Reduction Pneumoplasty Research Articles

Rehabilitation care in patients subjected to surgical intervention for lower lung volume reduction

Emphysema is a phenotype of chronic obstructive pulmonary disease (COPD), defined as an abnormal and permanent expansion of the respiratory space distant from the terminal bronchioles and destruction of the alveolar walls. Emphysema manifests clinically with shortness of breath by restricting airflow, hyperinflation, and loss of gas exchange surfaces in the lungs (also known as increased physiologic dead space). Lung volume reduction surgery (LVRS), also called reduction pneumoplasty or bilateral pneumonectomy, is a surgical technique that may be helpful for some patients with advanced emphysema who have poor control of their disease despite maximum dose of medication. Pulmonary rehabilitation (PR) is an integral part of the preparation and recovery from surgical interventions. PR has a significant place and role in supporting the recovery and quality of life of patients undergoing LVRS. The purpose of the study is е to present the role of PR in LVRS, outline the components and describe the expected benefits.

Lung volume reduction surgery: an overview

This study intends to review the literature on the efficacy, safety and feasibility of lung volume reduction surgery (LVRS) in patients with advanced emphysema. Studies on LVRS from January 1995 to December 2009 were included by using Pubmed (MEDLINE) and Cochrane Library literature in English. Search words such as lung volume reduction surgery or lung reduction surgery, pneumoplasty or reduction pneumoplasty, COPD or chronic obstructive pulmonary disease and surgery, were used. We also compared medical therapy and surgical technique. Studies consisting of randomized controlled trials, controlled clinical trials (randomized and nonrandomized), reviews and case series were analyzed. Questions regarding validity of the early clinical reports, incomplete follow-up bias, selection criteria and survival, confounded the interpretation of clinical data on LVRS. Patients with upper, lower and diffuse distribution of emphysema were included; we also analyzed as key points perioperative morbidity and mortality and lung function measurement as FEV1. Bullous emphysema was excluded from this review. Surgical approach included median sternotomy, unilateral or bilateral thoracotomy, and videothoracoscopy with stapled or laser ablation. Results of prospective randomized trials between medical management and LVRS are essential before final assessment can be established.

Body weight and nutritional changes after reduction pneumoplasty for severe emphysema: A randomized study

Background: The impact of reduction pneumoplasty on body weight and nutritional status has not previously been tested in a controlled study. Methods: We investigated 60 patients with severe emphysema who were randomly assigned to receive either reduction pneumoplasty (n = 30) or a 6-week respiratory rehabilitation program (n = 30). Nutritional status was evaluated by means of body mass index, triceps skin fold measurement, midarm muscle circumference, and biochemical blood values. Fat mass and fat-free mass were calculated by bioelectric impedance. Two treatment-related deaths occurred after reduction pneumoplasty and 1 death occurred after respiratory rehabilitation. Results: Functional and subjective improvements were significantly showed in reduction pneumoplasty group. Despite insignificant differences in energy intake, the reduction pneumoplasty group showed significant gain (P <.0001) relative to the respiratory rehabilitation group in mean weight changes at 3 months (1.82 ± 2.63 kg vs −0.57 ± 2.25 kg), 6 months (2.87 ± 3.79 kg vs −1.11 ± 2.64 kg), and 12 months (3.29 ± 4.01 kg vs −0.95 ± 1.90 kg). Both fat mass and fat-free mass increased after surgery, but only fat-free mass had a significant improvement (P =.001). Six-month weight gain in the reduction pneumoplasty group was significantly correlated with low baseline weight (ρ = −0.437, P =.02) and residual volume reduction (ρ = −0.446, P =.01). Total proteins (P =.003), albumin (P =.03), transferrin (P =.04), cholesterol (P =.003), hemoglobin (P =.01), triceps skin fold measurement (P <.0001), and midarm muscle circumference (P <.0001) were significantly increased only in the reduction pneumoplasty group. Conversely, in the respiratory rehabilitation group no nutritional index was significantly increased at 6 months after rehabilitation. Conclusions: Body weight and nutritional status improved only after reduction pneumoplasty and not after respiratory rehabilitation, and this was significantly related to fat-free mass increment. In the reduction pneumoplasty group, the residual volume result was significantly correlated with postoperative weight gain.J Thorac Cardiovasc Surg 2002;124:660-7

Reduction pneumoplasty versus respiratory rehabilitation in severe emphysema: a randomized study

Background. The purpose of the study was to determine in a prospective randomized trial the independent short-term physiologic impact of reduction pneumoplasty (RP) on respiratory rehabilitation (RR). Methods. Sixty patients eligible for RP were randomly selected by computer to receive either RP (n = 30) or comprehensive RR (n = 30). Pulmonary function tests, analysis of blood gas levels, measurement of respiratory muscle strength (maximal inspiratory and expiratory pressures), 6-minute walk test (6MWT), and incremental treadmill test (ITT), were performed at baseline and at 3 and 6 months. Results. Two treatment-related deaths occurred after RP and one after RR. At 6 months dyspnea index, maximal inspiratory pressure, 6MWT, ITT, and Pa o 2 were significantly improved in both groups whereas forced expiratory volume in 1 second and residual volume were significantly improved only in the surgical arm. In addition at 6 months, dyspnea index, 6MWT, maximal ITT, and Pa o 2 improved significantly more after RP than after RR. Conclusions. In our study short-term improvements in dyspnea index, oxygenation, inspiratory muscle strength, and exercise capacity occurred after either RP and RR. However dyspnea index, Pa o 2, and exercise capacity improved more after RP than after RR whereas pulmonary function improved only after RP.

Morphologic grading of emphysema is useful in the selection of candidates for unilateral or bilateral reduction pneumoplasty.

Radiologic morphology of emphysema proves useful in the selection of candidates for bilateral reduction pneumoplasty. We developed a simple morphologic grading system capable of identifying subsets of patients who had maximal functional improvement after unilateral or bilateral operation. Fifty-two patients who underwent unilateral (n=34) or bilateral (n=18) reduction pneumoplasty were evaluated. Emphysema morphology was visually scored by digital roentgenograms and high-resolution computed tomography. In each lung, severity of emphysema (ES), heterogeneity (DHT) and hyperinflation (DHF) degrees, were assessed. Asymmetric ratio of emphysema (ARE) between the lungs was expressed as: higher ES/lower ES scores. Morphometric data were correlated with absolute preoperative-postoperative FEV(1) change (DeltaFEV(1)). No difference was found between the unilateral and the bilateral group for ES and DHT. DHF was greater in the bilateral group (3.1 vs. 2.7, P=0.02) whereas ARE was greater in the unilateral group (1.29 vs. 1. 05, P=0.0001). Stepwise logistic regression extracted as best predictors of maximal DeltaFEV(1), ARE (odds ratio=238, Wald test P=0.04) in the unilateral group, and DHT (odds ratio=24, P=0.03) in the bilateral group. Unilateral group DeltaFEV(1) was greater in patients with ARE>/=1.3 (0.44 vs. 0.24 l, P=0.02). Bilateral group DeltaFEV(1) was greater in patients with DHT>1 (0.50 vs. 0.31 l, P=0. 03). No difference was found when comparing DeltaFEV(1) resulting from unilateral RP and ARE>/=1.3, and bilateral RP (0.44 vs. 0.41 l, not significant). This morphologic grading system identified subsets of patients who had maximal functional benefit from unilateral or bilateral reduction pneumoplasty and might be useful in the preoperative screening of candidates for either approach.

Intraoperative Spirometry during Reduction Pneumoplasty for Emphysema

Background : Surgical resection of severely emphysematous lung tissue can significantly ameliorate shortness of breath, possibly by reducing dynamic airway compression and auto-PEEP. We utilized online spirometry to examine the intraoperative relationship between expiratory flow rate and compliance changes associated with a reduction pneumoplasty. Methods : Eight surgical patients were anesthetized with IV propofol, isoflurane inhalation and thoracic epidural lidocaine/bupivacaine. A 37 or 39 left double lumen endobronchial tube (DLT) was placed and mechanical ventilation provided with tidal volume set at approximately 10 ml/kg. A Datex Ultima spirometer was placed at the proximal end of the DLT. Copies of flow/volume and pressure/volume curves (3-10 breaths) were obtained on a digital recorder during closed and open chest conditions, and before and after lung reduction. The mean ± SD of expired tidal volume (VT), inspiratory plateau airway pressure (Pplat), respiratory rate, % of breath exhaled in 1 sec (V1.0%), and total dynamic compliance (CT) was measured. Results : After a reduction pneumoplasty, CT decreased by an average 23% with open chest and 35% with closed chest conditions. Three subjects showed improved V1.0%, while 5 showed little change or reduced flow, hence no statistically significant change. There was no significant correlation between change in compliance and change in V1.0%(r2 = 0.24, p = 0.22). Conclusions : An emphysematous reduction pneumoplasty reliably reduces lung compliance. However, reduced lung compliance did not reliably predict improved expiratory flow rates after a reduction pneumoplasty. The further reduction in CT with sternal closure may have been due to the return of dynamic airway compression. (Korean J Anesthesiol 2000; 39: 656-661)

Thirty-sixth Annual Meeting January 31–February 2, 2000 Greater Fort Lauderdale/Broward County Convention Center, Fort Lauderdale, Florida

Thirty-sixth Annual Meeting January 31–February 2, 2000 Greater Fort Lauderdale/Broward County Convention Center, Fort Lauderdale, Florida

Thoracoscopic reduction pneumoplasty for severe emphysema: do pleural adhesions affect outcome?

Pleural adhesions are frequently encountered in patients undergoing reduction pneumoplasty. We evaluated the impact that pleural adhesions had on the surgical technique and outcome of thoracoscopic reduction pneumoplasty. 59 operated patients were divided into 2 groups depending on the presence (group A) or absence (group B) of pleural adhesions. At inter-group comparison (A versus B) a significant difference was found for mean duration of operation (128+/-55 min versus 73+/-33 min; p<0.005), morbidity (14 versus 9 patients; p<0.05), and hospital stay (14.1+/-11.8 days versus 12.0+/-7.4 days; p<0.001). Complications occurred less frequently in the last 29 patients than in the first 30 patients (11 versus 24; p<0.03). At histopathologic analysis subpleural (p<0.005) and interstitial fibrosis (p<0.001), and interstitial granulomas (p<0.012) were more frequent in group A specimens. At six months dyspnea index, six-minute-walk test, FEV1, FVC, PaO2, and prednisone and oxygen independence improved significantly in both groups. However FEV1 increased less in group A (1.20+/-0.2L vs 1.31+/-0.3L; p < 0.01). Pleural adhesions may be associated with increased morbidity and less improvement in FEV1 but they do not contraindicate thoracoscopic reduction pneumoplasty.

Surgical Treatment of Chronic Obstructive Pulmonary Disease

Over the past several decades, a number of surgical techniques have been developed for the treatment of chronic obstructive pulmonary disease. Many of these procedures have been abandoned because of lack of efficacy and/or high morbidity and mortality. At the present time, lung transplantation, reduction pneumoplasty for giant bullous emphysema, and lung volume reduction surgery are being performed in a number of centers. Data concerning the effectiveness of these procedures is accumulating and will ultimately need careful analysis to determine long-term outcomes in this group of patients.

Surgical treatment of chronic obstructive pulmonary disease.

Over the past several decades, a number of surgical techniques have been developed for the treatment of chronic obstructive pulmonary disease. Many of these procedures have been abandoned because of lack of efficacy and/or high morbidity and mortality. At the present time, lung transplantation, reduction pneumoplasty for giant bullous emphysema, and lung volume reduction surgery are being performed in a number of centers. Data concerning the effectiveness of these procedures is accumulating and will ultimately need careful analysis to determine long-term outcomes in this group of patients.

Unilateral thoracoscopic reduction pneumoplasty for asymmetric emphysema.

We prospectively analyzed the surgical and functional results of unilateral thoracoscopic reduction pneumoplasty which we performed by choice in patients with asymmetric emphysema. Between October 1995 and June 1997, 119 emphysematous patients were examined and 34 were operated upon. Among these, 14 selected patients with asymmetric distribution of emphysema in the lungs underwent unilateral reduction pneumoplasty (ten right, and four left). There were 13 males and one female, with a mean age of 62 years. Eligibility criteria included bullous and non-bullous end-stage emphysema with severe limitation to daily activity. No patient required conversion to thoracotomy. Mean operative time ranged between 70 and 240 min with a mean of 103 min. There was no postoperative mortality but five patients developed one or more complications: five prolonged air leaks (>7 days); two pulmonary infections; one empyema. No patient required postoperative mechanical ventilation. Median hospital stay was 8 days. At the 3-month follow-up the mean FEV1 increased from 0.8 l to 1.2 l (P < 0.001). Mean FVC increased from 2.6 l to 2.9 l (P < 0.001). The Medical Research Council dyspnea score decreased from a mean of 3.2 to 1.8 (P < 0.001). Asymmetric distribution is a frequent finding in patients with severe emphysema. Unilateral thoracoscopic reduction pneumoplasty may represent an ideal approach in this selected group of patients.

Lung Volume Reduction Surgery: Answering the Crucial Questions

Emphysema and other forms of COPD are not only common, but also have a poor prognosis. Mortality with severe COPD may be as high as 60% at 5 years and is associated with a significant degree of disability and cost to the health-care system. Building on Dr. Otto Brantigan's experience in the 1950s, when multiple-wedge resections of emphysematous lung were performed to decrease lung volume, thereby improving airflow and reducing hyperinflation, recent investigators, utilizing improved surgical and anesthetic technique, have redeveloped a surgical approach to the treatment of emphysema. The operations used to treat emphysema include excision of large bullae (bullectomy) and resection of diffusely emphysematous lung and are variously known as lung volume reduction surgery (LVRS), pneumectomy, and reduction pneumoplasty. These operations aim for a 20 to 30% reduction in lung volume and may be performed by stapler or laser resection, or both. The mechanisms of benefit have been attributed to enhanced elastic recoil, correction of ventilation perfusion mismatch, improved efficiency of respiratory musculature, and improved right ventricular filling. Questions that remain to be answered include duration of benefits, safety, and cost of LVRS. The National Heart, Lung, and Blood Institute and the Health Care Financing Administration have responded to the demand for more access to and information about LVRS by organizing both a national registry and controlled clinical trial of these procedures over a 7-year period. This multicenter trial intends to enroll patients with end-stage emphysema to compare methods of bilateral LVRS to maximal medical therapy.

Theoretical basis for improvement following reduction pneumoplasty in emphysema.

Reduction pneumoplasty may improve flow rates, comfort, and exercise tolerance in severe emphysema. The basis for improvement has not been systematically addressed. The major disability of emphysema stems from impairment of maximal expiratory flow-volume performance of the lung (MEFV). This requires the chest wall to operate at high volumes, which in turn severely compromises inspiratory muscle function. Clinical benefit, then, requires that MEFV performance improve so that the operating lung volume is reduced. This study presents theory and illustrative calculations. Removing nonventilating lung (e.g., bullae) simply displaces the MEFV curve down the volume axis. Removing ventilating parenchyma reduces both volume and maximal expiratory flow at iso-lung recoil pressure, and shortens the curve on the volume axis. The critical beneficial effect in both cases is reduction of the volume for a given limiting flow, VL (Vmax). Removing a given fraction of lung from the ventilating compartment is nearly as effective as removing it from the nonventilating compartment. Lowering of operating volumes benefits the strength, efficiency, endurance, and reserve of the inspiratory muscles and thus extends the metabolic scope of the emphysematous patient.

Health-care technology assessment of surgical procedures: the case of reduction pneumoplasty for emphysema.

End-stage chronic obstructive pulmonary disease (COPD) is frequent in the practice of pulmonology. The recent report that reduction pneumoplasty results in lung function improvement in a high proportion of patients with emphysema has raised the question of how effectively the medical profession assesses the efficacy of new surgical procedures. Unlike drugs and devices, the introduction of new surgical procedures is not regulated. Technique changes rapidly for a period of time after new procedures are introduced. Peer review is done mainly by quality-improvement activities in the surgeon's hospital and by publication in peer-reviewed journals. Randomized clinical trials (RCT) are procedurally and ethically difficult to do and few have been done for new surgical procedures. Some trials have been problematic. For example, a controlled cooperative trial of radial keratotomy resulted in unsuccessful antitrust suits brought by physicians and patients alleging that third-party payers would not reimburse them for surgery. RCTs that have been done have tended to be reported long after the procedure has been incorporated into surgical practice. A RCT of reduction pneumoplasty would be impossible at this time because of rapid flux in surgical techniques. There might also be ethical problems because of the substantial improvement in lung function of many patients in the existing case series, a level of improvement seen with no other treatment than lung transplantation. It is proposed that a prospective, cooperative, consecutive-case, observational study (registry) of reduction pneumoplasty for emphysema could greatly speed the acquisition of information about the efficacy of this new procedure.

Reduction Pneumoplasty for Giant Bullous Emphysema: Implications for Surgical Treatment of Nonbullous Emphysema

A review of the literature on reduction pneumoplasty for giant bullous emphysema was undertaken to identify current criteria for this surgical treatment and in the hope of obtaining insights into evaluating reduction pneumoplasty for nonbullous emphysema. Twenty-two retrospective case series, published since 1950, were retrieved by a computer search of the literature and a search of the Index Medicus prior to 1966. Reduction pneumoplasty is most effective when bullae are larger than one third of a hemithorax with evidence of compression of adjacent lung tissue and an FEV1 of less than 50% predicted; the presence of emphysema in nonbullous lung and the amount of compression are best judged by CT. The rationale for reduction pneumoplasty for nonbullous emphysema is supported by the similar early functional changes after reduction pneumoplasty for bullous and nonbullous-improvement of blood gas values and lung mechanics. A single study showing that decline of lung function after surgery for bullous emphysema was less in those who stopped smoking than in those who continued to smoke supports the need for preoperative and maintained smoking cessation in patients receiving reduction pneumoplasty. After 4 decades, the duration of improvement in lung function, whether worsening of emphysema occurs in remaining lung, and late morbidity and mortality after reduction pneumoplasty for bullous emphysema are not well defined. A registry with an unoperated-on comparison group could more rapidly accumulate such data after reduction pneumoplasty for nonbullous emphysema.