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lung volume reduction surgery; lung resection (LVRS)

Lung reduction surgery: Indications: 1) symptomatic despite optimal medical management - completion of pulmonary rehabilitation 2) lung bullae present occupying > 1/3 of a hemithorax & compress adjacent lung on CT 3) pulmonary emphysema - upper lobe emphysema with low exercise capacity - bilateral upper lobe emphysema on chest CT - FEV1 < 45%, but > 20% of predicted [1] - DLCO >= 20% of predicted - *post-bronchodilator total lung capacity > 150% of predicted & residual volume > 100% of predicted [1,6] - PaCO2 <= 60 mm Hg & PaO2 >= 45 mm Hg [1] Other criteria:* - *maximal voluntary ventilation < 50% of predicted - *maximal oxygen uptake of < 15 mL/kg/min - *< 76 years of age - *pCO2 < 60 mm Hg [1,6] - *arterial pO2 >= 45 mm Hg on room air [1,6] - *absence of pulmonary hypertension - *no severe comorbidity - *not of smoking for 6 months - *completion of a pulmonary rehabilitation program - *FEV1 20-45% of predicted - *DLCO >= 20% of predicted * In carefully selected patients, 1 year mortality is 5-25%. Benefits: - *make improve elastic recoil, diaphragm function & ventilation-perfusion mismatch - *may improve pulmonary function & gas exchange - *may improve exercise tolerance Contraindications: - homogeneously distributed or diffuse pulmonary emphysema [1] - FEV1 < 20% of predicted (relative) [1] Procedure: 1) Pneumonectomy, lobectomy, segmental resection 2) bronchoscopic lung volume reduction [5]* * 1-way valves are inserted into selected bronchi in emphysematous parts of the lung. The valves induce atelectasis by excluding air, while allowing venting of expired CO2. Special laboratory: Pulmonary function testing: 1) FEV1 must be > 2 liters 2) maximum breathing capacity > 50% of predicted 3) FVC > 50% of predicted Complications: 1) operative & post-operative mortality [3] is high when a) FEV1 < 20% of predicted b) DLCO < 20% of predicted 2) platypnea-orthodeoxia in patients with patent foramen ovale [1]

Related

lobectomy lung transplantation National Emphysema Treatment Trial segmentectomy; wedge resection of lung

General

pneumonectomy

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018.
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 24
  3. Journal Watch 21(20):159, 2001 National Emphysema Treatment Trial Research Group Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med. 2001 Oct 11;345(15):1075-83. PMID: 11596586
  4. Journal Watch 23(13):101, 2003 National Emphysema Treatment Trial Research Group, A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003 May 22;348(21):2059-73. PMID: 12759479 - National Emphysema Treatment Trial Research Group, Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema. N Engl J Med. 2003 May 22;348(21):2092-102. PMID: 12759480 - Drazen JM & Epstein AM Guidance concerning surgery for emphysema. N Engl J Med. 2003 May 22;348(21):2134-6 PMID: 12759481
  5. Wan IY, Toma TP, Geddes DM, Snell G, Williams T, Venuta F, Yim AP. Bronchoscopic lung volume reduction for end-stage emphysema: report on the first 98 patients. Chest. 2006 Mar;129(3):518-26. PMID: 16537847
  6. Berger RL, Decamp MM, Criner GJ, Celli BR. Lung volume reduction therapies for advanced emphysema: an update. Chest. 2010 Aug;138(2):407-17 PMID: 20682529
  7. Deslee G et al. Lung volume reduction coil treatment vs usual care in patients with severe emphysema: The REVOLENS randomized clinical trial. JAMA 2016 Jan 12; 315:175. PMID: 26757466 - Sciurba FC et al. Bronchoscopic lung volume reduction in COPD: Lessons in implementing clinically based precision medicine. JAMA 2016 Jan 12; 315:139 PMID: 26757462
  8. Ginsburg ME, Thomashow BM, Bulman WA et al The safety, efficacy, and durability of lung-volume reduction surgery: A 10-year experience. J Thorac Cardiovasc Surg. 2016 Mar;151(3):717-724.e1. Epub 2015 Oct 30. PMID: 26670190 Free Article