2. OBJECTIVES
Introduction and definition
NETT
Mechanisms of improvement
One-Stage Bilateral LVRS
Mortality and Morbidity
What to expect?
LVRS and Lung Transplantation
Articles
3. LVRS / reduction pneumoplasty / lung shaving / lung
contouring .
It is performed on patients with severe emphysema in order to
allow the remaining compressed lung to expand and thus
improve respiratory function.
LVRS
4. A form of (COPD) that is defined by abnormal and permanent
enlargement of the airspaces distal to the terminal bronchioles
and is associated with destruction of the alveolar walls.
In advanced stages of emphysema there is a sequence of events
:
EMPHYSEMA
Hyperinflation
Diaphragm mobility
Pleural pressure
Elastic recoil
5. Dr. Brantigan in 1957 was the first person to present the
concept of LVRS .
He proposed ( Resection of the most useless area and down
sizing the lung would help to restore the outward pull on the
small airway)
HISTORY
6. The first multi-center clinical
trial
5 years to complete. Recruitment ended on schedule in July 2002, and
follow up in December 2002.
7. There were 3 groups of patients that tend to benefit from
LVRS :
Group 1: Patients with predominantly upper lobe emphysema and low
exercise capacity.
Results: Improved survival and functional outcomes.
Group 2: Patients with predominantly upper lobe emphysema and high
exercise capacity.
Results : Improved functional outcomes.
Group 3: Patients with non-upper lobe emphysema and low exercise
capacity.
Results : Improved survival.
THE NATIONAL EMPHYSEMA TREATMENT TRIAL
NETT
12. CHEST WALL AND DIAPHRAGM
CONFIGURATION
Decreases rib cage diameter
Strength of inspiratory muscles
The diaphragm movement
13. A recent meta-analysis of randomized trials indicated that
following LVRS :
In an analysis of the NETT cohort :
Patients with upper-lobe emphysema on maximal exercise
showed:
higher output of CO2.
greater tidal volume.
increased hearth rate --------> slower and deeper breathing
patterns lasting for up to 24 months.
GAS EXCHANGE
Significant improvements occur both in
PaO2 and PaCO2
(Huang et al., 2011)
(Criner, 2009)
14. Improvement in both right and left ventricular function.
In an analysis from the NETT on pulmonary hemodynamic changes
at rest :
Except for a smaller change in end-expiratory capillary wedge
pressure, compared with medical treatment, LVRS was not
associated with an increase in pulmonary artery pressures.
CARDIOCIRCULATORY FUNCTION
( Criner et al., 2007 )
15. It is the most widely adopted approach since it produced :
The standard technique entails nonanatomical staple resection of
the most emphysematous lung tissue (resectional LVRS) carried
out on both lungs by :
median sternotomy
or VATS
through general anesthesia and single-lung ventilation.
ONE-STAGE BILATERAL LVRS
Greater functional and clinical
improvements
16. MORTALITY AND MORBIDITY
mortality rates
ranged between
0 and 17%
morbidity rate
of 59% has
been reported
in the NETT
Pulmonary
morbidity
within 90 days
30%
Cardiac
arrhythmia
23.5%
Cardiovascular
morbidity
within 90 days
20%
Pneumonia
18%
Reintubation
22%
(DeCamp et al., 2008)
17. The benefits of LVRS include significant improvements in :
BENEFITS
Exercise
capacity
Respiratory
function
Subjective
dyspnea
Quality of
life measures
Survival
18. Patients must participate in a 6 to 10 weeks pulmonary
rehabilitation program prior to surgery.
Immediately after the procedure, patients are allowed to breath
on their own.
Pain medication is given through an epidural catheter.
Drainage tubes are left in the chest.
Physical therapy is reinstituted early during the recovery phase
during the hospitalization.
WHAT TO EXPECT
19. Lung transplantation and LVRS both have advantages for patients
with severe emphysema.
LVRS AND LUNG TRANSPLANTATION
According to the age
LVRS
For older patients
Lung transplantation is
commonly 60–65 years
In young patients
LVRS - transplantation
20. LVRS proved to be able to delay the need for lung
transplantation by 3–6 years.
As a rule, lung transplantation can be performed safely after
LVRS
Findings of :
homogeneous or -1-antitrypsin-deficiency-related emphysema.
FEV1 < 20% predicted.
DLCO < 20% predicted.
Elevated pulmonary artery pressure.
The presence of scarring of the lungs or chronic inflammatory
changes.
LVRS AND LUNG TRANSPLANTATION
lung transplantation
24. Pao2 During Restful Breathing, Unloaded Pedaling, and Maximum Exercise at
Baseline and at 6, 12, and 24 Months
25. CONCLUSION
During exercise following LVRS, patients with severe
emphysema improve carbon dioxide elimination and dead
space, breathe slower and deeper, and report less dyspnea.
31. CONCLUSION
In selected patients with homogeneous pulmonary
emphysema, LVRS can be successfully performed with
low perioperative mortality. Significant
improvements in dyspnea, lung function and exercise
capacity are maintained for several years
(LVRS) is a procedure which removes approximately 20-35% of the poorly functioning, space occupying lung tissue from each lung
By reducing the lung size, the remaining lung and surrounding muscles (intercostals and diaphragm) are able to work more efficiently.
That intensifies expiratory muscle recruitment
is the first multi-center clinical trial designed to determine the role, safety, and effectiveness of bilateral lung volume reduction surgery (LVRS) in the treatment of emphysema. A secondary objective is to develop criteria for identifying patients who are likely to benefit from the procedure.
randomized, multicenter trial which compared the results of LVRS to medical therapy
These patients have improved survival and functional outcomes after LVRS compared to medical therapy.
These patients have improved functional outcomes after LVRS but no difference in survival compared to medical therapy
These patients have improved survival after LVRS but no difference in survival compared to medical therapy.
represent the ideal candidates for LVRS in terms of expected magnitude and duration of benefits
reported that LVRS decreases middle-to-lower anterior-to-posterior rib cage diameter as assessed by chest radiography and CT whereas, in another elegant study, Cassart et al. [62] have found that by decreasing the overall lung volume, LVRS makes the diaphragm dome move upwards and increases the area of muscle juxtaposed to the rib cage. Lower operating lung volumes have been reported to eventually lead to improvements in strength and efficiency of inspiratory muscles.
In an analysis of the NETT cohort, Criner and coworkers [68] reported that following LVRS, patients with upper-lobe emphysema on maximal exercise showed higher output of CO2, greater tidal volume, and increased hearth rate, which were associated with slower and deeper breathing patterns lasting for up to 24 months
Right and left ventricular function can be impaired in patients with advanced emphysema due to reduced end-diastolic volumes
beneficial effects of LVRS on right ventricular filling and performance have been hypothesized by our group [71] who reported that improvements in right ventricular function indexes occurred on exercise after LVRS and correlated with a reduction in RV/TLC. In a similar manner, Jörgensen et al. [72] reported post-LVRS increases in left ventricular end-diastolic dimensions and filling, eventually resulting in improved left ventricular function.
One-stage bilateral LVRS is the most widely adopted approach since it produced greater functional and clinical improvements than unilateral treatment
Median sternotomy is one of many incisions that can be made in the thorax and gives a wide view of the thoracic cavity
video-assisted thoracoscopic procedures: Video-assisted thoracoscopic surgery (VATS) is minimally invasive thoracic surgery that does not use a formal thoracotomy incision.
mortality rates ranged between 0 and 17% in previous studies (Table 2) whereas an overall morbidity rate of 59% has been reported in the NETT
major pulmonary and cardiovascular morbidity within 90 days post-LVRS occurred in 30% and 20% of patients, respectively
Cardiac arrhythmia was the most common complication with a rate of 23.5%
. Rates for pneumonia and need of reintubation were 18% and 22%, respectively
To optimize exercise capacity and improve early postoperative recovery,
Immediately after the procedure, patients are awakened from the general anesthetic and allowed to breath on their own.
to help control postoperative discomfort.
. to drain any excess air or fluid from the chest after surgery
Patients are discharged from the hospital once the patient is mobile, tolerating a regular diet and drainage tubes have been removed.
patients demonstrated to improve dyspnea, respiratory function, exercise capacity, and quality of life in patients with severe emphysema.
For older patients, LVRS remains the only surgical option to achieve a significant clinical benefit whereas patients aged 55–60 are more difficult to address since the benefits of LVRS may be lost over time when they reach an age limit which may be critical for lung transplantation.
In young patients who fulfill the criteria for both surgical treatments, LVRS can be performed first to postpone lung transplantation
