From the Guidelines
Patients with severe COPD should be referred for lung volume reduction surgery (LVRS) evaluation when they have upper lobe-predominant emphysema, significant hyperinflation, low exercise capacity despite maximal medical therapy, and remain symptomatic with dyspnea limiting daily activities, as indicated by the National Emphysema Treatment Trial 1.
Indications for Referral
The following are indications for referral for LVRS:
- Upper lobe-predominant emphysema
- Significant hyperinflation
- Low exercise capacity despite maximal medical therapy
- Remain symptomatic with dyspnea limiting daily activities
- FEV1 between 20-45% of predicted
- Total lung capacity >100% predicted
- Residual volume >150% predicted
- Carbon monoxide diffusing capacity >20% predicted
Patient Selection
Ideal candidates for LVRS should be:
- Former smokers (abstinent for at least 4 months)
- Completed pulmonary rehabilitation
- No significant comorbidities that would increase surgical risk
Contraindications
Contraindications for LVRS include:
- Severe heart disease
- Pulmonary hypertension
- Homogeneous emphysema
- Very low FEV1 (<20% with homogeneous disease)
- Continued smoking
- Significant pleural adhesions The National Emphysema Treatment Trial suggested that patients with severe COPD (defined as an FEV1 <45% predicted) with a predominance of emphysema in the upper lobes and with reduced exercise capacity may experience significant improvements in symptoms, health status, lung mechanics, exacerbation rates, and even survival with LVRS 1. However, the therapy is costly, and patients should be carefully selected to ensure the best outcomes 1.
From the Research
Indications for Referral for Lung Volume Reduction Surgery
The following are indications for referral for lung volume reduction surgery in patients with COPD:
- Upper lobe predominant emphysema in the setting of advanced disease 2
- Low exercise tolerance 2
- Survival advantage compared with maximal medical therapy for those with upper lobe predominant emphysema and low exercise tolerance 2
- Giant bullae occupying at least one-third of the hemithorax and compressing some adjacent lung tissue, where bullectomy has been demonstrated to improve dyspnea and lung function 2
- Chronic respiratory failure due to COPD who have not improved despite maximal surgical and medical therapy, where lung transplantation remains an option in those without significant comorbid conditions 2
- Severe chronic obstructive pulmonary disease (COPD) with significant symptoms and functional impairment, where lung-volume reduction surgery (LVRS) has been shown to improve dyspnea, dynamic hyperinflation, and respiratory muscle function 3
Patient Selection
Careful patient selection is paramount to the success of lung volume reduction surgery, as there are patients in whom LVRS may increase mortality 2.