Treatments Emphysema / Lung Volume Reduction Surgery

Surgery can help patients with emphysema to breathe better.

Background:

Emphysema is a progressive disease that in some cases will significantly compromise the quality of life for people with severe emphysema. Inhalers may help only about 10% of people with severe emphysema. Because medical management has provided only minimal impact on the disease, a variety of surgical procedures have been tried. Our surgeons helped to develop surgical treatments for emphysema and have written over 100 journal articles about that topic. The most effective operation has been lung volume reduction surgery (LVRS).

Indications:

  • Symptoms: Patients who are symptomatic despite maximal medical management for severe emphysema. They usually complain of shortness of breath with activities of daily living, such as showering, carrying, walking short distances, and bending.
  • Pulmonary Function Test: Severe obstructive lung disease, with typically the following PFTs: FEV1 20-40% predicted, TLC > 120% predicted, RV > 200% predicted.
  • Imaging: CXR shows hyperinflated lungs with a depressed diaphragm. CT scan shows heterogeneous pattern of emphysema in the lungs (generally much worse in upper lobes, than in the lower lobes). This is usually confirmed with a lung perfusion scan.
  • LVRS: Our surgeons have published 100 journal articles about how the operation works, patient selection and results. About 50-75% of both the right and left upper lobes are resected. This can be performed with VATS or a median sternotomy. Average length of stay is 7 days. Mortality rate is about 2%. 80% of patients develop air leak from the lung so their chest tubes may remain > 1 week after the procedure. About 75% of people on oxygen before the operation will no longer need the operation after they recover from the operation.
  • National Emphysema Treatment Trial (NETT): a study supported by the NIH and Medicare to compare surgery and medical treatment for severe emphysema. Dr McKenna was one of the principal investigators for the study.

Results

The NETT proved that the operation provided better quality of life, exercise ability, pulmonary function, and even survival than medical treatment. About 75% of patients who used oxygen before the operation did not need it after the LVRS. Patients who are short of breath despite maximal medical management for emphysema, should see specialists who are experienced with treatment of emphysema to determine if they are candidates for lung volume reduction surgery.
References regarding LVRS:
  • McKenna RJ Jr, Brenner M, Gelb A, Mullin M, Singh N, Peters H, Panzera J, Calmese J, Schein M. A randomized prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996; 111:317-22.
  • McKenna RJ Jr, Brenner M, Fischel RJ, Gelb AF. Should lung reduction surgery for emphysema be unilateral or bilateral? J Thorac Cardiovasc Surg 1996; 112:1331-9.
  • McKenna RJ Jr, Brenner M, Fischel RJ, Singh N, Yoong B, Gelb AF, Osann K. Patient selection criteria for lung volume reduction surgery. J Thorac Cardiovasc Surg 1997;114:957-64.
  • The National Emphysema Treatment Trial Research Group. Effects of Lung Volume Reduction Surgery versus Medical Therapy: Results from the National Emphysema Treatment Trial. New Engl J Med 348(21):2059-73, 2003 May 22.
  • Houck WV. Fuller CB. McKenna RJ Jr. Video-assisted thoracic surgery upper lobe trisegmentectomy for early-stage left apical lung cancer. Ann Thorac Surg. 78(5):1858-60, 2004 Nov.
  • The 3M™ Surgical Sealant Study Group, Allen MS, Wood DE, Hawkins RW, Harpole DH, McKenna RJ Jr., Walsh GL, Vallieres E, Miller DL, Nichols FC, Smythe RW, Davis RD. Randomized Study to Evaluate a New Polymeric Sealant for Sealing Intraoperative Air Leaks Occurring During Pulmonary Resection. Ann Thorac Surg. 2004;77:1792-801
  • McKenna R J Jr. Bronchial Blockers for LVRS. J Bronchology 2004