What are the recommendations for lung volume reduction surgery (LVRS) in patients with Chronic Obstructive Pulmonary Disease (COPD) based on the National Emphysema Treatment Trial (NETT)?

Lung Volume Reduction Surgery (LVRS) Recommendations Based on the National Emphysema Treatment Trial (NETT)

LVRS should be considered for patients with severe COPD who have upper lobe-predominant emphysema and reduced exercise capacity, as this specific group shows improved survival, exercise capacity, and quality of life compared to medical therapy alone. 1, 2

Patient Selection Criteria

• LVRS is recommended for patients with severe COPD (FEV1 <45% predicted) who have upper lobe-predominant emphysema on imaging 1, 2
• Optimal candidates have reduced exercise capacity (<25W for women, <40W for men on cycle ergometry) 1, 2
• Preoperative comprehensive pulmonary rehabilitation is essential to optimize patients before surgery and accurately assess exercise capacity 3
• Patients with homogeneous emphysema and low exercise capacity may experience improved exercise capacity and health status, but not survival benefit 3

Contraindications

• LVRS is absolutely contraindicated in patients with FEV1 ≤20% predicted combined with either:
  • Homogeneous emphysema on HRCT, or
  • DLCO ≤20% predicted 1, 2
• These high-risk patients have significantly increased mortality with LVRS 3
• Patients with homogeneous emphysema and good exercise capacity should not undergo LVRS due to higher mortality risk 3

Benefits of LVRS in Appropriate Candidates

• Survival benefit for patients with upper lobe-predominant emphysema and low exercise capacity 3, 4
• Significant improvements in:
  • Exercise capacity and walking distance 3, 4
  • Pulmonary function (FEV1 improvement of approximately 286cc at one year) 5
  • Quality of life scores 4
  • Dyspnea 3
  • Reduced exacerbation rates (0.27 vs. 0.37% per person-year) 4

Outcomes Based on NETT Subgroups

• Group B (upper lobe-predominant emphysema with low exercise capacity): Lower mortality, better exercise capacity, and improved health status compared to medical therapy 3
• Group C (upper lobe-predominant emphysema with good exercise capacity): No survival benefit but improved exercise capacity and health status 3
• Group D (homogeneous emphysema with low exercise capacity): No survival benefit but improved exercise capacity and health status 3
• Group E (homogeneous emphysema with good exercise capacity): Higher mortality, not candidates for LVRS 3
• Group A (very high-risk patients): Should not be considered for surgery 3

Long-term Outcomes

• Mortality rates for LVRS are greater up to one year, equivalent by three years, and lower after four years compared to medical therapy alone 4
• Five-year probability of death is significantly lower in upper-lobe predominant disease with low exercise capacity (0.36 vs. 0.54) 4
• BODE index (body mass index, airflow obstruction, dyspnea, and exercise capacity) improves significantly at one year post-LVRS 5

Considerations and Limitations

• Cost-effectiveness ratio is $98,000 per quality-adjusted life year over 3 years 1, 2
• Significant postoperative complications, including air leaks after thoracotomy, occur in up to 90% of patients 1
• Surgical approaches include median sternotomy or video-assisted thoracoscopic surgery (VATS) 5
• For giant bullae (occupying >1/3 of hemithorax), bullectomy may be more appropriate than LVRS 1, 2
• Lung transplantation remains an option for patients who are not candidates for LVRS 1, 2

Alternative Approaches

• Bronchoscopic lung volume reduction techniques may be considered for patients who are not surgical candidates, though they have limited efficacy and lack regulatory approval for COPD 1, 2
• Minimally invasive surgical techniques are being investigated to potentially reduce complication rates 2