What are the criteria for considering lung volume reduction surgery in a Chronic Obstructive Pulmonary Disease (COPD) patient?

From the Guidelines

Lung volume reduction surgery should be considered for COPD patients with severe emphysema, predominantly in the upper lobes, and reduced exercise capacity, as defined by an FEV1 <45% predicted and maximal exercise capacity <25 W for women and <40 W for men, as evidenced by the National Emphysema Treatment Trial 1. When deciding if a COPD patient needs lung volume reduction surgery, several criteria must be met.

• The patient should have severe COPD, defined as an FEV1 <45% predicted, with a predominance of emphysema in the upper lobes.
• The patient should have reduced exercise capacity, defined as maximal exercise capacity <25 W for women and <40 W for men on a standard incremental cycle ergometer test.
• Patients with giant bullae, which are isolated gas-filled cavities occupying one-third of the ipsilateral hemithorax, surrounded by relatively normal parenchyma, can also benefit from bullectomy, as it can improve lung mechanics, symptoms, functional performance, and health status 1. The decision to proceed with lung volume reduction surgery should be made after careful consideration of the potential benefits and risks, including the high cost of the therapy and the potential for significant air leaks and prolonged hospital stay 1.
• The patient should have failed to achieve adequate symptom control with optimal medical management, including bronchodilators, inhaled corticosteroids, vaccination, and pulmonary rehabilitation.
• The patient should be an ex-smoker, have completed pulmonary rehabilitation, and demonstrate no significant comorbidities that would increase surgical risk. It is essential to note that lung volume reduction surgery is not suitable for all COPD patients, and the selection of candidates should be based on individual assessment and careful evaluation of the potential benefits and risks.

From the Research

Criteria for Lung Volume Reduction Surgery in COPD Patients

The decision to perform lung volume reduction surgery (LVRS) in patients with Chronic Obstructive Pulmonary Disease (COPD) is based on several criteria, including:

• Severity of emphysema: Patients with upper-lobe predominant emphysema are more likely to benefit from LVRS 2
• Exercise capacity: Patients with poor exercise capacity before surgery may experience improvements in six-minute walk distances and quality-of-life scores after LVRS 2, 3
• Pulmonary function: Patients with a forced expiratory volume in one second (FEV1) of less than 20% of predicted and either homogeneous emphysema or diffusing capacities (DLCO) less than 20% of predicted are not considered good candidates for LVRS due to high peri-operative mortality rates 2
• Symptom severity: Patients with severe dyspnea and exercise intolerance may benefit from LVRS, which can improve symptoms and quality of life 3

Patient Selection

Patient selection is crucial to ensure the effectiveness and safety of LVRS. The following patients are not considered good candidates for LVRS:

• Those with homogeneous emphysema and low FEV1 2
• Those with significant pulmonary artery hypertension and hypercapnic respiratory failure 4
• Ventilator-dependent patients, although some studies suggest that LVRS can be beneficial in select cases 4

Surgical Techniques

LVRS can be performed using various techniques, including:

• Stapler device wedge excision and closure 5
• Video-assisted thoracoscopic surgery (VATS) 5
• Thoracotomy/sternotomy 5
• Laser resection of emphysematous parenchyma, although this technique has been found to be unsuccessful in most clinics 5

Outcomes

LVRS can result in significant improvements in:

• Pulmonary function, including FEV1 and forced vital capacity (FVC) 5, 2, 3
• Exercise capacity and six-minute walk distances 2, 3
• Quality of life, including symptoms and functional status 2, 3
• Survival, particularly in patients with upper-lobe predominant emphysema and poor exercise capacity before surgery 3