Effect of Lung-Volume Reduction Surgery in Patients with Severe Emphysema
Effect of Lung-Volume Reduction Surgery in Patients with Severe Emphysema
abstract & commentary
Synopsis: This study found that in selected patients with severe emphysema, lung-volume reduction surgery can improve FEV1, walking distance, and quality of life. Whether it reduces mortality is uncertain.
Source: Geddes D, et al. N Engl J Med 2000;343:239-245.
This was a randomized controlled trial in 48 patients comparing the effects of lung-volume reduction surgery (LVRS) vs. standard medical therapy. The inclusion criteria were severe emphysema as shown on computed tomography (CT) with no restrictions on the pattern or distribution of the emphysema, age younger than 75 years, a FEV1 greater than 500 mL, use of oxygen less than 18 hours per day, steroid dose of less than 10 mg per day, and PCO2 of less than 45 mm Hg. The exclusion criteria were patients with isolated bullae, asthma, previous thoracic surgery, or other serious medical conditions.
The patients were given medical treatment consisting of a smoking-cessation program, a trial of therapy with prednisolone (30 mg/d for 2 weeks), inhaled beta-adrenergic agonists, anticholinergics, oral theophylline, oral antibiotics to be kept at home for use when needed for chest infections, and vaccination against influenza and pneumococcus. Patients without any clear contraindication on initial assessment were entered into a six-week program of outpatient rehabilitation, consisting of physiotherapy and occupational therapy, with nursing, nutritional, and social services. After rehabilitation, patients were randomly assigned to surgery or to continued medical treatment. Both groups were reassessed at three, six, and 12 months after randomization and yearly thereafter.
Primary outcome measures were mortality, changes in FEV1, shuttle-walking distance, and quality of life at six months. The secondary measures were changes in forced vital capacity (FVC), total lung capacity (TLC), residual volume (RV), inspiratory and expiratory mouth pressures, and arterial-blood gas values.
Bilateral lung resection was performed through a median sternotomy or by thoracoscopy. Lung resection was performed with the use of various mechanical staplers, with or without bovine-pericardial-strip reinforcement. The baseline characteristics of patients did not differ significantly between the groups.
There were five deaths in the surgical group (21%) and three in the medical group (12%). Analysis of the entire study group showed no significant difference in survival between groups (P = 0.29). The changes from baseline differed significantly between the medical and surgical groups at six months for FEV1 (-80 mL and +70 mL, respectively; P = 0.02), shuttle-walking distance (-20 m and +50 m; P = 0.02), and SF-36 scores (-12 and +22; P = 0.003), for FEV1 at three months; and for shuttle-walking distance and SF-36 score at 12 months. Differences between surgical and medical groups were significant for total lung capacity, residual volumes, and inspiratory mouth pressure at three, six, and 12 months.
COMMENT By David Ost, MD, & Syed Rizvi, MD
LVRS has recently re-emerged as a surgical option for the treatment of end stage chronic obstructive pulmonary disease (COPD) due to underlying severe emphysema. Advocates of the surgery claim that it represents a significant breakthrough in the management of this challenging group of patients. The mechanism of action is thought to be an increase in lung elastic recoil after the targeted emphysematous tissue is resected. This leads to an increase in FEV1, decrease in functional residual capacity, increase in maximum voluntary ventilation, and increase in exercise capacity.1
Young and colleagues conducted a systematic review of 19 case series meeting rigorous methodological criteria for inclusion from 75 potentially relevant studies. The pattern of results was consistent across individual studies, despite a significant degree of clinical heterogeneity, and it was concluded that LVRS appears to represent a promising option in the management of patients with severe emphysema.2 Ferguson and colleagues demonstrated that LVRS produces significant improvements in exercise performance, dyspnea, and quality of life in selected patients with severe emphysema.3 Benditt and colleagues showed that LVRS improves maximal O2 consumption and maximal minute ventilation.4 This trial supports the benefits of lung volume reduction surgery as evidenced by statistically significant benefits in terms of FEV1, shuttle-walking distance, and quality of life at various follow-up times. The mortality was similar in the two groups, but the study had too few patients to evaluate this end point adequately. Although most patients who underwent surgery had considerable benefit, a few did not. In contrast, the condition of most of the patients treated medically worsened. Overall, this study supports the promising results demonstrated by other investigators using LVRS. More conclusive evidence will be available when the National Emphysema Treatment Trial (NETT) is completed.
References
1. Matsuzawa Y, et al. Nihon Kokyuki Gakkai Zasshi 1998;36(4):323-329.
2. Young J, et al. Thorax 1999;54(9):779-789.
3. Ferguson GT, et al. Am J Respir Crit Care Med 1998; 157:1195-1203.
4. Benditt JO, et al. Am J Respir Crit Care Med 1997; 156:561-566.
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