lung volume reduction surgery ( lvrs )

33
Mashail AlRayes 4 th year RT student UOD LUNG VOLUME REDUCTION SURGERY “ LVRS

Upload: mashail-alrayes

Post on 28-Jan-2018

508 views

Category:

Health & Medicine


3 download

TRANSCRIPT

Page 1: Lung volume reduction surgery ( LVRS )

Mashail AlRayes

4 th year RT student

UOD

LUNG VOLUME REDUCTION

SURGERY “LVRS”

Page 2: 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

Page 3: Lung volume reduction surgery ( LVRS )

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

Page 4: Lung volume reduction surgery ( 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

Page 5: Lung volume reduction surgery ( LVRS )

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

Page 6: Lung volume reduction surgery ( LVRS )

The first multi-center clinical

trial

5 years to complete. Recruitment ended on schedule in July 2002, and

follow up in December 2002.

Page 7: Lung volume reduction surgery ( LVRS )

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

Page 8: Lung volume reduction surgery ( LVRS )

CRITERIA FOR THE CANDIDATES

Page 9: Lung volume reduction surgery ( LVRS )

THE IDEAL CANDIDATES FOR LVRS

Patients with upper-lobe predominant

emphysema and low exercise capacity

Page 10: Lung volume reduction surgery ( LVRS )

MECHANISMS OF IMPROVEMENT

Cardiocirculatory Function

Gas Exchange

Chest Wall and Diaphragm

Configuration

Lung Elastic Recoil

Page 11: Lung volume reduction surgery ( LVRS )

LUNG ELASTIC RECOIL

lung elastic recoil

dynamic complianceIntrinsic PEEPwork of breathing

Residual volume

exercise tolerance

ventilatory mechanics

Page 12: Lung volume reduction surgery ( LVRS )

CHEST WALL AND DIAPHRAGM

CONFIGURATION

Decreases rib cage diameter

Strength of inspiratory muscles

The diaphragm movement

Page 13: Lung volume reduction surgery ( LVRS )

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)

Page 14: Lung volume reduction surgery ( LVRS )

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 )

Page 15: Lung volume reduction surgery ( LVRS )

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

Page 16: Lung volume reduction surgery ( LVRS )

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)

Page 17: Lung volume reduction surgery ( LVRS )

The benefits of LVRS include significant improvements in :

BENEFITS

Exercise

capacity

Respiratory

function

Subjective

dyspnea

Quality of

life measures

Survival

Page 18: Lung volume reduction surgery ( LVRS )

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

Page 19: Lung volume reduction surgery ( LVRS )

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

Page 20: Lung volume reduction surgery ( LVRS )

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

Page 21: Lung volume reduction surgery ( LVRS )

ARTICLE

Page 22: Lung volume reduction surgery ( LVRS )

Baseline demographics, Respiratory function and emphysema

distribution

Page 23: Lung volume reduction surgery ( LVRS )

Measurements During Maximum Exercise at Baseline

and 6, 12 and 24 Months

Page 24: Lung volume reduction surgery ( LVRS )

Pao2 During Restful Breathing, Unloaded Pedaling, and Maximum Exercise at

Baseline and at 6, 12, and 24 Months

Page 25: Lung volume reduction surgery ( LVRS )

CONCLUSION

During exercise following LVRS, patients with severe

emphysema improve carbon dioxide elimination and dead

space, breathe slower and deeper, and report less dyspnea.

Page 26: Lung volume reduction surgery ( LVRS )

ARTICLE

Page 27: Lung volume reduction surgery ( LVRS )

Baseline demographics

Page 28: Lung volume reduction surgery ( LVRS )

Baseline Hemodynamic Variables In Medical and Lung

Volume Reduction Surgery Groups

Page 29: Lung volume reduction surgery ( LVRS )

CONCLUSION

In comparison to medical therapy, LVRS was not

associated with an increase in pulmonary artery

pressures.

Page 30: Lung volume reduction surgery ( LVRS )

ARTICLE

Page 31: Lung volume reduction surgery ( LVRS )

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

Page 32: Lung volume reduction surgery ( LVRS )

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

Page 33: Lung volume reduction surgery ( LVRS )