As palliative treatment, lung volume reduction surgery can be offered to a selected subset of chronic obstructive pulmonary disease patients. Careful adherence to established inclusion and exclusion criteria is critical to achieve good outcomes. The evolution of surgical techniques toward minimally invasive approaches has improved outcomes. The fully extrathoracic access combining a subxiphoid incision with subcostal port placement allowed a further decrease in perioperative pain, which favors spontaneous respiratory drive and early postoperative mobilization. Less aggressive resections and better match for size of the hemithorax have contributed to a short-term reduction in morbidity and continued improvements in cardiopulmonary function.
Key points
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Lung volume reduction surgery (LVRS) can be offered to a carefully selected subset of chronic obstructive pulmonary disease patients.
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Bilateral LVRS is recommended.
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Minimally invasive approaches improve outcomes.
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Extrathoracic subxiphoid incision with subcostal ports decrease postoperative pain to improve spontaneous breathing and early mobilization.
Introduction
Initially described in the 1950s by Brantigan and colleagues, lung volume reduction surgery (LVRS) was highly controversial until the completion of the National Emphysema Treatment Trial (NETT) in the late 1990s. This study demonstrated that patients with both upper-lobe predominant emphysema and low baseline exercise capacity benefited from surgery in terms of survival and quality of life. It also demonstrated this benefit was durable. Patients assigned to LVRS in the NETT underwent bilateral stapled lung volume reduction through either a median sternotomy (MS) or a video-assisted bilateral thoracic surgery (VATS). With stringent selection criteria being adopted after the NETT trial, the subsequent era saw a transition from maximally invasive resections carried out via sternotomy toward bilateral VATS surgeries. For these procedures, the intraoperative general anesthesia was complemented by an epidural catheter to improve postoperative pain management and allow for early patient mobilization. In this article, the authors review the historical evolution of surgical techniques used to perform LVRS, including the recent development of subxiphoid surgery, especially when coupled with subcostal port placement further reduced postoperative pain.
Anesthetic management
LVRS is routinely performed under intubated general anesthesia using a left-sided double-lumen endotracheal tube (ET). A single lumen tube can first be placed to perform flexible bronchoscopy for evaluation of the bronchial tree and to assess and clear secretions. A microbiology sample should be obtained to help guide antibiotic management should the patient develop postoperative infectious complications.
Ventilation must be protective during surgery, as the major risk faced by chronic obstructive pulmonary disease (COPD) patients during positive pressure ventilation is a further increase in air trapping resulting in hemodynamic instability. Low tidal volumes (5–8 mL/kg) to achieve low plateau pressures (<15–20 cm H 2 O) and low to no positive end-expiratory pressure at a slower rate (10–12 breaths per minute) to increase in the inspiratory-to-expiratory ratio (1:3) are strategies to prevent air trapping. Nevertheless, disconnecting the ET from the vent will drop ventilator tension-related life-threatening situations. If the patient remains hypotensive upon ET tube disconnection, the alternative diagnosis of tension pneumothorax must be evoked and addressed. Soon after positioning, ventilation to the first addressed side must be stopped to allow enough time for the lung to deflate.
The major downside of protective ventilation in these patients is hypercapnia, which will be tolerated in a “permissive” strategy as long as pH is kept greater than 7.25. This permissive strategy also includes oxygenation, as Fi o 2 is kept as low as possible to achieve saturations greater than 90%. Before extubation, the permissive hypercapnia must be recognized and fully reversed to avoid and exacerbate the drowsiness associated with higher Pa co 2 after extubation. For the same purpose, the authors very cautiously use opioids for pain management during LVRS, as their undesirable effects (eg, prolonged respiratory depression) may greatly impact the early postoperative period. Short-acting synthetic opioids (eg, fentanyl or remifentanil) are therefore definitively preferred intraoperatively in these patients. Opioids should be used very cautiously postoperatively and avoided in the epidural in the early postoperative period.
Over time, refinements in the authors’ surgical techniques have resulted in less surgical pain, which, on the one hand, decreases pain management requirements, and on the other hand, improves early patient mobilization postoperatively. By using the fully extrathoracic approach depicted in later discussion, the authors have now moved away from using epidural catheters in LVRS patients. Ultimately, the goal is to improve the patient’s respiratory drive after extubation and in the early postoperative period. Extubated, awake, and alert patients are then transferred to the intensive care unit (ICU) for 24 to 48 hours of monitoring. Patients failing this strategy are placed on bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP). The authors favor early tracheostomy for patients who are finally reintubated.
Surgical aspects
Strategy
Following the NETT trial and with experience, more data concerning LVRS became available, defining inclusion and exclusion criteria for LVRS. Patient selection is the initial step of the surgical strategy, and these patient characteristics have been shown to accurately predict outcome. The authors therefore recommend diligently respecting these criteria as a critical guide to develop a safe LVRS program ( Table 1 ). Next, although unilateral LVRS may produce an excellent result in the highly selected patient, the bilateral procedure has been shown to be the procedure of choice, because it provides improved survival and physiology with no increased morbidity or mortality compared with the unilateral procedure ( Table 2 ).
| Inclusion Criteria | Exclusion Criteria |
|---|---|
| History and physical examination, chest roentgenogram, and HRCT scan consistent with bilateral emphysema | CT evidence of diffuse emphysema judged inappropriate for LVRS |
| Severe upper-lobe predominant emphysema | Dysrhythmia or exercise-related syncope that might pose a risk during exercise or training |
| Severe non-upper-lobe predominant emphysema with low exercise capacity | Resting bradycardia; frequent multifocal PVCs; complex ventricular arrhythmia; sustained SVT |
| Body mass index ≤31.1 kg/m 2 (men) or ≤32.3 kg/m 2 (women) | Myocardial infarction within 6 mo and LVEF <45% |
| Stable with ≤20 mg prednisone (or equivalent) each day | Congestive heart failure within 6 mo and LVEF <45% |
| Plasma cotinine level ≤13.7 ng/mL (or arterial carboxyhemoglobin ≤2.5% if using nicotine products) | Uncontrolled hypertension (systolic >200 mm; diastolic >110 mm) |
| Non-smoking for 4 mo | History of recurrent infections with clinically significant sputum production |
| FEV1 ≥45% predicted (15% predicted if age 70 y) | Pleural or interstitial disease that precludes surgery |
| TLC ≥100% predicted postbronchodilator | Clinically significant bronchiectasis |
| RV ≥150% predicted postbronchodilator | Previous lung transplant, LVRS, lobectomy |
| P co 2 ≤60 mm Hg | Pulmonary hypertension: peak systolic PAP ≥45 mm Hg or mean PAP ≥35 mm Hg |
| P o 2 ≥45 mm Hg on room air | Requirement for > 6 L oxygen to keep saturation ≥90% with exercise |
| Postrehabilitation 6-min walk distance of ≥140 m | Unplanned weight loss of >10% usual weight in previous 90 d |
| Able to complete 3 min unloaded pedaling in exercise tolerance test | |
| Approval for surgery by cardiologist if unstable angina, LVEF <45%, arrhythmia |
| Author, Year | n | Technique | Mortality (%) | LOS (d) | Change in FEV 1 |
|---|---|---|---|---|---|
| McKenna, 1996 | 87 | Unilateral | 3 | 11.4 | 31% |
| Naunheim, 1996 | 50 | Unilateral | 2 | 13 | 35% |
| Keenan, 1996 | 57 | Unilateral | 2 | 17 | 27% |
| Cooper, 1996 | 150 | Bilateral | 4 | 13.5 | 51% |
| Kotloff, 1996 | 80 | Bilateral | 13.8 | 22 | 41% |
| Argentano, 1996 | 85 | Bilateral | 7 | 17 | 61% |
| McKenna, 1997 | 154 | Bilateral | 4 | 11 | 52% |
| Kotloff, 1996 | 40 | Bilateral | 2. S | 15 | 41% |
| NETT, , 2003/4 | 511 | Bilateral | 2.2 | 10 | NR |
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