Lung Volume Reduction Surgery

Original Editor - Donald John Auson Top Contributors - Donald John Auson and Kim Jackson

Description

Lung Volume Reduction Surgery (LVRS) is a surgical procedure wherein lung tissue is resected from patients with COPD, particularly those with severe emphysema. the procedure is usually done through 3 different techniques: (1) via open sternotomy, (2) via video-assisted thorascopic surgery or (3) via thoracotomy.[1]

A multi-center prospective randomized controlled trial, came to known as National Emphysema Treatment Trial (NETT), was done in 1999-2002. The study aimed to compare medical management alone versus medical management with LVRS as treatment for severe emphysema. NETT involved 1, 218 randomized patients, one of the largest and most complete collection of data regarding patients with emphysema. In addition to the guidelines and criteria made based on NETT, it also highlighted the need to address not only the pulmonary issues but also other issues such as nutrition, cardiac disease, and anxiety and depression. [2]

Indication

LVRS is usually indicated for patients[1]:

  • With severe emphysema
  • Aged below 70 years old
  • With no smoking history within the last 6 months
  • Not able to exercise well after completing pulmonary rehabilitation


A criteria was made based on NETT for the selection of candidates.[3] This include:

  • Age below 75 years old
  • Emphysema (bilateral severe emphysema, predominantly upper-lobe)
  • Non-smoker more than 4 months
  • Clinically stable on no more than 20 mg prednisone daily
  • Significant functional limitation after 6–12 wk of pulmonary rehabilitation on optimal medical therapy
  • Demonstrated compliance with medical regimen
  • Post-bronchodilator FEV1 ⩽ 45% predicted for all ages and ⩾15% if age ⩾70 yr
  • Hyperinflation demonstrated by TLC ⩾ 100% predicted and RV ⩾ 150% predicted
  • Postrehabilitation 6MWD > 140 m
  • Low postrehabilitation exercise capacity (demonstrated by maximal achieved cycle ergometry watts)

Clinical Presentation

Patients suffering from severe emphysema may present with:

  • Severe dyspnea
  • Wheezing
  • Reduced exercise capacity

Diagnostic Tests

Diagnostic procedures and laboratory studies for screening of candidates include[1]:


A set of screening and evaluation process was made based on NETT.[3] This includes:

  • Screening Phase
    • History, physical examination, chest radiograph, and basic laboratory studies
    • α1-Antitrypsin testing
    • Chest CT Scan
    • Pulmonary function testing: spirometry, lung volumes via body plethysomography, carbon monoxide diffusing capacity
  • Formal Evaluation Phase
    • Dyspnea evaluation
    • Arterial blood gas
    • Cardiopulmonary exercise testing
    • Oxygen titration and Six-minute walk
    • BODE score (Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity index)
    • Quantitative perfusion nuclear lung scan
    • Cardiac evaluation: echocardiogram, dobutamine-radionuclide cardiac scan
    • Evaluation by medical team including pulmonologists, surgeon, nursing, and rehabilitation staff

Preoperative Rehabilitation Program

  • Assessment to determine if patient is a candidate for surgical intervention
  • Communication between interdisciplinary team members involved in patient care
  • Formulation of appropriate preoperative management/ exercise training program
  • Preoperative exercise training to reduce possible complications after surgery
  • Educate the patient
    • Possible risks/ complications and how to avoid them
    • Postoperative pain management
    • Mobilization after surgery
    • Lung expansion techniques
    • Energy conservation techniques
  • Psychological Support
  • Nutritional Support

Postoperative Rehabilitation Program

  • Assessment of postoperative patient
  • Formulation of appropriate postoperative management/ exercise training program
  • Postoperative pain management
  • Mobilization of postoperative patient
  • Postoperative exercise training
  • Psychological support
  • Nutritional support

Resources

National Emphysema Treatment Trial- National Heart, Lung, and Blood Institute

Lung Volume Reduction Surgery- Lung.org

Guidelines for Pulmonary Rehabilitation Programs- AACVPR

References

  1. 1.0 1.1 1.2 Lung Volume Reduction Surgery | American Lung Association. Lung.org. Available from: https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/lung-volume-reduction-surgery
  2. Criner G, Cordova F, Sternberg A, Martinez F. The National Emphysema Treatment Trial (NETT) | Part I: Lessons Learned about Emphysema | American Journal of Respiratory and Critical Care Medicine. Atsjournals.org. [cited 10 April 2020]. Available from: https://www.atsjournals.org/doi/full/10.1164/rccm.201103-0454CI
  3. 3.0 3.1 DeCamp Jr. M, Lipson D, Krasna M, Minai O, McKenna Jr. R, Thomashow B. The Evaluation and Preparation of the Patient for Lung Volume Reduction Surgery | Proceedings of the American Thoracic Society. Atsjournals.org. Available from: https://www.atsjournals.org/doi/full/10.1513/pats.200707-087ET