Lung volume reduction surgery (LVRS)

Overview

Lung volume reduction surgery is a treatment option for individuals with severe emphysema, a form of chronic obstructive pulmonary disease (COPD). The procedure aims to help these patients breathe more easily. A multispecialty team of experts plays a crucial role in evaluating and identifying those who may benefit from the surgery, as not all patients are suitable candidates.

The surgery involves the removal of diseased lung tissue that is no longer functioning effectively. By using minimally invasive techniques, surgeons can excise these damaged areas, allowing the remaining healthy lung tissue to operate more efficiently. This process can lead to significant improvements in breathing and overall lung function.

Post-surgery, many patients experience reduced shortness of breath and an enhanced quality of life. They often find it easier to engage in physical activities and exercise. Additionally, this therapy has the potential to extend the lives of some patients, providing a critical benefit beyond improved daily functioning.

Reasons for undergoing the procedure

In order to improve the functioning of the remaining lung tissue, a thoracic surgeon will remove between 20% and 35% of the damaged lung tissue during lung volume reduction surgery. This results in more effective contraction and relaxation of the diaphragm, the muscle that separates the chest from the abdomen, which facilitates better breathing.

Research indicates that LVRS benefits just a selected group of people. You may be qualified if you:

• Under the age of 75.
• Experience severe shortness of breath (dyspnea) despite medication and pulmonary rehabilitation.
• Have the most significant damage in the upper region of the lungs (apex), with minimal damage in other lung areas.
• Have overinflated lungs with signs of severe air trapping.
• Do not currently smoke and have stop from smoking for at least four months.
• Can participate in six to ten weeks of pulmonary rehabilitation before surgery and ten to twelve sessions afterward.

Your healthcare provider may recommend the following to determine if lung volume reduction surgery is appropriate for you:

• Comprehensive imaging and evaluations, such as heart and lung function tests, exercise assessments, and a computed tomography (CT) scan of your lungs to pinpoint the location and severity of emphysema.
• Participation in pulmonary rehabilitation, a program aimed at improving physical and emotional health, helping individuals manage their condition more effectively.

Risk

While healthcare providers follow procedures to minimize risks, all surgeries carry potential risk. The risks of lung volume reduction surgery include the following:

• Reaction to anesthesia.
• Developing pneumonia or experiencing a collapsed lung (pneumothorax).
• Blood clot.
• Requiring more than two days of mechanical ventilation post-surgery.
• Experiencing a prolonged air leak, which may require drainage with a chest tube. Typically, most air leaks heal within a week.
• Myocardial infarction.

Risks that are less likely to occur are death, heart attacks, abnormal heart rhythm, and wound infection. In patients whose emphysema does not primarily impact the upper lung lobes and who have a strong exercise tolerance, lung volume reduction surgery may not enhance lung function and may even worsen survival rates.

Before the procedure

Before undergoing lung volume reduction surgery, your healthcare provider may require several tests to assess your suitability for LVRS based on your symptoms and disease characteristics. These tests may include:

• Cardiac tests: Your healthcare provider can evaluate the function of your heart with the use of an electrocardiogram (EKG), an echocardiography (heart ultrasound), and a stress test.
• Exercise tests: Your healthcare provider can assess your exercise tolerance level with the use of a six-minute walk test and a metabolic exercise stress test, also known as a cardiopulmonary exercise test.
• Imaging test:Chest x-rays and high-resolution CT scans help your healthcare provider assess the degree of lung air trapping and identify areas with significant damage.
• Lung diffusion test: Your diffused lung carbon monoxide capacity, or DLCO, may need to be more than 20% of the expected amount.
• Pulmonary function tests: The possibility that LVRS will help people is evaluated by pulmonary function testing, particularly for those whose forced expiratory volume in one second, or FEV1, is less than 45% on spirometry tests.
• Ventilation/perfusion scan (V/Q scan) and arterial blood gas tests: These tests can provide your healthcare provider with additional information regarding the function of your respiratory system.

You will get instructions from your healthcare provider on how to get ready for LVRS. Complication or risk can be reduced by carefully following their recommendations. Your healthcare provider might recommend the following:

• Refrain from eating for eight hours before the procedure (fast).
• Refrain from taking certain medications or adjust your medication schedule as instructed.
• Arrange for transportation home after spending a few days in the hospital.
• Make sure you let your healthcare provider know about all of your prescriptions, including over-the-counter (OTC) and herbal supplements.

During the procedure

During lung volume reduction surgery, you will be under general anesthesia and supported by a breathing machine. The procedure is generally performed using minimally invasive techniques. Your surgeon will make several small incisions on both sides of your chest to access the lung. In some cases, a single larger incision may be made either in the middle of your chest or between the ribs on the right side.

During the surgery, the surgeon will use surgical staplers to remove damaged sections of the lung, isolating the affected areas and ensuring a secure closure along the healthy lung tissue. Tubes will be placed to drain fluid from your lungs as part of the post-surgical care. After the operation, the incisions will be closed and covered with surgical dressings. The surgery typically lasts between one to three hours, depending on the specifics of the procedure.

The surgery involves removing 20% to 35% of the damaged lung tissue. This can help restore the diaphragm to its natural shape, potentially improving breathing comfort.

After the procedure

After the surgery, you will be closely monitored by your healthcare team until you wake up. Following this, you’ll spend a few days in the hospital for recovery. This period allows healthcare providers to address any post-operative issues promptly and ensure that your recovery proceeds smoothly.

Outcome

According to research, those who had lung volume reduction surgery often had better results than people who did not have surgery. Along with occasionally reporting a higher quality of life, they frequently showed increased lung function and increased ability for activity.

Lung volume reduction surgery can offer several benefits, including:

• Enhanced quality of life
• Improved lung function
• Reduced shortness of breath
• Greater exercise capacity
• Better breathing mechanics
• Decreased pressure on the diaphragm

LVRS offers symptom relief and enhances the quality of life for about half of those who undergo the procedure. Although it is not a cure for emphysema, the measure of success is based on how much better you feel post-surgery. The symptom relief typically lasts between two to five years.

Individuals with an inherited form of emphysema known as alpha-1-antitrypsin deficiency-related emphysema are unlikely to benefit from lung volume reduction surgery. Instead, a lung transplant may be a more effective treatment option for them. To ensure optimal care, patients with this condition should be referred to a multidisciplinary team of healthcare professionals.

Contact your healthcare provider with any questions or concerns before or after surgery. If you notice any signs of infection, a collapsed lung, or other serious complications, seek immediate medical attention. Symptoms to watch for include:

• Fever
• Chest pain
• Severe difficulty breathing
• Cyanosis (bluish discoloration of the skin, lips, or nails)