Lung-Volume Reduction Surgery as an Alternative or Bridging Procedure to Lung Transplantation

Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions

Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.

[Lung Cancer Surgery for Severe COPD with Emphysema: Tumor Resection with Improvement of Lung Function]

Lung Cancer Surgery for Severe COPD with Emphysema: Tumor Resection with Improvement of Lung Function Abstract. The golden standard for the therapy of early stage non-small cell lung cancer consists of surgical resection, usually performed as lobectomy or segmentectomy. These procedures demand a certain operability, including certain lung functional reserves. Patients with COPD and emphysema usually have lung function values far below that. Nevertheless, these patients can be offered treatmentif at the same time they qualify for concomitant lung volume reduction surgery (LVRS). LVRS with simultaneous tumor resection can consolidate the diagnosis, provide definite histology, correct staging, and thorough tumor resection might even improve the postoperative lung function. As with all patients with a (possible) diagnosis of cancer, the indication must be discussed in an interdiscplinary tumor board.

Lung volume reduction surgery as salvage procedure after previous use of endobronchial valves

OBJECTIVES

Lung volume reduction (LVR) is an efficient and approved treatment for selected emphysema patients. There is some evidence that repeated LVR surgery (LVRS) might be beneficial, but there are no current data on LVRS after unsuccessful bronchoscopic LVR (BLVR) with endobronchial valves (EBVs). We hypothesize good outcome of LVRS after BLVR with valves.

METHODS

In this study, we retrospectively investigated all patients who underwent LVRS between 2015 and 2019 at 2 centres after previous unsuccessful EBV treatment. They were further divided into subgroups with patients who never achieved the intended improvement after BLVR (primary failure) and patients whose benefit was fading over time due to the natural development of emphysema (secondary failure). Patients with severe air leak after BLVR and immediate concomitant LVRS and fistula closure thereafter were analysed separately.

RESULTS

A total of 38 patients were included. Of these, 19 patients had primary failure, 15 secondary failure and 4 were treated as an emergency due to severe air leak. At 3 months after LVRS, forced expiratory volume in 1 s had improved significantly by 12.5% (P = 0.011) and there was no 90-day mortality. Considering subgroups, patients with primary failure after BLVR seem to profit more than those with secondary failure. Patients with severe air leak after BLVR did not profit from fistula closure with concomitant LVRS.

CONCLUSIONS

LVRS after previous BLVR with EBVs can provide significant clinical improvement with low morbidity, although results might not be as good as after primary LVRS.

Lung Volume Reduction Surgery in Patients with Homogeneous Emphysema

Randomized controlled trials have demonstrated that lung volume reduction surgery (LVRS) improves exercise capacity, lung function, and quality of life in patients with heterogenous emphysema on computed tomographic and perfusion scan. However, most patients have a nonheterogenous type of destruction. These patients, summarized under "homogeneous emphysema," may also benefit from LVRS as long they are severely hyperinflated, and adequate function is remaining with a diffusing capacity of the lungs for carbon monoxide greater than 20% and no pulmonary hypertension. Surgical mortality is low when patients are well selected.

Lung Volume Reduction Surgery Before Lung Transplantation: A Propensity-Matched Analysis

BACKGROUND

Lung volume reduction surgery (LVRS) is treatment option for chronic obstructive pulmonary disease, the second most common indication for lung transplantation (LTx) in the United States. Lung volume reduction surgery before LTx is controversial. Single-institution studies report contradicting results, and the impact of undergoing LVRS before LTx on outcomes after LTx is unclear.

METHODS

We reviewed the United Network for Organ Sharing database for all adults (aged more than 18 years) who underwent first-time LTx for chronic obstructive pulmonary disease in the lung allocation score era. We used patient demographic and clinical characteristics and lung allocation score to propensity match patients who did and patients who did not undergo LVRS before LTx. The primary exposure was prior LVRS. The primary outcome was graft failure after LTx. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards models were used to assess outcomes.

RESULTS

A total of 4905 patients with chronic obstructive pulmonary disease underwent LTx between May 2005 and March 2017. Of them, 107 patients (2.2%) underwent LVRS before LTx. Propensity matching generated 212 matches (106 LVRS+LTx, and 106 LTx only). Median survival was significantly longer in the LTx only cohort (6.5 vs 3.4 years, P = .034). Lung volume reduction surgery before lung transplantation was associated with significantly increased risk of graft failure after lung transplant (hazard ratio 1.72; 95% confidence interval, 1.13 to 2.60; P = .01).

CONCLUSIONS

In this national, propensity-matched analysis of LVRS before LTx, we show that LVRS is associated with a significantly increased risk of graft failure. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed postoperatively.

Joint Statement of the German Respiratory Society and German Society of Thoracic Surgery in Cooperation with the German Radiological Society: Structural Prerequisites of Centres for Interventional Treatment of Emphysema

Interventional treatment of emphysema offers a wide range of surgical and endoscopic options for patients with advanced disease. Multidisciplinary collaboration of pulmonology, thoracic surgery, and imaging disciplines in patient selection, therapy, and follow-up ensures treatment quality. The present joint statement describes the required structural and quality prerequisites of treatment centres. This is a translation of the German article "Positionspapier der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Thoraxchirurgie in Kooperation mit der Deutschen Röntgengesellschaft: Strukturvoraussetzungen von Zentren für die interventionelle Emphysemtherapie" Pneumologie. 2020;74:17-23.

Lung volume reduction surgery: from National Emphysema Treatment Trial to non-intubated awake video-assisted thoracoscopic surgery

Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.

Lung transplantation for emphysema

Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.

Indications for lung transplant referral and listing

Lung transplantation is a valuable therapeutic option for many patients with severe lung disease who have exhausted other medical or surgical therapies. However, since lungs are not a manufacturable organ like artificial heart valves or left ventricular assist devices, and since they are a limited resource compared to number of patients requiring the organs, the Department of Health and Human Services set the Final Rule of organ allocation in 1998. This led to development and implementation of Lung Allocation Score (LAS) in 2005. The score broadly divides lung diseases into 4 diagnostic criteria with a coefficient factor given to each category. The score is based on the prognostic factors of each patient to determine the risk of mortality without a transplant combined with the probability of patient survival post-transplant. Most of the guidelines for "Indications for referral and listing in lung transplant" is based on consensus opinion as there is limited amount of robust data and trials about this topic. The International Society for Heart and Lung Transplant (ISHLT) has published three editions for candidate selection and listing. In this article, we have attempted to highlight the guidelines and incorporated other disease specific prognostic factors that are not captured in the LAS. Ultimately, there are other factors like geographic location, height, blood group, preformed antibodies, transplant center experience, past wait times and transplant rate, availability of organs, etc., which also play a role especially when considering listing a patient for lung transplant. We also highlighted a representative disease in each category and most criteria for that disease will apply to other diseases in that category. Finally, this article does not delve into the history and reasoning behind each guideline but is meant to provide a general overview of indications and contraindications applicable in the field of adult lung transplantation.

Lung volume reduction followed by lung transplantation-considerations on selection criteria and outcome

Lung transplantation (LuTX) and lung volume reduction (LVR), either surgical (LVRS: lung volume reduction surgery) or endoscopic (ELVR: endoscopic lung volume reduction), are established therapies in the treatment of end-stage chronic obstructive pulmonary disease (COPD) patients. Careful patient selection is crucial for each intervention. If these techniques are sequentially applied there is a paucity of available data and individual center experiences vary depending on details in selection criteria and operative technique. This review aims to summarize the published data with a focus on LuTX after LVRS. This review covers patient selection for LuTX and LVR, technical considerations, limitations and outcomes. Published literature was identified by systematic search on Medline and appropriate papers were reviewed. Seven case reports/series, 7 comparative observational studies and one multicenter database analysis incorporating a total of 284 patients with LuTX and LVR were evaluated. Prior LVR can significantly affect intraoperative and postoperative risks after subsequent LuTX. Careful patient selection and timing and the choice of appropriate techniques such as minimal invasive LVRS and using ECMO as extracorporeal support during LuTX if required can minimize those risks, ultimately leading to very good postoperative outcomes in terms of lung function and survival. LVRS has the potential to delay listing and to bridge patients to LuTX by improving their physical condition while on the waiting list. After single lung transplantation (SLuTX) contralateral LVRS can counteract the deleterious effects of native lung hyperinflation (NLH). LVR and LuTX are adjunct therapies in the treatment of end-stage COPD. The combination of both can safely be considered in selected patients.

Clinical management of lung volume reduction in end stage emphysema patients

Following the evaluation of surgical lung volume reduction (LVR) in the National Emphysema Treatment (NETT) trial, different endoscopic LVR procedures have been developed for severe emphysema. Among those, endobronchial valve placement is the best evaluated method. All these therapies aim at reducing hyperinflation and at improving respiratory mechanics. It has been shown that these procedures can improve quality of life, lung function and exercise capacity in a significant and clinically meaningful way in suitable patients. Optimal medical therapy, physical rehabilitation, smoking cessation and respiratory insufficiency assessments should been thoroughly evaluated by a multi-disciplinary team before considering any LVR procedure. Clinical experience is necessary to decide if a patient is an appropriate candidate for a surgical or an interventional LVR procedure, to choose the optimal treatment strategy and to provide a high-level of care after the intervention, particularly when complications such as pneumothorax or persistent air leak occur in this already severely ill patient population. High volume emphysema care centers, providing a broad spectrum of different LVR procedures and involving a multidisciplinary team in the diagnostic process, are best suited to provide an optimal outcome. The aim of this manuscript is to describe the structures and procedures required to achieve the best possible outcome even in patients with advanced stage of their emphysema disease, including patients who are candidates for lung transplantation.

Lung volume reduction surgery beyond the NETT selection criteria

Lung volume reduction surgery (LVRS) for symptomatic patients with advanced emphysema was proven to be successful in a large randomized multi-center trial (NETT) and in several smaller randomized single center trials. This evidence primarily concerns patients with heterogeneous, upper-lobe predominant emphysema and low exercise tolerance within certain selection criteria regarding lung function values. As the most important effect of LVRS is generated by reducing the hyperinflation, even patients with homogeneous emphysema morphology profit from the procedure. Simultaneously, by removing distended and functionless areas in heterogeneous emphysema, also patients with seriously impaired diffusion capacity, moderate pulmonary arterial hypertension, a history of previous LVRS and alpha-1-antitrypsin-deficiency (AATD) can be considered as candidates for (re-)-LVRS. This article summarizes indications for LVRS in these various subtypes of emphysema patients.

[What place for lung volume reduction surgery for emphysema?]

Lung volume reduction surgery (LVRS) has been part of the management for the treatment of selected emphysematous patients for two decades. In a large randomized American trial (NETT), lung volume reduction surgery was shown to improve overall survival at 5 years as well as exercise capacity and health-related quality of life, especially in cases of upper-lobe-predominant emphysema and low exercise capacity. Inclusion criteria were pretreatment FEV1≤45 %, TLC≥100 %, RV≥150 %, room air resting PaCO₂≤60mmHg and PaO₂≥45mmHg. Patients with FEV1≤20 % and either a DLCO<20 % or homogeneous emphysema were at increased risk of mortality following LVRS and should not be considered for this procedure. Despite this evidence base, lung volume reduction surgery is performed infrequently, competing with lung transplantation and new endoscopic volume reduction techniques.

A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure

Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.

Repeated lung volume reduction surgery is successful in selected patients

OBJECTIVES

Lung volume reduction surgery (LVRS) improves dyspnoea, quality of life and may even prolong survival in carefully selected patients with end-stage emphysema. The benefit may be sustained for several years and vanishes with the natural progression of the disease. Data on repeated surgical treatment of emphysema are scarce. The aim of this study was to evaluate the safety, effects and outcomes of repeated LVRS (Re-LVRS) in patients no longer benefiting from their initial LVRS.

METHODS

Between June 2002 and December 2013, 22 patients (9 females) with advanced emphysema underwent Re-LVRS at a median of 60 months (25-196) after their initial LVRS. While initial LVRS was performed thoracoscopically as a bilateral procedure, Re-LVRS was performed unilaterally by a video-assisted thoracoscopic technique in 19 patients and, due to adhesions, by thoracotomy in 3 patients. Pulmonary function test (PFT) was performed at 3 and 12 months postoperatively.

RESULTS

Lung function at Re-LVRS was similar to that prior to the first LVRS. The 90-day mortality rate was 0%. The first patient died 15 months postoperatively. The median hospitalization time after Re-LVRS was significantly longer compared with the initial LVRS [14 days, interquartile range (IQR): 11-19, vs 9 days, IQR: 8-14; P = 0.017]. The most frequent complication was prolonged air leak with a median drainage time of 11 days (IQR: 6-13); reoperations due to persistent air leak were necessary in 7 patients (32%). Five patients (23%) had no complications. Lung function and Medical Research Council (MRC) score improved significantly for up to 12 months after Re-LVRS, with results similar to those after initial bilateral LVRS. The average increase in the forced expiratory volume in 1 s (FEV1) was 25% (a 7% increase over the predicted value or 0.18 l) at 3 months, and the mean reduction in hyperinflation, assessed by relative decrease in RV/TLC (residual volume/total lung capacity), was 12% at 3 months (a decrease of 8% in absolute ratios). The mean MRC breathlessness score decreased significantly after 3 months (from 3.7 to 2.2).

CONCLUSIONS

Re-LVRS can be performed successfully in carefully selected patients as a palliative treatment. It may be performed as a bridge to transplantation or in patients with newly diagnosed intrapulmonary nodules or during elective cardiac surgery. Morbidity is acceptable and outcomes may be satisfactory with significantly improved lung function and reduced dyspnoea for at least 12 months postoperatively.

Outcomes in lung transplantation after previous lung volume reduction surgery in a contemporary cohort

OBJECTIVES

Lung volume reduction surgery (LVRS) provides palliation and improved quality of life in select patients with end-stage chronic obstructive pulmonary disease (COPD). The effect of previous LVRS on lung transplant outcomes has been inadequately studied. We report our experience in the largest single institution series of these combined procedures.

METHODS

The records of 472 patients with COPD undergoing lung transplantation or LVRS between 1995 and 2010 were reviewed. Outcomes of patients undergoing transplant after LVRS were compared with outcomes of patients undergoing transplant or LVRS alone. Survival was compared using log-rank tests and the Kaplan-Meier method.

RESULTS

Demographics, comorbidities, and spirometry were similar at the time of transplantation. Patients who had undergone lung transplant after LVRS had longer transplant operative times (mean 4.4 vs 5.6 hours; P = .020) and greater hospital length of stay (mean 17.6 vs 29.1 days; P = .005). Thirty-day mortality and major morbidity were similar. Posttransplant survival was reduced for transplant after LVRS (median, 49 months; 95% confidence interval [CI], 16, 85 months) compared with transplant alone (median, 96 months; 95% CI, 82, 106 months; P = .008). The composite benefit of combined procedures, defined as bridge from LVRS to transplant of 55 months and posttransplant survival of 49 months (total 104 months), was comparable with survival of patients undergoing either procedure alone.

CONCLUSIONS

Lung transplant after LVRS leads to minimal additional perioperative risk. The reduced posttransplant survival in patients undergoing combined procedures is in contradistinction to reports from other smaller series. When determining the best surgical treatment for patients with more severe disease, the benefit of LVRS before transplant should be weighed against the consequence of reduced posttransplant survival.

[Lung volume reduction surgery for emphysema and bullous pulmonary emphysema]

The improvement of respiratory symptoms for emphysematous patients by surgery is a concept that has evolved over time. Initially used for giant bullae, this surgery was then applied to patients with diffuse microbullous emphysema. The physiological and pathological concepts underlying these surgical procedures are the same in both cases: improve respiratory performance by reducing the high intrapleural pressure. The functional benefit of lung volume reduction surgery (LVRS) in the severe diffuse emphysema has been validated by the National Emphysema Treatment Trial (NETT) and the later studies which allowed to identify prognostic factors. The quality of the clinical, morphological and functional data made it possible to develop recommendations now widely used in current practice. Surgery for giant bullae occurring on little or moderately emphysematous lung is often a simpler approach but also requires specialised support to optimize its results.

Prevention of pleural adhesions using a membrane containing polyethylene glycol in rats

BACKGROUND

Recurrent thoracotomies regardless of the cause are not a rare occurrence. However, each thoracotomy results in adhesion to some extent. This adhesions increase morbidity and mortality presents a significant inconvenience for surgeons and prolongs the length of operations.

OBJECTIVE

We investigated the efficacy of Prevadh®, an anti-adhesion agent to prevent intrapleural adesions following thoracotomy in a rat model.

METHODS

Twenty male adult Wistar Albino rats were divided into a sham group (Group A, n = 4), a control group (Group B, n = 8), and a study group (Group C, n = 8). Only left thoracotomy was performed in Group A. Group B underwent left thoracotomy, induction of adhesion, and 1 ml saline solution was administered to the thoracic cavity. However, in Group C underwent left thoracotomy, induction of adhesion, and Prevadh® was placed between the pleura and the lung. The rats were sacrificed on day 21, and adhesions were analyzed using both macroscopic and histopathological methods. The results were statistically analyzed. A value of P<0.05 was considered statistically significant.

RESULTS

Mean lengths of adhesion differed statistically significantly among all three groups, while mean intensity of adhesion differed between Group A and Group B, and between Group B and Group C (P>0.05). There was also a statistically significant difference between Group A and Group C in mesothelium proliferation score (P>0.05). No statistically significant differences were found among the groups in terms of pleural thickness, macrophage and mononuclear cell infiltration (P>0.05).

CONCLUSIONS

Prevadh® was shown in a rat model to effectively prevent post-thoracotomy adhesions.

Results of lung transplantation in patients with chronic obstructive pulmonary disease

OBJECTIVE

The objective of this study was to evaluate the results and survival rates of patients who underwent lung transplantation (LT) to treat chronic obstructive pulmonary disease (COPD).

METHODOLOGY

We performed a retrospective analysis of 63 patients with COPD who underwent LT between 1996 and 2007. Our statistical analysis was based on descriptive statistics and survival analysis (Kaplan-Meier and log-rank test).

RESULTS

Sixty-three LTs were performed in 53 male and 10 female patients with COPD. Twenty-eight LTs were unipulmonary and 35 were bipulmonary. Four cases required extracorporeal circulation. Surgical complications arose in 18 cases. There were 3 cases of intraoperative death as a result of cardiac failure. The most frequent long-term complications were hypertension (39.7%), renal failure (42.9%), and neoplasms (20.6%). Overall survival times (mean, 2553 days) were 75.9%, 74.15%, 65.67%, 55.87%, and 42.05% at 1, 2, 3, 5, and 10 years, respectively. No differences were observed in survival according to the following: donor age >30 years (P = 8), type of transplantation (unilateral vs bilateral; P = .57), donor intubation time >48 hours (P = .2), or donor oxygenation index <450 mm Hg (P = .3).

CONCLUSIONS

No differences were observed in survival according to the type of transplantation (unilateral vs bilateral), which suggests that unipulmonary transplantation is a reasonable option, given that this procedure reduces both the ischemia time compared with bilateral transplantation and the surgery time, as well as offering more efficient use of donor organs.

Lungenparenchymerkrankungen

Das Lungenemphysem ist pathologisch-anatomisch definiert. Man versteht darunter eine irreversible abnorme Erweiterung der lufthaltigen Räume distal der Bronchioli terminales, die mit einer Destruktion der Alveolarsepten einhergeht. Neben der chronischen Bronchitis und der Bronchiolitis ist das Lungenemphysem eine der morphologischen Komponenten der chronisch-obstruktiven Lungenkrankheit (COPD). Bei fortgeschrittenen Formen der COPD besteht mit Regelmäßiigkeit ein erhebliches Lungenemphysem.

Update in Surgical Therapy for Chronic Obstructive Pulmonary Disease

Bullectomy for giant bullae, lung volume reduction surgery, and lung transplantation are three surgical therapies that may benefit highly selected patients with advanced chronic obstructive pulmonary disease. In this article, each procedure is reviewed, with an emphasis on guidelines for patient selection and clinical outcomes for the practicing pulmonologist. Recent results from the National Emphysema Treatment Trial, updated International Society for Heart and Lung Transplantation Registry data, and revised guidelines for patient selection for lung transplantation are discussed.