Comparison of early functional results after volume reduction or lung transplantation for chronic obstructive pulmonary disease

Results of the Diaphragmatic Plication Database: 10 Years' Experience

BACKGROUND

Unilateral diaphragmatic paralysis or paresis (UDP) in adults is an often overlooked disease which relevantly impairs the patient's lung function and quality of life. Particularly in idiopathic UDP, there is no evidence for conservative therapy and only little evidence for surgical therapy.

METHODS

The method involves retrospective single-center analysis of patients with UDP persistent for at least 1 year who were operated by diaphragmatic resection, plication, and augmentation with a polypropylene mesh. The patients were tested for lung and diaphragmatic function, six-minute walk test (6MWT), and blood gas analysis before, 3 and 12 months after surgery.

RESULTS

In total, 85 patients received surgery for UDP. The most frequent reasons for UDP were idiopathic (67%), iatrogenic (mainly cardiac and cervical spine surgery; 24%), and trauma (9%). The mean operation time was 84 ± 24 minutes, the length of hospital stay 8.4 ± 3.9 days, chest tubes were removed after 11.7 ± 4.1 days. Overall morbidity was 42%, mortality 0%. Forced expiratory volume in one second (FEV1) in supine position improved by 12.4% absolute, vital capacity by 11.8% absolute, and sniff nasal inspiratory pressure by 1.4 kPa 12 months after surgery (p <0.001 each). Total lung capacity increased by 6.8% absolute at 12 months (p = 0.001) The 6MWT distance improved by 45.9 m at 3 months and 50.9 m at 12 months (p = 0.001, each).

CONCLUSION

Surgical therapy for UDP is highly effective in the long term. The superiority over conservative treatments needs to be evaluated prospectively with standardized physiotherapeutic protocols. FEV1 in supine position and 6MWT are easy to perform tests and represent statistically and patient-relevant outcomes.

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.

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.

Chronic obstructive pulmonary disease

COPD is characterized by airflow limitation that is not fully reversible. The morphological basis for airflow obstruction results from a varying combination of obstructive changes in peripheral conducting airways and destructive changes in respiratory bronchioles, alveolar ducts, and alveoli. A reduction of vascularity within the alveolar septa has been reported in emphysema. Typical physiological changes reflect these structural abnormalities. Spirometry documents airflow obstruction when the FEV1/FVC ratio is reduced below the lower limit of normality, although in early disease stages FEV1 and airway conductance are not affected. Current guidelines recommend testing for bronchoreversibility at least once and the postbronchodilator FEV1/FVC be used for COPD diagnosis; the nature of bronchodilator response remains controversial, however. One major functional consequence of altered lung mechanics is lung hyperinflation. FRC may increase as a result of static or dynamic mechanisms, or both. The link between dynamic lung hyperinflation and expiratory flow limitation during tidal breathing has been demonstrated. Hyperinflation may increase the load on inspiratory muscles, with resulting length adaptation of diaphragm. Reduction of exercise tolerance is frequently noted, with compelling evidence that breathlessness and altered lung mechanics play a major role. Lung function measurements have been traditionally used as prognostic indices and to monitor disease progression; FEV1 has been most widely used. An increase in FVC is also considered as proof of bronchodilatation. Decades of work has provided insight into the histological, functional, and biological features of COPD. This has provided a clearer understanding of important pathobiological processes and has provided additional therapeutic options.

Lung volume reduction surgery after lung transplantation for emphysema-chronic obstructive pulmonary disease

Lung Volume Reduction Surgery (LVRS) has become a palliative treatment for patients with advanced emphysema and disabling dyspnea. After single lung transplantation in chronic obstructive pulmonary disease, LVRS may be indicated to improve graft dysfunction caused by native lung hyperinflation compressing the grafted lung. This common complication is the subject of our study, which showed LVRS to be helpful to manage this situation. We performed an observational retrospective and descriptive study using the data of 293 patients transplanted in our center between January 1996 and October 2011. Some of the patients who underwent a single lung transplantation developed native lung hyperinflation years after the transplantation, interfering with respiratory function due to graft compression.

Lung transplant in end-staged chronic obstructive pulmonary disease (COPD) patients: a concise review

Lung transplantation is commonly used for patients with end-stage lung disease. However, there is continuing debate on the optimal operation for patients with chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis. Single-lung transplantation (SLT) provides equivalent short- and medium-term results compared with bilateral lung transplantation (BLT), but long-term survival appears slightly better in BLT recipients (especially in patients with COPD). The number of available organs for lung transplantation also influences the choice of operation. Recent developments suggest that the organ donor shortage is not as severe as previously thought, making BLT a possible alternative for more patients. Among the different complications, re-implantation edema, infection, rejection, and bronchial complications predominate. Chronic rejection, also called obliterative bronchiolitis syndrome, is a later complication which can be observed in about half of the patients. Improvement in graft survival depends greatly in improvement in prevention and management of complications. Despite such complications, graft survival in fibrosis patients is greater than spontaneous survival on the waiting list; idiopathic fibrosis is associated with the highest mortality on the waiting list. Patients should be referred early for the pre-transplantation work-up because individual prognosis is very difficult to predict.

Update on lung transplantation for emphysema

Lung transplantation in the modern era remains an evolving field and a viable option for patients suffering from end-stage emphysema. Recent modifications for recipient prioritization has resulted in a modest decrease in the number of patients with emphysema receiving transplants. More time will be required to determine what impact, if any, these modifications will have on the overall survival of patients with end-stage emphysema. Ongoing research will address persistent issues with lung transplantation, most notably, primary graft dysfunction and chronic BOS.

Functional results of unilateral lung volume reduction surgery in alpha1-antitrypsin deficient patients

Lung volume reduction surgery (LVRS) has been shown to improve lung function and exercise tolerance in patients with severe emphysema. Some predictors of poor outcome have been described but the role of alpha₁-antitrypsin (α₁-AT) deficiency is still not well known. The aim of this study was to analyze the results of unilateral LVRS in our center according to the α₁-AT status. The results of LVRS in 17 deficient patients and 35 nondeficient patients were analyzed at 3–6 months and 1 year after surgery. Compared with baseline, a significant improvement of FEV₁, partial pressure in arterial blood (PaO₂), dyspnea score and walking distance was observed in the two groups at 3–6 months after surgery and the studied parameters remained significantly improved at 1 year in the nondeficient group. By contrast, PaO₂ and walking distance returned towards baseline in the deficient group at 1 year whereas improvement of FEV₁ and dyspnea score was persistent. Mean values of FEV₁ at baseline, 3–6 months, and 1 year were 22 ± 6%, 29 ± 11%, and 26 ± 9% and 28 ± 12%, 38 ± 17%, and 40 ± 17% predicted in the deficient group and in the non-deficient group, respectively. In conclusion, the functional benefit is short-lasting in α₁-AT deficient patients after unilateral LVRS.

Hyperinflation and its management in COPD

Chronic obstructive pulmonary disease (COPD) is characterized by poorly reversible airflow limitation. The pathological hallmarks of COPD are inflammation of the peripheral airways and destruction of lung parenchyma or emphysema. The functional consequences of these abnormalities are expiratory airflow limitation and dynamic hyperinflation, which then increase the elastic load of the respiratory system and decrease the performance of the respiratory muscles. These pathophysiologic features contribute significantly to the development of dyspnea, exercise intolerance and ventilatory failure. Several treatments may palliate flow limitation, including interventions that modify the respiratory pattern (deeper, slower) such as pursed lip breathing, exercise training, oxygen, and some drugs. Other therapies are aimed at its amelioration, such as bronchodilators, lung volume reduction surgery or breathing mixtures of helium and oxygen. Finally some interventions, such as inspiratory pressure support, alleviate the threshold load associated to flow limitation. The degree of flow limitation can be assessed by certain spirometry indexes, such as vital capacity and inspiratory capacity, or by other more complexes indexes such as residual volume/total lung capacity or functional residual capacity/total lung capacity. Two of the best methods to measure flow limitation are to superimpose a flow–volume loop of a tidal breath within a maximum flow–volume curve, or to use negative expiratory pressure technique. Likely this method is more accurate and can be used during spontaneous breathing. A definitive definition of dynamic hyperinflation is lacking in the literature, but serial measurements of inspiratory capacity during exercise will document the trend of end-expiratory lung volume and allow establishing relationships with other measurements such as dyspnea, respiratory pattern, exercise tolerance, and gas exchange.

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.

Predictors of Mortality in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) has become a major and growing health problem, with a mortality rate that continues to increase. Several factors, have been identified as individual predictors of mortality in COPD. This article reviews individual predictors for mortality. It also discusses the ability of an integrated, multidimensional tool to more broadly characterize COPD severity, assess response to therapeutic interventions and exacerbations, and predict mortality.

Surrogates of mortality in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) remains a leading cause of disability and death in the United States. The identification and amelioration of systemic manifestations of COPD may improve long-term outcomes, including survival. These systemic manifestations often correlate with increased risk of mortality and may be considered surrogates of disease severity. Several potential clinical surrogates are evaluated, including airflow obstruction, dyspnea, malnutrition, hypoxemia, exercise capacity, lung hyperinflation, and anemia. The evidence in support of the impact of various COPD treatment modalities on systemic manifestations of COPD is also reviewed. Finally, the usefulness of measuring body mass index, degree of airflow obstruction, dyspnea, and exercise capacity in combination (the BODE index), as a measure of disease severity and mortality risk in COPD, is examined and found to be a simple-to-use tool for predicting COPD-related hospitalization and mortality.

Lung volume reduction surgery as a bridge to lung transplantation

Lung volume reduction surgery (LVRS) improves lung function, exercise capacity, and quality of life in patients with advanced emphysema. In some patients with emphysema who are candidates for lung transplantation, LVRS is an alternative treatment option to lung transplantation, or may be used as a bridge to lung transplantation. Generally accepted criteria for LVRS include severe non-reversible airflow obstruction due to emphysema associated with significant evidence of lung hyperinflation and air trapping. Both high resolution computed tomography (CT) scan of the chest and quantitative ventilation/perfusion scan are used to identify lung regions with severe emphysema which would be used as targets for lung resection. Bilateral LVRS is the preferred surgical approach compared with the unilateral procedure because of better functional outcome. Lung transplantation is the preferred surgical treatment in patients with emphysema with alpha1 antitrypsin deficiency and in patients with very severe disease who have homogeneous emphysema pattern on CT scan of the chest or very low diffusion capacity.

Long-term nonpharmacologic management of patients with chronic obstructive pulmonary disease

A comprehensive treatment plan for managing patients with chronic obstructive pulmonary disease (COPD) involves appropriate use of nonpharmacologic as well as pharmacologic interventions. Nonpharmacologic intervention begins with an aggressive effort toward smoking cessation, which has been proven to slow the accelerated rate lung function that characterizes COPD and to decrease all-cause mortality in patients with COPD. Proper nutrition and regular exercise are vital for all patients. Some patients with documented hypoxemia from more severe disease may require long-term oxygen therapy. Pulmonary rehabilitation benefits most patients, and even surgical intervention with lung volume reduction surgery or lung transplantation may help a limited number of patients. This article reviews the nonpharmacologic interventions that may be used in conjunction with maximized pharmacologic therapy in the long-term management of patients with COPD.

[Lung transplantation]

Lung transplantation is indicated for patients with cystic fibrosis, emphysema, pulmonary fibrosis or pulmonary hypertension whose life expectancy is less than two years. Criteria of severity are detailed. Three types of transplantation can be proposed: single lung transplant for fibrosis and dry emphysema; bilateral lung transplant for cystic fibrosis, and certain types of emphysema and pulmonary hypertension; heart-lung transplant for pulmonary hypertension and Eisenmenger syndrome. Due to insufficient supply of donor organs, one quarter of the candidates die on the waiting list and the limit for inscription is often 60 years. Postoperative mortality at two months is about 15% and is related to graft dysfunction, infection, bronchial complications,... Acute rejection usually occurs during the first year. Chronic rejection is expressed by obliterating bronchiolitis, the leading cause of death after one year. There is a risk of cancer (EBV-induced lymphoproliferative syndromes and skin cancer). Five-year survival is still only about 50%. Immunosuppressor treatments still cause numerous adverse effects (hypertension, renal toxicity...); function and quality-of-life have however greatly improved.

Lung transplantation for emphysema

Great strides have been made in lung transplantation in the past two decades. Changes in technique, immunosuppression regimens, and treatment of infectious complications have led to improvements in survival and functional results. Current areas of discussion concern the use of single lung transplantation versus bilateral sequential lung transplantation and the criteria for allocating donor lungs. This article reviews the current state of lung transplantation for emphysema and provides insight from more than one decade of experience with Washington University's lung transplant program.

Chronic obstructive pulmonary disease. 10: Bullectomy, lung volume reduction surgery, and transplantation for patients with chronic obstructive pulmonary disease

There are currently three surgical treatments for emphysema: bullectomy, lung transplantation, and lung volume reduction surgery (LVRS). Unfortunately, most emphysema patients are poor candidates for any surgical intervention. A meticulous selection process is favoured in which indications and contraindications are considered and the best solution is devised for each patient. Patients with giant bullae filling half the thoracic volume and compressing relatively normal adjacent parenchyma are offered bullectomy; those with hyperinflation, heterogeneous distribution of destruction, forced expiratory volume in 1 second (FEV(1)) >20%, and a normal carbon dioxide tension (PCO(2)) are offered LVRS; and patients with diffuse disease, lower FEV(1), hypercapnia, and associated pulmonary hypertension are directed towards transplantation. Using these criteria, few patients are serious candidates for surgical procedures. Combinations of LVRS and lung transplantation, either simultaneously or sequentially, are possible but rarely necessary.

State of the art in thoracospic surgery: a personal experience of 2000 videothoracoscopic procedures and an overview of the literature

BACKGROUND

Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable.

METHODS

Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n = 910), wedge resections (n = 261), lobectomies (n = 221), pneumonectomies (n = 6), the diagnosis and treatment of pleural diseases (n = 200), the treatment of pneumothorax (n = 170), giant bullae (n = 57), lung volume reduction surgery (LVRS) for emphysema (n = 41), the diagnosis and treatment of mediastinal diseases (n = 133), the treatment of esophageal diseases (n = 39), and 30 other miscellaneous procedures.

RESULTS

A review of the literature indicates that videothoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications.

CONCLUSIONS

Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.

Outcomes of lung volume reduction surgery followed by lung transplantation: a matched cohort study

BACKGROUND

Lung volume reduction surgery (LVRS) has been demonstrated to provide symptomatic relief and to improve lung function in patients with end-stage emphysema. The goal of this study was to assess the additional morbidity associated with lung transplantation after LVRS for end-stage emphysema with regard to immediate postoperative outcomes, longitudinal spirometry, and survival rates compared to an age-, gender-, procedure-matched, and transplant time-matched cohort that had lung transplantation alone.

METHODS

We compared the postoperative and long-term outcomes of a sequential procedure cohort to a matched cohort to assess the possible added post-transplant morbidity.

RESULTS

Fifteen patients who underwent sequential LVRS (including 11 unilateral LVRS, 4 bilateral LVRS) and lung transplantation (ipsilateral in 7 and contralateral in 8) on average 28.1 +/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7 months) later were assessed. No significant differences were noted in pretransplant demographics, post-transplant variables, longitudinal spirometric indices, or survival. A trend toward a lower pretransplant arterial carbon dioxide tension was apparent in the sequential procedure cohort. Group analysis revealed a significant increase in the number of patients requiring transfusion and in the total number of units transfused in patients undergoing ispsilateral transplantation after LVRS; a significant increase in the length of intensive care unit stay; and a trend toward an increase in the duration of hospital stay in patients undergoing lung transplantation within 18 months of LVRS.

CONCLUSIONS

In appropriate candidates, LVRS bridged the time to transplantation by an average of 28.1 +/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7 months) without significantly increasing post-transplant morbidity or mortality. Furthermore, bilateral LVRS bridged the time to transplantation to a greater extent than unilateral LVRS (34.9 +/- 29.8 months; median, 32.1 months versus 25.4 +/- 16.3 months; median, 22.3 months; p = 0.23).

Thoracoscopy and transplantation: a new attractive tool

BACKGROUND

Transplanted patients on immunosuppressive treatment have an increased risk of infections or neoplasms. Transplantation candidates with infection or a suspected malignancy are excluded from transplantation. In patients already transplanted, thoracoscopy can resolve complications or treat the pulmonary pathology without compromising the precarious existing reactive equilibrium. These patients require an approach that is as least traumatic as possible.

METHODS

From September 1991 to December 2000, of 2068 videothoracoscopic procedures carried out at our hospital, 2 were in patients who had undergone transplantation and 3 in candidates for kidney, liver, and bone marrow transplantation. Starting from our personal experience in videothoracoscopy as a diagnostic and therapeutic approach, the possibilities of the method in the field of transplantation are reported by a review of the literature carried out by consulting the reference systems of the most important data banks.

CONCLUSIONS

In our experience, videothoracoscopy had a major impact on the management of candidates for transplant, because it allowed us to rule out or treat conditions that would have determined exclusion from a transplant program. In transplanted patients, videothoracoscopy allows a correct diagnosis and treatment with minimal trauma.

Lung volume reduction surgery in emphysema: a systematic review

The aim of this study was to systematically review the literature regarding the safety and efficacy of lung volume reduction surgery (LVRS) in patients with emphysema. Studies on LVRS to August 2000 were identified using MEDLINE, Embase, Current Contents, and the Cochrane Library. Human studies of patients with upper, lower or diffuse distributions of emphysema were included. All types of bullous emphysema were excluded. A surgeon and researcher independently assessed the retrieved articles for their inclusion in the review. When LVRS was compared with medical management, at 2 years LVRS was associated with a higher FEV1 and at least equivalent survival. The use of staple excision of selected areas of lung appeared to be more efficacious than laser ablation. There is insufficient evidence to show preference for median sternotomy or videoscopically assisted thoracotomy, as the more safe and efficacious procedure. In highly selected patients with emphysema LVRS is deemed an acceptable treatment. To fully evaluate the safety and efficacy of LVRS, outcomes beyond 2 years must be included. The results of prospective randomized trials between medical management and LVRS, now in progress, are essential before a final assessment can be made.

Skeletal muscle dysfunction in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major health care problem. Formerly mainly a disease of men, women are increasingly frequently afflicted. In many of these patients, exercise intolerance is the chief complaint. Few effective therapies are available. In recent years, dysfunction of the muscles of ambulation has been identified as a source of a portion of the exercise intolerance these patients experience, and this dysfunction has been shown to be, at least in part, remediable. Mechanisms inducing muscle dysfunction include disuse atrophy, malnutrition, low levels of anabolic steroids, and myopathy from corticosteroid use. Endurance exercise training has been conclusively demonstrated to improve exercise tolerance in COPD. Recent studies suggest that strength training is beneficial as well. A new frontier of therapy for muscle dysfunction in COPD is the use of anabolic hormones. Testosterone supplementation has been shown to increase muscle mass and strength in both hypogonadal and eugonadal healthy men. Low-dose testosterone supplementation is being considered for use in postmenopausal women. Though short-term administration of testosterone in moderate doses seems to be well tolerated in both men and women, further studies are required before safety and effectiveness can be established for routine use in COPD patients.

Lung transplantation for chronic obstructive pulmonary disease

Lung transplantation is able to provide dramatic gains in pulmonary function to patients with advanced pulmonary emphysema. At the present time, however, transplantation is available to a strictly defined pool of candidates, and outcomes are limited by numerous respiratory and nonrespiratory postoperative complications. Further progress is needed in expanding the supply of donor lungs, minimizing perioperative complications, and optimizing postoperative immunologic management.

Lung volume reduction surgery for emphysema

Over the past decades, extensive literature has been published regarding surgical therapies for advanced COPD. Lung-volume reduction surgery would be an option for a significantly larger number of patients than classic bullectomy or lung transplantation. Unfortunately, the initial enthusiasm has been tempered by major questions regarding the optimal surgical approach, safety, firm selection criteria, and confirmation of long-term benefits. In fact, the long-term follow-up reported in patients undergoing classical bullectomy should serve to caution against unbridled enthusiasm for the indiscriminate application of LVRS. Those with the worst long-term outcome despite favourable short-term improvements after bullectomy have consistently been those with the lowest pulmonary function and significant emphysema in the remaining lung who appear remarkably similar to those being evaluated for LVRS. With this in mind, the National Heart, Lung and Blood Institute partnered with the Health Care Finance Administration to establish a multicenter, prospective, randomized study of intensive medical management, including pulmonary rehabilitation versus the same plus bilateral (by MS or VATS), known as the National Emphysema Treatment Trial. The primary objectives are to determine whether LVRS improves survival and exercise capacity. The secondary objectives will examine effects on pulmonary function and HRQL, compare surgical techniques, examine selection criteria for optimal response, identify criteria to determine those who are at prohibitive surgical risk, and examine long-term cost effectiveness. It is hoped that data collected from this novel, multicenter collaboration will place the role of LVRS in a clearer perspective for the physician caring for patients with advanced emphysema.

Bilateral versus single lung transplantation for chronic obstructive pulmonary disease: intermediate-term results

BACKGROUND

There is controversy regarding the transplant procedure of choice in chronic obstructive pulmonary disease. We reviewed our intermediate-term outcomes with single lung transplantation (SLT) versus bilateral lung transplantation (BLT).

METHODS

We retrospectively reviewed 130 patients with chronic obstructive pulmonary disease: 84 underwent SLT, 46 BLT. The mean age was 51.1 +/- 1.2 years for those who underwent BLT and 56.2 +/- 0.7 years for those who underwent SLT (p < 0.0001). Male patients represented 65% of the BLT group and 46% of the SLT group (p = 0.04). Spirometry and 6-minute walk tests were obtained preoperatively and at 3- to 6-month intervals. Posttransplant survival and survival from time of onset of bronchiolitis obliterans syndrome were calculated by Kaplan-Meier method. The mean follow-up was 32.4 months.

RESULTS

The 90-day mortality rate was 13.0% For BLT and 15.5% for SLT (p = 0.71). Actuarial survival rates at 1, 3, and 5 years were 82.6%, 74.6%, and 61.9% for BLT and 72.2%, 63.4%, and 57.4% for SLT; the favorable survival trend with BLT did not achieve statistical significance. There were no differences in preoperative spirometry or 6-minute walk tests. The improvements in forced expiratory volume in one second, forced vital capacity (FVC), and 6 MWT were significantly greater following BLT. The incidence of bronchiolitis obliterans syndrome was 22.4% in SLT and 22.2% in BLT; survival following onset of bronchiolitis obliterans syndrome was similar.

CONCLUSIONS

For patients with chronic obstructive pulmonary disease, BLT is associated with superior lung function, exercise tolerance, and a trend toward enhanced survival. Younger candidates may be best suited for BLT. Given the limited donor lungs, SLT remains the preferred alternative for all other patients.

Acute respiratory failure after lung volume reduction surgery

In this study, we characterized patients who developed respiratory failure postoperatively after lung volume reduction surgery (LVRS). We retrospectively reviewed the records of 72 patients who underwent LVRS from February 1995 to February 1998, examining perioperative variables and complications. Twenty-one patients (29%) developed postoperative respiratory failure, five due to hypoxemia, nine due to hypercapnia, and seven secondary to hemodynamic instability. The hospital mortality was 33% among patients who developed respiratory failure. No preoperative clinical or physiologic variable (including percent ideal body weight, serum albumin, prednisone use, lung function, maximal O(2) uptake on exercise testing, 6-min walk distance, and hemodynamic parameters) was predictive of postoperative respiratory failure. Patients who developed respiratory failure were older (63 +/- 7 versus 57 +/- 8 yr, p = 0.01), had longer anesthesia time (188 +/- 96 versus 127 +/- 56 min, p = 0.001), had a higher incidence of coronary artery disease (40% versus 10%, p = 0.001) and performance of concomitant surgical procedures during the LVRS operation (40% versus 2%, p < 0.001) compared with those without respiratory failure. All patients who underwent simultaneous surgery, which were mostly for cardiac disease, developed respiratory failure. Risk factor analysis confirmed that older patients and those undergoing cardiac surgery combined with LVRS are at increased risk for postoperative respiratory failure.

One year follow-up of the first bilateral living-donor lobar lung transplantation in Japan

One-year follow-up results on Japan's first bilateral living-donor lobar lung transplantation concern a 24-year-old woman who had become ventilator-dependent due to severe bronchiectasis associated with primary ciliary dyskinesia. Surgery was conducted using her sister's right lower lobe and her mother's left lower lobe. Total forced vital capacity of the 2 transplanted lobes was 51.7% of the recipient's predicted forced vital capacity. One-year after transplantation, her forced vital capacity was 2,160 ml--73.2% of her predicted forced vital capacity. The recipient's sister's decrease in forced vital capacity was 410 ml and that of her mother 440 ml. The recipient and donors have since returned to normal, unrestricted lives.

Lung volume reduction surgery (LVRS) for emphysema: initial experience at the University Hospital Gasthuisberg. Leuven LVRS Group

Emphysema is a disabling disease, for which there is no curative therapy available today. Lung transplantation offers a valuable option for a very selected number of patients, however, due to the enormous organ shortage, only few patients can be offered such a therapy. Recently there has been important resurgence of interest in lung volume reduction surgery and as a consequence, we have embarked in such a program since may 1997. We have now performed unilateral lung volume reduction surgery in 29 emphysema patients (25 on the right and 4 on the left side). Twenty-four patients were already discharged home. There has been no perioperative mortality. The mean hospital stay was 19.8 +/- 11.4 days (range, 8-47 d). Twenty patients of whom we already have follow-up data during 6 months (m) form the further basis of this report. Six weeks after the procedure the FEV1 increased from 0.82 +/- 0.28 L (28 +/- 8%) to 1.05 +/- 0.39 L, a mean increase of 28%. There was a further increase of the FEV1 to a maximum of 1.06 +/- 0.42 L at 6 m, a mean maximum increase of 29% (p = 0.0046, ANOVA). Similarly, the FVC increased from 2.80 +/- 1.10 L to 3.15 +/- 1.00 L, a mean increase of 12.5%. A further increase was also obtained at 6 m and was 19.6% (3.35 +/- 1.05 L, p = 0.014, ANOVA). The maximum decrease in RV was obtained at 3 m (from 5.91 +/- 1.37 L to 4.37 +/- 0.85 L (p = 0.0001, ANOVA), a mean decrease of 26%. The maximum TLC decrease was demonstrated at 3 m (from 8.71 +/- 1.71 L to 7.60 +/- 1.56 L (p = 0.002, ANOVA), a mean decrease of 12.8%. Afterwards there was again a gradual raise of the TLC. The six minute walking distance increased from 231 +/- 31 m to 272 +/- 34 m (p = NS) after pulmonary rehabilitation and to 416 +/- 77 m at 3 m and 415 +/- 18 m at 6 m (p = 0.0002, ANOVA) after the operation. The quality of life (measured with a standardized questionnaire, the Nottingham Health Profile) improved significantly in several domains (e.g. mobility, pain, energy, emotions and social) at 3 m postoperatively. There was one late death (at 6 m) due to an unknown cause. The actuarial survival rate was therefore 100% at 3 m and 95% at 12 m. In conclusion, unilateral thoracoscopic lung volume reduction surgery is a new and safe treatment modality for patients suffering from severe end-stage emphysema. The objective and subjective improvement is marked and the mortality is very low. Rigid selection criteria are, however, necessary to be able to guarantee an optimal result.

Significance of percutaneous cardiopulmonary bypass support for volume reduction surgery with severe hypercapnia

In patients with reduced respiratory function, lung resection is associated with high risk because separate ventilation is generally needed for safe management. For patients with end-stage emphysema, intraoperative respiratory management is important and particularly difficult because neither incomplete oxygenation nor selective ventilation can be performed, so the operation may be interrupted. In this study, we assess the effectiveness of the percutaneous cardiopulmonary support (PCPS) system for lung volume reduction surgery in patients with severe hypercapnia (arterial carbon dioxide tension >50 mm Hg) and discuss the significance of PCPS for patients who are beyond the standard criteria for lung volume reduction surgery (LVRS). We studied 3 patients with severe hypercapnia due to emphysema who underwent volume reduction surgery. One patient was previously treated surgically for contralateral pneumothorax. All patients had a severe smoking history and were suspected to have fragile lungs. During the operation. PCPS provided sufficient support flow. Intraoperative management using PCPS was easy, and no severe complications were observed. One patient exhibited severe hemodynamic deterioration on postoperative Day 15. Other patients' PaCO2 improved postoperatively. One had a calcification of a femoral artery, but there was no trouble inserting a cannula. Bilateral or unilateral volume reduction surgery was performed under PCPS in patients with end-stage emphysema. We conclude that PCPS is an adjunct to LVRS, useful for intraoperative management of some patients with severe hypercapnea, and the LVRS indications can be extended.

Different effects of lung volume reduction surgery and lobectomy on pulmonary circulation

OBJECTIVE

To clarify the effects of lung volume reduction surgery (LVRS) on cardiopulmonary circulation during exercise in comparison with pulmonary lobectomy for lung cancer.

SUMMARY BACKGROUND DATA

LVRS improves pulmonary function and dyspnea symptoms acutely in selected patients with heterogeneous emphysema. However, there are few data concerning the effects of LVRS on the cardiopulmonary circulation, especially during exercise.

METHODS

Pulmonary function tests and pulmonary hemodynamic study at rest and during exercise were performed before and 6 months after LVRS (seven patients) or pulmonary lobectomy (eight patients). In the workload test, an electrically braked bicycle ergometer (25 w) was used in the supine position for at least 2 minutes or until exhaustion or breathlessness developed.

RESULTS

After lung lobectomy, the values of vital capacity, percentage of predicted vital capacity, forced expiratory volume in 1 second, percentage of predicted forced expiratory volume in 1 second, residual volume/total lung capacity, and maximal voluntary ventilation deteriorated significantly. Six months after LVRS, however, vital capacity, percentage vital capacity showed no significant change, and forced expiratory volume in 1 second, percentage of forced expiratory volume in 1 second, diffusing capacity for carbon monoxide, and maximal voluntary ventilation showed marked improvement. Cardiac index was changed neither at rest nor during exercise in either group by the operation. Although postoperative pulmonary arterial pressure in the lobectomy group was significantly increased by the exercise, LVRS did not affect postoperative pulmonary arterial pressure at rest or during exercise. Pulmonary capillary wedge pressure in the lobectomy group showed no significant change after the operation, whereas LVRS ameliorated the marked elevation of pulmonary capillary wedge pressure observed during exercise. After lobectomy, significant increases in the pulmonary vascular resistance index were observed at rest and during exercise. LVRS markedly increased the pulmonary vascular resistance index at rest but not during exercise. In the lobectomy group, the postoperative flow-pressure curve moved upward, and its gradient became steeper than the preoperative one. In the LVRS group, the curve moved upward in a parallel fashion. These results show that much more right-sided heart work is needed to achieve the same cardiac output against higher pulmonary arterial pressure, not only after lobectomy but also LVRS.

CONCLUSION

The current study demonstrated that the effects of LVRS on the cardiopulmonary circulation were not negligible, especially during exercise, and successful LVRS may depend on improved respiratory function and also preserved cardiac function that can tolerate the damage to the pulmonary vascular bed induced by this operation.

A pilot study of expiratory flow limitation and lung volume reduction surgery

STUDY OBJECTIVES

To examine the relationships between changes in expiratory flow limitation (FL) during anesthesia and postoperative responses to lung volume reduction surgery (LVRS).

DESIGN

Prospective consecutive case comparison.

SETTING

University medical center.

PATIENTS

Eight patients with severe emphysema.

INTERVENTIONS

General anesthesia with muscle paralysis and thoracic epidural analgesia were provided for LVRS via median sternotomy.

MEASUREMENTS

FEV(1), functional residual capacity (FRC), and total lung capacity (TLC) were measured preoperatively and 3 months postoperatively. Tidal volume (VT) flow/volume (F/V) curves were obtained with a Pitot-type spirometer. VT, expiratory flow rate at 0. 25 x VT (V'VT,25% ), and peak expiratory flow rate (V'VT,MAX) were obtained from VT F/V curves to derive V'VT,25%/V'VT,MAX ratio as a measure of FL.

RESULTS

Closed chest VT F/V curves during anesthesia pre-LVRS showed four patients with FL (group A) whose V'VT,25%/V'VT, MAX ratio was 0.38 +/- 0.06 (mean +/- SD) and four patients without FL (group B) whose V'VT,25%/V'VT,MAX ratio was 0.82 +/- 0.06 (p = 0. 0001). Closed chest post-LVRS V'VT,25%/V'VT,MAX ratio during anesthesia increased by 0.48 +/- 0.08 in group A, compared with a 0. 19 +/- 0.16 reduction in group B (p = 0.0001). Preoperative FEV(1) was 0.57 +/- 0.10 L for group A vs 0.82 +/- 0.13 L for group B (p = 0.02). Postoperative FEV(1) increased by 67 +/- 40% for group A (p = 0.03) vs 29 +/- 21% for group B (not significant). FRC decreased by 33 +/- 3% for group A vs 17 +/- 5% for group B (p = 0.0007), and FRC/TLC decreased by 0.14 +/- 0.05 for group A vs 0.01 +/- 0.07 for group B (p = 0.026). Post-LVRS V'VT,25%/V'VT,MAX ratio change during anesthesia correlated with postoperative reduction in FRC (r(2) = 0. 89, p = 0.0004) and FRC/TLC (r(2) = 0.52, p = 0.045).

CONCLUSION

Post-LVRS change in V'VT,25%/V'VT,MAX ratio during anesthesia showed a linear relationship with 3-month postoperative improvement in dynamic hyperinflation. Thus, V'VT,25%/V'VT,MAX ratio may help provide valuable insights into the interactions between chest wall recoil, dynamic hyperinflation, and VT flow rates in patients with severe COPD and LVRS.

Development of a giant bulla after lung volume reduction surgery

Lung volume reduction surgery (LVRS) is being evaluated in the treatment of emphysema. The proposed mechanisms of improvement are increased elastic recoil of the lung and improved mechanical efficiency of the muscles of respiration. We report a unique patient with emphysema who developed a giant bulla 3 years subsequent to LVRS. The patient underwent extensive evaluation, including measurements of lung mechanics. Bullectomy was performed, but it was unsuccessful. Although the mechanisms behind the development of giant bullous disease remain speculative, heterogeneous improvement in elastic recoil following LVRS may be one of the responsible mechanisms.

Acute native lung hyperinflation is not associated with poor outcomes after single lung transplant for emphysema

BACKGROUND

Single-lung transplantation for emphysema may be complicated by acute native lung hyperinflation (ANLH) with hemodynamic and ventilatory compromise. Some groups advocate the routine use of independent lung ventilation, double-lung transplant, or right-lung transplant with or without contralateral lung volume reduction surgery in high-risk patients. The goal of this study was to determine the incidence of ANLH and identify its potential predictors.

METHODS

We reviewed 51 consecutive single-lung transplants for emphysema. Symptomatic ANLH was defined as mediastinal shift and diaphragmatic flattening on chest x-ray with hemodynamic or respiratory failure requiring cardiopressor agents or independent lung ventilation. Preoperative and postoperative physiologic and hemodynamic data were analyzed from both recipients and donors.

RESULTS

Sixteen patients developed radiographic ANLH; 8 were symptomatic, 2 severely so. We could not identify high-risk patients before transplant by pulmonary function tests, predicted donor total lung capacity (TLC)/actual recipient TLC ratio, pulmonary artery pressures, or the side transplanted. There was a trend toward an increased incidence of symptomatic ANLH in patients with bullous emphysema on chest computed tomography, but this was accounted for primarily by patients with alpha1-antitrypsin deficiency (4/13 vs 4/38 with chronic obstructive pulmonary disease, P = 0.10). No patient required cardiopulmonary bypass or inhaled nitric oxide intraoperatively. Patients with acute native lung hyperinflation did not have increased reperfusion edema as measured by chest x-ray score or PaO2/F(I)O2 ratio. Compared to patients without ANLH, symptomatic patients had longer ventilator times (64.9+/-14.6 hours vs 40.4+/-3.9, P = 0.02, ANOVA) and longer lengths of stay (19.3+/-2.1 days vs 13.7+/-1.3, P = 0.07), but 30-day survival was 100%. Two symptomatic patients required independent lung ventilation or inhaled nitric oxide; the others were managed with decreased minute ventilation, early extubation, and cardiopressor agents. No patient required early lung volume reduction surgery or retransplantation. Acute native lung hyperinflation had no effect on FEV1 or 6-minute walk results at 1 year; survival at 1, 2, or 3 years; or the rate of acute rejection, infection, or bronchiolitis obliterans syndrome greater than grade 2.

CONCLUSION

Acute native lung hyperinflation is common radiographically but is rarely clinically severe. Although there was a trend toward an increase in symptomatic ANLH in patients with bullous emphysema, a high-risk group could not be identified preoperatively. Our results do not support the routine use of bilateral lung transplant, the exclusive use of right single-lung transplant, simultaneous lung volume reduction surgery, or independent lung ventilation for patients with emphysema. Management strategies should be employed that limit overdistension of the native lung and lead to early extubation.

Surgical treatment of chronic obstructive pulmonary disease

Over the past several decades, a number of surgical techniques have been developed for the treatment of chronic obstructive pulmonary disease. Many of these procedures have been abandoned because of lack of efficacy and/or high morbidity and mortality. At the present time, lung transplantation, reduction pneumoplasty for giant bullous emphysema, and lung volume reduction surgery are being performed in a number of centers. Data concerning the effectiveness of these procedures is accumulating and will ultimately need careful analysis to determine long-term outcomes in this group of patients.

Relationship between resting hypercapnia and physiologic parameters before and after lung volume reduction surgery in severe chronic obstructive pulmonary disease

Patients with severe chronic obstructive pulmonary disease (COPD) have varying degrees of hypercapnia. Recent studies have demonstrated inconsistent effects of lung volume reduction surgery (LVRS) on PaCO2; however, most series have excluded patients with moderate to severe hypercapnia. In addition, no study has examined the mechanisms responsible for the reduction in PaCO2 post-LVRS. We obtained spirometry, body plethysmography, diffusion capacity, respiratory muscle strength, 6-min walk test, and incremental symptom-limited maximal exercise data in 33 consecutive patients pre- and 3 to 6 mo post-LVRS, and explored the relationship between changes in PaCO2 and changes in the measured physiologic variables. All patients underwent bilateral LVRS via median sternotomy and stapling resection by the same cardiothoracic surgeon. Patients were 57 +/- 8 yr of age with severe COPD, hyperinflation, and air trapping (FEV1, 0.73 +/- 0.2 L; TLC, 7.3 +/- 1.6 L; residual volume [RV], 4.8 +/- 1.4 L), and moderate resting hypercapnia (PaCO2, 44 +/- 7 mm Hg; range, 32 to 56 mm Hg). Post-LVRS, PaCO2 decreased by 4% (PaCO2 pre 44 +/- 7 mm Hg, PaCO2 post 42 +/- 5 mm Hg; p = 0.003). Patients with higher baseline values of PaCO2 had the greatest reduction in PaCO2 post-LVRS (r = -0.61, p < 0.001). Significant correlations existed between reduction in PaCO2 and changes in FEV1 (r = -0.56; p = 0.0007), maximal inspiratory pressure (PImax) (r = -0.46; p = 0.009), diffusing capacity of the lungs for carbon monoxide (DLCO) (r = -0.47; p = 0.008), and RV/TLC (r = 0.41; p = 0. 02). Correlation existed also between reduction in PaCO2 and breathing pattern at maximal exercise: maximal minute ventilation (V Emax) (r = -0.47; p = 0.009), and tidal volume (VT) (r = -0.40; p = 0.02). The changes in PaCO2 post-LVRS showed marked intersubject variability. We conclude that LVRS, by reducing hyperinflation, air trapping, and improving respiratory muscle function, enables the lung and chest wall to act more effectively as a pump, thereby increasing alveolar ventilation and reducing baseline resting PaCO2. In addition, patients with higher baseline levels of PaCO2 demonstrate the greatest reduction in PaCO2 post-LVRS, and should not be excluded from receiving LVRS.

Improvements in lung function, exercise, and quality of life in hypercapnic COPD patients after lung volume reduction surgery

STUDY OBJECTIVE

To determine the impact of preoperative resting hypercapnia on patient outcome after bilateral lung volume reduction surgery (LVRS).

METHODS

We prospectively examined morbidity, mortality, quality of life (QOL), and physiologic outcome, including spirometry, gas exchange, and exercise performance in 15 patients with severe emphysema and a resting PaCO2 of > 45 mm Hg (group 1), and compared the results with those from 31 patients with a PaCO2 of < 45 mm Hg (group 2).

RESULTS

All preoperative physiologic and QOL indices were more impaired in the hypercapnic patients than in the eucapnic patients. The hypercapnic patients exhibited a lower preoperative FEV1, a lower diffusing capacity of the lung for carbon monoxide, a lower ratio of PaO2 to the fraction of inspired oxygen, a lower 6-min walk distance, and higher oxygen requirements. However, after surgery both groups exhibited improvements in FVC (group 1, p < 0.01; group 2, p < 0.001), FEV1 (group 1, p=0.04; group 2, p < 0.001), total lung capacity (TLC; group 1, p=0.02; group 2, p < 0.001), residual volume (RV; group 1, p=0.002; group 2, p < 0.001), RV/TLC ratio (group 1, p=0.03; group 2, p < 0.001), PaCO2 (group 1, p=0.002; group 2, p=0.02), 6-min walk distance (group 1, p=0.005; group 2, p < 0.001), oxygen consumption at peak exercise (group 1, p=0.02; group 2, p=0.02), total exercise time (group 1, p=0.02; group 2, p=0.02), and the perceived overall QOL scores (group 1, p=0.001; group 2, p < 0.001). However, because the magnitude of improvement was similar in both groups, and the hypercapnic group was more impaired, the spirometry, lung volumes, and 6-min walk distance remained significantly lower post-LVRS in the hypercapnic patients. There was no difference in mortality between the groups (p=0.9).

CONCLUSIONS

Patients with moderate to severe resting hypercapnia exhibit significant improvements in spirometry, gas exchange, perceived QOL, and exercise performance after bilateral LVRS. The maximal achievable improvements in postoperative lung function are related to preoperative level of function; however, the magnitude of improvement can be expected to be similar to patients with lower resting PaCO2 levels. Patients should not be excluded from LVRS based solely on the presence of resting hypercapnia. The long-term benefit of LVRS in hypercapnic patient remains to be determined.