From the Guidelines
Lung volume reduction surgery (LVRS) should be considered for carefully selected patients with severe chronic obstructive pulmonary disease (COPD) and upper lobe-predominant emphysema, as it may improve symptoms, health status, lung mechanics, exacerbation rates, and even survival. According to the National Emphysema Treatment Trial, as referenced in the American Thoracic Society/European Respiratory Society statement 1, patients with severe COPD (defined as an FEV1 < 45% predicted) and reduced exercise capacity may experience significant improvements with LVRS.
Patient Selection
When selecting patients for LVRS, it is crucial to consider those with:
- Severe COPD (FEV1 < 45% predicted)
- Upper lobe-predominant emphysema
- Reduced exercise capacity (maximal exercise capacity < 25 W for women and < 40 W for men)
- Completed pulmonary rehabilitation
- Quit smoking for at least 6 months
- Evidence of hyperinflation with heterogeneous emphysema on imaging
Procedure and Outcomes
The procedure involves removing approximately 20-30% of the most damaged lung tissue, allowing the remaining healthier lung tissue to expand and function more efficiently. This improves breathing mechanics by restoring the normal dome shape of the diaphragm and reducing airway compression. Patients typically experience improved lung function, exercise capacity, and quality of life following successful LVRS, as noted in the statement 1. However, potential complications include air leaks, pneumonia, and respiratory failure, with a perioperative mortality rate of 5-10%.
Post-Operative Care
Recovery requires 1-2 weeks of hospitalization followed by several months of rehabilitation. LVRS should be performed at centers with expertise in both the procedure and the comprehensive care of emphysema patients, as the therapy is costly and associated with significant morbidity, including prolonged hospital stays due to air leaks after thoracotomy 1.
From the Research
Overview of Lung Volume Reduction Surgery
- Lung volume reduction surgery (LVRS) is a procedure designed to alleviate symptoms of breathlessness and improve the quality of life for selected patients with severe emphysema 2, 3.
- The surgery involves resecting hyperinflated, nonfunctional areas of the lung to reduce thoracic volume, improve chest wall and diaphragmatic mechanics, and enhance ventilation to the remaining portions of the lung 2, 3.
Benefits of Lung Volume Reduction Surgery
- LVRS has been shown to significantly improve exercise capacity, quality of life, and survival, especially in individuals with upper-lobe predominant emphysema and low-baseline exercise capacity 4.
- The surgery can also improve pulmonary function, including forced expiratory volume in one second (FEV1) and total lung capacity (TLC) 2, 5.
- LVRS can reduce symptoms of dyspnea and improve mobility, as measured by the 6-minute-walking distance and pulmonary function tests 5.
Surgical Techniques and Outcomes
- LVRS can be performed bilaterally or unilaterally, with bilateral resection resulting in better functional outcomes 2, 5.
- The surgery can be performed using median sternotomy or video-assisted thoracoscopy (VAT) 2.
- Refinements in operative technique and postoperative care have led to a decline in hospital stay and mortality rates, with current average hospital stay ranging from 7-11 days 3, 6.
- Early mortality rates have been reported to be around 3-5%, with late mortality rates ranging from 2-5% 2, 3.
Alternative Treatment Options
- Bronchoscopic lung volume reduction, achieved by deflating nonfunctioning parts of the lung, is a less invasive and safer approach to LVRS 4.
- Endobronchial valve implantation and endobronchial coils are also viable treatment options for severe hyperinflation in selected cases of homogeneous disease 4.