Lung Volume Reduction Surgery - Diagnosis and Treatment
What is lung volume reduction surgery?
Lung volume reduction surgery (LVRS) is a surgical procedure performed to remove diseased, emphysematous lung tissue. This procedure:
- Reduces the size of an over-inflated lung; and
- Allows the expansion of the remaining, often more functional lung.
Lung volume reduction surgery has been shown to help improve breathing ability, lung capacity and overall quality of life in selected patients.
Who is a candidate for lung volume reduction surgery?
Lung volume reduction surgery is a procedure used for some patients with severe emphysema, a common type of chronic obstructive pulmonary disease (COPD), disabling dyspnea (shortness of breath, difficulty breathing) and evidence of severe air trapping.
Emphysema is an ongoing and progressive disease caused largely by cigarette smoking. The disease damages the lungs and makes breathing difficult.
The effectiveness of lung volume reduction surgery depends on the location or extent of the diseased tissue, as well as the patient’s exercise tolerance and ability to tolerate surgery.
Lung volume reduction surgery may be an appropriate treatment for select patients who meet established criteria. The results of the National Emphysema Treatment Trial (NETT) study, first published in 2003, identified four sub-groups of patients who had different risks and benefits from LVRS, specifically:
Group 1: Mostly upper-lobe emphysema and low exercise capacity.
These patients are more likely to live longer and are more likely to function better after LVRS than after medical treatment. This patient group may receive the most benefit from LVRS, as compared with the other patient groups.
Group 2: Mostly upper-lobe emphysema and high exercise capacity.
These patients are more likely to function better after LVRS than after medical treatment.
Group 3: Diffuse emphysema and low exercise capacity.
These patients have similar survival and function after LVRS as after medical treatment.
Group 4: Diffuse emphysema and high exercise capacity.
These patients have worse survival after LVRS than after medical treatment and do not appear to benefit from surgery.
Patients who fall into Group 1 are the best candidates for LVRS. Your thoracic surgeon and pulmonologist will discuss your treatment options to determine the best treatment for you.
Diagram of the Lung and its Lobes
What tests are needed to determine if LVRS is needed?
Your physician can determine if LVRS is an appropriate treatment for you by performing the following tests:
- Chest x-ray
- Pulmonary function tests
- Arterial blood gas (to measure levels of carbon dioxide and oxygen in the blood)
- Electrocardiogram (EKG)
- High resolution, computed tomography scan
- Oxygen titration
- Six-minute walk
- Cardiopulmonary exercise test
- Right heart catheterization (only if additional tests are required)
- Cardiac stress test
- Pulmonologist consultation
How is lung volume reduction surgery completed?
The goal of LVRS is to remove up to 30 percent of each lung, making the lungs smaller and allowing them to function better. Lung volume reduction surgery can be performed by either a sternotomy or with a minimally invasive technique called thoracoscopy. Cleveland Clinic thoracic surgeons have expertise in all of the surgical techniques for LVRS. Your surgeon will carefully evaluate you to determine the safest surgical approach to treat your medical condition.
The median sternotomy involves cutting through the breastbone to open the chest. Both lungs (a bilateral approach) are reduced at the same time in this procedure.
A minimally-invasive technique, the thoracoscopy requires 3 to 5 small incisions made on both sides of the chest, between the ribs. A videoscope is inserted through one of the incisions to allow the surgeon to see your lungs. A stapler and grasper are inserted in the other incisions and are used to remove the most damaged areas of the lung. The stapler is used to reseal the remaining lung.
Thoracoscopy can be used to operate on either one (unilateral) or both lungs (bilateral) and allows your surgeon to assess and resect any part of the lungs.
What are the benefits and risks of lung volume reduction surgery?
The National Emphysema Treatment Trial (NETT)’s results confirm that LVRS is beneficial for patients with predominant upper lobe disease and low exercise capacity, as compared with medical treatment.
While effective for some patients, there are risks involved with lung reduction surgery, including:
- Air leakage (occurring when air leaks from the lung tissue, coming from the suture line into the chest cavity)
- Pneumonia or infection
- Heart attack
- Death (due to worsening of one of the above complications)
In 2006, overall mortality remained at about 1.0 percent for all thoracic procedures performed at Cleveland Clinic, despite the increasing complexity of procedures and comorbid illnesses.
Cleveland Clinic thoracic surgeons performed 1,487 procedures in 2006.
How long will I be in the hospital following lung reduction surgery?
You should expect to stay 5 to 10 days in the hospital following lung reduction surgery. Pulmonary rehabilitation usually begins within the first 4 to 6 weeks after surgery, and is a very important part of your recovery.
Are there alternatives to surgery for lung volume reduction?
Approaches that use endobronchial valves to achieve lung volume reduction without the need for incisions are currently being investigated. These valves are placed into the inside of the lung via a bronchoscopy. During a bronchoscopy, a long, thin tube called a bronchoscope is passed through the nose or mouth and down the airway as far as necessary. A small camera conveys the images to a television monitor.
Fishman A, et al. National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003 May 22;348(21):2059-73. Epub 2003 May 20.
PMID: 12759479 [PubMed - indexed for MEDLINE]