Lung Volume Reduction Surgery Research Articles

Looking Forward to Future Outcomes With a Control Group

In this issue of The Annals of Thoracic Surgery, the study, titled “Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure,” is indeed, a unique article.1 In almost all series that are published pertaining to lung volume reduction surgery for emphysema, there is a predominance of patients with upper-lobe disease. In fact, it is unusual for upper-lobe disease to not represent more than 90% of the series. In contradistinction, this report is focused on some patients with lower-lobe disease.

Lung volume reduction surgery: from National Emphysema Treatment Trial to non-intubated awake video-assisted thoracoscopic surgery.

Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.

The effects of lung volume reduction treatment on diffusing capacity and gas exchange.

Lung volume reduction (LVR) treatment in patients with severe emphysema has been shown to have a positive effect on hyperinflation, expiratory flow, exercise capacity and quality of life. However, the effects on diffusing capacity of the lungs and gas exchange are less clear. In this review, the possible mechanisms by which LVR treatment can affect diffusing capacity of the lung for carbon monoxide (D LCO) and arterial gas parameters are discussed, the use of D LCO in LVR treatment is evaluated and other diagnostic techniques reflecting diffusing capacity and regional ventilation (V')/perfusion (Q') mismatch are considered.A systematic review of the literature was performed for studies reporting on D LCO and arterial blood gas parameters before and after LVR surgery or endoscopic LVR with endobronchial valves (EBV). D LCO after these LVR treatments improved (40 studies, n=1855) and the mean absolute change from baseline in % predicted D LCO was +5.7% (range -4.6% to +29%), with no real change in blood gas parameters. Improvement in V' inhomogeneity and V'/Q' mismatch are plausible explanations for the improvement in D LCO after LVR treatment.

Patient-directed Volume Reduction for Emphysema: Sequential Surgical and Endobronchial Techniques

Lung volume reduction (LVR) surgery has traditionally been performed as a 1-stage bilateral procedure or staged at a predetermined interval. However to maximize the overall benefit we have allowed the patient to determine the timing of further interventions and have added endobronchial LVR into the protocol. We have reviewed the long-term outcome. Three hundred thirty-one LVR procedures were performed on 254 patients (median age, 61 years [range, 23-79]) with baseline predicted lung function of (mean ± SD) forced expiratory volume in 1 second 28% ± 11% and residual volume 253% ± 53%. The initial procedure was by video-assisted thoracoscopic surgery in 236 patients (unilateral, 227; bilateral, 9), by open surgery in 5, and by endobronchial valve insertion in 13. Sixty-four patients received a second and 13 a third LVR procedure. The median time interval between first and third stage was 5.8 years (range, 1.9-10) RESULTS: In the subgroup of patients who underwent staged procedures there was a significant improvement in predicted forced expiratory volume in 1 second from 28% at baseline to 34% up to 6 years. There was sustained reduction in static lung volumes up to 8 years: Predicted residual volume remained reduced from 259% to 189%. There were sustained improvements over baseline in health status: EuroQol-5D improved from 50 ± 26 to 62 ± 23 (P < .01) for up to 5 years and the Short Form 36-item questionnaire for up to 9 years. Overall 30-day mortality was 3%. Median survival was 5.6 years (95% confidence interval, 4.7-6.9). A program of staged unilateral procedures of LVR has resulted in sustained benefits for up to 9 years in physiology and health status.

Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure

Bronchoscopic valve placement constitutes an effective endoscopic lung volume reduction (ELVR) therapy in patients with severe emphysema and low collateral ventilation. After the most destroyed lobe is occluded with valves, significant target lobe volume reduction leads to improvements in lung function, exercise capacity, and quality of life. The effects are not consistent in some patients, leading to long-term therapy failure. We hypothesized that surgical lung volume reduction (LVRS) would reestablish ELVR short-term clinical improvements after ELVR long-term failure. This retrospective single-center analysis included all patients who underwent consolidating LVRS by lobectomy after long-term failure of valve therapy between 2010 and 2015. Changes in forced expiratory volume in 1 second, residual volume, 6-minute walking distance, and Modified Medical Research Council dyspnea score 90 days after ELVR and LVRS were analyzed, and the outcomes of both procedures were compared. LVRS was performed in 20 patients after ELVR failure. A lower lobectomy was performed in 90%. The 30-day mortality of the cohort was 0% and 90-day mortality was 5% (1 of 20). The remaining 19 patients showed a significant increase in forced expiratory volume in 1 second (+27.5% ± 19.4%) and a reduction in residual volume (-21.0% ± 17.4%) and total lung capacity (-11.1% ± 11.1%). This resulted in significant improvements in exercise tolerance (6-minute walking distance:+56 ± 60 m) and relief of dyspnea (ΔModified Medical Research Council:-1.8 ± 1.4 points.). Consolidating LVRS by lobectomy after failure of a previously successful ELVR is feasible and results in significant symptom relief and improvement of lung function.

Correlation between quantitative multi-detector computed tomography lung analysis and pulmonary function tests in chronic obstructive pulmonary disease patients

BackgroundChronic obstructive pulmonary disease [COPD] is a very common disease in developing as well as in developed countries. Using CT has a growing interest to give a phenotypic classification helping the clinical characterization of COPD patients. So, the aim of the present study was to evaluate whether there was a significant correlation between quantitative computed tomography lung analysis and pulmonary function tests in chronic obstructive pulmonary disease patients.ResultsThe study included 50 male patients with a mean age of 62.82 years ± 8.65 years standard deviation [SD]. Significant correlation was found between the pulmonary function tests [FEV1 and FEV1/FVC ratio], and all parameters of quantitative assessment with – 950 HU [the percentage of low-attenuation areas (% LAA)]. Pulmonary function tests according to GOLD [Global Initiative for Chronic Obstructive Lung Disease] guidelines revealed that 4% had normal pulmonary function, 8% had mild obstructive defect, 32% had moderate obstructive defect, 26% had severe obstructive defect, and 30% had very severe obstructive defect.ConclusionAutomated CT densitometry defining the emphysema severity was significantly correlated with the parameters of pulmonary function tests and providing an alternative, quick, simple, non-invasive study for evaluation of emphysema severity. Its main importance was the determination of the extent and distribution of affected emphysematous parts of the lungs especially for selecting the patients suitable for the lung volume reduction surgery.

Veno-Venous Extracorporeal Lung Support as a Bridge to or Through Lung Volume Reduction Surgery in Patients with Severe Hypercapnia.

Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.

Role of Imaging in Bronchoscopic Lung Volume Reduction Using Endobronchial Valve: State of the Art Review.

Chronic obstructive pulmonary disease (COPD) is becoming one of the leading causes of mortality and morbidity throughout the world. The National Emphysema Treatment Trial demonstrated that lung volume reduction surgery can improve pulmonary function, exercise capacity, and quality of life in select subgroups of patients with COPD. In recent years, few bronchoscopic lung volume reduction (BLVR) procedures have undergone clinical trials with the goal of establishing an effective and safe alternative approach for reducing hyperinflation in patients with severe emphysema who are symptomatic despite optimal medical management, but are poor surgical candidates. Of these BLVR procedures, only deployment of 1-way endobronchial valves (EBVs) has the largest pool of scientific data available to date to support its clinical utility. Two EBV systems have been food and drug administration-approved within the last year to meet the clinical demands of this select group of patients with COPD. On the basis of the results of multiple randomized clinical trials, the recommendations of the original 2016 Expert Panel Report on BLVR usage criteria of EBV have been updated in 2019. The outcome of EBV therapy is maximized in certain image-based COPD phenotypes. Imaging plays a major role in patient selection, target lobe identification, and in the management of postprocedural adverse events. With the expected widespread use of EBV therapy in the coming years, knowledge and familiarity of the Role of Imaging in BLVR using EBVs is essential for radiologists attempting to make meaningful contribution toward improving clinical outcomes.

Pre‐operative optimisation for chronic obstructive pulmonary disease: a narrative review

Chronic obstructive pulmonary disease is a condition commonly present in older people undergoing surgery and confers an increased risk of postoperative complications and mortality. Although predominantly a respiratory disease, it frequently has extra-pulmonary manifestations and typically occurs in the context of other long-term conditions. Patients experience a range of symptoms that affect their quality of life, functional ability and clinical outcomes. In this review, we discuss the evidence for techniques to optimise the care of people with chronic obstructive pulmonary disease in the peri-operative period, and address potential new interventions to improve outcomes. The article centres on pulmonary rehabilitation, widely available for the treatment of stable chronic obstructive pulmonary disease, but less often used in a peri-operative setting. Current evidence is largely at high risk of bias, however. Before surgery it is important to ensure that what have been called the 'five fundamentals' of chronic obstructive pulmonary disease treatment are achieved: smoking cessation; pulmonary rehabilitation; vaccination; self-management; and identification and optimisation of co-morbidities. Pharmacological treatment should also be optimised, and some patients may benefit from lung volume reduction surgery. Psychological and behavioural factors are important, but are currently poorly understood in the peri-operative period. Considerations of the risk and benefits of delaying surgery to ensure the recommended measures are delivered depends on patient characteristics and the nature and urgency of the planned intervention.

Evidence-based review of bronchoscopic lung volume reduction.

Emphysema sequentially leads to the loss of gas exchanging surface and an abnormal shape of the diaphragm generating dyspnea refractory to standard medical therapy. Lung volume reduction surgery (LVRS) is a surgical treatment option for patients with severe emphysema whose symptoms are uncontrolled on standard therapy. Bronchoscopic LVR (bLVR) is a process by which lung volume reduction is achieved in a minimally invasive manner using bronchoscopy-guided insertion of valves, coils, sealants, or by thermal vapour ablation like techniques. These therapies have developed over the last few years and have variable results in patients. We have summarized the current evidence available on each of these methods in this review.

Identification of target zones for lung volume reduction surgery using three-dimensional computed tomography rendering.

BackgroundThe key issues for performing lung volume reduction surgery (LVRS) is the identification of the target zones. Recently introduced three-dimensional computed tomography rendering methods are used to identify the morphological distribution and its severity of lung emphysema by densitometry. We demonstrate a new software for emphysema imaging and show the pre- and post-operative results in patients undergoing LVRS planned based on this new technology.MethodsA real-time three-dimensional image analysis software system was used pre- and 3 months post-operatively in five patients with heterogeneous emphysema and a single patient with homogeneous morphology scheduled for LVRS. Focus was on low attenuation areas with <950 HU, distribution on both lungs and the value of the three-dimensional images for planning surgery. Functional outcome was assessed by pulmonary function tests after 3 months.ResultsFive patients underwent bilateral LVRS and one patient had unilateral LVRS. All patients showed a median increase in forced expiratory volume in 1 s of 70% (range 30–120%), compared with baseline values. Hyperinflation (expressed as residual volume/total lung capacity ratio) was reduced by 30% (range 5–32%). In the patients with heterogeneous emphysema, the pre- and post-operative computed tomography scans and the densitometries showed a decrease in low attenuation areas by 23% (right side) and by 17% (left side), respectively.ConclusionWe demonstrate three-dimensional computed tomography-rendered images for planning personalised remodelling of hyperinflated lungs using LVRS. This user-friendly software has the potential to assist surgeons and interventional pulmonologists to select patients and to visualise target areas in LVRS procedures.

Lung Volume Reduction in Pulmonary Emphysema.

Severe emphysema with hyperinflation presents a therapeutic challenge. Inhaled medication has limited efficacy in individuals with mechanical constraints to the respiratory pump and impaired gas exchange. Lung volume reduction surgery (LVRS) reestablishes some semblance of normal physiology, resecting grossly expanded severely diseased tissue to restore the function of compromised relatively healthy lung, and has been shown to significantly improve exercise capacity, quality of life, and survival, especially in individuals with upper-lobe predominant emphysema and low-baseline exercise capacity, albeit with higher early morbidity and mortality. Bronchoscopic lung volume reduction achieved by deflating nonfunctioning parts of the lung is promoted as a less invasive and safer approach. Endobronchial valve implantation has demonstrated comparable outcomes to LVRS in selected individuals and has recently received approvals by the National Institute of Clinical Excellence in the United Kingdom and the Food and Drug Administration in the United States of America. Endobronchial coils are proving a viable treatment option in severe hyperinflation in the presence of collateral ventilation in selected cases of homogeneous disease. Modalities including vapor and sealant are delivered using a segmental strategy preserving healthier tissue within the same target lobe-efficacy and safety-data are, however, limited. This article will review the data supporting these novel technologies.

Lung Volume Reduction Surgery Prior to Lung Transplantation: A Propensity-Matched Analysis

Lung volume reduction surgery (LVRS) is a therapeutic option in the treatment of chronic obstructive pulmonary disease (COPD), the most common indication for lung transplantation (LTx). LVRS prior to LTx is controversial. Single institution studies report contradicting results, and the impact of undergoing LVRS prior to LTx on outcomes after LTx is unclear. We performed a propensity-matched analysis of outcomes after LTx in patients who underwent LVRS using a national database of LTx. We reviewed the Scientific Registry of Transplant Recipients for all adults (age>18) who underwent first-time LTx for COPD in the Lung Allocation Score (LAS) era. We used patient demographics and LAS to match patients who did and did not undergo LVRS. The primary exposure was prior LVRS. We used multivariate logistic regression modeling to evaluate the primary outcome, one-year mortality, and secondary outcomes, chronic rejection by one year requiring treatment and prolonged ventilation (>5 days). Long-term survival was compared using Kaplan Meier testing. A total of 5,061 patients underwent LTx between January 2005 and March 2017. The average patient age at transplant was 60.7±6.0 years, and 2,591 (51.2%) patients were male. The mean LAS at transplant was 34.9±6.1. A total of 111 (2.2%) patients underwent LVRS prior to LTx. Propensity matching generated 111 matches. Multivariate logistic regression modeling in this group revealed a 16% increased risk of mortality at one year among patients who underwent LVRS prior to LTx (OR: 1.16, 95% CI: 1.01-1.32, p=0.03). There was no statistically significant difference in risk of chronic rejection by one year requiring treatment (p=0.5) or prolonged ventilator support (p=0.5) among the two groups. The Kaplan Meier survival analysis demonstrated a significant survival deficit between patients who received LVRS and those who did not at five years post-transplant (52.3% vs. 66.3% p=0.01). In this national, propensity matched analysis of LVRS prior to LTx, we show that LVRS is associated with a significantly increased risk of mortality. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed post-operatively. Further studies are necessary to identify why these patients may be at increased risk of adverse outcomes after LTx.

Awake Thoracic Surgery with Extracorporeal Membrane Oxygenation

A 75-year old patient with a right sided secondary pneumothorax and prolonged air leak showed upper lobe predominant bullous emphysema. Due to the patients extremely reduced general condition neither an open approach nor a thoracoscopic approach seemed possible. Hence, we performed an awake lung volume reduction surgery with perioperative single site veno-venous extracorporeal membrane oxygenation. No heparin was administered. The extracorporeal membrane oxygenation (ECMO) could be weaned up to the second postoperative day. The further postoperative course was uneventful. This current case suggests that combining awake surgery with extracorporeal membrane oxygenation could be a future concept in extremely compromised patients.

Regadenoson myocardial perfusion scintigraphy for the evaluation of coronary artery disease in patients with lung disease: A series of five cases

Coronary artery disease (CAD) is a leading cause of death and morbidity globally. Myocardial perfusion scintigraphy (MPS) is commonly used for the diagnosis of CAD, necessitating hyperaemia achieved either by physical exertion or by pharmacological stress, most commonly through use of a coronary arteriolar dilator. This is challenging in patients with respiratory conditions because exercise may be submaximal and adenosine is contraindicated because of the risk of bronchoconstriction. Regadenoson is the only selective adenosine A2A receptor agonist approved as a vasodilator in MPS. The risk of bronchospasm with regadenoson has been investigated in large, randomised trials; however, patients with the most severe respiratory conditions were not included. In this case series, we present the use of regadenoson MPS in five patients with moderate-to-severe lung conditions, including patients requiring lung volume reduction surgery and lung transplant. In all cases, regadenoson MPS provided valuable information for risk assessment and treatment optimisation. Although dyspnoea occurred in all patients, regadenoson was well tolerated without serious adverse events or bronchospasm; in no case was intervention required to treat dyspnoea.

Intérêt de la chirurgie de kystes pulmonaires liés à des dépôts de chaînes légères

Light chain deposition disease is a rare anatomo-clinical disorder, which rarely leads to cystic lung destruction. We report the case of a 62years old female patient with a history of a monoclonal gammopathy of unknown significance who developed progressive dyspnea. Thoracic CT-scan demonstrated a diffuse pulmonary cystic disorder with predominance in the right lower lobe. Thoracoscopic surgical resection of that lobe led to a diagnosis of non-amyloid kappa light chain deposits. Surgery also resulted in a lung volume reduction effect with clinical and functional benefits related to improved ventilation of adjacent segments. This report of pulmonary cystic disorder related to a light chain deposition disease highlights the potential clinical and functional benefits observed after lung volume reduction surgery.

5-Year Survival after Endobronchial Coil Implantation: Secondary Analysis of the First Randomised Controlled Trial, RESET

Background: Lung volume reduction surgery is a proven treatment for emphysematous patients with hyperinflation, but the precarious health of candidates has prompted development of less invasive approaches. Bronchoscopic implanted endobronchial coils, shape-memory nitinol filaments, shrink emphysematous lung tissue to restore elastic recoil and to tether airways to maintain patency. Studies have demonstrated an acceptable safety profile and improvements in lung function, exercise capacity, and quality of life out to 3 years. Volume reduction is key. However, data for longer-term survival are limited. Objective: The aim of this study was to establish the 5-year overall and transplant-free survivals of subjects whose procedure in the first randomized controlled trial, RESET, achieved clinically meaningful reduction in residual volume (RV). Methods: Patients and their primary care doctors were contacted to confirm vital status and history of additional interventions. Death certificates were acquired via the General Registry Office. Survival time was calculated for responders achieving a reduction of ≥10% in RV compared to non-responders. Results: 39 patients completed the planned bilateral sequential treatments. Six patients received unilateral implants. At 5 years, 22 patients had died. The overall survivals at 1, 2, 3, 4 and 5 years were 88.9, 88.9, 77.8, 64.4 and 50.6%, respectively. Two patients underwent lung transplantation at 52 and 59 months and were alive at 5 years. The transplant-free (TF) survivals at 1, 2, 3, 4 and 5 years were 88.9, 88.9, 77.8, 64.4 and 46.7%, respectively. Volume reduction responders (n = 18) at 3 months had a 5-year TF survival of 66.7% compared to 36.4% for non-responders (n = 22; p = 0.07). Higher baseline inspiratory capacity (HR 0.13, 95% CI 0.02–0.73; p = 0.02) and partial pressure of oxygen (pO₂) (HR 0.57, 95% CI 0.38–0.86; p < 0.01) values were predictive of survival for the entire cohort and were not influenced by age. Conclusions: Endobronchial coil implantation appears to confer a 5-year survival advantage for those who achieved a 10% reduction in RV at 3 months. Ongoing trials are designed to clarify the mechanisms of action of coils and to refine patient selection.

Effects of Desflurane and Propofol During Lung Volume Reduction Surgery

Effects of Desflurane and Propofol During Lung Volume Reduction Surgery

Analysis of lung volume reduction surgery results with video-assisted thoracoscopic surgery in emphysematous lung patients.

AimIn our study, we aimed to evaluate the results of patients who underwent lung volume reduction surgery with video-assisted thoracoscopic surgery due to diffuse or upper lobe limited emphysema.Material and methodsPatients who underwent lung volume reduction surgery (LVRS) for emphysema in our clinic between March 2015 and January 2020 were included in the study. The files of the patients were evaluated retrospectively. Age, gender, smoking history, hospitalization time, drain removal time, complications, and postoperative pulmonary function test values were evaluated in the patient records.ResultsTwenty-four of the patients were male and 2 were female. The average age was determined as 49.6. Twenty-six patients underwent 31 surgical procedures, 5 of which were bilateral. Twenty-seven of them were performed by videothoracoscopic LVRS. Preoperative mean forced expiratory volume in 1 s (FEV1) value was 32.7%, total lung capacity 132%, residual volume 280%. The average length of hospital stay was found to be 7.75 days (4–19), and the time to remove the thorax drain was 9.5 (4–23) days. FEV1: 1.78 (48.5%) was found in the pulmonary function tests of the patients at the 6th month postoperative controls. According to preoperative FEV1, 48.3% improvement was detected.ConclusionsVolume reduction surgery is a treatment method that positively affects the natural course of emphysema in addition to quitting smoking and oxygen therapy. Patients with predominantly emphysema in the upper lobes, low exercise capacity, and appropriate FEV1 values benefited most from this treatment.

Bronchoscopic lung volume reduction by histoacryl

Background Lung volume reduction can be accomplished by bronchoscopy, a procedure that represents a potential alternative to lung volume reduction surgery. The initial physical approach to bronchoscopic lung volume reduction (BLVR) was based on the simple concept that collapse of target regions could be initiated using a washout solution to disrupt the surfactant function and be maintained with a biocompatible ‘tissue sealant’ to prevent re-expansion. Aim The aim was to evaluate the safety and efficacy of BLVR using an adhesive material (histoacryl blue glue) in patients with emphysema and emphysematous bullae. Settings and design Prospective interventional analysis from two centers’ registry, namely The Bronchology Unit at Chest Department, Ain Shams University and The Bronchoscopy Unit of Kobry El Kobba Military Chest Hospital. Patients and methods The study included 40 patients having emphysema. All the patients had spirometry, arterial blood gases, 6 min walking test, and body plethysmography. All these tests were performed before and 90 days after the procedure. Results Residual volume decreased by 15.30% (P=0.567), forced expiratory volume in the first second increased by 11.43% (P=0.088), forced vital capacity increased by 22.92% (P=0.007), and 6-min walking distance increased by 70.39% (P=0.021). Postprocedure complications were minor with no mortality. Conclusion BLVR therapy using histoacryl blue glue is well tolerated and safe in patients with emphysematous bulla and diffuse emphysema. Treatment is associated with modest improvement in pulmonary function test values, increased exercise performance, and reduced dyspnea.