Lung Volume Reduction Surgery in the United States From 2007 to 2013: Increasing Volumes and Reason for Caution

Abstract

Lung volume reduction surgery (LVRS) has been associated with an improvement in survival and quality of life metrics when performed for a well-defined group of patients with upper lobe predominant emphysema.1Vogelmeier C.F. Criner G.J. Martinez F.J. et al.Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary.Am J Respir Crit Care Med. 2017; 195: 557-582Crossref PubMed Scopus (1946) Google Scholar, 2Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1670) Google Scholar Despite this, a previous study of the Nationwide Inpatient Sample (NIS) in CHEST (December 2014) reported a logarithmic drop in LVRSs from 2000 to 2010.3Ahmad S. Taneja A. Kurman J. Dagar G. Kumar G. National trends in lung volume reduction surgery in the United States: 2000 to 2010.Chest. 2014; 146: e228-e229Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar We hypothesized that the availability of long-term survival data from the National Emphysema Treatment Trial (NETT)4Naunheim K.S. Wood D.E. Mohsenifar Z. et al.Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group.Ann Thorac Surg. 2006; 82: 431-443Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar and inclusion in the Global Initiative for Chronic Obstructive Lung Disease guidelines1Vogelmeier C.F. Criner G.J. Martinez F.J. et al.Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary.Am J Respir Crit Care Med. 2017; 195: 557-582Crossref PubMed Scopus (1946) Google Scholar may have increased utilization. We performed a retrospective analysis of the NIS between the years 2007 to 2013 for patients who underwent LVRS (International Classification of Diseases, Ninth Revision, Clinical Modification 32.22). The NIS database is a 20% weighted sample of all US hospital discharges. Our composite primary outcome was inpatient mortality or need for tracheostomy during the admission. A total of 2,815 LVRSs were performed from 2007 to 2013. In-hospital mortality was 5.5%, the number of patients requiring tracheostomy was 5.5%, and the overall composite primary outcome was 10.5%. The number of LVRS procedures performed was 320 in 2007 and 605 in 2013, with a significant increase noted over time (P = .0016, R2 = 0.72) (Fig 1). Composite primary outcome was independently associated with a higher number of diagnoses on admission (16.6 ± 7.0 vs 10.3 ± 5.2, P < .001) and a higher rate of secondary pulmonary hypertension (60.3% vs 5.7%, P < .001). Poor outcome was associated with higher mean hospital charges ($802,164 vs $207,874, P < .001) and longer hospital length of stay (44.3 ± 41.7 vs 14.8 ± 17.8 days, P < .001). Multivariate logistic regression analysis demonstrated an association with higher number of diagnoses on admission (adjusted OR, 1.17; 95% CI, 1.10-1.24 per additional diagnosis) and presence of secondary pulmonary hypertension (adjusted OR, 4.4; 95% CI, 1.7-11.5). Our analysis indicates a lower mortality compared with the previous NIS study (5.5% vs 6.1%), but still compares unfavorably with the NETT reporting 30-day mortality of 3.6% overall, 2.2% when high-risk patients were excluded (FEV1 < 20% and homogenous emphysema or diffusing capacity for carbon monoxide < 20%), and 1.4% for patients with upper lobe predominant and low exercise capacity.2Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1670) Google Scholar Although it is encouraging that the number of LVRSs is increasing, we recommend careful consideration of comorbidities before undertaking LVRS. Clinically significant pulmonary hypertension (mean pulmonary artery pressure ≥ 35 mm Hg or systolic pulmonary artery pressure ≥ 45 mm Hg) was an exclusion criterion in the original NETT. Although the NIS database does not allow for severity stratification of pulmonary hypertension, the prevalence in our study is concerning. Further study into the significance of comorbidities in the setting of LVRS is warranted. Author contributions: A. H. A. is the guarantor for the content of this manuscript. A. H. A. conceptualized the design of the work, drafted the work, and revised it critically. U. H. and S. M. assisted in interpretation of the data, revised it critically, and gave final approval. J. Z. assisted in the analysis and interpretation, revised it critically, and gave final approval.