Surgical management of Severe Emphysema
Lung Volume Reduction
Severe emphysema, a chronic obstructive pulmonary disease (COPD), can be managed surgically through procedures like lung volume reduction surgery (LVRS) and the placement of endobronchial valves (BLVR).
LVRS involves the removal of the most damaged parts of the lungs, improving the performance of the remaining, healthier lung tissue. This can enhance breathing mechanics and gas exchange, reducing breathlessness and improving exercise capacity.
Endobronchial valves, are minimally invasive devices placed in the airways leading to the more damaged lung areas. These one-way valves allow air to exit these regions during exhalation but prevent air from entering during inhalation. This results in the collapse of the diseased lung areas, effectively excluding them from ventilation. The remaining healthier lung areas can then expand and function more efficiently, improving overall lung function and quality of life.
Both LVRS and endobronchial valve placement aim to improve lung function by excluding the more destroyed and less perfused parts of the lungs. However, patient selection is crucial, and these procedures should be considered as part of a comprehensive treatment plan for severe emphysema.
Investigations for Emphysema Diangosis
Lung Function Tests
Lung Function Tests
Lung Function Tests
Lung function tests, like spirometry, measure airflow and lung volumes, helping diagnose emphysema. In emphysema with these tests reveal reduced airflow, increased residual volume, and total lung capacity, indicating trapped air and lung overexpansion, characteristic of hyperinflation.
Chest X-ray
Lung Function Tests
Lung Function Tests
A chest X-ray in diagnosing severe emphysema shows an increased lung field, flattened diaphragm, and decreased vascular markings. These signs indicate over-expanded lungs due to trapped air, a characteristic feature of emphysematous hyperinflation.
Shuttle Walk Test
Lung Function Tests
Shuttle Walk Test
The Shuttle Walk Test or 6-Minute Walk Test assesses exercise capacity in emphysema patients with hyperinflation. Reduced walking distance indicates impaired lung function and exercise intolerance, common in severe emphysema. It helps gauge disease severity and response to treatment.
Which patients will benefit from Surgery?
Computed Tomography (CT)
Computed Tomography (CT) is essential in assessing patients for lung volume reduction surgery or endobronchial valve placement. It provides detailed images of the lungs, allowing doctors to visualize the extent and distribution of emphysematous changes, including areas of low attenuation (indicative of destroyed lung tissue) and bullae (large air spaces). CT can also measure lung volumes, helping to identify hyperinflation.
StratX® Lung Analysis Report
StratX analysis is a quantitative CT analysis used in planning volume reduction procedures in emphysema. It helps identify hyperinflated, less functional lung regions for targeted treatment, improving procedure outcomes and patient’s lung function post-procedure. StratX analysis also aids in assessing fissure integrity, which is crucial for endobronchial valve placement. Complete fissures minimize collateral ventilation, making valve treatment more effective.
Lung Ventilation-Perfusion (V/Q) scan
These scans provide a detailed assessment of both the airflow (ventilation) and blood flow (perfusion) in different regions of the lungs. In emphysema, certain areas of the lungs are often more damaged and show poor ventilation and perfusion. V/Q scans help identify these less functional areas, which are then targeted for volume reduction. By doing so, the procedure spares the healthier, more functional lung tissue.
Preparation for surgery and Prehabilitation
Smoking cessation
Optimisation of medical treatment
Optimisation of medical treatment
Smoking cessation is a crucial step in preparation for lung volume reduction surgery in patients with emphysema. Continued smoking can worsen lung damage, reduce the effectiveness of the surgery, and increase postoperative complications. Quitting smoking before surgery allows the lungs to start healing, improves lung function, and enhances the body’s ability to recover post-surgery. It also reduces the risk of surgical complications such as infections and respiratory failure.
Optimisation of medical treatment
Optimisation of medical treatment
Optimisation of medical treatment
Optimisation of medical treatment is a vital step in preparing for lung volume reduction surgery. It involves ensuring that the patient’s existing lung condition is managed as effectively as possible with medications. This can include bronchodilators to widen the airways, corticosteroids to reduce inflammation, or antibiotics to treat infections. Optimising these treatments also helps to minimise potential complications during and after the procedure.
Heart Echocardiography
Pulmonary rehabilitation
Pulmonary rehabilitation
Heart echocardiography, or an echocardiogram, is a non-invasive test that uses ultrasound to visualize the heart’s structure and function. In preparation for lung volume reduction surgery, it plays a crucial role in assessing the patient’s cardiac health. It helps detect any underlying heart conditions that could complicate the surgery or anaesthesia, such as heart failure, valve disorders, or pulmonary hypertension, which is common in severe emphysema.
Pulmonary rehabilitation
Pulmonary rehabilitation
Pulmonary rehabilitation
Pulmonary rehabilitation plays a significant role in preparing patients for lung volume reduction surgery. It’s a comprehensive intervention program that improves the physical and psychological condition of people with lung disease. The program includes patient education, exercise training, nutrition advice, and emotional support. By improving physical strength and endurance, pulmonary rehabilitation helps patients better tolerate the surgery and recover faster postoperatively.
Procedures for Lung Volume Reduction
Chartis assessment
The Chartis assessment is a critical step before inserting endobronchial valves in patients with severe emphysema. It’s a catheter-based system that measures airflow and pressure in the targeted lung area. The goal is to assess collateral ventilation, the airflow between different parts of the lung that can bypass the valves, rendering them ineffective. If the Chartis assessment shows low or no collateral ventilation, the patient is likely to benefit from valve placement. This ensures the procedure is tailored to the patient’s unique lung anatomy and disease state, maximizing the chances of successful treatment and improved lung function.
Placement of endobronchial valves
The process of inserting endobronchial valves in patients with severe emphysema is a minimally invasive procedure performed under general anaesthesia. The physician uses a bronchoscope to navigate to the targeted airway leading to the diseased part of the lung. The one-way endobronchial valve is then placed into the airway using a delivery catheter. This valve allows air to leave the diseased lung area but prevents it from re-entering. Over time, the treated part of the lung collapses, allowing the healthier parts of the lung to expand and function more efficiently.
Lung Volume Reduction Surgery
In Lung Volume Reduction Surgery (LVRS), either through Robotic-Assisted Thoracic Surgery (RATS) or Video-Assisted Thoracic Surgery (VATS), the most damaged parts of the lungs are removed, allowing the remaining healthier lung tissue to expand and function more efficiently. RATS and VATS are minimally invasive techniques that use small incisions, reducing recovery time. The surgery can be unilateral, involving one lung, or bilateral, involving both lungs, depending on the patient’s condition. LVRS can significantly improve breathing, exercise capacity, and quality of life in carefully selected patients with severe emphysema and hyperinflation.
Post-Operative Follow-up & Interventions
Improvement of respiratory mechanics
Improvement of respiratory mechanics
Improvement of respiratory mechanics
In emphysema, hyperinflation of the lungs impairs their ability to effectively exchange oxygen and carbon dioxide, leading to breathlessness. LVRS reduces this hyperinflation, allowing the diaphragm and chest wall to return to a more normal position and improving their mechanical advantage. This enhances lung compliance, reduces the work of breathing, and improves gas exchange. Consequently, patients experience less shortness of breath, improved exercise tolerance, and a better quality of life.
Future re-intervention
Improvement of respiratory mechanics
Improvement of respiratory mechanics
Emphysema is a progressive disease and even though Lung Volume Reduction can significantly improve symptoms and lung function, it is not a curative procedure. Over time, the remaining lung tissue may continue to deteriorate due to the ongoing disease process, leading to symptom recurrence. In such cases, patients may require staged or repeat interventions, targeting different lung areas.