Vapor ablation treatment of obstructive lung disease

A treatment of obstructive lung disease includes aiming a condensable vapor towards the airway wall, causing a band-shaped lesion to grow to a depth into the airway wall. Ablation parameters are set to control the depth of the band-shaped lesion to encompass the epithelial layer and exclude the smooth muscle layer of the airway. A wide variety of configurations of the vapor delivery are described to create ablation patterns in the airways of the patient with particular emphasis on treating chronic bronchitis.

BACKGROUND OF THE INVENTION

The present invention relates to medical methods for treating obstructive and or inflammatory lung disease, and more specifically to minimally invasive medical methods and apparatus' for ablating the inner wall of the airways to limit contraction and obstruction within airways.

Chronic obstructive pulmonary disease (COPD) and asthma are lung inflammatory diseases and affect many people. Each disease is characterized by limited airflow, and interferes with normal breathing. Although COPD includes a number of diseases including chronic bronchitis and emphysema, it is generally characterized by airflow obstruction. People with airflow obstruction may have a number of symptoms including smooth muscle contraction, chronic cough with excess sputum production, and general thickening of the airway wall, all of which result in obstruction of normal breathing.

Various approaches to treat COPD and asthma include pharmacological treatment and interventional treatments.

Pharmacological treatment is an approach applied to most patients. For example, it is not uncommon for a physician to administer an inhaled bronchodilator (short or long acting) once or twice daily to relax and temporarily open airways. However, the side effects of the pharmacological agents include: nausea and vomiting, diarrhea, palpitations, a rapid heartbeat, an irregular heartbeat, headaches, and problems sleeping (insomnia), all of which are undesirable.

On the other hand, some patients are candidates for interventional treatments.

A variety of thermal ablation based interventional treatments have been described as therapies to treat diseased airways.

U.S. Pat. No. 9,867,648 to Mulcahey, for example, describes a cryospray treatment of airway tissue. Spray cryotherapy is applied by spraying liquid nitrogen directly onto the bronchial wall with the intent of ablating superficial airway cells and initiating a regenerative effect on the bronchial wall.

Radiofrequency ablation techniques have also been described wherein energy is delivered to the airway wall in a variety of locations to ablate diseased tissue. An example of a RF based bronchial thermoplasty to reduce excess smooth muscle in the airway is described in U.S. Pat. No. 6,488,673 to Laufer et al. See also, the The Alair™ Bronchial Thermoplasty System (manufactured by Boston Scientific, Corporation, Marlborough, Mass., USA).

These thermal ablative technologies non-selectively ablate various layers of the airway wall, often undesirably ablating non-target tissues beyond the epithelium. As a consequence of damage to tissues beyond the therapeutic targets of the epithelium, an inflammatory cascade can be triggered, resulting in inflammation, which can lead to an exacerbation, and remodeling. As a result, the airway lumen can be further reduced. Thus, continued improvements in interventional procedures are needed which are more controlled, targeted to specific depths and structures that match the physiologic malady, while limiting the amount of inflammatory response and remodeling.

Accordingly, a system and method to treat obstructive lung and inflammatory disease that overcomes the above-mentioned challenges is still desirable.

SUMMARY OF THE INVENTION

The present invention includes an apparatus, system and method for ablating tissue for the treatment of obstructive lung or inflammatory diseases, and is particularly suitable for treatment of chronic bronchitis and asthma.

In embodiments, vapor is aimed directly towards the surface of the airway to create a ring-shaped ablation layer extending into the airway wall to a depth. In embodiments, the depth is controlled by ablation parameters to include only the epithelial layers and exclude other layers, such as smooth muscle. In embodiments, the depth of the ablation layer is controlled to be less than 1 mm, and more preferably between 0.3 and 0.7 mm, and most preferably about 0.4 to 0.6 mm.

In embodiments, an apparatus includes a distal section and at least one egress port along the distal section. The egress port aims condensable vapor at the airway wall.

In embodiments, the egress port is aimed such that the flowpath of the vapor is substantially perpendicular to the airway wall.

The configuration of the egress port(s) may vary. In embodiments, the distal section has a tubular shaped wall, and the egress port is disposed along the wall.

In embodiments, a plurality of egress ports are disposed circumferentially about the wall of the catheter. Additional egress ports or sets of egress ports may be located along a length of the catheter shaft.

In embodiments, the target region or section of the airway is isolated from a non-target section of the airway by at least one occluding member. The occluding member may be disposed proximal or distal to the egress port. In embodiments, occluding members are present on both the distal and proximal side of the egress port to define a volume or space which the vapor fills. In embodiments, the occluding members are expandable members such as an inflatable balloon.

In embodiments, the shaft may be operable with a proximal hub or handle to rotate or axially move the distal working section and egress port(s) relative to the isolation member. The hub may include a means to controllably advance and rotate the shaft carrying the egress ports relative to the balloon. In an embodiment, the means is a threaded shaft and mating grooves to allow incremental advancement of one of the components to the other.

In embodiments, a target region along the airway, and optionally an optimal route to the target region, is predetermined.

In embodiments, the vapor is delivered in pulses, and optionally, the heated vapor and a cooling gas is delivered in pulses according to an adjustable or varying duty cycle.

In embodiments, the duty cycle is adjusted based on the measured depth of the lesion.

In embodiments, the duty cycle commences at a first range, and is adjusted to a second range wherein the second range is less than the first range. In embodiments, the first range is from 70 to 100%, and the second range is under 50%.

In embodiments, the method further comprises visually monitoring the surface of the airway and computing a real-time hue change as the ablation layer is forming. In embodiments, the depth of ablation is controlled by halting the vapor delivery if the real-time hue change reaches a predetermined threshold hue change.

Still other descriptions, objects and advantages of the present invention will become apparent from the detailed description to follow, together with the accompanying drawings.

DETAILED DESCRIPTION OF THE INVENTION

Before the present invention is described in detail, it is to be understood that this invention is not limited to particular variations set forth herein as various changes or modifications may be made to the invention described and equivalents may be substituted without departing from the spirit and scope of the invention. As will be apparent to those of skill in the art upon reading this disclosure, each of the individual embodiments described and illustrated herein has discrete components and features which may be readily separated from or combined with the features of any of the other several embodiments without departing from the scope or spirit of the present invention. In addition, many modifications may be made to adapt a particular situation, material, composition of matter, process, process act(s) or step(s) to the objective(s), spirit or scope of the present invention. All such modifications are intended to be within the scope of the claims made herein.

Methods recited herein may be carried out in any order of the recited events which is logically possible, as well as the recited order of events. Furthermore, where a range of values is provided, it is understood that every intervening value, between the upper and lower limit of that range and any other stated or intervening value in that stated range is encompassed within the invention. Also, it is contemplated that any optional feature of the inventive variations described may be set forth and claimed independently, or in combination with any one or more of the features described herein.

All existing subject matter mentioned herein (e.g., publications, patents, patent applications and hardware) is incorporated by reference herein in its entirety except insofar as the subject matter may conflict with that of the present invention (in which case what is present herein shall prevail).

Now, with reference toFIG.1, pertinent anatomy is shown and described serving to facilitate understanding of the invention. Particularly,FIG.1illustrates a human respiratory system10. The respiratory system10resides within the thorax12that occupies a space defined by the chest wall and the diaphragm16. The human respiratory system10includes left lung lobes44and46and right lung lobes48,50, and52.

The respiratory system10may be characterized by a tree-like structure formed of branched airways including the trachea18; left and right main stem bronchus20and22(primary, or first generation) and lobar bronchial branches24,26,28,30, and32(second generation). Segmental and subsegmental branches further bifurcate off the lobar bronchial branches (third and fourth generation). Each bronchial branch and sub-branch communicates with a different portion of a lung lobe, either the entire lung lobe or a portion thereof.

FIGS.2A,2Billustrate cross sectional views of an airway in a normal state72and a diseased state72′, respectively. The diseased state may arise from, e.g., asthma, chronic bronchitis, or otherwise.

With reference toFIG.2A, smooth muscles74are shown axially spaced along the airway in an uncontracted state. Nerves76communicate with the smooth muscles, and control movement of the smooth muscles74. The nerves can affect the size or diameter of the airway passageway by causing the smooth muscles to constrict or expand. Blood vessels78serve to transport blood therethrough.

FIG.2Aalso shows an epithelium layer80supported by basement membrane84. The epithelium layer80is generally comprised of cells including goblet cells, columnar cells, and basal cells. The epithelium layer may have a depth ranging from 5 to 100 μm. Finally, a mucus layer82coats the epithelium layer.

FIG.2Billustrates an airway72′ in a diseased state. The smooth muscles74are notably contracted. The epithelium layer80′ is substantially narrowed and the mucus layer82′ is increased and further narrows the airway.

Depending on the degree of the disease, the contracted and obstructed airways make breathing strained, if not impossible. Embodiments of the invention discussed herein provide methods and apparatus' to treat obstructive and/or inflammatory diseases of the lung.

Bronchoscopy Approach

FIG.3illustrates a bronchoscopic procedure in accordance with some embodiments of the present invention.FIG.3shows a bronchoscope100having a working channel into which an energy delivery catheter200(or another tool) is inserted. Bronchoscope100is inserted into a patient's lungs while the proximal portion of the energy delivery catheter200remains outside of the patient. Energy delivery catheter200is adapted to operatively couple to an energy generator300as further discussed below. Examples of energy delivery catheters include, without limitation, a condensable vapor ablation catheter as described herein.

Energy Generator

FIG.4Ais a schematic diagram of an energy generator300configured as a vapor generator. In embodiments, vapor generator is configured to deliver a controlled dose of vapor to one or more target lung tissues. Vapor generator300is adapted to convert a biocompatible liquid301(e.g. saline, sterile water or other biocompatible liquid), into a wet or dry vapor, which is then delivered to one or more target tissues. A wet vapor refers to a vapor that contains vaporous forms of the liquid as well as a non-negligible proportion of minute liquid droplets carried over with and held in suspension in the vapor. A dry vapor refers to a vapor that contains little or no liquid droplets. In general, vapor generator300is configured to have a liquid capacity between about 5 and 1000 cc and configured to generate a vapor having a pressure between about 5-100 psig and temperatures between about 100-175° C.

In embodiments, vapor generator300is configured as a self-contained, medical-grade generator unit comprising at least a vaporizing unit302, a fluid inlet304, and a vapor outlet306. The vaporizing unit302comprises a fluid chamber for containing a fluid301, preferably a biocompatible, sterile fluid, in a liquid state. In embodiments, vapor outlet306is coupled to one or more pipes or tubes314, which in turn are placed in fluid communication with an energy delivery catheter200. Vapor flow from vapor generator300to a catheter (and specifically a vapor lumen of said catheter) is depicted as a vapor flow circuit314wherein flow of the vapor in circuit314is indicated by arrows314inFIG.4. In a preferred embodiment, vapor generator is configured to deliver a repeatable dose of vapor to the energy delivery catheter. Suitable doses of vapor range from 100 to 1000 calories.

Vaporizer unit302is configured to heat and vaporize a liquid contained therein. Other components can be incorporated into the biocompatible liquid301or mixed into the vapor. For example, these components can be used to control perioperative and/or post procedural pain, enhance tissue fibrosis, and/or control infection. Other constituents, for the purpose of regulating vapor temperatures and thus control extent and speed of tissue heating, can be incorporated; for example, in one implementation, carbon dioxide, helium, other noble gases can be mixed with the vapor to decrease vapor temperatures.

Vaporizing unit302is also shown having a fluid inlet304to allow liquid301to be added to the fluid chamber as needed. Fluid chamber can be configured to accommodate or vaporize sufficient liquid as needed to apply vapor to one or more target tissues. Liquid in vaporizing unit302is heated and vaporized and the vapor flows into vapor outlet306. A number of hollow tubular shafts or pipes314are adapted to fluidly connect vapor outlet306to the catheter, described herein.

With reference toFIG.4B, in embodiments, a flexible hollow tube or umbilical-like cord410extends from the generator400and terminates in a handle (420). The handle is adapted to operatively couple to an energy delivery catheter440via a hub assembly (such as hub assembly450shown inFIG.5and discussed herein). In embodiments, the hub assembly450or other connecting means is configured to allow for a secure, fluidly sealed, and quick release between the catheter440and generator handle420. Examples of suitable quick connect and release mechanisms include, without limitation, Luer Lock hub assemblies and fittings.

In embodiments, a catheter and vapor generator are configured to be directly coupled to one another via mating connectors. Vapor delivery is controlled by the generator, a controller external to the generator, or actuating buttons and mechanisms on the catheter itself. For example, the catheter may comprise a handpiece portion to control vapor doses.

Although the vapor generator is described above having various specific features, the components and configurations of the vapor generator and catheter systems may vary. Additional vapor ablation systems are described in, for example, U.S. Patent Publication No. 2015/0094607 to Barry et al., and Pat. No. 7,913,698 to Barry et al., and Pat. No. 8,322,335 to Barry et al., and Pat. No. 7,993,323 to Barry et al.

In other embodiments, a condensable vapor is created in the handle portion of the catheter system. Consequently, a separate vapor generator unit is not required. Systems including a resistive heater are described in, for example, U.S. Patent Publication No. 2016/0220297 to Kroon et al., U.S. Patent Publication No. 2014/0276713 to Hoey et al., and U.S. patent application Ser. No. 16/203,541, filed Nov. 28, 2018, and entitled “VAPOR ABLATION HANDPIECE”. Indeed, embodiments of the invention include a wide range of mechanisms to create and transport vapor through the working catheter as described herein.

Vapor Ablation Catheter

FIG.5illustrates a vapor ablation catheter440in accordance with one embodiment of the invention. Catheter440is shown having a proximal section442, a distal end section460, and intermediate section therebetween. Proximal section442is shown with hub450which may be connected to the generator as described above. Intermediate section is flexible and continues to distal end section460. Examples of suitable materials for the catheter shaft include polyimide, PEBAX, silicone, PEEK, and stainless-steel braiding.

FIG.6is an enlarged view of the distal section460of vapor ablation catheter440in an airway462. The catheter is shown extending from a working channel of a bronchoscope464. Light from the bronchoscope illuminates the airway lumen.

Vapor470is shown being emitted from an axially-aimed distal port480towards the target section of the airway. The catheter440also includes an isolation member482to isolate the vapor470to the target tissue. The isolation member is visually transparent, allowing the physician to see through the member. Examples of isolation members include, without limitation, inflatable members, balloons, and expandable members.

FIG.7Ashows an enlarged view of a distal section of another catheter500in an airway504delivering vapor510. Unlike the catheter440discussed above, catheter500aims the vapor510directly towards the airway wall504. The flowpath of the vapor is perpendicular to the airway wall. The distal section of the catheter500features a bend512ranging from 60 to 120 degrees, and preferably about 80-100 degrees, and most preferably about 90 degrees.

An isolation member520holds the catheter in place while emitting vapor and isolates the vapor to the target region. Additionally, in embodiments, the isolation member520includes a coupler524, allowing the shaft526of the catheter to rotate relative to the isolation member. An example of a coupling mechanism is a tubular passageway through which the shaft526of the vapor catheter extends therethrough. Preferably, the components cooperate with one another to be fluidly sealed but axially and rotatably movable. In embodiments, an O-ring or gasket (e.g., a Teflon O-ring) is provided to facilitate a seal and permit motion between the components.

With reference toFIG.7B, a handle550is shown that enables the physician to rotate the tip of the catheter to create a band-shaped ablation zone. Particularly, in the embodiment shown inFIG.7B, handle550of catheter includes a hub560to which the isolation member520is connected. The vapor delivery shaft570is axially moveable within the hub assembly560. Additionally, a knob580is connected to a proximal end of the vapor catheter to allow the physician to conveniently rotate and axially move the catheter relative to the balloon.

Rotation may be clock-wise or counter clockwise. Example rotation angles are between 0 and 180, up to 360 or more. Additionally, the physician may axially advance the catheter in combination with rotation to generate an elongated tubular ablation zone along the surface of the airway.

The incremental or controlled movement may be accomplished via a shaft advancement means. In embodiments, the hub assembly560includes a threaded shaft584to allow for incrementally advancing and rotating of the shaft relative to the balloon. As a result of this motion, the catheter can create a circumferentially complete band ranging from 5 to 20 mm in width (w).

The depth (d) of the ablation lesion may also be controlled. In embodiments, the physician controls ablation parameters for the vapor delivery to limit the depth (d) of ablation to less than 1 mm, and in embodiments, between 0.3 and 0.7 mm, and preferably less than 0.5 mm into the wall. In embodiments, the parameters include but are not limited to vapor temperature, flowrate, and duration of vapor delivery. Non-limiting exemplary time durations to limit the ablation depth (d) to the above desired depths is less than 1 minute, less than 30 seconds, and less than 10 seconds. Exemplary non-limiting temperatures range from that described above to more preferably less than 100 degrees C. In embodiments, the duration of vapor delivery and temperature are adjusted to ablate the upper layer of the epithelium including the goblet cells, or top layer of the epithelium, and to let the underling tissue architecture remain intact. In embodiments, the time and temperature are set as described above to treat only the epithelium cell layers discussed above yet not damage deeper layers.

The depth of thermal ablation can also be controlled by a pulsing or duty cycle application of the vapor. Pulsing allows for the limited vapor dispersed to condense and be followed by a brief cooling period which will slow penetration of the steam energy. Alternating steam and cooling gas application to the wall can provide a fine/precise depth of penetration. A 10% duty cycle (10 parts steam followed by 90 parts cooling) will result in a shallower penetration of the ablation than a 50% duty cycle. A controlled solenoid and valve mechanism (similar to a fuel injector) could be programed to alternate gasses and achieve this duty cycle. Where a slow and more precise ablation is desired, the physician may opt for a lower duty cycle under 50%, or perhaps from 10 to 20%. On the other hand, for a deeper ablation zone, the physician may opt for a higher duty cycle. In embodiments, the higher or fast ablation duty cycle may range from 70 to 100%.

The depth of penetration can be monitored via observation and color change of the bronchial wall via an optical comparator system. Without intending to being bound by theory, as vapor is applied to the bronchial surfaces, the pink coloration of the lumen will change from pink to white in a progressive fashion from all pink to all white, where partial ablation is a mix of pink and white coloration. With this color change a correlation can be established between the coloration and the depth of penetration. As all airways are not the exact hue of pink, one could similarly monitor the change from the original color to be correlated to the energy delivered and depth of penetration.

The measure (or computation) of color change could be performed by an optical comparator system capable of graphic processing of the color vs a known color scale. An example of a suitable optical assessment technology is BLD Blood Leak Detector, manufactured by Sonotec US Inc. (Islandia, N.Y.) or the TT Electronics Photologic V OPB9000 reflective optical sensor, manufactured by TT Electronics (Boston, Mass.). With such an optical quality assessment of hue and difference from baseline, a system and method could be controlled by a feedback loop which would stop the application of vapor when the color change desired (e.g., a threshold hue change) had been verified, therefore achieving the desired depth of penetration. In embodiments, the vapor emission is halted when the real-time color change of the surface of the airway reaches a predetermined threshold color change.

The duty cycle for vapor ablation may also be adjusted (or varied) during a procedure. A high duty cycle could be applied to start to speed initial growth of the ablation depth. With significant Hue change as assessed by the optical comparator system, the duty cycle could be reduced (e.g., reduced by 10-25, 50 or in some embodiments 75%) to slow the growth of the depth of penetration and arrive asymptotic to the desired depth of penetration/hue for a precise control.

FIG.8Ashows the distal section of another vapor ablation catheter610. Vapor ablation catheter610is similar to the vapor catheter described above except it features a laterally disposed egress port612. Vapor614is aimed directly at the airway wall620. Isolation member618secures the catheter in place, blocks the vapor from passing, and isolates a target section of the airway to be ablated distal to the isolation member.

FIG.8Bshows the distal section of another vapor ablation catheter650. Vapor ablation catheter650is similar to the vapor catheter610described above except that it features an isolation member652distal to the egress port660. Vapor662is shown aimed at the airway wall620but the vapor is prohibited by the isolation member652from flowing distally into more remote airways not shown.

FIG.8Cshows the distal section of another vapor ablation catheter680. Vapor ablation catheter680is similar to the vapor catheters610,650described above except that it features two isolation members682,684. Isolation members682,684are distal and proximal to the egress port(s)690, respectively. In a sense, the isolation members and catheter have a dumbbell shaped configuration.

Vapor692is shown aimed at the airway wall620and is limited to the volume defined between the isolation members682,684and the airway wall620. In this manner, collateral damage to non-target tissues and airways is prohibited.

FIG.9shows a distal section of another vapor delivery catheter900. Vapor ablation catheter900is similar to the vapor catheters described above except it features a plurality of laterally and circumferentially disposed egress ports910,912, etc. for the vapor920,922to be aimed towards the airway wall930to create a complete continuous ring of ablation932.

The ports910,912, etc. are shown in a group. Adjacent ports are spaced from one another such that the vapor flowpath (as the vapor flows into the wall) from one port overlaps with the vapor flowpath from an adjacent port. In embodiments, the distance (center to center) between the adjacent ports ranges from 0.5 to 5 mm.

The number of egress ports910,912, etc. may vary widely and range from 1-20, and more preferably 6-12. Additionally, the shape and size of the egress ports may vary. In embodiments, the egress port has a circular shape and a diameter in the range of 0.1 to 2 mm.

Optionally, although not shown, an isolation member may be disposed proximally, distally, or both proximally and distally to the group of egress ports.

FIG.10shows a distal section of another vapor delivery catheter950. Vapor ablation catheter950is similar to the vapor catheter described above in connection withFIG.9except it features an axially-offset (or spaced) configuration of egress ports952,954, etc. for the vapor962,964to be aimed towards the airway wall970to create a set or chain of spaced-apart rings of ablation972,974. Adjacent ports952,954can be spaced apart a predetermined distance (m) to generate preplanned ablation pattern such as the pattern shown inFIG.11wherein adjacent rings990,992, etc. are offset from one another a predetermined distance (m). In embodiments, the predetermined distance (m) ranges from 4 to 15 mm.

Also, the number of discrete groups of ports may vary from that shown inFIG.10(namely, 4 spaced apart groups). In embodiments, the number of spaced apart groups ranges from 2-8, more preferably 2-6, and most preferably from 2-4.

Additional examples of vapor delivery catheter configurations are described in the literature. Another example of a vapor catheter having components and structures which may be combined with the subject invention is described in U.S. Pat. No. 8,444,636 to Shadduck and Hoey; and U.S. Patent Publication No. 2014/0025057 to Hoey and Shadduck. The catheter and tip configuration may vary widely and the invention is only intended to be limited as recited in the appended claims.

Chronic Bronchitis or Asthma Treatment Method

FIG.12is a flowchart illustrating a method1000for the treatment of obstructive lung and/or inflammatory disease such as chronic bronchitis and asthma.

Step1010states to identify the target region along an airway in the lung of a patient to ablate. An example of a candidate region to ablate may be a portion along the trachea, main bronchus, bronchioles from 1 generation up to the 5 generation. Endoscopy or noninvasive means such as MRI may be applied to view and identify the target.

Step1020states to plan route to the target tissue. Optionally, planning software is employed to visualize the target region in renderings of the patient's lungs (e.g. a 3D reconstruction of the airway tree based on a patient's CT or MRI image data). Examples of route planning techniques are described in U.S. Pat. No. 9,037,215 and U.S. Patent Publication No. 2009/0156895, both to Higgins et al. See also the LungPoint® Planner, manufactured by Broncus Medical, Inc., (San Jose, Calif.).

Step1030states to advance the catheter to the target tissue. As described above, the physician may advance the catheter through the working channel of a scope to the target region.

Step1040states to isolate the target region. In embodiments, this step is performed as described above by inflating or expanding one or more isolation members to limit the vapor to the target region or section of airway.

Step1050states to aim an egress port of the catheter at the surface of the airway wall. Aiming may be performed as described above by rotation of the port, movement of the port axially, or providing multiple ports circumferentially or axially along the shaft of the catheter.

Optionally, the distance between the airway wall and the port is adjusted by, e.g., switching out another catheter having a different diameter shaft to position each of the egress ports closer or farther from the airway wall.

In embodiments, a method further comprises controlling or adjusting the distance from the egress port to the surface of the airway based on a target depth to be achieved by the emitted vapor.

Step1060states to deliver a vapor dose towards the target. As described herein, the vapor dose is controlled by various ablation parameters to provide an amount of energy to the target region to cause necrosis to a depth as described herein, and in particular embodiments, such that only the top layer of the epithelium is ablated. In embodiments, the ablation parameters are controlled such that the vapor dose ranges from 100 to 1000 calories. The amount of energy can be controlled by time duration, flow rate, temperature, duty cycle, and vapor quality.

Alternative Embodiments

The invention has been discussed in terms of certain embodiments. One of skill in the art, however, will recognize that various modifications may be made without departing from the scope of the invention. For example, numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention. For example, in embodiments, lesions may be created by the vapor systems described above which form non-band shaped lesions on the airway. Lesions may be sprayed/painted on epithelium of the airway in a non-contiguous manner, in patches, segments, half rings, arcuate segments, etc., and the control parameters can be used to limit the depth of the lesion to the target depth, preferably less than 1 mm so as to leave the underlying tissue architecture intact. Moreover, while certain features may be shown or discussed in relation to a particular embodiment, such individual features may be used on the various other embodiments of the invention.