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 Recommendations Based on NETT Trial

Lung volume reduction surgery (LVRS) is strongly recommended for COPD patients with upper lobe-predominant emphysema and low exercise capacity, as this group shows improved survival, exercise capacity, and quality of life compared to medical therapy alone. 1, 2

Patient Selection Criteria

• LVRS should be considered for patients with severe COPD (FEV1 <45% predicted) who have upper lobe-predominant emphysema on imaging 1, 2
• Patients should have reduced exercise capacity (maximal exercise capacity <25W for women, <40W for men on cycle ergometry) 1, 2
• Pre-operative pulmonary rehabilitation is essential for optimal patient selection and outcomes 3
• LVRS is contraindicated in high-risk patients with FEV1 ≤20% predicted combined with either homogeneous emphysema or DLCO ≤20% predicted due to increased mortality risk 1, 2

Benefits by Patient Subgroup

• Group B (upper lobe-predominant emphysema with low exercise capacity): Shows lower mortality, better exercise capacity, and improved health status compared to medical therapy 3
• Group C (upper lobe-predominant emphysema with good exercise capacity): Shows improved exercise capacity and health status but no survival benefit 3
• Group D (homogeneous emphysema with low exercise capacity): Shows improved exercise capacity and health status but no survival benefit 3
• Group E (homogeneous emphysema with good exercise capacity): Higher mortality with LVRS; not candidates for surgery 3

Specific Outcomes

• Survival: Probability of survival at 1 year is 0.98 and at 3 years is 0.95 when using NETT selection criteria 4
• Exercise capacity: Significant improvements in 6-minute walk distance (433 vs. 300m, p<0.002) 5
• Lung function: FEV1 improvement of approximately 286cc one year after surgery 4
• Quality of life: Higher scores (45.3 vs. 27.5, p<0.001) compared to medical treatment 5
• Exacerbation rate: Lower rate per person-year (0.27 vs. 0.37%, p=0.0005) 5

Surgical Approach and Complications

• LVRS can be performed via median sternotomy or video-assisted thoracoscopic surgery (VATS) 4
• Significant postoperative complications, particularly air leaks after thoracotomy, occur in up to 90% of patients 1
• Mortality risk is higher in the immediate postoperative period (up to 1 year) but becomes equivalent by 3 years and potentially lower after 4 years compared to medical therapy 5

Alternative Approaches

• Bullectomy may be appropriate for patients with giant bullae (occupying >1/3 of hemithorax) surrounded by relatively normal parenchyma 1, 2
• Bronchoscopic lung volume reduction techniques may be considered for patients who are not candidates for LVRS, though they have limited efficacy 1, 2
• Lung transplantation remains an option for patients with end-stage COPD who are not candidates for LVRS 1, 2

Cost Considerations

• LVRS has a cost-effectiveness ratio of $98,000 per quality-adjusted life year over 3 years 1, 2
• Despite higher costs ($137,000 vs. $100,200 over five years), the improvements in lung function, exercise capacity, and quality of life make LVRS preferable to medical therapy alone in appropriate candidates 5

Long-term Follow-up

• Even in initially high-risk patients excluded from the original NETT recommendations, longer-term follow-up suggests comparable outcomes after the initial high-risk period 6
• Quality-adjusted survival models favor LVRS after approximately 4 years of follow-up, despite initial higher risk 6