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 sometimes secondary to COPD. They are the result of an obstruction within the bronchiole tubes or bronchus. 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 a bullectomy 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
- Cor pulmonale
- When 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.
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.
Lung transplants are performed as a means of surgical intervention for a variety of lung diseases including pulmonary fibrosis and pulmonary hypertension. COPD, however, is the most common indication for lung transplantation.
Patients who are less than 65 years old with end-stage COPD in the absence of other significant disease should be considered for lung transplant evaluation and referral. Some programs will consider patients who are older than 65 years, but strict criteria must be met for consideration.
Those who who would reap the highest reward from lung transplantation include patients that demonstrate the following:
- An FEV1 of 20% or less of the predicted
- Those with associated pulmonary hypertension
- Those whose chance for survival would be greater if they had a lung transplant, than if they did not
Additionally, potential transplant candidates should be ambulatory, the appropriate weight, and highly motivated with an adequate support system.
It is interesting to note that previous bullectomy or LVRS is not a contraindication for lung transplantation. These procedures can actually help serve as a bridge to lung transplantation for some patients.
While a lung transplant does not improve survival in COPD patients, benefits from lung transplantation must be looked at in terms of functional and quality-of-life benefit.
To see a step-by-step photo guide to lung transplant surgery, visit the Lung Transplant Image Gallery.
The burden that COPD places upon a patient can severely impact their quality of life. To those with end-stage COPD that do not respond well to medication, surgical intervention may be an option. Only your primary care provider can determine if you would make a good candidate for this type of surgery.
American Lung Association. LVRS Fact Sheet. August, 2005.
American Thoracic Society, European Thoracic Society. 2004. Standards for the diagnosis and management of patients with COPD. Version 1.2. 2005. Available at http://www.thoracic.org.
Huang FRCPC, Max MD, Singer, FRCPC, Lianne G. MD. http://www.medscape.com/viewarticle/502203 "Surgical Interventions for COPD". Geriatrics Aging. 2005; 8(3): 40-46.
Fishman A, Martinez F, Naunheim K, Piantadosi S, Wise R, Ries A, et al; "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;348(21): 2059–2073.
Hosenpud JD, Bennett LE, Keck BM, Edwards EB, Novick RJ. Effect of diagnosis on survival benefit of lung transplantation for end-stage lung disease. Lancet 1998;351(9095):24–27.
National Emphysema Treatment Trial Research Group. Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med 2001;345(15):1075–1083.
Snider G. Reduction pneumoplasty for giant bullous emphysema: implications for surgical treatment of nonbullous emphysema. Chest 1996;109(2):540–548.