lung volume reduction surgery ( lvrs )
TRANSCRIPT
Mashail AlRayes
4 th year RT student
UOD
LUNG VOLUME REDUCTION
SURGERY “LVRS”
OBJECTIVES
Introduction and definition
NETT
Mechanisms of improvement
One-Stage Bilateral LVRS
Mortality and Morbidity
What to expect?
LVRS and Lung Transplantation
Articles
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
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
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
The first multi-center clinical
trial
5 years to complete. Recruitment ended on schedule in July 2002, and
follow up in December 2002.
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
CRITERIA FOR THE CANDIDATES
THE IDEAL CANDIDATES FOR LVRS
Patients with upper-lobe predominant
emphysema and low exercise capacity
MECHANISMS OF IMPROVEMENT
Cardiocirculatory Function
Gas Exchange
Chest Wall and Diaphragm
Configuration
Lung Elastic Recoil
LUNG ELASTIC RECOIL
lung elastic recoil
dynamic complianceIntrinsic PEEPwork of breathing
Residual volume
exercise tolerance
ventilatory mechanics
CHEST WALL AND DIAPHRAGM
CONFIGURATION
Decreases rib cage diameter
Strength of inspiratory muscles
The diaphragm movement
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)
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 )
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
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)
The benefits of LVRS include significant improvements in :
BENEFITS
Exercise
capacity
Respiratory
function
Subjective
dyspnea
Quality of
life measures
Survival
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
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
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
ARTICLE
Baseline demographics, Respiratory function and emphysema
distribution
Measurements During Maximum Exercise at Baseline
and 6, 12 and 24 Months
Pao2 During Restful Breathing, Unloaded Pedaling, and Maximum Exercise at
Baseline and at 6, 12, and 24 Months
CONCLUSION
During exercise following LVRS, patients with severe
emphysema improve carbon dioxide elimination and dead
space, breathe slower and deeper, and report less dyspnea.
ARTICLE
Baseline demographics
Baseline Hemodynamic Variables In Medical and Lung
Volume Reduction Surgery Groups
CONCLUSION
In comparison to medical therapy, LVRS was not
associated with an increase in pulmonary artery
pressures.
ARTICLE
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
http://www.hindawi.com/journals/isrn/2014/418092/#B
9
http://www.cts.usc.edu/lungvolumereductionsurgery.ht
ml
http://www.atsjournals.org/doi/full/10.1164/ajrccm.159.
4.9808060#.Vxsx2l47YiC
REFERENCES