What is the role of lung volume reduction surgery in treating severe Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Lung volume reduction surgery (LVRS) can be beneficial for select patients with severe emphysema-predominant COPD, particularly those with upper lobe-predominant emphysema and low exercise capacity despite optimal medical management, as it can improve lung function, exercise capacity, quality of life, and potentially survival compared to medical therapy alone. This procedure involves removing damaged portions of the lungs to allow the remaining healthier lung tissue to function more efficiently. Candidates for LVRS typically have severe emphysema with hyperinflation, particularly in the upper lobes, and have failed to improve with optimal medical therapy including bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, and smoking cessation. The best results occur in patients with upper lobe-predominant emphysema and low exercise capacity despite optimal medical management, as shown in the National Emphysema Treatment Trial 1.

Key Considerations

• The surgery reduces lung hyperinflation, improves elastic recoil, enhances diaphragmatic function, and can improve breathing mechanics.
• However, LVRS carries significant risks including prolonged air leaks, pneumonia, and mortality (1-5% in experienced centers) 1.
• Patients must undergo comprehensive evaluation including pulmonary function tests, CT scans, exercise testing, and cardiac assessment before being considered.
• Those with FEV1 less than 20% predicted, diffusing capacity less than 20% predicted, homogeneous emphysema, significant pulmonary hypertension, or continued smoking are generally not good candidates.
• For appropriate patients, LVRS can improve lung function, exercise capacity, quality of life, and potentially survival compared to medical therapy alone, as supported by recent guidelines 1.

Recent Guidelines and Evidence

• The most recent and highest quality study, published in 2017, confirms that patients with COPD with upper-lobe emphysema and low postrehabilitation exercise capacity experienced improved survival when treated with LVRS compared with medical treatment 1.
• Pulmonary rehabilitation administered before LVRS is safe and effective, and can lead to significant improvements in peak exercise workload, walking endurance, dyspnea, and quality of life 1.
• The role of LVRS in the management of COPD is supported by recent clinical practice guidelines, which emphasize the importance of individualized treatment and comprehensive evaluation 1.

From the Research

Role of Lung Volume Reduction Surgery in Treating Severe COPD

• Lung volume reduction surgery is a treatment option for patients with severe Chronic Obstructive Pulmonary Disease (COPD) characterized by emphysema and hyperinflation 2, 3.
• The goal of lung volume reduction surgery is to reduce lung hyperinflation, improve lung function, quality of life, and exercise capacity in carefully selected patients 3.
• Lung volume reduction surgery has been shown to improve exercise capacity and health status in patients with end-stage COPD, although it remains difficult to predict which patients will benefit from the procedure 4.
• The technique of lung volume reduction surgery is undergoing progress, with numerous new surgical and endoscopic procedures being developed, including bronchoscopic lung volume reduction options such as one-way endobronchial valves, coils, thermal vapor ablation, and sclerosant agents 2, 3.

Patient Selection and Treatment Outcomes

• Patient selection is crucial in determining the optimal treatment option, with consideration of possible adverse events or contraindications, and discussion in a multidisciplinary team is highly recommended 3.
• Lung volume reduction surgery may be beneficial in patients with an increased residual volume/total lung capacity ratio, and emphysema heterogeneity is likely to be related to the response 4.
• The procedure has been shown to improve lung function, exercise capacity, and quality of life in selected patients, although potential complications and long-term outcomes need to be considered 5, 6.

Comparison with Other Treatment Options

• Lung volume reduction surgery is one of several treatment options available for patients with severe COPD, including respiratory rehabilitation, bronchoscopic lung volume reduction, and lung transplantation 4, 6.
• Respiratory rehabilitation has been shown to improve exercise capacity and health status in patients with COPD, and may be considered a prime treatment option 4.
• Lung transplantation is also a consideration for select patients with severe COPD, with careful evaluation of clinical indications, selection of candidates, and potential complications 6.