pulmonary disorders
Treatment of Stable COPD
Surgery in Stable COPD
Surgical options for treatment of severe COPD include Lung volume reduction Lung transplantation Lung volume reduction surgery consists of resecting nonfunctioning emphysematous areas. The procedure improves lung function, exercise tolerance, and quality of life in patients with severe, predominantly upper-lung emphysema who have low baseline exercise capacity after pulmonary rehabilitation. Mortality is increased in the first 90 days after lung volume reduction surgery, but survival is higher at 5 years. The effect on arterial blood gas measurements is variable and not predictable, but most patients who require oxygen therapy before surgery continue to need it. Improvement is less than that with lung transplantation. The mechanism of improvement is believed to be enhanced lung recoil and improved diaphragmatic function. Operative mortality is about 5%. The best candidates for lung volume reduction surgery are patients with an FEV1 20 to 40% of predicted, a DLCO>20% of predicted, significantly impaired exercise capacity, heterogeneous pulmonary disease on CT with an upper-lobe predominance, PaCO2<50 mm Hg, and absence of severe pulmonary hypertension and coronary artery disease. Rarely, patients have extremely large bullae that compress the functional lung. These patients can be helped by surgical resection of these bullae, with resulting relief of symptoms and improved pulmonary function. Generally, resection is most beneficial for patients with bullae affecting more than one third of a hemithorax and an FEV1 about half of the predicted normal value. Improved pulmonary function is related to the amount of normal or minimally diseased lung tissue that was compressed by the resected bullae. Serial chest x-rays and CT scans are the most useful procedures for determining whether a patient’s functional status is due to compression of viable lung by bullae or to generalized emphysema. A markedly reduced DLCO (<40% predicted) indicates widespread emphysema and suggests a poorer outcome from surgical resection. Lung and Heart-Lung Transplantation can be single or double. Perioperative complications tend to be lower with single-lung transplantation, but some evidence shows that survival time is increased with double-lung transplantation. Candidates for transplantation are patients Endobronchial valves that cause atelectasis of emphysematous target regions of the lung in selected patients who do not have collateral ventilation to these regions are available in selected centers. Placement of an endobronchial valve is an alternative to lung volume reduction surgery in some patients. Surgical lung volume reduction is usually bilateral, whereas bronchoscopic procedures are usually unilateral and therefore result in less improvement. 