left lung later this month.

COPD includes two main conditions, emphysema and chronic bronchitis, and most patients have elements of both. Emphysema, as it advances, destroys the air sacs, or alveoli, that exchange air between the lungs and surrounding tissue and bloodstream. Diseased portions of the lung overinflate, become inelastic and trap air. Meanwhile, the expanded sacs push against the lung's healthier areas. Patients may feel as if they are suffocating. Medications may cease to work.

More severe cases of COPD affect an estimated three to four million people in the U.S. Dr. Mehta estimates as many as one million may be candidates for some form of lung volume reduction through surgery or the new less-invasive coil procedure. The surgery requires a large incision, or several small ones, in the chest to excise diseased tissue. The aim is to allow the patient to breathe easier with the remaining healthier portion of the lungs.

In a large study a decade ago, called the National Emphysema Treatment Trial, the surgery didn't show an overall survival advantage over medical management. It did show an advantage in patients whose disease was worse in upper lobes of the lungs and whose exercise capacity was low. Still, the procedure is little used. Complication rates are high. Relatively few centers in the country offer the procedure.

'In the right patients, we've proven that lung reduction surgery works, but doctors aren't referring patients for the procedure and patients aren't interested in doing major surgery,' says Frank Sciurba, director of the Pulmonary Function and Exercise Physiology Lab at the University of Pittsburgh Medical Center and principal investigator for its part of the coils-implant trial. One aim of the trial, he says, is to determine which patients have the right lung structure and physiology to benefit from the coils procedure.

The coils trial isn't studying costs. 'In the long run the hope is this could be more cost-effective,' says Dr. Sciurba, by reducing hospitalization costs, complications and readmissions. A PneumRx spokeswoman says the coils procedure in Europe costs $15,000. 'We aren't yet far enough along in the U.S. market to have a valid comparison,' she says.

Experts have had mixed results with other nonsurgical techniques, such as chemical sealants and steam to destroy the diseased part of the lung. In another current clinical trial, researchers are guiding a small, umbrella-shaped valve into the airways that redirects air from less healthy to more healthy parts of the lung while letting trapped air escape. An earlier trial of the valves ended without meeting the requirements for Food & Drug Administration approval, but Redmond, Wash., device maker Spiration Inc., is funding a new trial to determine if the procedure can help reduce over-inflation of the lung and improve overall lung function and quality of life.

D. Kyle Hogarth, director of bronchoscopy and assistant professor of medicine at the University of Chicago who is leading an arm of the valve study there, says a possible risk to the use of any device is infection from foreign bodies inserted into the lung. While coils aren't designed to be removed, valves could be removed if necessary, he says. Because emphysema can affect individual patients' lungs differently, in the future, patients may end up qualifying for both coils and valves, 'to treat different types of abnormalities and breathing problems,' Dr. Hogarth says.

為了幫助身患致命肺病的病患在不動大手術(shù)的情況下也能更輕松地呼吸，各家醫(yī)院正在測試新的治療手段,。

據(jù)美國疾病控制和預(yù)防中心(Centers for Diesease Control and Prevention)稱,，超過1,500萬人已確診患有慢性阻塞性肺疾病（或簡稱為COPD）,。另外還有數(shù)百萬人可能不知道自己身患此病,。在美國，該疾病是排在心臟病和癌癥之后的第三大死因,。在直接醫(yī)保支出中,，治療慢性阻塞性肺疾病的相關(guān)費(fèi)用將近300億美元。

吸煙是引發(fā)慢性阻塞性肺疾病的主要原因,，但它也與二手煙,、空氣污染以及工作場所的粉塵和化學(xué)物質(zhì)有關(guān),。基因可能也會起到一些作用,，這也就是為什么有些煙民會發(fā)展成COPD患者,、而有些卻并未患病的原因。

一些病情嚴(yán)重的COPD患者可能得送去做手術(shù),，通過手術(shù)摘除肺部的病變部位,。但這種有風(fēng)險(xiǎn)、耗財(cái)力的治療手段并不常用,，一部分原因是因?yàn)槭中g(shù)后的恢復(fù)期較長,，而且很多病人還會患上術(shù)后并發(fā)癥。

目前,，美國有20多個(gè)醫(yī)療中心都在測試一種新技術(shù)：將特殊的內(nèi)窺鏡通過口腔或鼻腔伸進(jìn)人的體內(nèi),，然后用它將金屬線圈植入肺部。一切就位以后,，金屬線圈就會擠壓病變組織,，讓肺上相對健康的部位更自由地呼吸。其他醫(yī)院也在研究一種小傘狀閥門,，它能把空氣從肺上那些狀況欠佳的部位重新引至更健康的部位,。

克利夫蘭診所(Cleveland Clnic) 的介入治療醫(yī)師阿圖爾·C·梅塔(Atul C. Mehta)說：“如果成功了，我們就能幫助大量患者改善生活質(zhì)量,，而且可能以一種無創(chuàng)傷性的方式提高生存率,。”克利夫蘭診所是參與了線?治療試驗(yàn)的醫(yī)學(xué)中心之一,。

在歐洲,，這種線圈從2008年起就已經(jīng)獲批投入使用。歐洲的一些研究已顯示,，這種療法對病人來說很安全,，而且能顯著改善肺機(jī)能、運(yùn)動能力與生活質(zhì)量,。目前,，美國的研究是由加州山景城(Mountainview, Calif.)的RneumRx Inc.公司資助的，該公司是所用線圈的制造商,。雖然吸煙者可以在慢性阻塞性肺疾病形成前戒煙來進(jìn)行預(yù)防,，但一旦肺部受損，那病情就無法逆轉(zhuǎn)了,。大多數(shù)患者都是靠使用名為支氣管擴(kuò)張劑的吸入性藥物、用氧和肺康復(fù)療法來維持的,。

瑪麗·摩根(Mary Morgan)是住在俄亥俄州帕爾馬(Parma, Ohio)的一名護(hù)士,。七年前,，她被確診為肺氣腫，肺氣腫是慢性阻塞性肺疾病的一種表現(xiàn)形式,。即便如此,，她還是繼續(xù)抽了好幾年煙。因?yàn)樗f這個(gè)病“當(dāng)時(shí)并沒有太困擾我”,。兩年后,，55歲的摩根患上了肺炎，還不得不打911急救電話,，因?yàn)槟菚r(shí)她已無法呼吸,。雖然她已戒了煙，但是仍需要一直吸氧,。她還經(jīng)常喘氣,，講話時(shí)一次也說不了幾個(gè)詞。摩根說：“已經(jīng)病到這個(gè)地步了,，如此痛苦煎熬,，都不想再活下去了?！?/p>

摩根在完成了一次肺康復(fù)治療后,，于去年12月份獲準(zhǔn)在克利夫蘭診所接受線圈試驗(yàn)治療。梅塔醫(yī)生及另一位肺科專家在她的右肺下部植入了12個(gè)小線圈,。她術(shù)后僅在醫(yī)院待了一晚便出了院,，還稱自己幾乎是馬上就感覺好多了。一個(gè)月后的測試顯示,，她的呼吸狀況改善了30%,。她仍在補(bǔ)充吸氧并計(jì)劃本月晚些時(shí)候再在左肺植入另外一些線圈。

慢性阻塞性肺疾病包括兩種主要的病癥,，肺氣腫和慢性支氣管炎,，而大多數(shù)患者是兩者兼具。隨著肺氣腫的病情加重,，它會破壞氣?,，或稱為肺泡——它們負(fù)責(zé)交換肺部及周遭組織與血流間的空氣。肺的病變部位將會過度膨脹,、變得沒有彈性并滯留空氣,。于此同時(shí)，擴(kuò)張的氣囊也會擠壓肺部相對健康的部位,?；颊呖赡軙械街舷ⅲ幬镏委焺t可能失效。

病情更嚴(yán)重的慢性阻塞性肺疾病在美國估計(jì)影響到了三,、四百萬人,。梅塔醫(yī)生預(yù)計(jì)，多達(dá)一百萬人可能需要通過手術(shù)進(jìn)行某種形式的肺減容或新型的低創(chuàng)傷線圈療法,。這類手術(shù)需要在胸部開一個(gè)大切口或幾個(gè)小切口以切除病變組織,。其目的是為了能讓病人用余下的、肺上相對健康的部位更容易地呼吸,。

10年前進(jìn)行的一項(xiàng)名為“全國肺氣腫治療試驗(yàn)”(National Emphysema Treatment Trial)的大型研究顯示,，與藥物治療相比，手術(shù)并未顯現(xiàn)出會給病患在總體上帶來更高的存活率,。該研究倒是表明,，在有些患者身上，手術(shù)療法更具優(yōu)勢——這些患者的上肺葉病變更嚴(yán)重,，他們的運(yùn)動能力也差,。即便如此，這種治療手段還是用得少之又少,。其并發(fā)癥的患病率也高,。而在美國，提供這種療法的醫(yī)療中心也相對較少,。

匹茲堡大學(xué)醫(yī)學(xué)中心(University of Pittsburgh Medical Center)肺功能與運(yùn)動生理學(xué)實(shí)驗(yàn)室(Pulmonary Function and Exercise Physiology Lab)主任,、該校部分線圈植入試驗(yàn)的主要研究者弗蘭克·休爾巴(Frank Sciurba)說：“我們已經(jīng)證明，在適合動手術(shù)的病人身上,，肺減容手術(shù)的確有效,，但醫(yī)生們不會將病患送去接受這種療法，而患者自身也對大手術(shù)沒什么興趣,?！彼€稱，試驗(yàn)的目的之一就是確定什么樣的患者擁有適應(yīng)線圈療法的肺部結(jié)構(gòu)與生理機(jī)能,，從而能從該療法中獲益,。

線圈療法的相關(guān)試驗(yàn)并未探討成本問題。休爾巴博士說：“長遠(yuǎn)的希望是,，（通過降低住院成本,、減少并發(fā)癥和再入院的情況），該療法能更劃算,?！盤neumRx公司的一名女發(fā)言人稱，進(jìn)行線圈療法在歐洲需要花費(fèi)1.5萬美元,。她還說：“我們尚未深入美國市場,，所以還無法作出一個(gè)有效的比較。”

而在其他非手術(shù)治療技術(shù)方面,，專家們已收獲了好壞不一的結(jié)果,，比如用化學(xué)密封劑和蒸汽去破壞肺上的病變部位,。在目前另一起臨床試驗(yàn)中,，研究人員牽引一個(gè)小傘型閥門進(jìn)入氣道，把空氣從肺部欠佳的部位重新導(dǎo)至肺上更為健康的部位,，同時(shí)讓殘留空氣排出來,。早些時(shí)候的一次閥門療法試驗(yàn)因未滿足美國食品藥物管理局(Food & Drug Administration)的認(rèn)證要求而收場，但華盛頓州雷德蒙德市(Redmond, Wash.)器具制造商Spiration Inc. 公司現(xiàn)正出資進(jìn)行一項(xiàng)新試驗(yàn),，以確認(rèn)這種療法能否幫助減少肺部過度膨脹并改善肺的整體機(jī)能,、提高生命的質(zhì)量。

芝加哥大學(xué)(University of Chicago)的支氣管鏡檢主任,、醫(yī)藥學(xué)助理教授D·凱爾·賀加斯(D. Kyle Hogarth)正帶領(lǐng)一隊(duì)人在進(jìn)行閥門研究,。他說，不管使用什么器具設(shè)備,，都存在這樣一種潛在風(fēng)險(xiǎn)：植入肺部的外來物引發(fā)感染,。他還說，線圈本身就未設(shè)計(jì)成可移除的,，而閥門,，如果有必要，則可以摘除,。因?yàn)榉螝饽[對每個(gè)患者的肺部影響會因人而異,，所以患者在未來有可能既可以進(jìn)行線圈植入，又可以接受閥門療法,。賀加斯博士說：“這么做是為了治療不同類型的病癥和呼吸問題,。”