ABSTRACT
Many patients with severe chronic obstructive pulmonary disease (COPD) experience
incapacitating breathlessness and exercise limitation. Multiple surgical techniques
have been utilized to achieve resection of giant, localized bullae with documented
short-term benefit in pulmonary function and dyspnea in highly selected patients.
The poorest long-term outcome has been noted in those with greater degrees of emphysema
in the remaining lung, greater underlying chronic bronchitis, and a bulla occupying
less than one third of the hemithorax, particularly if compressed normal lung is not
evident. Lung volume reduction surgery (LVRS) in the absence of giant bullae has become
more widely accepted in selected patients. Bilateral LVRS procedures appear to result
in greater short-term improvement than unilateral LVRS, whereas physiological benefits
appear similar with video-assisted thoracoscopy (VATS) or median sternotomy (MS) techniques.
Improvement in dyspnea and health status after LVRS has been documented and appears
to be better preserved over longer-term follow-up than physiological improvement.
Clear direction has been provided in identifying optimal candidates for bilateral
LVRS; patients with a postbronchodilator forced expiratory volume in 1 second (FEV1) ≤ 20% predicted and a diffusing capacity for carbon monoxide (DLCO) ≤ 20% predicted or homogeneous emphysema exhibit a much higher mortality with LVRS
than with medical management. Patients with upper-lobe predominant emphysema and a
low postrehabilitation exercise tolerance exhibited a decreased risk of mortality
after LVRS. Patients with non-upper lobe predominant emphysema on high-resolution
computed tomography (HRCT) and a high postrehabilitation exercise capacity exhibit
an increased risk of death after LVRS. Patients with upper lobe predominant emphysema
and a high postrehabilitation exercise capacity or patients with non-upper lobe predominant
emphysema and a low postrehabilitation exercise capacity do not have a survival advantage
or disadvantage, whereas those with upper lobe predominant emphysema treated surgically
are more likely to improve their exercise capacity after surgery. Lung transplantation
is an option for a more limited number of patients. Consistent short-term spirometric
improvement after both single- and double-lung transplant has been documented. Long-term
results of lung transplantation are limited by significant complications that impair
survival; an ∼80% 1-year, 50% 5-year, and 35% 10-year survival has been reported.
Bronchiolitis obliterans is the most important long-term complication of lung transplantation
resulting in decreased pulmonary function. In general, a COPD patient can be considered
an appropriate candidate for transplantation when the FEV1 is below 25% predicted and/or the paCO2 is ≥ 55 mm Hg.
KEYWORDS
Chronic obstructive lung disease - emphysema - lung volume reduction surgery - lung
transplantation
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Fernando J MartinezM.D.
Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine,
University of Michigan Health System
3916 Taubman Center, 1500 E. Medical Center Dr.
Ann Arbor, MI 48109-0360
Email: fmartine@umich.edu