Skip to Main Content

++

Treatment of patients with chronic obstructive pulmonary disease (COPD) traditionally has been the task of the internal medicine physician. Current American Thoracic Society and World Health Organization recommendations for treatment of COPD include the use of bronchodilators, anti-inflammatory agents, oxygen therapy, aids to assist with smoking cessation, and pulmonary rehabilitation.1 The National Emphysema Treatment Trial, a large multicenter randomized clinical trial to evaluate the effectiveness of lung volume-reduction surgery (LVRS) for the treatment of emphysema, has mandated a change in this traditional thinking. The findings of this trial, while applicable only to a defined subset of COPD patients with advanced upper lobe predominant disease and reduced exercise capacity, clearly indicate that LVRS can affect lung physiology, symptoms, and even mortality for this disease.2

++

Although the results of this trial have provided a new treatment option for many patients with advanced emphysema, LVRS nevertheless is associated with substantial morbidity and mortality. Even when performed by experienced physicians at tertiary referral centers, LVRS is associated with a 5% 90-day mortality rate and a 30–40% incidence of complications, including respiratory failure, prolonged air leak, pneumonia, cardiac arrhythmia, and gastrointestinal complications.3 Furthermore, when expressed in terms of quality-adjusted life-years, LVRS is more expensive than other currently accepted surgical interventions that improve quality of life for individuals with end-stage disease, such as coronary artery bypass grafting, cardiac transplantation, and lung transplantation4 (Table 89-1).

++
Table Graphic Jump Location
Table 89-1. Cost Effectiveness of LVRS
++

LVRS alters respiratory physiology in several ways, and improvements after treatment result from a combination of these distinct effects.5–9 As originally proposed by Brantigan and Mueller in the 1950s10 and convincingly demonstrated by Fessler and colleagues,13 LVRS partially normalizes the mechanical relationship between the hyperinflated emphysematous lung and surrounding chest wall by increasing the vital capacity and isovolume transpulmonary recoil pressures. This “resizing” process appears to be the primary mechanism responsible for physiologic improvements after lung reduction.

++

Other factors play a role. Increased recoil pressures cause an increase in airway conductance in a subset of patients, presumably by raising airway isovolume transmural pressures and increasing airway dimensions.11 The reduction in lung size after LVRS normalizes diaphragmatic and chest wall dimensions and improves ventilatory capacity by shortening the operating length over which the respiratory muscles contract. In a smaller number of patients, temporary improvements in oxygenation have been observed as a result of local changes in lung impedance that act to normalize ventilation/perfusion matching. LVRS also may improve dynamic lung mechanics by eliminating lung zones with the longest expiratory time constants, not only reducing the tendency for gas trapping and dynamic hyperinflation during exercise but also increasing the inspiratory capacity.12

++

Alternatives ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessSurgery Full Site: One-Year Subscription

Connect to the full suite of AccessSurgery content and resources including more than 160 instructional videos, 16,000+ high-quality images, interactive board review, 20+ textbooks, and more.

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessSurgery

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.