Surgical Therapies for Chronic Obstructive Pulmonary Disease

Key points

Rationale for lung volume reduction

Lung hyperinflation has been recognized as a major contributor to poor respiratory function and has been associated with increased mortality as well.^2,3 In addition to poor respiratory function, hyperinflation increases the sensation of dyspnea and causes a reduction in exercise capacity owing to distortions of the chest wall and pulmonary muscle mechanics.⁴ Furthermore, hyperinflation is associated with decreased cardiac function.⁵ Thus, hyperinflation has been an ever important target of

History of lung volume reduction surgery

LVRS was initially described in the 1950s.⁶ He described the surgery as “an operation directed at restoration of a physiologic principle … not concerned with the removal of pathologic tissue.” Despite sound physiology and some promising outcomes, the surgery was never widely used or studied until the 1990s. A case series of 20 patients with severe emphysema and hyperinflation was published showing that surgical resection of 20% to 30% of each lung resulted in improvements in lung volume,

The National Emphysema Treatment Trial

The earlier studies, while confirming the potential benefits of LVRS left questions regarding patient selection and mortality, paving the way for The National Emphysema Treatment Trial (NETT).^11,12 The NETT was a randomized trial that enrolled more than 1200 subjects from 17 centers into 2 groups; maximal medical therapy versus LVRS plus maximal medical therapy. Patients in both arms were medically optimized and participated in a pulmonary rehabilitation program before baseline testing and

Lung volume reduction surgery: current state

Despite clear benefits in carefully selected patients, LVRS has not been used as a mainstay of therapy in the population with emphysema. In fact, LVRS was only performed about 3300 times in the United States from 2000 to 2010 with numbers decreasing in the latter part of the decade.²³ Although still relatively few, in 2013 numbers had increased with 605 surgeries performed, nearly doubling the total from 2007.²⁴ The relatively low number of lung volume reduction surgeries is certainly due in

Bullectomy

A bulla is defined as an airspace in the lung with a diameter of greater than 1 cm. Most bullae are clinically insignificant and not amenable to surgery. A giant bulla is an air space in the lung that occupies about 30% or more of the hemithorax. Giant bullae are rare and typically associated with cigarette smoking. Additionally, marijuana smoking,²⁷ intravenous drug use,²⁸ and human immunodeficiency virus infection²⁹ have all been linked to the development of giant bullae.

The clinical effect

Lung transplantation in chronic obstructive pulmonary disease

Lung transplantation was first performed and published as a case report in 1963.³⁶ Since then, more than 50,000 lung transplantations³⁷ have been performed with more than 2700 lung transplantations performed in the United States in 2019³⁸ and more than 2000 lung transplants performed in Europe in 2016.³⁹ Between 1995 and 2012, COPD was the most common indication for lung transplantation worldwide, accounting for more than 39% of the total lung transplant volume.³⁷ Outcomes have improved over

Summary

Surgical intervention in advanced emphysema can offer considerable improvement to a patient’s quality of life and in some cases even confer a mortality benefit. The most crucial aspect of surgical intervention in COPD is proper and meticulous patient selection. Table 2 summarizes common indications for LVRS, bullectomy, and lung transplantation. Before surgery is offered, patients must fail optimal medical therapy and should participate in a pulmonary rehabilitation program. Of the surgical

Disclosure

Dr. Marchetti reports personal fees from Astrazeneca, personal fees from Realta Life Sciences, grants from Blade Therapeutics, grants from NIH, outside the submitted work.

Dr. Duffy has nothing to disclose.

Dr. Criner reports grants and personal fees from Galaxo Smith Kline, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Chiesi, grants and personal fees from Mereo, personal fees from Verona, grants and personal fees from Astra Zeneca, grants and personal fees