Lung Volume Reduction Procedures

Both procedures reduce the area of the over-expanded and damaged lung to allow the more normal remaining lung to work more efficiently. This allows patients to breathe easier.

This surgical approach to lung disease is found to benefit patients with upper lobe predominant emphysema and a low baseline exercise capacity. This means that the lung disease affecting the upper parts of the lungs in patients with relatively lower exercise ability tend to have the best outcomes from this treatment.

LVRS vs. BLVR: Using Endobronchial Valves

With BLVR the endobronchial valves help reduce hyperinflation, which happens when air becomes trapped in the airways of the lungs.

Hyperinflation is what makes breathing hard for emphysema patients. By guiding a bronchoscope through the mouth or nose into the lungs, endobronchial valves are then inserted into the lungs to block diseased parts of the lung. Illustration of an endobronchial valve being implanted in the lung via a special tool called a bronchoscope.

Unlike lung volume reduction surgery, endobronchial valves are a minimally invasive procedure that can be performed in the doctor's office. The valves help to reduce pressure on the lungs, allowing easier and deeper breaths while improving the patient's overall quality of life. In addition, there is no need for general anesthesia or major incisions which can lead to faster recovery times and fewer risks associated with any surgical procedure.

In general, the best candidates for a successful surgery tend to be those who:

• Have severe lung damage (emphysema), particularly in the upper part of the lung
• Are physically active and able to exercise
• Are non-smokers
• Have been diagnosed with COPD for at least 2 years
• Have no other health conditions

Findings from the National Emphysema Treatment Trial

The results of the National Emphysema Treatment Trial (NETT) study, first published in 2003, identified four sub-groups of patients who had different risks and benefits from LVRS:

Group 1: Mostly upper lobe emphysema and low exercise capacity. These patients are more likely to live longer and are more likely to function better after LVRS than after medical treatment. This patient group may receive the most benefit from LVRS, as compared with the other patient groups.

Group 2: Predominantly upper lobe emphysema and high exercise capacity. This patient group falls somewhere in between Group 1 and Group 4 in terms of the benefits of LVRS compared to medical treatment. While LVRS may provide some improvement in survival and function, the benefits may not be as significant as in Group 1.

Group 3: Predominantly lower lobe emphysema and low exercise capacity. This patient group has the least benefit from LVRS compared to the other patient groups and may be better served by medical therapy than surgical intervention.

Group 4: Predominantly lower lobe emphysema and high exercise capacity. These patients have a similar response to LVRS as Group 1, with improved survival and better function after surgery compared to medical treatment. However, the benefits may not be as significant as in Group 1.

It is important to note that the NETT study is just one piece of the puzzle when it comes to determining the best treatment option for patients with severe emphysema. Each patient is unique and may have different needs and circumstances that affect their response to treatment. Therefore, a thorough evaluation by a team of experts is essential in determining the best treatment plan for each individual patient.

Before undergoing LVRS, patients must be evaluated by a pulmonologist and thoracic surgeon. This will determine if you are an ideal candidate and which procedure may be best for you.

Required preoperative testing include:

• Pulmonary function tests
• Six minute walk test
• Arterial blood gas to measure levels of carbon dioxide and oxygen in the blood
• CT scans of the lungs, electrocardiography (ECG), echocardiogram and a lung perfusion scan
• Cardiopulmonary exercise test including a 6-minute walk test, performed on a treadmill or stationary bike to assess cardiac and pulmonary function

Other testing may be required depending on your health and specific situation. To be a candidate, you must have stopped smoking for at least 4 months and have completed a pulmonary rehabilitation program.

An ideal candidate for the LVRS procedure will:

• Have severe lung damage (emphysema), particularly in the upper part of the lung
• Have completed a pulmonary rehabilitation program
• Have not smoked for at least 4 months
• Do not have severe heart disease or other health problems that make surgery higher risk
• Do not require larger doses of steroids (prednisone), >20 mg daily
• Do not require over 6L of oxygen at rest

An ideal candidate for the BLVR procedure will:

• Have severe lung damage (emphysema)
• Have completed a pulmonary rehabilitation program
• Have not smoked for at least 4 months and to commit to not smoking after valve placement, as valves may stop working with continued lung destruction
• Do not have severe heart disease or other health problems that make the procedure higher risk
• Do not have frequent COPD exacerbations (frequent courses of prednisone/steroids)
• Do not require larger doses of steroids (prednisone), >15 mg daily

Who may not be a candidate for Lung Volume Reduction Surgery?

People who are born with an inherited form of emphysema, called alpha-1-antitrypsin deficiency-related emphysema, are not likely to benefit from lung volume reduction surgery. A lung transplant may be a better treatment option than lung volume reduction surgery for these individuals.

What are the Benefits of Surgical Lung Volume Reduction?

Both procedures can result in significant improvements in quality of life, allowing patients to breathe easier and do more. In some cases, it may even allow patients to live longer and decrease the amount of oxygen they need.

Studies have shown that lung volume reduction surgery improves exercise capacity, lung function and quality of life in selected patients when compared with people who were treated non-surgically.

Why choose LVRS over other treatment options for COPD and Emphysema?

UC Health is home to the best and brightest. Whether it is valves for bronchoscopy lung volume reduction or a minimally invasive, bronchoscopic lung volume reduction surgery, patients who come to our program are guaranteed to receive the highest level of care and a personalized, multidisciplinary treatment approach.

What are the Risks of Lung Volume Reduction Surgery?

There are some risks and common complications associated with both LVRS and BLVR.

Risks for Lung volume reduction surgery (LVRS) include:

• Wound infection
• Prolonged air leak into the chest cavity (needing your chest tube in longer than normal)
• Bleeding
• Pain or numbness at the incision site
• Infection such as pneumonia
• Respiratory failure
• Atrial fibrillation (irregular heartbeat that is usually temporary and controlled with medication)

Risks of Bronchoscopic lung volume reduction (BLVR) include:

• Pneumonia
• Respiratory failure
• Pneumothorax (air around the lung)
• COPD Exacerbation

In the days leading up to the procedure, the patient may need to undergo additional tests and imaging studies to ensure that they are healthy enough for surgery. They may also need to stop taking certain medications or make other lifestyle changes in preparation for the procedure.

Overall, the evaluation process before LVRS is thorough and designed to ensure that the patient receives the safest and most effective treatment possible.

For Lung Volume Reduction Surgery (LVRS):

Patients are typically in the hospital for an average of 7 days, sometimes shorter or longer, after LVRS.  After leaving the hospital, you will not do everything you did before surgery.

What will my recovery look like?

Your body will need almost 2 months to return to a normal activity. Patients should expect to start seeing a benefit (improvement in quality of life, breathing easier) in about 3 months after surgery.

Patients are seen for follow up at 2 weeks, 6 weeks, 6 months and 1 year after the procedure and annually thereafter.

For Bronchoscopic Lung Volume Reduction (BLVR):

Your body will need around 2 weeks—although up to 6 weeks —to recover and ultimately find a benefit. There can be further gradual improvement out to 6 months, thereafter the valves are kept in place indefinitely and can undergo revision if needed. 

Patients are cleared to return to pulmonary rehabilitation at 2 weeks post-procedure.