For selected patients and those with severe disease, surgical options may be considered, including lung volume reduction surgery (LVRS) and lung transplantation. Many patients with COPD are not candidates for either procedure for a variety of reasons, including significant comorbidities. However, when utilized appropriately, these approaches may improve quality of life and chances of survival. Smoking cessation is an absolute requirement before consideration of any surgical options.
The mechanism for clinical improvement with LVRS is thought to be related to enhanced lung elastic recoil. Surgical removal of lung areas that have lost elastic recoil reduces hyperinflation in the remaining lung and restores ventilation to preserved parts of the lung that were previously compressed. Safe and successful application of LVRS requires appropriate patient selection: Those with heterogeneous, upper lobe-predominant disease, and a low exercise capacity after completing pulmonary rehabilitation (defined as <gender specific 40th percentile maximum workload - 25W in women, 40W in men) derive the greatest benefit, while individuals with an FEV1 less than 20 percent predicted with either DLCO greater than 20 percent predicted or homogeneous emphysema have increased mortality and no benefit.
Since institution- and surgeon-specific volume are important determinants of outcomes, patients are likely to travel to referral institutions for surgery. Therefore, knowledge of these factors and evaluation of cardiac and other factors related to the ability to tolerate surgery can optimize referral practice. A1AT deficiency-related emphysema does not benefit from surgery. Although subjects with upper-lobe-predominant disease and a high exercise capacity do not gain a mortality benefit, there is sufficient improvement in measures of quality of life to warrant individualized discussions of risk and benefit, given the relatively long survival in otherwise healthy individuals with severe emphysema.
In a retrospective analysis of a subset of patients evaluated with automated software, six-month improvement in FEV1, exercise capacity, and respiratory-specific quality of life had a weak but significant correlation with pre-operative ratios of upper lobe versus lower lobe disease severity. Although increased mucus plugs in the resected tissue have been correlated with survival, CT analysis of airway wall thickness offer no predictive information on outcomes.
Lung transplantation provides a less clear survival advantage in COPD, when survival on the waiting list was compared with post-transplant survival. In the United States, organ allocation has been adjusted to reflect this fact. However, lung transplantation clearly enhances quality of life in patients with severe COPD who are good surgical candidates.
Reposted with permission from Decision Support in Medicine, LLC.