Critical Care of the Lung Volume Reduction Surgery Patient

Abstract

Lung volume reduction surgery (LVRS) offers the potential to improve lung function, exercise tolerance, and quality of life for patients with advanced emphysema. At present, the specific role of this procedure in the treatment of advanced emphysema is a subject of ongoing investigation. LVRS is most commonly performed bilaterally via either median sternotomy or video thoracoscopic approach with resection of the most severely affected lung tissue to reduce the overall lung volume by 20–30%. This results in improvements in lung elastic recoil, airway conductance, chest wall, and diaphragmatic function leading to greater inspiratory and expiratory airflow, decreased hyperinflation, and improved exercise tolerance. The greatest improvement after LVRS occurs within 3–6 months after surgery. In the perioperative period, however, lung function may be compromised by surgical incisions, pain, chest tubes, retained secretions, pneumonia, and parenchymal injury associated with resection. The risks of LVRS are not insignificant, with reported mortality prior to hospital discharge ranging from 2.5 to 14%. Pulmonary complications may include respiratory failure, persistent air leaks, pneumonia, tracheobronchitis, retained secretions, atelectasis, pneumothorax, bleeding, and sternal wound infections or dehiscence. Cardiac and gastrointestinal complications are the most common extrathoracic causes of perioperative morbidity after LVRS. Although many patients have an uneventful postoperative course, patients who experience complications frequently require prolonged mechanical ventilation and intensive care. Critical care practitioners must therefore be familiar with LVRS, its potential complications, and the ICU management of LVRS patients.