National Emphysema Treatment Trial Research Articles

Utilizing Clinical Trial Data to Assess Timing of Surgical Treatment for Emphysema Patients.

Lung volume reduction surgery (LVRS) and medical therapy are 2 available treatment options in dealing with severe emphysema, which is a chronic lung disease. However, or there are currently limited guidelines on the timing of LVRS for patients with different characteristics. The objective of this study is to assess the timing of receiving LVRS in terms of patient outcomes, taking into consideration a patient's characteristics. A finite-horizon Markov decision process model for patients with severe emphysema was developed to determine the short-term (5 y) and long-term timing of emphysema treatment. Maximizing the expected life expectancy, expected quality-adjusted life-years, and total expected cost of each treatment option were applied as the objective functions of the model. To estimate parameters in the model, the data provided by the National Emphysema Treatment Trial were used. The results indicate that the treatment timing strategy for patients with upper-lobe predominant emphysema is to receive LVRS regardless of their specific characteristics. However, for patients with non-upper-lobe-predominant emphysema, the optimal strategy depends on the age, maximum workload level, and forced expiratory volume in 1 second level. This study demonstrates the utilization of clinical trial data to gain insights into the timing of surgical treatment for patients with emphysema, considering patient age, observable health condition, and location of emphysema. Both short-term and long-term Markov decision process models were developed to assess the timing of receiving lung volume reduction surgery in patients with severe emphysema.How clinical trial data can be used to estimate the parameters and obtain short-term results from the Markov decision process model is demonstrated.The results provide insights into the timing of receiving lung volume reduction surgery as a function of a patient's characteristics, including age, emphysema location, maximum workload, and forced expiratory volume in 1 second level.

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

Robotic Surgery and Adjunctive Technology: Stretching the Limits of What Is Possible

Chronic obstructive pulmonary disease is the fourth leading cause of death in the world and is a significant cause of mortality and morbidity. Although medical management is the standard of care, as the symptoms progress and lung function declines, nonmedical options become available to patients. Lung volume reduction surgery has been a well-established surgery for the treatment of severe emphysema since the National Emphysema Treatment Trial in 2003 showed a survival advantage for patients with upper lobe emphysema and low baseline exercise capacity. 1 Mannino D.M. Kiriz V.A. Changing the burden of COPD mortality. Int J Chron Obstruct Pulmon Dis. 2006; 1: 219-233 PubMed Google Scholar For patients without upper lobe emphysema, alternative modalities have been investigated to improve functional status. Endoscopic lung volume reduction is an emerging nonsurgical strategy to help bridge the gap between optimal medical management and surgery. In patients with severe emphysema, results from the Improving Patient Outcomes by Selective Implantation of the Zephyr EBV (IMPACT) trial and the Pulmonx Endobronchial Valves Used in Treatment of Emphysema (LIBERATE) study have shown excellent improvements in patient’s lung function, exercise capacity, and quality of life over medical therapy. 2 Fishman 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: 2059-2073 Crossref PubMed Scopus (1656) Google Scholar ,3 Criner G.J. Sue R. Wright S. et al. A multicenter randomized controlled trial of Zephyr endobronchial valve treatment in heterogeneous emphysema (LIBERATE). Am J Respir Crit Care Med. 2018; 198: 1151-1164 Crossref PubMed Scopus (160) Google Scholar Robotic Lung Volume Reduction Surgery With Extracorporeal Membrane OxygenationThe Annals of Thoracic SurgeryVol. 114Issue 5PreviewLobectomy for consolidation of failed endoscopic lung volume reduction for emphysema has been reported in selected patients with favorable results but with considerable morbidity. The challenging issues in such patients are frailty caused by severe emphysema itself, poor tolerance to single-lung ventilation, target lobe hyperinflation, and inability to use gas inflation for the minimally invasive resection. Careful planning, including use of a robotic platform and extracorporeal membrane oxygenation support, can circumvent such difficulties and ensure a safe, minimally invasive resection in the high-risk emphysematous patient. Full-Text PDF

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.

Survival benefit of lung transplantation compared with medical management and pulmonary rehabilitation for patients with end-stage COPD.

BackgroundCOPD patients account for a large proportion of lung transplants; lung transplantation survival benefit for COPD patients is not well established.MethodsWe identified 4521 COPD patients in the United Network for Organ Sharing (UNOS) dataset transplanted from May 2005 to August 2016, and 604 patients assigned to receive pulmonary rehabilitation and medical management in the National Emphysema Treatment Trial (NETT). After trimming the populations for NETT eligibility criteria and data completeness, 1337 UNOS and 596 NETT patients remained. Kaplan–Meier estimates of transplant-free survival from transplantation for UNOS, and NETT randomisation, were compared between propensity score-matched UNOS (n=401) and NETT (n=262) patients.ResultsIn propensity-matched analyses, transplanted patients had better survival compared to medically managed patients in NETT (p=0.003). Stratifying on 6 min walk distance (6 MWD) and FEV1, UNOS patients with 6 MWD <1000 ft (∼300 m) or FEV1 <20% of predicted had better survival than NETT counterparts (median survival 5.0 years UNOS versus 3.4 years NETT; log-rank p<0.0001), while UNOS patients with 6 MWD ≥1000 ft (∼300 m) and FEV1 ≥20% had similar survival to NETT counterparts (median survival, 5.4 years UNOS versus 4.9 years NETT; log-rank p=0.73), interaction p=0.01.ConclusionsOverall survival is better for matched lung transplant patients compared with medical management alone. Patients who derive maximum benefit are those with 6 MWD <1000 ft (∼300 m) or FEV1 <20% of predicted, compared with pulmonary rehabilitation and medical management.

Hypercapnia in Advanced Chronic Obstructive Pulmonary Disease: A Secondary Analysis of the National Emphysema Treatment Trial.

Hypercapnia develops in one third of patients with advanced chronic obstructive pulmonary disease (COPD) and is associated with increased morbidity and mortality. Multiple factors in COPD are thought to contribute to the development of hypercapnia including increased carbon dioxide (CO2) production, increased dead space ventilation, and the complex interactions of deranged respiratory system mechanics, inspiratory muscle overload and the ventilatory control center in the brainstem. However, these factors have not previously been systematically analyzed in a large, well-characterized population of severe COPD patients. This is a secondary analysis of the clinical, physiologic and imaging data from the National Emphysema Treatment Trial (NETT). All patients with complete baseline data for the key predictor variables were included. An inclusive list of 32 potential predictor variables were selected a priori based on consensus of the investigators and literature review. Stepwise variable selection yielded 10 statistically significant associations in multivariate regression. A total of 1419 patients with severe COPD were included in the analysis; mean age 66.4 years (standard deviation 6.3), 38% females, and 422 (29.7%) had baseline hypercapnia. Key variables associated with hypercapnia were low resting partial pressure of oxygen in blood, low minute ventilation (Ve), high volume of exhaled carbon dioxide, low forced expiratory volume in 1 second, high residual volume, lower % emphysema on chest computed tomography, use of oxygen, low ventilatory reserve (high Ve/maximal voluntary ventilation), and not being at high altitude. Low diffusing capacity for carbon monoxide showed a positive association with hypercapnia in univariate analysis but a negative correlation in multivariate analysis. Measures of dyspnea and quality of life did not associate with degree of hypercapnia in multivariable analysis. Hypercapnia in a well-characterized cohort with severe COPD and emphysema is chiefly related to poor lung mechanics, high CO2 production, and a reduced ventilatory capability. Hypercapnia is less impacted by gas exchange abnormalities or the presence of emphysema.

Lung Volume Reduction Surgery: Reinterpreted With Longitudinal Data Analyses Methodology

The largest randomised controlled trial evaluating results of lung volume reduction surgery (LVRS) was conducted by the National Emphysema Treatment Trial (NETT) that published a series of reports for outcomes up to 24 months. However, patient outcomes were difficult to interpret due to limitations in and the presentation of conventional statistical analyses applied to longitudinal data. We reevaluated the NETT results using longitudinal data methodology to report longer-term outcomes to facilitate interpretation by clinicians and patients who are considering LVRS for emphysema management. Trial data were released by the United States National Institutes of Health and the National Heart, Lung, and Blood Institute and analyzed using a mixed-effects model. Data on the difference in lung function variables between patients receiving LVRS vs medical care out to 5 years were estimated and are presented. The 5-year differences in patients randomised to LVRS were a small but sustained improvement in lung function indicators of forced expiratory volume in 1 second, forced vital capacity, and residual volume of+1.4% (P < .001),+3.44% (P < .001) and-19.49% (P < .001) of the predicted values, respectively. With regards to physiological function, the 5-year difference in patients randomised to LVRS was an overall 0.89 W improvement in maximum workload (P= .069),-4.12 improvement in shortness of breath score (P < .001), and 0.088 improvement in quality of well-being score (P= .102). Our results suggest that LVRS continues to have an important role in the treatment of patients with severe emphysema, with long-term benefits to lung function variables and a sustained improvement to the relief of dyspnea.

Loneliness and ED Visits in Chronic Obstructive Pulmonary Disease.

The primary objective of this study was to investigate the association of loneliness and the incidence of ED visits in a large and well-characterized cohort of patients with severe chronic obstructive pulmonary disease (COPD); the association of loneliness with performance measures and health perception was the secondary objective. Baseline data were used from the National Emphysema Treatment Trial (NETT), which investigated the effectiveness of lung volume reduction surgery in patients with moderate-to-severe COPD. Patients received Quality of Wellbeing questionnaires, which asked about loneliness and social isolation. For comparing baseline variables between lonely and non-lonely subjects, we used χ2 tests for categorical variables and Wilcoxon tests for continuous variables. The association of loneliness with ED visits and health perception was assessed with a logistic model that adjusted for multiple critical confounders. The study took place from December 2002, to December 2004, with a follow-up period of 5 years to assess loneliness and 24 months to assess use of the emergency department. There were 1218 patients analyzed, mean age 65 (standard deviation [SD] 12), 47% were women, FEV 1% 41 (SD 12); 7.9% of participants reported feeling lonely. These individuals had worse health ratings, 6-minute walk tests (6MWTs), and breathlessness. Loneliness was independently associated with ED visits after adjusting for age, lung function, dyspnea, 6MWT, treatment, and gender, odds ratio (OR) 1.57 (95% confidence interval [CI], 1.005-2.466), P=.04. This study suggests that loneliness in patients with COPD is significantly and independently associated to ED visits and reduced health perception. Addressing loneliness of patients with COPD in the outpatient setting may contribute to improved health perception and less health care utilization.

Single versus Double Lung Transplantation for Chronic Obstructive Lung Disease(COPD)

Purpose Although COPD patients account for a large proportion of lung transplants, whether double lung transplantation (DLT) versus single (SLT) improves survival for COPD patients is not well established. Methods We identified 4521 COPD patients in the United Network for Organ Sharing (UNOS) database transplanted between May 2005 and August 2016. 604 patients assigned to the rehabilitation arm of the National Emphysema Treatment Trial (NETT), to receive only pulmonary rehabilitation and standard medical management, served as a control group. After trimming the UNOS population for NETT eligibility criteria, 539 UNOS single lung transplant recipients, 802 UNOS double lung transplant recipients and 604 NETT patients remained. Starting at transplantation time for UNOS patients, and randomization time for NETT patients, Kaplan-Meier estimates of subsequent transplant-free survival were compared between the matched UNOS SLT (n=183) and NETT (n=183); matched UNOS DLT (n =193) and NETT (n=193); UNOS SLT (n=529) and UNOS DLT (n=529). Results The median survival time for the trimmed samples was 5.1 years (IQR=0.8) for NETT, 4.8 years (IQR=1.3) for UNOS SLT, and 6.0 years (IQR=1.3) for UNOS DLT. In propensity-matched analyses, transplanted patients in UNOS SLT had better survival compared to medically managed patients in NETT (p=0.005); UNOS DLT had better survival compared to NETT (p=0.001) and median survival for UNOS DLT was 6.0 years and UNOS SLT was 5.5 years, a difference that was not statistically significant (p=0.1). Conclusion Both SLT and DLT lead to longer survival time compared to pulmonary rehabilitation and standard medical treatment. DLT may not offer better survival compared to SLT.

Frailty and Clinical Outcomes in Chronic Obstructive Pulmonary Disease.

Frailty represents an increased vulnerability to adverse health outcomes. The frailty phenotype conceptual model (three or more patient attributes of wasting, exhaustion, low activity, slowness, and weakness) is associated with increased morbidity and mortality in geriatric populations. Our objective was to describe the risks associated with frailty in patients with chronic obstructive pulmonary disease. Data from the National Emphysema Treatment Trial (NETT) were retrospectively analyzed. The frailty phenotype conceptual model was operationalized as three or more frailty parameters (a body mass index decrease of ≥5% over 12 months, self-reported exhaustion, low 6-minute walk distance, or physical activity or respiratory muscle strength in the lowest quartile). Frail participants were compared with participants with two or fewer frailty parameters. Participants were followed starting 12 months after NETT randomization (to minimize surgical effect) for 24 months. Univariate, multivariate, Kaplan-Meier, and Cox proportional hazard analyses were performed, adjusting for treatment arm, age, modified Medical Research Council dyspnea scale, sex, and baseline forced expiratory volume in 1 second (FEV1). Multiple imputation was used for missing values. The participants (N = 902) were predominantly white (94.5%) males (59.5%), with a median age of 67 years (interquartile range, 63-70 yr) and a median FEV1% predicted of 26 (interquartile range, 20-33). Six percent of the participants (95% confidence interval [CI], 4.5 to 7.6) were frail. The incidence rate of frailty was 6.4 per 100 person-years. Frail participants reported significantly worse disease-specific and overall quality of life by St. George's Respiratory Questionnaire total score (mean difference of 11.6; 95% CI, 7.6 to 15.6; P < 0.001), mental composite on Medical Outcomes Survey Short Form-36 (mean difference -6.8; 95% CI, -10.0 to -3.6; P < 0.001), and physical composite scores on Medical Outcomes Survey Short Form-36 (mean difference -16.7; 95% CI, -21.3 to -12.1; P = 0.001). Frail participants had an increased rate of hospitalization (adjusted hazard ratio, 1.6; 95% CI, 1.1 to 2.5; P = 0.02) and an adjusted increase in hospital use of 8.0 days (95% CI, 4.4 to 11.6; P < 0.001) compared with nonfrail participants. Frail participants had a higher mortality rate (adjusted hazard ratio, 1.4; 95% CI, 0.97 to 2.0; P = 0.07). Among adults with chronic obstructive pulmonary disease, our measure of frailty (modified from the Fried frailty phenotype) was associated with incident and longer-duration hospitalization, and with poor quality of life.

Celebration of the 50-Year Anniversary of the National Heart, Lung, and Blood Institute Division of Lung Diseases: A Half-Century of Landmark Clinical Trials.

The National Institutes of Health (NIH)-National Heart, Lung, and Blood Institute's (NHLBI) Division of Lung Diseases is celebrating its 50th anniversary. On this occasion, we are reviewing the major landmark clinical trials that were initiated by the NHLBI's Division of Lung Disease and that have had substantial impact on our understanding of chronic obstructive pulmonary disease (COPD) and how it is best treated. Although some of these trials did not show hypothesized treatment benefits for COPD, they have enabled clinicians to provide care for individuals with COPD relying on the most rigorous evidence. The 5 trials that are reviewed here are: the Intermittent Positive Pressure Breathing Trial, the Nocturnal Oxygen Treatment Trial, the Lung Health Study, the National Emphysema Treatment Trial, and the Long-term Oxygen Treatment Trial. These clinical trials have not only set the standards for COPD care but have served as models for the state-of-the-art conduct of clinical research in COPD.

Effect of Lung Volume Reduction Surgery on Respiratory Muscle Strength in Advanced Emphysema.

Background: Long-term effects of lung volume reduction surgery (LVRS) on respiratory muscle strength and effects of age, sex, and emphysema pattern on these changes are unknown. Therefore, we aimed to determine the long-term effect of LVRS on respiratory muscle strength changes in severe emphysema. Methods: The National Emphysema Treatment Trial was a prospective controlled multicentered trial, comparing LVRS to optimal medical treatment on survival and maximal exercise capacity. We examined percentage change in maximum inspiratory pressure (MIP) from baseline to 36 months follow-up to determine impact of LVRS as well as age, sex, emphysema pattern and exercise capacity on changes in MIP compared to medical treatment. Results: LVRS individuals had significantly greater increases in MIP from baseline compared to medical individuals at all follow-ups (LVRS 19.8 ± 42.3%, medical 3.2 ± 29.3%, p<0.0001, 12 months). The LVRS group had significant decreases in total lung capacity (TLC), residual volume (RV), functional residual capacity (FRC) and RV/TLC compared to the medical arm at all follow-up periods. Males and individuals 65-70 years of age had significantly greater increases in MIP following LVRS compared to the medical arm at all follow-ups; this same relationship was seen at up to 24 months for low exercise capacity, upper lobe predominant emphysema. Conclusions: LVRS significantly increases inspiratory muscle strength up to 3 years post-operatively, with male sex, age 65-70 years and low exercise capacity, upper lobe predominant emphysema especially associated with increased MIP. Inspiratory muscle strength increases were associated with decreases in non-invasive markers of dynamic hyperinflation, suggesting that LVRS allows inspiratory muscles to return to their optimal length-tension relationship.

Long-Term Results After Lung Volume Reduction Surgery: A Single Institution’s Experience

The National Emphysema Treatment Trial (NETT) showed a clear survival and quality of life benefit for patients selected for lung volume reduction surgery (LVRS). However, long-term outcomes after LVRS are still lacking. The aim of this study was to evaluate overall mortality and functional durability in this single-institution cohort of patients undergoing LVRS. A single-institution registry identified all patients who had undergone LVRS from January 2006 through August 2017. Records were retrospectively reviewed, and data were collected to include pulmonary functions test values, he University of California, San Diego shortness of breath questionnaire and complication and mortality rate. LVRS was performed in 135 patients with a2.2% 90-day mortality rate (n= 3). Estimated 1-, 2- and 5-year survival was 0.94 (95% confidence interval [CI], 0.88 to 0.97), 0.91 (95% CI, 0.83 to 0.95), and 0.71 (95% CI, 0.57 to 0.81), respectively. Mean improvement in forced expiratory volume in 1 second% predicted from preoperative baseline at 1 and 2 years was 5.3 (95% CI, 3.1 to 7.4) and 4.3 (95% CI, 1.9 to 6.6), respectively. There was a mean improvement in maximum workload of 5.2 W (95% CI, 0.9 to 9.4) at 1 year. Also, shortness of breath questionnaire scores had a mean decrease of-17.3 points (95% CI,-21.8 to-13) at 6 months and-13.9 points (95% CI,-18.4 to-9.3) at 1 year. LVRS is an effective operation with overall improvement in functional status and quality of life in appropriately selected patients.

Lung volume reduction surgery in the post-National Emphysema Treatment Trial era.

Lung volume reduction surgery (LVRS) as means to improve the pulmonary function and quality of life of patients with chronic obstructive pulmonary disease (COPD) can be traced back to the 1950's and early work by Otto Brantigan. Joel Cooper revived this concept with pioneering work in the 1990's. His work, along with others, led to the National Emphysema Treatment Trial (NETT) which demonstrated a quality of life and survival benefit for certain subsets of patients with emphysema. While the outcomes of carefully selected patients are excellent, with proven benefits in both quality of life and overall survival, the volume of LVRS being performed remains low. The procedure is highly regulated in the United States and is only performed in Centers for Medicare and Medicaid Services (CMS) approved programs. Programs are required to follow the NETT selection criteria. The program at Columbia University Medical Center/New York Presbyterian Hospital remains active. Utilizing the NETT criteria, we continue to perform LVRS with no operative mortality and excellent long-term outcomes.

Clinical management of lung volume reduction in end stage emphysema patients

Following the evaluation of surgical lung volume reduction (LVR) in the National Emphysema Treatment (NETT) trial, different endoscopic LVR procedures have been developed for severe emphysema. Among those, endobronchial valve placement is the best evaluated method. All these therapies aim at reducing hyperinflation and at improving respiratory mechanics. It has been shown that these procedures can improve quality of life, lung function and exercise capacity in a significant and clinically meaningful way in suitable patients. Optimal medical therapy, physical rehabilitation, smoking cessation and respiratory insufficiency assessments should been thoroughly evaluated by a multi-disciplinary team before considering any LVR procedure. Clinical experience is necessary to decide if a patient is an appropriate candidate for a surgical or an interventional LVR procedure, to choose the optimal treatment strategy and to provide a high-level of care after the intervention, particularly when complications such as pneumothorax or persistent air leak occur in this already severely ill patient population. High volume emphysema care centers, providing a broad spectrum of different LVR procedures and involving a multidisciplinary team in the diagnostic process, are best suited to provide an optimal outcome. The aim of this manuscript is to describe the structures and procedures required to achieve the best possible outcome even in patients with advanced stage of their emphysema disease, including patients who are candidates for lung transplantation.

Quantifying patient centered outcomes associated with the use of bilateral endobronchial coil treatment in patients with severe emphysema

Objective: To determine the impact of endobronchial coils on health-related quality-of-life (HRQoL). This paper utilizes trial data to identify the predictors of HRQoL in patients with severe emphysema, and subsequently estimates the impact of a new treatment on HRQoL (measured by utilities). These utility estimates are used to generate indicative long-term QALY estimates for a range of clinically plausible scenarios as a precursor to cost-effectiveness analyses.Methods: Patient level HRQoL data from RENEW and the National Emphysema Treatment Trial (NETT) were combined and mapped to generic EuroQol 5-dimension health utility questionnaire (EQ-5D) values using a published algorithm. Multilevel statistical models were developed using treatment, time, response, and baseline characteristics (EQ-5D, age, gender, FEV1, lung RV) to predict EQ-5D over time. Lifetime QALY estimates were generated using published survival data from NETT (assuming no impact of treatment on mortality) and four clinically plausible response profiles. Each response profile was combined with assumptions around treatment impact (constant or time varying).Results: After controlling for baseline characteristics, both treatment and response had a statistically significant impact (p < .001) on utility (+0.101 and +0.061, respectively). When combined with selected baseline characteristics and time, Coils and Standard of Care (SoC) generated more QALYs than SoC alone in all scenarios, with incremental lifetime benefit ranging from 0.29–0.55 QALYs.Conclusions: Coils and SoC resulted in statistically significant improvements in HRQoL compared to SoC alone in patients with severe emphysema.

Endobronchial Coils Versus Lung Volume Reduction Surgery or Medical Therapy for Treatment of Advanced Homogenous Emphysema.

Rationale: Bronchoscopic lung volume reduction utilizing shape-memory nitinol endobronchial coils (EBC) may be safer and more effective in severely hyperinflated homogeneous emphysema compared to medical therapy or lung volume reduction surgery (LVRS). Methods: The effect of bilateral EBC in patients with homogeneous emphysema on spirometry, lung volumes and survival was compared to patients with homogeneous emphysema randomized in the National Emphysema Treatment Trial (NETT) to LVRS or medical therapy. NETT participants were selected to match EBC participants in age, baseline spirometry, and gender. Outcomes were compared from baseline, at 6 and 12 months. Results: There were no significant baseline differences in gender in the EBC, NETT-LVRS or medical treatment patients. At baseline no differences existed between EBC and NETT-LVRS patients in forced expiratory volume in 1 second ( FEV1) or total lung capacity (TLC) %-predicted; residual volume (RV) and diffusing capacity of the lung for carbon monoxide (DLco) %-predicted were higher in the EBC group compared to NETT-LVRS (p < 0.001). Compared to the medical treatment group, EBC produced greater improvements in FEV1 and RV but not TLC at 6 months. FEV1 and RV in the EBC group remained significantly improved at 12-months compared to the medical treatment group. While all 3 therapies improved quality of life, survival at 12 months with EBC or medical therapy was greater than NETT-LVRS. Conclusion: EBC may be a potential therapeutic option in patients with severe homogeneous emphysema and hyperinflation who are already receiving optimal medical treatment.

Long-term survival and symptomatic relief in lower lobe lung volume reduction surgery.

Lung volume reduction surgery (LVRS) has been demonstrated to provide symptomatic relief and improve lung function in patients with end-stage emphysema. The National Emphysema Treatment Trial specifically noted functional benefits in patients with predominantly upper lobe emphysema and demonstrated improvement in quality-of-life parameters, in patients with non-upper lobe emphysema and a low-baseline exercise capacity. We aimed to investigate whether physiological and health status benefits correlated with lower lobe LVRS. A retrospective analysis was performed from our prospectively collected patient database. A total of 36 patients with severe, non-upper lobe predominant emphysema underwent lower lobe LVRS in our institution, over a 20-year period. The assessments consisted of measurements of body mass index, pulmonary function tests and health-related quality of life using the Short Form 36-item questionnaires. Forced expiratory volume in 1 s was seen to improve 3 months [coefficient of time = 1.55 (0.88, 2.21); P < 0.0001] after the procedure, maintained until the first 6 months [0.48 (0.12, 0.85); P = 0.010], decline over the second half of the first year and gradually return to preoperative levels after 2 years, while residual volume to total lung capacity (%) ratio was seen to follow a similar pattern with significant decrease from baseline after 3 months [coefficient of time = -1.76 (-2.75, -0.76); P = 0.001] and 6 months [-1.05 (-1.51, -0.59); P < 0.0001]. Quality-of-life improvements were mainly noted in physical components. Contrary to a widely held misconception following the National Emphysema Treatment Trial that lower lobe lung volume reduction does not offer significant benefits to patients with non-upper lobe predominant emphysema, we feel justified in offering lower lobe LVRS in these patients when they meet the same selection criteria as upper lobe LVRS.

A perspective on lung volume reduction surgery for pulmonary emphysema

Emphysema is progressive lung disease characterised by pathological hyperinflation. It results in exercise intolerance, dyspnea, impaired quality of life and high mortality. Medical treatment does not alter the progression of emphysema instead the multi-center national emphysema treatment trial (NETT) demonstrated that lung volume reduction surgery (LVRS) is a successful surgical therapy which improves respiratory function, exercise capacity, and quality of life in selected patients with severe emphysema particularly if associated with upper-lobe predominance and low exercise capacity. The surgical technique has evolved from open surgery towards less invasive procedure as video assisted thoracoscopic surgery (VATS) for lung volume reduction. There remains some debate whether LVRS should be one stage bilateral or staged unilateral surgery and its merit in those without clear target areas or with predominantly lower lobe emphysema. The relative merits of perfusion scintigraphy and chest computerised tomography scan (CT) to identify target areas for resection are also debated. There is, in general, an overestimation of the risks associated with the procedure. Individualised scoring systems may allay such fears. However, because of these considerations of morbidity and cost-effectiveness for LVRS, less invasive techniques have been promoted such as endobronchial valves and endobronchial coils, yet their usage is restricted by collateral ventilation (CV), and variable outcomes. LVRS may be considered as a bridge to or even a realistic alternative to lung transplantation in the absence of significant cardiorespiratory failure but even in the elderly with increased risk.

Lung Volume Reduction Surgery - State of the Art 2016

In a number of large case series in the mid-1990s, lung volume reduction surgery (LVRS) was shown to reduce dyspnoea and improve pulmonary function and quality of life in patients with advanced pulmonary emphysema. The large randomised National Emphysema Treatment Trial (NETT) confirmed this in the early 2000s and also demonstrated that selected patients live longer after surgery. Patient selection is crucial to the success of the procedure and should be performed at a specialised experienced centre with a multidisciplinary team approach on emphysema treatment. The upper-lobe predominant heterogeneous type of emphysema is the best indication, but there are other types of emphysema morphology that are also eligible for surgery, if ideally chosen. Nowadays there is also growing evidence for positive effects after different types of bronchoscopic lung volume reduction (BLVR) with increasing quality. These methods add to the range of multimodal emphysema treatment.