January 15, 2009
Sudish Murthy, MD
Staff Thoracic Surgeon, Department of Cardiothoracic Surgery, Miller Family Heart & Vascular Institute
Cleveland Clinic Host: Dr. Murthy has just joined us, welcome Dr. Murthy, it is great to have you with us. Lets get started with some questions.
Speaker Dr. Sudish Murthy: Thank you for having me.
frosty1: Wife and I both have breathing problems from past smoking. Doc said we will only get worse and give our things away soon. We are on Advaie and Spiriva but really no help. We are classed as COPD with mild emphysema and want to know if there is a minimally invasive surgery to help us. We quit smoking months ago. Thank You. We are in our sixties.
Speaker Dr. Sudish Murthy: It is impossible to predict the rate of decline in lung function in patients with emphysema. The most important intervention is smoking cessation and both of you should be congratulated in accomplishing this.
Most strategies to treat emphysema that are nonmedical - ie. lung volume reduction - generally are reserved for patients with severe emphysema not mild emphysema. The most important therapies for patients with mild emphysema include the medications you are currently on, but importantly pulmonary rehab ( regular exercise). As emphysema progresses the use of oxygen particularly at night can dramatically improve how a patient feels.
For patients with moderate to severe emphysema - where medical therapy has been optimized - and significant debilities still persists - lung volume reduction is considered a reasonable alternative. For some patients, lung transplantation is an alternative.
There are several approaches to achieve lung volume reduction. The one that has been the most rigorously tested and has been shown to be a benefit for selected patients is surgical lung volume reduction. This is a high risk undertaking but has demonstrated benefit in appropriate patients. There are newer less invasive procedures to achieve lung volume reduction - though none as yet - produce the effects of surgical lung volume reduction. The criteria to qualify for these therapies for emphysema are lengthy and I would suggest you contact the advanced lung disease team for specifics here at the Clinic.
jusane: how is it determined if you have COPD or emphysema?
Speaker Dr. Sudish Murthy: It is determined based on assessment of pulmonary function by spirometry. Specifically patients are asked to take as deep a breath as they can and asked to exhale as forcefully as they can. The amount of the breath that was inhaled that is subsequently exhaled in that same breath in one second is measured.
Patients with emphysema typically are unable to exhale a significant amount of their inhaled air (air trap). That measurement is recorded on pulmonary function testing and generally defines the degree of severity of emphysema.
Patients with emphysema also have chest xrays and/or ct scans that demonstrate lung destruction.
Lung Volume Reduction Surgery (LVRS) and alternatives
sandyg0720: I have recently met with Dr.'s at the University of Florida in Gainesville pursuing a consult on the possibility of LVRS. I was told I don't qualify because the emphysema is not isolated to the top lobes. I was also told that I should consider Lung transplants. What are your requirements for LVRS?
Speaker Dr. Sudish Murthy:As I mentioned this is a very complicated evaluation and it is difficult to address this issue in this forum - but there are other endobronchial lung volume reduction strategies that have been devised for patients with emphysema distributed equally throughout the lung. These are novel therapies and currently under investigation but trials are open at major institutes across the country - including Cleveland Clinic.
jusane: What are the newer less invasive procedures used instead of lvrs.
Speaker Dr. Sudish Murthy: Endobronchial lung volume reduction can be achieved by the application of a variety of experimental devices applied into the lungs through a bronchoscope (a small camera passed through the nose into the windpipe). There are currently several experimental trials of various devices underway throughout the country including several here at the Cleveland Clinic.
jusane: the lvrs options you mention are only available thru clinical trial. are there any other options to lvrs that are readily available.
Speaker Dr. Sudish Murthy:Surgical LVRS is covered by medicare for appropriate candidates. Generally patients will have no evidence of heart disease and will need to demonstrate severe COPD on spriometry and have most of their emphysema restricted to the upper portions of their lungs. Surprisingly, patients who are more invalid with this type of disease can derive both a improvement in quality of life and length of life through LVRS. However, the risks of LVRS are quite steep. And - consequently LVRS is restricted to only a handful of centers that have demonstrated some expertise in this field across the country. Most of these are also lung transplant centers.
TomAz: My Pulmonary Doctor told me that my next step would have to be either LVRS or Tx what are the newest thing out there that you alluded to?
Speaker Dr. Sudish Murthy: There are devices which attempt to simulate the effect of surgical LVRS which are placed endoscopically. These devices thus far do not appear to completely recapitulate the outcome of LVRS - however, they are markedly safer and are in active clinical investigations. To qualify for trials of these devices requires a thorough evaluation at that center participating in the trial. We would be happy to see you here at our Advanced Lung Disease Center.
jusane: I read in one of the COPD forums that Cleveland Clinic in FL was doing lvrs. Was this poster misinformed?
Speaker Dr. Sudish Murthy:: LVRS perhaps - Lung Transplant - No. Currently, I think they are not doing LVRS as they have had a change in their surgical staff approximately 1 month ago.
TomAz: I am 60 yrs old healthy except for COPD what is my best option LVRS or Tx?
Speaker Dr. Sudish Murthy: The severity and distribution of the COPD is critical in determining your best option at this point. In addition your body mass index, kidney function, bone health, and other medical history also become important determinants. We have transplanted relatively fit patients with endstage lung disease - even up to the age of 75 at this institute.
This is extending the criteria for lung transplant but in some patients their body aside from their lung disease suggest they are more similar to a 50 year old rather than a 70 year old - so we have made exceptions and offered these patients transplant listing. On the flip side - I have had some patients with ideal emphysema for LVRS who have enjoyed a greater than 5 year benefit from this intervention and Remember there is no immunosuppression with LVRS - it is a complex question and unfortunately cannot be answered without a full comprehensive evaluation.
Cleveland Clinic Host: During the chat Dr. Murthy mentioned our Advanced Lung Disease Program, if you would like more information or to schedule an appointment to see one of our specialist, please call 216.445.4215.
jusane: How many years do you think it will be before these alternatives to lvrs will be approved and available everywhere?
Speaker Dr. Sudish Murthy: One recent endobronchial valve was turned down by the FDA this month for broad use in patients with severe emphysema. The reason for the rejection was that in the pivotal clinical trial completed approx. 6 months ago the efficacy of the device could not be demonstrated to be a significant improvement over no device placement at all. This was the first of several devices which are being trialed right now and many of the future device designs has been adjusted due to this devices failure. My guess - 3 to 5 years away.
sandyg0720: Is the Cleveland Clinic in Florida doing Lung transplants?
Speaker Dr. Sudish Murthy: No - they may be involved in identifying potential lung transplant candidates but do not have the resources to staff a comprehensive lung transplant and lung surgery program. Those patients tend to come up to Cleveland to our main campus.
fran: What is the incidence of infection for lung transplants?
Speaker Dr. Sudish Murthy: By the very nature that lung transplantation obligates the patient to life long immunosuppression, should indicate that transplant patients will constantly be confronted with infections. As the field has progressed prophylaxis for specific infections has improved. And - the number of life-threatening infections that inflict lung transplant patients has gradually decreased. This is unfortunately the collateral damage that usually accompanies any solid organ transplant and in the case of lung transplant - infections that occur often occur in the transplanted organ.
briceCA: I have been treated for copd for many years. I have end stage pulmonary fibrosis now and non small cell cancer treated with a lobectomy some years ago. Any chance of lung transplant?
Speaker Dr. Sudish Murthy: A personal history of cancer - in particular lung cancer - is often a contraindication for consideration of lung transplant. The interval between time of lung cancer treatment and time of lung transplant consideration becomes critical. At least 5 years would have had to pass. The problem with transplanting patients with cancer arises from the immuno-suppression needed for transplantation which almost always reactivates a dormant cancer if it is still present. Consequently there needs to be quite a bit of time between the cancer treatment and the transplant evaluation to rule out the potentially dormant cancer.
karab: I have lung nodules - are all lung nodules bad - my doctor wants to do more testing. I am scared.
Speaker Dr. Sudish Murthy:In a very famous study based from Cornell University in NY. 1000 high risk patients for lung cancer (moderate to heavy smokers - age greater than 50 years)were offered screening chest CT scans. Of the 1000 patients and 1000 CT scans obtained, over 200 patients were found to have nodules. We know from previous studies that the incidence of lung cancer in heavy smokers is far less than 20 percent. Consequently, the nodules identified in the study were not all cancers. In fact when follow studies were complete of the initial 1000 patients, and over 200 patients with nodules - ultimately approximately 20 patients were found to have lung cancer. This puts the frequency screen of lung cancer in heavy smokers at approx. 2 percent. This translates to the concept that most nodules - even in smokers - are not cancer. However, because lung cancer is most curable when it is detected early - most of us are uncomfortable simply watching a nodule in a high risk patient without some additional testing that would suggest that the nodule is not cancer.
The extremes that some physicians go to determine this vary and some physicians will request multiple tests and some will use less testing and more clinical judgment. Most nodules identified accidentally on CT scanning that are less than 8 mm can usually be followed with a scan at 6 months to determine growth without any additional testing. Larger nodules generally mandate some kind of additional testing (PET scan, needle aspiration, bronchoscopy, or even removal).
frosty1_2: If a nodule does not change in size with repeat CT scan...then should one worry or should this be biopsied?
Speaker Dr. Sudish Murthy: The size and specific characteristics of the nodule on the CT scan must be figured into any algorithm to observe, biopsy or remove a nodule. Nodules with calcium within them and have not had change in size for two years and are less than 2 cm are traditionally considered benign. Moreover with the advent of pet scanning - the assessment of whether the nodule is benign can more easily be made. Particularly if it has been observed with no growth during the surveillance period.
gregct: A CT showed I have nodes in my lungs and infiltrates. I do have shortness of breath. Is this a sign of cancer?
Speaker Dr. Sudish Murthy: It could be. Cancer usually presents as a dominant nodule - not as scattered infiltrates and nodules. In advanced cancer there is usually a dominant nodule in the lung and numerous local lymph nodes in the region that are enlarged.
When someone has a variety of areas of the lung with infiltrates and some regional lymph nodes inflamed or enlarged, an inflammatory condition is as likely as cancer. And - I suspect additional diagnostic tests would be indicated for you.
Left Lower Lobe Infiltrate
jon: What is a left lower lobe infiltrate? Does it go away or require surgery?
Speaker Dr. Sudish Murthy: Left lower lobe infiltrate is most typical of pneumonia or inflammation or focal lung collapse. There are a few types of lung cancer that present as an infiltrate (smear on a chest xray) rather than the standard nodule typically encountered. And - if an infiltrate on a chest xray or ct scan does not resolve with the typical interventions (antibiotics or time) then additional diagnostics should be employed (bronchoscopy).
philly02: My husband had fluid on his lungs and the doctor removed it = now it is back. Why does it keep coming back?
Speaker Dr. Sudish Murthy: Pleural effusion has a number of causes - the most common are medical problems such as some form of heart disease, kidney disease or even liver disease. Consequently a thorough evaluation of these medical systems is indicated. Additional causes of pleural effusion are system inflammatory conditions, chest infections, hemorrhage, or cancer.
I suspect the fluid that was removed from your husband was tested for a variety of these possibilities. If the fluid returns after it has been drained once - the chance that it will return again - if the underlying cause was not determined and corrected - is well above 50 percent.
georgia98: My doctor told me he has to remove some water around my lungs? How is that done? What causes that?
Speaker Dr. Sudish Murthy: The issue of cause has been briefly addressed in a prior question. The technique that is used involves the drainage of fluid through a small needle. The fluid can be identified prior to the procedure by use of an ultrasound to mark the maximal depth of fluid and easiest site of evacuation. The patient is usually brought to a procedure room and the affected side is sterility prepared. Novacaine is generally used as the anesthetic to freeze the area and the fluid is then accessed with a small gauge catheter. complications from the procedure are rare but do include bleeding, and lung collapse. The anticipated frequency of either of these is about 1 -2 percent range.
sandyg0720: I have had CT scans 3 times a year for nodules since 2004 and had 2 needle aspirations, luckily all tests came back ok. But I get 2-3 new ones each time I have a scan. Should I be concerned about what damage they are possibly doing ? If I get too many can the lungs shut down?
Speaker Dr. Sudish Murthy: There is no question that the radiation dose from a CT scan done frequently can ultimately add up. Although based on current recommendations, this dose of radiation is hard to exceed even with 4 CT scans a year. That you continue to get small nodules suggests an inflammatory condition such as sarcoidosis or granulomatous disease and the indication for cT scan just to document new nodules is probably not a worthwhile enterprise Perhaps your scans could be reduced to one or two per year - especially if a benign condition has been confirmed by needle aspiration.
jusane: Is there one primary factor that determines how short of breath a person will be. FEV1, DLCO, RV?
Speaker Dr. Sudish Murthy: That is a good question. And it is surprising that patients who you would believe to be wheel chair bound based on one measurement would seem to be quite functional despite this. The answer - there is not particular indicator to be short-winded. Importantly - even patients with extremely low FEV1 can improve their pulmonary function and functional status by enrolling and participating in active pulmonary rehab (by exercising)
frosty1_2: Dr. have you ever seen lung involvement with a patient with long standing Elevated parathyroid levels? Thanks
Speaker Dr. Sudish Murthy: Is this a parathyroid adenoma - I have seen and removed parathyroid tumors in the chest - although none were in the lung - they were all in the mediastinum. I am not aware of any specific pulmonary complications from hyperparathyroidism.
Lung Cancer and Lobectomy
bajaj4: I have been operated right lower lobectomy 10 yrs ago. now i have itching problem all over the body especially in my back, no physical symptoms is there. It feels something crawling in my blood. You rub it and you are comfortable. again that feeling occurs some other part of the body. Its very irritating. No medication has worked out. I just wanted to know whether that lobectomy operation is the cause for this? If not what can be the other reason and remedy? Please help me out. Thanks.
Speaker Dr. Sudish Murthy: Unlikely that your symptoms are related to the operation. Most likely causes would be medication-related or some type of allergy.
richard: If a person has lung cancer, does surgery on the lung speed up missed cancer cells? My dad had a partial lobectomy to make sure that they got all the lung cancer - but wonder - how do they know they got it all.
Speaker Dr. Sudish Murthy:For LOCALIZED lung cancer, surgical removal offers the best chance of cure. For advanced lung cancer, therapy centers around chemotherapy and radiation, and occasionally includes surgery. There is no evidence at this point in time that an operation speeds up cancer. It is possible, however, that the immune system may become less functional after a major stress (such as surgery or a variety of other stresses) and that this can account for acceleration of tumor spread. Consequently, rapid recovery and attention to nutrition are essential components of a successful outcome following cancer surgery of ANY type.
sk123: My father was diagnosed with lung cancer and the doctors want to operate. My mother is holding up life-saving surgery because she heard somewhere that once the chest is opened during surgery, the cancer will spread much faster and my father will die much sooner. Is this true?
Speaker Dr. Sudish Murthy:: This was answered in a similar question today by Dr. Murthy - For LOCALIZED lung cancer, surgical removal offers the best chance of cure. For advanced lung cancer, therapy centers around chemotherapy and radiation, and occasionally includes surgery. There is no evidence at this point in time that an operation speeds up cancer. It is possible, however, that the immune system may become less functional after a major stress (such as surgery or a variety of other stresses) and that this can account for acceleration of tumor spread. Consequently, rapid recovery and attention to nutrition are essential components of a successful outcome following cancer surgery of ANY type.
PTerry: I have a general question, why is lung cancer generally so inoperable.
Speaker Dr. Sudish Murthy:The reason why lung cancer is more often than not inoperable is that it is diagnosed late in its course. Unlike, say, breast cancer, where an enlarging tumor can eventually be picked by the superficial deformity it cause, lung cancer insidiously advance, largely undetected, until they crop up widely spread throughout the body. Hence the interest in surveillance of high-risk patients.
fran: At what point is surgery recommended for someone with Pectus Excavatum?
Speaker Dr. Sudish Murthy:For the pediatric population, the reason is often cosmesis, and the procedure can be done with relatively minimal incursion. For the younger adult 20-35, the indications for operation would be significant pulmonary or cardiac compression (declining spirometry, or heart ECHO with pericardial fluid). I am not aware of indications in patients older than 35. Most people who are going to get symptomatic from their pectus get it by their early 30s. That's not to say there are no cosmetics issues in the older population. There is nothing particularly cosmetic about the way this deformity is corrected in adults, at least if your really trying to solve the problem. However, I do suspect that you might be able to find a cosmetic surgeon who would be happy to place a prosthesis under the defect to prop up the skin.
Cleveland Clinic Host: I am sorry to say our time with Dr.Murthy is up. Thank you Dr. Murthy for being with us.
Speaker Dr. Sudish Murthy:There were many great questions. Thank you for having me.
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