Types of Surgical Intervention
There are three types of surgical procedures that may an option for the patient with end-stage COPD, who is suffering from severe symptoms.
Bullae are enlarged (greater than 1 cm) air spaces within the lungs that are commonly secondary to COPD. They are the result of an obstruction within the bronchiole tubes or bronchus. These giant bullae cause substantial compression on the underlying, healthy lung tissue which in turn, reduces blood flow and oxygen to the lungs. This causes worsening shortness of breath.
Once the bullae are removed by means of a surgical procedure called a bullectomy, the healthy air sacs in the lungs can expand and breathing will become easier.
The typical candidate for this type of surgery includes those patients who suffer from severe dyspnea, hemoptysis or repeated bullae infections. Your doctor may prescribe the following tests as a method of evaluating your lung function prior to surgery:
- Chest x-ray
- Chest CT
- Pulmonary function tests
- Ventilation/perfusion (VQ)scan
- Angiography of the lungs (for some patients)
Factors that may contraindicate having a bullectomy include:
- The presence of multiple, smaller bullae
- Advanced emphysema in the non-bullous adjacent lung
- Hypercapnia
- Cor pulmonale
- When forced expiratory volume (FEV1) is less than 40% predicted or 500 ml
Although this procedure is possible, a bullectomy is rarely performed, as only an extremely small fraction of patients with emphysema have giant bullae. According to Chest, the risk of death during or immediately after surgery is 0-22% in published cases. Other complications include prolonged air leaks, lung infection and respiratory failure.
Lung Volume Reduction Surgery (LVRS)
LVRS involves removing approximately 30% of the diseased lung tissue so that healthy lung tissue can work more efficiently. It is a procedure that helps people who have severe emphysema breathe better so they can lead a more productive life.
Patients who would benefit most from this procedure are those with severe emphysema in the upper lobes of the lungs, who are a low risk for surgery and who have not responded well to pulmonary rehabilitation prior to surgery. Success of LVRS is directly related to meticulous selection of patients who meet this criteria.
A large study concluded that those with severe emphysema in the upper lobes of the lung and a low risk for surgery, but who do not respond to rehabilitation prior to surgery, would benefit most from LVRS. The study also showed that patients at high risk for surgery and those with emphysema in other parts of the lung would have the least benefit and could even be harmed (NETT studies).
To be considered for LVRS, patients have to fulfill the following criteria:
- Having a history of emphysema
- Not smoking for four months prior to and throughout the evaluation process
- Not having had a previous LVRS
- Not having had a previous coronary artery bypass or certain heart conditions
In addition, the patient must undergo pulmonary therapy both before and after the surgery.
It should be clarified that while the LVRS surgery has been shown to help improve breathing ability, lung capacity, and overall quality of life. It does not prolong survival.
