Baby and child development

This article was published in Australian Doctor, www.australiandoctor.com.au on 29 January 2015 by Dr James Best.

Parental anxiety over their offspring’s progress is a common presentation. 

Because GPs see babies and small children so frequently, we are in a terrific position to monitor their developmental progress, and I am passionate this should remain a core role of the GP.

Parents can be guided by us on important developmental milestones, how they can foster healthy development, and importantly, what not to be worried about.

Gross motor development

Monitoring gross motor development is relatively easy. The neurological control of the infant’s body travels from the top down and from the inside out. It is analogous to a flag unfolding.

If you are in an art class drawing an adult, you will draw the hips at the halfway point, the nipple line a quarter of the way down, and the patellae three-quarters of the way down. If you divide the first 12 months of a child’s life into quarters, you will quite conveniently find that gross motor development roughly corresponds to these points.

That is, at three months a baby should have control of their chest; at six months their hips (sitting usually happens at 7-8 months old); at nine months their knees (eg, crawling, bum-shuffling or commando crawling); and at one year their feet (standing holding on, but not necessarily walking).

Beyond 12 months, children will expand this neurological connection into increasingly complex activities (see box: Gross motor skills to encourage).

As well as providing a monitoring role, GPs can encourage parents to foster their child’s gross motor development by actively providing opportunities for their children to work on these skills (see table 1). The whole world seems to be telling parents to cocoon children for safety, but development is fostered through opportunity, and safe exposure should be encouraged.

Something parents occasionally get wrong is to not provide enough tummy time (“He/she doesn’t like it!”). Once children are sitting, hard surfaces are fine — they won’t hurt their back. Hard surfaces are also fine to crawl on.

Spring-loaded jumping devices used prior to achieving walking do not foster motor development, and may lead to toe-pointing once walking occurs (ie, tight Achilles). Walking chairs (‘walkers’) will not help an infant’s motor development and are downright dangerous around stairwells. There is no benefit of shoes prior to standing.

Baby gates tend to come off too late. Once a child is developmentally ready to access an area safely (eg, stairs), parents should let them do it.

Another parental worry is that the child will fall when beginning to walk — but this is to be expected: one study showed children on average fell around 17 times an hour when learning to walk.

GROSS MOTOR SKILLS TO ENCOURAGE

(12 months to 6 years)

  • 2.5 years: jumping
  • 2 years: Walking up stairs holding onto an adult hand, and possibly attempting alternating feet with each stair
  • 3 years: starting to try to use a tricycle
  • 5-6 years: weaning the trainer wheels off the bike
  • 6 years: skipping

Fine motor development

Fine motor development mimics that of gross motor, with a steady progression down the body, then an ‘unfolding’ pattern of control of movement, with extension and opening out of joints (particularly hands and fingers), followed by increasing complexity of movements.

An easy way to remember the principles of fine motor development is to think of the first nine months in terms of whole-hand activity, and the second nine months (9-18 months) as individual digit activity (see box: Fine motor skills).2

Encourage parents to provide age-appropriate opportunities for their children to develop these skills. In a similar fashion to gross motor skills, parental anxiety regarding fine motor skills often surrounds worry about exposing them to activities they perceive as potentially unsafe.

Examples of this include not letting a child use pencils or other markers because of lead toxicity (even though there is no lead!), unfounded concerns about choking risks in older children, and in particular, doing things for their child (eg, cutting up food, doing up a zipper) before the child has an opportunity to have a go at it themselves.

FINE MOTOR SKILLS

Whole-hand activities (0-9 months)

  • 3-6 months: Include grasping objects passed to them, looking at objects they are holding (‘object regard’) and possibly banging objects onto a surface, such as a tray in a high chair.
  • 6-9 months: Banging objects together. By nine months, babies should be doing hand-to-hand transfers and purposefully releasing objects.
Individual finger activities (9-18 months)

  • Pinching (pulp-to-pulp), pincing (tip-to-tip with curled fingers) and pointing, all of which can emerge progressively.
  • Pointing is an important milestone. It is often present by 12 months and should be present by 18 months. Prior to a child developing their own point, they will reach out towards things, straightening out fingers while they reach. This action will be followed by the index finger being straightened in isolation while the other fingers are curled. We start in the first year of life by ‘following a point’; that is, looking at an object when someone says: “Look at the …”  As well as following a point, a child will often be pointing themselves by 12 months. A young child points for several different reasons. Sometimes it is to share something interesting with another person, sometimes it is to get something they want, and sometimes it is to find out what something is called.

Social development

The first major challenge parents face with their child’s social development is with infant crying. The normal pattern is for crying to start increasing about two weeks of age, peak around two months, and then settle down about 3-4 months, perhaps five.

Parents, however, often feel that their baby’s crying is way beyond anything they were expecting. Through the prism of parental sleep deprivation, infant crying (which can frequently be up to five hours a day) can be overwhelming. A useful resource for parents on infant crying, produced by developmental paediatricians, is the Purple Program on the National Center on Shaken Baby Syndrome website.

Of course, a crying baby should be assessed for other causes of perceived prolonged crying, such as urinary tract and other infections, hernias and milk protein intolerance. Feeding, growth and developmental domains should be reviewed.

Parental conditions, such as postnatal depression should also be considered. If the GP is confident that this is ‘normal’ infant crying, they should offer necessary support, including reassuring parents that they are not doing anything wrong. There are emerging paediatric nurses in the community as well who can help.

Around six months old, babies frequently develop separation anxiety, often resulting in subsequent parental anxiety.

Separation anxiety is a normal developmental phenomenon, which occurs when an infant becomes more aware of ‘object permanence’ (something existing when it is out of sight). Parents, particularly mothers, may worry about causing distress through separation (eg, leaving the baby in the cot to self-settle), but this is something that we want a child to learn to handle.

A step-ladder approach (gently increasing a child’s exposure to separation, as they increase their skills to cope) will help. Separation anxiety often peaks around 14-18 months, and then decreases through preschool years.

Stranger anxiety — usually appearing around 7-9 months and reducing after 14 months — is similar to separation anxiety. It is also best managed through graduated exposure.

Tantrums, which are common between 18 months and three years, cause a lot of parental anxiety. Parents often don’t understand why they happen or what to do about them. There is a lot of misinformation about tantrums, frequently over-emphasising control rather than guidance.

Tantrums happen because a young child has no other mechanism for handling an emotionally challenging situation. Diverting a child from predictable tantrum triggers, ‘scaffolding’ (giving necessary support) to handle the event (eg, a five-minute warning), distraction, or active listening in the build-up to a tantrum, can be useful strategies to employ.

Once a child is mid-tantrum, any attempts at negotiation will be ineffective. Afterwards, an unemotional and calm response from the parent will tell the child that tantrums don’t work (although, of course, this can be difficult for a stressed parent).

Skill-building toddlers on how to handle emotionally challenging situations is best done either before or after. Rousing at a child is counter-productive — they are still learning to control their emotions, and this will just increase the risk of them becoming demoralised and losing self-esteem.

Speech and communication development

Once children start developing speech, parents tend to worry about vocal clarity and the number of words. Certainly, vocabulary and articulation issues are important.

A child’s vocabulary will often start to quickly expand around 18 months of age. Word combining, small sentences and increasingly reciprocal (back-and-forth) conversation expand markedly over the next 18 months. Articulation also improves over this time, with about 25% of articulation intelligible at 18 months, 50-75% intelligible at two years and 75-100% at three years. Other articulation issues, such as lisps and stutters, may require investigation and/or referral to a paediatric speech therapist.

In contrast, parents tend to underestimate the importance of receptive language development (understanding), sentence structure and grammar (semantics), and the social use of language (pragmatics). The last can be encouraged by involving children in prolonged reciprocal conversations (See box: Techniques to develop reciprocal conversations).

TECHNIQUES TO DEVELOP RECIPROCAL CONVERSATIONS

  • Observe, wait, and listen for the child’s language
  • Don’t interrupt
  • Follow the child’s lead
  • Balance questions and commands with comments
  • Use routines and structured activities that provide opportunity for language to emerge
  • Encourage the child to take turns in conversation (especially using pauses)
  • Label; repeat; expand on what the child says; extend the topic
  • Talk about topics the child is interested in

If GPs have an appreciation of normal development, this will enable them to effectively monitor for any concerns. Encouraging parents towards strategies that foster these skills, as well as educating them on common misconceptions that cause anxiety, will help the GP help their patients, both child and parent.

TABLE 1: MOTOR DEVELOPMENT SCREENING

Age

Expected motor developmental milestones

‘What to encourage’ discussion points

 

6 WEEKS
  • eyes mostly moving together
  • some head control, not flopping everywhere
  • symmetrical movements of limbs
• tummy time in small grabs of time
4 MONTHS
  • hands to midline and then to mouth
  • hand regard
  • lifts knees
  • tracks objects through 180 degrees
  • lifts head up 90 degrees when lying prone
  • grasps objects handed to them
  • tummy time in small grabs of time
  • point and look at objects with them
  • handing objects to them to grasp
  • objects over pram or lying flat that they can see and hit with hands
6 MONTHS
  • propped up sitting (independent sitting 7-8 months)
  • hands down in front of them, hands to feet
  • keeping head level with body when pulled to sitting position
  • rolling up on extended arm when placed in prone and creeping when placed in prone
  • possibly banging objects on a surface
  • pull apart or stretch toys
  • push-pull toys when sitting
  • handing objects to them to grasp or bang on a surface (and modelling this)
  • tummy time — 50% of time awake
12 MONTHS
  • takes weight on feet when feet placed on ground in standing position (parachute them) or standing holding onto furniture
  • transitions by moving in and out of positions
  • cruising (probably) and crawling
  • points and follows a point (possibly)
  • grasps with index and thumb
  • claps hands
  • opportunities to use their feet (eg, cruising)
  • opportunities to plan movement (eg, in boxes/cushions to crawl over/pull to stand, etc)
  • opportunities to rake, pinch or pincer objects (eg, berries, sultanas or cut-up snacks in high chair)
  • self-feeding opportunities
  • using an open cup and spoon
18 MONTHS
  • walks well and probably holding hands upstairs
  • climbing on and off everything
  • attempting a jump
  • isolated ‘tip to tip’ pincer
  • bilateral play — hands doing different things
  • eyes point, focus and track a moving object
  • posting objects into containers
  • supervision with stairs, but let them do it
  • if they fall, encourage them to get themselves up
  • holding and using crayons, paints and markers
  • picking up small objects (eg, in high chair)
  • provide opportunities such as toe threading/throwing and bilateral play
  • starting to manage dressing themselves and other self-care activities (give them a chance)
4 YEARS
  • moving towards learning to ride bike
  • catching a ball onto chest
  • catch a larger ball with their hands
  • throwing a ball overarm
  • hopping
  • wash and dry hands
  • doing puzzles independently
  • bike riding, climbing, swimming
  • catching, throwing, hitting (one and two hands) different-sized balls and types of bats
  • writing with a ‘kissing grip’ (thumb and index finger just touching), for as long as possible (to encourage grip endurance)
  • activities that encourage pinching dexterity and endurance (eg, using blocks, threading and colouring in)
  • supervised brushing of teeth

*Article produced with the assistance of Therapies for Kids, Annandale, NSW.

LUTS Not just 'a part of ageing'

This article was published in the Australian Doctor, www.australiandoctor.com.au 12 February 2015 by Dr Jeremy Grummet.

A better understanding of lower urinary tract symptoms and possible treatment options is the aim of a new men’s health campaign.

Lower urinary tract symptoms (LUTS) are highly prevalent in men over 50 in Australia, and the most common cause in this age group is benign prostatic hyperplasia (BPH).1,2 Despite having a higher mortality from cardiovascular disease, accidents, suicide and cancer, men see doctors less often than women.3

The new More than once a night campaign, endorsed by men’s health group Foundation 49, has been launched to address both of these issues in one hit.

The multimedia campaign focuses in a light-hearted way on the symptom of nocturia ­— one of the most common symptoms in the cluster of LUTS — and its effect not only on the man, but also his partner, and the disrupted sleep it can cause them both.

It’s a call to action for men with these symptoms to see their GP for an assessment, and — if necessary — gain access to the highly effective treatment options that are now available.

When to treat
Of course, many men with such symptoms may not need any treatment at all. If the presentation is clearly of mild uncomplicated LUTS (ie, not neurogenic, and no haematuria or infection) and symptoms are not too irritating, then reassurance is all that is required.4 In addition, many of these men have concerns about their risk of prostate cancer, which can also be appropriately addressed at the consultation.

About 20% of all men in this age group have moderate to severe LUTS.5 Many of these men may not seek medical attention for various reasons, including the belief that such symptoms are just part of ageing and that they simply need to “put up with them”.

BPH, the most common cause of such symptoms, is certainly age-related, but if it is interfering with quality of life, men need to know there is an array of simple and effective interventions that may make all the difference.

Lifestyle management
The first line of intervention for mildly irritating symptoms is lifestyle advice.4 This includes reducing intake of caffeine and alcohol, both of which may have a diuretic and irritant effect. Timing of general fluid intake can also be modified. In the absence of chronic retention, a bladder training nurse may be of help. Constipation should also be treated.

If lifestyle changes prove inadequate, or the symptoms are more severe, there is now a plethora of medications that GPs can prescribe which have been shown in randomised control trials to be beneficial (see Table 1).

Medical management
Alpha blockers remain a commonly used option. By relaxing smooth muscle at the bladder neck and within the prostate, they act quickly so that relief can be felt within just a few days of use.6 However, they do not arrest the growth of the prostate in BPH.

Prazosin is as effective as any other alpha blocker, but is not selective for the receptors at the bladder outlet alone, and so has a higher rate of postural hypotension than selective alpha blockers, such as tamsulosin. As a result, prazosin should be introduced in slowly increasing doses while monitoring blood pressure, especially in the elderly. Retrograde ejaculation is another side effect.

The 5-alpha reductase inhibitors dutasteride and finasteride are another treatment option. They shrink the prostate by altering the levels of androgen within the gland. They are therefore only useful if the prostate is enlarged enough to cause a mass effect. Their effect is slow to manifest, and it can take 3-6 months before any improvement is noticeable.

In shrinking the prostate gland, 5-alpha reductase inhibitors do change the natural history of BPH — unlike alpha blockers — and so have been found to reduce the risk of acute retention and the need for surgery.7,8

Due to the different mechanisms as well as onset of action, alpha blockers and 5-alpha reductase inhibitors complement each other well, with combination therapy providing greater benefit than treatment with either agent alone.9 In recent years, tamsulosin and dutasteride have been made available together in a single preparation, taken once daily.

However, 5-alpha reductase inhibitors carry risks that need to be borne in mind before prescribing. Erectile dysfunction and reduced libido are well-documented side effects, but their true incidence is yet to be quantified. Gynaecomastia is rare. In addition, a higher incidence of high-grade prostate cancer has been found in men on 5-alpha reductase inhibitors compared with placebo.10

Men taking 5-alpha reductase inhibitors need PSA levels followed up periodically, with discussion about the risks. As 5-alpha reductase inhibitors shrink prostate glandular tissue, the PSA is expected to drop by 50% within 12 months. Therefore, any rise in PSA while taking the drug prompts immediate referral to a urologist.

LUTS in older men also comprise the overactive bladder symptoms of urinary frequency and urgency, which can be the most irritating. These storage symptoms may be a result of the bladder’s response to outlet obstruction from BPH, but they can also occur de novo as a part of ageing, as evidenced by older women having a similar rate of this kind of LUTS.11

Anticholinergic medications are effective in treating overactive bladder symptoms by reducing contractions of the detrusor muscle, and can be used in conjunction with other agents, particularly if storage symptoms predominate.

Table 1: Medication options for GPs treating LUTS

Drug type Examples Comments
Alpha blockers Prazosin, tamsulosin Relax bladder outlet, rapid onset, risk of postural hypotension
5-alpha reductase inhibitors Dutasteride, finasteride Shrink prostate gland, slow onset, risk of sexual dysfunction, lowers PSA
Anticholinergics Oxybutinin, solifenacin, darifenacin Reduce OAB symptoms, risk of dry mouth
Beta-3 agonists Mirabegron Reduce OAB symptoms, early experience only
PDE-5 inhibitors Tadalafil Relax lower urinary tract smooth muscle, also treats erectile dysfunction
Alpha blocker/5-alpha reductase inhibitors Tamsulosin/dutasteride More effective than either agent alone, single daily tablet combination
Vasopressin analogue Desmopressin For nocturia only, monitor sodium level-risk of hyponatraemia

Like alpha blockers, anticholinergic drugs can be bladder receptor selective (eg, solifenacin and darifenacin) or non-selective (eg, oxybutynin), with the latter more likely to cause dry mouth. Contrary to traditional thinking, the risk of precipitating acute retention with these drugs is very low.12

Mirabegron is the first beta-3 agonist to be recently approved for use for overactive bladder LUTS. It has a similar action to the anticholinergics on the bladder. Its potential advantage lies in its lack of anticholinergic side effects. Preliminary evidence of its effectiveness in men is encouraging, but it is yet to enter official guidelines.13

Further adding to the ever-expanding armamentarium in this field are the phosphodiesterase-5 (PDE-5) inhibitors, better known for their efficacy in treating erectile dysfunction. They appear to act by relaxing smooth muscle in the bladder, prostate and urethra.14

To date, only the daily 5mg dose of tadalafil has been approved for use in LUTS. These drugs have the obvious potential advantage of simultaneously treating erectile dysfunction, also common in this age group.

The final medical therapeutic option with proven efficacy is the vasopressin analogue, desmopressin. This agent is sometimes used for men who have nocturia as the predominant symptom. However, it is less often prescribed than the other available agents due to its risk of hyponatraemia, and the consequent need for monitoring of sodium levels, and its gastrointestinal side effects.15

Phytotherapy
Phytotherapy (use of plant extracts) has long been thought to be of potential benefit for older men with LUTS. However, in 2013, the European Association of Urology Guidelines Committee could not make any recommendations due to the heterogeneous nature of phytotherapy products and the poor methodology of trials.14

Surgical management
For the most severe LUTS, lifestyle advice and medical therapy may need to be bypassed for surgical intervention. Absolute indications for surgery include acute retention, bladder stones, recurrent UTI and obstructive uropathy.

Surgery involves removal of obstructing tissue and is most commonly performed as a standard transurethral resection of the prostate (TURP), or by using laser technology to either vaporise or enucleate affected tissue.

These surgical options are highly effective and, apart from the expected side effect of retrograde ejaculation, carry a low risk of other side effects, such as erectile dysfunction, urethral stricture and urinary incontinence.16

So with all the available highly effective interventions to treat LUTS in middle-aged and older men, from lifestyle advice through medications to surgery, men need not suffer in silence.

It is hoped that the “More than once a night” campaign will encourage men to see their GPs, not only to have their LUTS assessed and treated if necessary, but also to provide an opportunity for them to get a general check-up. In doing so, we might just be able to reduce the higher rate of preventable illness and death seen in men.

Dr Grummet is a urological surgeon. He is chair, genito-urinary cancer multidisciplinary team, Alfred Health; adjunct senior lecturer, department of surgery, Monash University; and member and spokesman Foundation 49: Men’s Health, Cabrini, Victoria.

Online resources

References:

  1. International Journal of Urology 1997; 4:40-46.
  2. Lancet 2005; 366:218-24.
  3. Medical Journal of Australia 2006; 16:81-83.
  4. European Urology 2013; 64:118-40.
  5. World Journal of Urology 2013; 31:673-82.
  6. Urology 2004; 64:1081-88.
  7. New England Journal of Medicine 1998; 26:557-63.
  8. NEJM 2003; 349:2387-98.
  9. European Urology 2010; 57:123-31.
  10. NEJM 2003; 349:215-24.
  11. European Urology 2006; 50:1606-14.
  12. Journal of Urology 2006; 3:999-1004.
  13. Journal of Urology 2014. PubMEd; 25254938; online.
  14. Journal of Sexual Medicine 2014; 11:1539-45.
  15. Neurourology and Urodynamics 2004; 23:302-05.
  16. European Urology 2010; 58:384-97.

New options for patients with COPD

The following article was published in Australian Doctor:  www.australiandoctor.com.au by Dr Nicholas CL Chin.

Endobronchial valve therapy offers a new, non-surgical option for patients with COPD.

COPD is a debilitating pulmonary disease characterised by abnormal and permanent dilatation of airspace distal to the terminal bronchioles.

The resultant gradual destruction of the alveolar walls impairs gas exchange, leading to progressive gas trapping, and subsequent deterioration in pulmonary function, exercise capacity and quality of life.

In the early 1990s, the surgical technique of lung volume reduction was found to improve respiratory function, exercise tolerance, quality of life and survival in selected patients with heterogeneous, predominantly upper lobe COPD.

Many of these findings emerged from the National Emphysema Treatment Trial (NETT) in the US.

However, as well as these benefits, data from the NETT showed a high risk of death among patients with very low forced expiratory volume (FEV1 less than or equal to 20% of predicted), low diffusing capacity of the lung for carbon monoxide (DLCO less than or equal to 20% of predicted) and a homogeneous pattern of COPD.

Related News:

And post-operative care frequently involved an ICU stay because of prolonged air leak. In some patients, the procedure was associated with significant risk of morbidity without attaining clinical improvement.

All these factors have resulted in the exclusion of most patients with severe COPD from lung volume reduction surgery.

Current management
Over the past decade, the technique of bronchoscopic treatment of COPD has emerged as a safer and more cost-effective alternative.

Various bronchoscopic lung volume reduction techniques have been described, including radiofrequency fenestration of the bronchial wall with stent placement, umbrella blockers, and injection of fibrin glue.

Endobronchial plugs and blockers were the initial methods adopted, but later abandoned due to the high risk of postobstructive pneumonia and device migration.

More recently, endobronchial valve therapy has re-emerged with the development and utilisation of one-way endobronchial (Zephyr, left) and intrabronchial (Spiration, right) valves (pictured below).

AD20Mar15_TUZephyrValve   AD20Mar15_TUSpirationValve   
These are novel, implantable one-way valves that are deployed into targeted bronchopulmonary segments via flexible bronchoscopy.

Their goal is to achieve complete atelectasis of a segment of hyperinflated lung, which is commonly seen in severe COPD, thus mimicking the physiological changes of lung volume reduction surgery (see below).

AD20Mar15_TUFig2a

 

AD20Mar15_TUFig2b

Discussion
Patient selection for endobronchial valve therapy
Patient assessment is of utmost importance in ensuring treatment success.

It is recommended that all COPD patients who have significant ongoing symptoms, despite optimal medication and completion of pulmonary rehabilitation, should be referred to a respiratory physician for consideration of endobronchial valve therapy, especially if they have FEV1 of 15-45% predicted, and residual volume of greater than180% predicted.

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Patients who meet these criteria will be further assessed for the heterogeneity of their disease, and for fissure integrity with high-resolution computer tomography of the chest, quantitative ventilation and the presence of collateral ventilation.

Role of computer tomography in predicting success
The utilisation of high-­resolution computer tomography assessment pre- and post-procedure has significantly improved the success rate of endobronchial valve therapy.

The presence of complete fissure integrity tends to be associated with higher improvements in FEV1 and higher scores in the St George’s Respiratory Questionnaire, than with other subgroups, at 6-12 months.

Collateral ventilation
One of the other major limitations to successful endobronchial valve therapy is the presence of collateral ventilation. Collateral ventilation is defined as the ventilation of alveolar structures through passages or channels that bypass the normal airways.

The additional valve deployment to the adjacent ipsilateral lobe will thus be required to artificially close the ventilation loop and ultimately achieve complete atelectasis.

A recent study demonstrated that Chartis Pulmonary Assessment System (pictured below) could predict with 75% accuracy which patients would obtain significant clinical response to valve therapy.

AD20Mar15_TUFig3

Improvement in pulmonary function tests
Studies have shown improvement in forced vital capacity (FVC) at 90 days, reduction in residual volume (RV) at 30 and at 90 days, as well as improvement in DLCO at four weeks.

The Six-Minute Walk Test
Four studies recorded an improvement in the Six-Minute Walk Test, with Herth et al describing an average improvement of 15m among its subjects.

Quality of life improvement
Five studies have independently recorded an improvement in patients’ quality of life following valve therapy.

In the VENT studies, there was up to five units improvement in the St George’s Respiratory Questionnaire at six months. This benefit was similarly observed at 12 months post valve insertion.

The questionnaire consists of 50 questions, and is designed to measure impact on overall health, daily life and perceived wellbeing of patients with COPD. A mean change score of four units is associated with slightly efficacious treatment.

Complications
The majority of valve recipients experience no complications. The most common complications associated with this procedure are COPD exacerbations and non-valve pneumonia.

The more serious, but uncommon, complications include pneumothorax, with or without prolonged air leak, valve migration and/or expectoration, post-obstructive pneumonia, and/or empyema and massive haemoptysis.

This is a marked advantage compared with the overall higher perioperative mortality rate of lung volume reduction surgery, with the most common complication, prolonged air leak, alone approaching 40%.

Accessibility
Although many studies have adopted the National Emphysema Treatment Trial inclusion/exclusion criteria to exclude patients with more severe disease, bronchoscopic lung volume valve reduction is minimally invasive and is better tolerated than surgical lung volume reduction.

It is also relatively cost-effective compared with its surgical counterpart, in terms of product cost, procedure time and the skilled expertise required.

Currently in Australia, endobronchial valve insertion is approved by the TGA and has been assigned an MBS item number. However, it is not yet subsidised by the PBS, and so is only accessible privately.

Conclusion
Endobronchial valve therapy is an emerging technique in the management of severe COPD.

In carefully selected patients with end-stage COPD, it is effective in improving pulmonary function, exercise capacity and the quality of life of patients not responding to conventional medication and pulmonary rehabilitation. It is a relatively safe and cost-effective procedure, particularly when compared with lung volume reduction surgery.

Dr Chin is a specialist in both general medicine and respiratory medicine. He practises with Eastern Health and consults in Melbourne, Victoria.

References on request.