The effect of nutritional status on morbidity in COPD patients undergoing bilateral lung reduction surgery

Endoscopic Lung Volume Reduction in Relation to Body Mass Index in Patients with Severe Heterogeneous Emphysema

BACKGROUND

In chronic obstructive pulmonary disease (COPD), body mass index (BMI) is significantly lower in the emphysema-dominant type. Endoscopic lung volume reduction (ELVR) is an innovative way of treating severe emphysema. However, the specific associations of low BMI values and outcomes of ELVR is not well-studied.

OBJECTIVES

We evaluated associations between initial BMI and changes in major outcomes after endobronchial valve (EBV) placement in patients with heterogeneous severe emphysema.

METHODS

In a retrospective cohort study, patients were divided into 2 groups based on their baseline BMI (higher BMI ≥21 kg/m2 [n = 18] and lower BMI <21 kg/m2 [n = 63]). Demographics, procedure data, pulmonary function test and 6-min-walk test (6MWT), dyspnea score (according to the modified Medical Research Council [mMRC] scale), BODE (BMI, airflow obstruction, dyspnea, exercise capacity) index, and complications were recorded. After 6 months, changes in variables (dWeight and dBMI) were recorded.

RESULTS

Comparing the 2 groups, we found the following: a dWeight of -2.34 kg and +3.39 kg (p value <0.01) and a dBMI of -0.74 and +1.99 kg/m2, in the higher BMI and lower BMI group, respectively (p value <0.01). Changes in forced expiratory volume <1 s (FEV1), 6MWT, mMRC score, and BODE index were not statistically significant. The most common complication was pneumothorax. The lower BMI group experienced more complications than the higher BMI group (40 vs. 24%).

CONCLUSION

Baseline BMI is relevant when selecting candidates for ELVR. Our results show that the COPD patients with a lower BMI gained a significant amount of weight, thus increasing their BMI after the procedure. The rate of complications was higher in the lower BMI group. These findings should alert physicians and encourage nutritional assessment in this population.

Surgery and transplantation - Guidelines on Parenteral Nutrition, Chapter 18

In surgery, indications for artificial nutrition comprise prevention and treatment of catabolism and malnutrition. Thus in general, food intake should not be interrupted postoperatively and the re-establishing of oral (e.g. after anastomosis of the colon and rectum, kidney transplantation) or enteral food intake (e.g. after an anastomosis in the upper gastrointestinal tract, liver transplantation) is recommended within 24 h post surgery. To avoid increased mortality an indication for an immediate postoperatively artificial nutrition (enteral or parenteral nutrition (PN)) also exists in patients with no signs of malnutrition, but who will not receive oral food intake for more than 7 days perioperatively or whose oral food intake does not meet their needs (e.g. less than 60–80%) for more than 14 days. In cases of absolute contraindication for enteral nutrition, there is an indication for total PN (TPN) such as in chronic intestinal obstruction with a relevant passage obstruction e.g. a peritoneal carcinoma. If energy and nutrient requirements cannot be met by oral and enteral intake alone, a combination of enteral and parenteral nutrition is indicated. Delaying surgery for a systematic nutrition therapy (enteral and parenteral) is only indicated if severe malnutrition is present. Preoperative nutrition therapy should preferably be conducted prior to hospital admission to lower the risk of nosocomial infections. The recommendations of early postoperative re-establishing oral feeding, generally apply also to paediatric patients. Standardised operative procedures should be established in order to guarantee an effective nutrition therapy.

The increase in body mass index observed after lung volume reduction may act as surrogate marker of improved health status

OBJECTIVE

To assess the effects of lung volume reduction surgery (LVRS) on body mass index (BMI).

METHODS

Prospective data was collected on a series of 63 patients undergoing LVRS (bilateral in 22 patients, unilateral in 41 patients). Median age was 58 (41-70) years. The peri-operative effects of LVRS on BMI, lung function and health status (assessed by SF 36 questionnaire) were recorded at 3, 6, 12 and 24 months.

RESULTS

We found an overall increase in BMI after LVRS, which was significant up to 2 years. These changes correlated with the changes in FEV1 (R = 0.3, P < 0.01 6 months after LVRS) and diffusing capacity for carbon monoxide (DLCO) (R = 0.5, P < 0.01 6 months after LVRS). At 6 months, when the best results in health status were found, the patients were divided in a responders group (improved SF 36 score) and a non-responders group (same or worse SF 36 score) for each of the 8 domains of the SF 36. In 6 domains the non-responders showed no increase in BMI. In 6 domains the responders showed a significant increase in BMI.

CONCLUSION

LVRS significantly improves postoperative BMI, which correlates with improvements in DLCO and reflects changes in health status.

Patient selection for lung volume reduction surgery

LVRS represents a valid surgical option for a limited number of patients who have symptomatic emphysema. The results of recent controlled studies have provided a realistic view of LVRS outcomes and yielded a validated algorithm for selection of optimal candidates for surgery. Furthermore, the NETT has provided simultaneously collected cost data that have provided a unique view of the costs and benefits of LVRS in patients who have advanced emphysema. Additional data collection will better define the long-term benefits of such surgical intervention in patients who have COPD.

Sustained improvements in dyspnea and pulmonary function 3 to 5 years after lung volume reduction surgery

OBJECTIVES

To determine long-term survival rates of patients who underwent lung volume reduction surgery (LVRS) for emphysema and the factors associated with longer survival, and to evaluate levels of perceived dyspnea and health-related quality of life (HRQL) after a follow-up period of 3 to 5.5 years.

DESIGN

Retrospective observational study.

SETTING

Academic medical center

METHODS

Telephone and postal surveys were used to obtain patient dyspnea scores and HRQL scores. Hospital databases and state registries were searched to determine patient survival and pulmonary function.

RESULTS

Of 54 patients undergoing LVRS, 29 patients (18 men and 11 women) were available for follow-up, which ranged from 36 to 66 months (mean +/- SE, 51 +/- 1.5 months). There was significant sustained improvement in modified Medical Research Council scores compared to pre-LVRS: 2.19 +/- 0.19 vs 2.88 +/- 0.14 (p = 0.0000). Eleven of 22 patients demonstrated an increase in all three Mahler baseline dyspnea index grades of at least one level. Baseline body mass index (BMI) and post-LVRS length of stay (LOS) were significantly associated with survival: survivor vs deceased baseline BMI, 24.2 +/- 0.6 vs 21.4 +/- 0.5 (p = 0.002), and post-LVRS LOS, 15.4 +/- 1.7 days vs 28.7 +/- 5.3 days (p = 0.015). Compared to pre-LVRS, 20 patients with mean follow-up time of 45 months demonstrated significant sustained improvements in FEV(1) percentage of predicted (31.4 +/- 2.1% vs 39.8 +/- 3.5%, p = 0.038), total lung capacity percentage of predicted (136 +/- 4% vs 122 +/- 3%, p = 0.0004), and residual volume percentage of predicted (237 +/- 14% vs 172 +/- 11%, p = 0.0001). Patient HRQL measured using the Dartmouth Primary Care Co-operative Quality of Life questionnaire was more favorable than that reported in aged-care settings. Caregiver burden scale scores indicate caring for a recipient of LVRS carries similar burden to that for caring for individuals with other chronic illnesses.

CONCLUSIONS

In this population, a majority of the LVRS patients survived for >/= 3 years. Among survivors, dyspnea and lung function benefits were seen. Baseline BMI and postoperative LOS were significantly associated with survival.