Prospective Randomized Trial Comparing Bilateral Lung Volume Reduction Surgery to Pulmonary Rehabilitation in Severe Chronic Obstructive Pulmonary Disease

Abstract

Several uncontrolled studies report improvement in lung function, gas exchange, and exercise capacity after bilateral lung volume reduction surgery (LVRS). We recruited 200 patients with severe chronic obstructive pulmonary disease (COPD) for a prospective randomized trial of pulmonary rehabilitation versus bilateral LVRS with stapling resection of 20 to 40% of each lung. Pulmonary function tests, gas exchange, 6-min walk distance, and symptom-limited maximal exercise testing were done in all patients at baseline and after 8 wk of rehabilitation. Patients were then randomized to either 3 additional months of rehabilitation or LVRS. Thirty-seven patients met study criteria and were enrolled into the trial. Eighteen patients were in the medical arm; 15 of 18 patients completed 3 mo of additional pulmonary rehabilitation. Thirty-two patients underwent LVRS (19 in the surgical arm, 13 crossover from the medical arm). After 8 wk of pulmonary rehabilitation, pulmonary function tests remained unchanged compared with baseline data. However, there was a trend toward a higher 6-min walk distance (285 +/- 96 versus 269 +/- 91 m, p = 0.14) and total exercise time on maximal exercise test was significantly longer compared with baseline values (7.4 +/- 2.1 versus 5.8 +/- 1.7 min, p < 0.001). In 15 patients who completed 3 mo of additional rehabilitation, there was a trend to a higher maximal oxygen consumption (V O(2)max) (13.3 +/- 3.0 versus 12.6 +/- 3.3, p < 0.08). In contrast, at 3 mo post-LVRS, FVC (2.79 +/- 0.59 versus 2.36 +/- 0.55 L, p < 0.001) and FEV(1) (0.85 +/- 0.3 versus 0.65 +/- 0.16 L, p < 0.005) increased whereas TLC (6.53 +/- 1.3 versus 7.65 +/- 2.1 L, p < 0.001) and residual volume (RV) (3.7 +/- 1.2 versus 4.9 +/- 1.1 L, p < 0.001) decreased when compared with 8 wk postrehabilitation data. In addition, Pa(CO(2)) decreased significantly 3 mo post-LVRS compared with 8 wk postrehabilitation. Six-minute walk distance (6MWD), total exercise time, and V O(2)max were higher after LVRS but did not reach statistical significance. However, when 13 patients who crossed over from the medical to the surgical arm were included in the analysis, the increases in 6MWD (337 +/- 99 versus 282 +/- 100 m, p < 0.001) and V O(2)max (13.8 +/- 4 versus 12.0 +/- 3 ml/kg/min, p < 0.01) 3 mo post-LVRS were highly significant when compared with postrehabilitation data. The Sickness Impact Profile (SIP), a generalized measure of quality of life (QOL), was significantly improved after 8 wk of rehabilitation and was maintained after 3 mo of additional rehabilitation. A further improvement in QOL was observed 3 mo after LVRS compared with the initial improvement gained after 8 wk of rehabilitation. There were 3 (9.4%) postoperative deaths, and one patient died before surgery (2.7%). We conclude that bilateral LVRS, in addition to pulmonary rehabilitation, improves static lung function, gas exchange, and QOL compared with pulmonary rehabilitation alone. Further studies need to evaluate the risks, benefits, and durability of LVRS over time.

Effects of Lung Volume Reduction Surgery on Gas Exchange and Breathing Pattern During Maximum Exercise

“…LVRS resulted in an approximately 20% reduction in the percentage of patients exhibiting ventilatory limitation as a primary cause for exercise termination. These data support improvements in lung, 14,15,18,26,27 chest wall, 9,16 and respiratory muscle mechanics, 5,7 as responsible for enhancing exercise performance following LVRS. Our data show that ventilatory improvements occur following LVRS throughout the continuum of exercise, from submaximal (unloaded cycling) through maximum symptom-limited exercise workloads.…”

“…[3][4][5][6][7][8][9] Dynamic hyperinflation and an elevated work of breathing precipitate breathlessness, thereby decreasing exercise tolerance and quality of life. 1,10,11 Lung volume reduction surgery (LVRS) increases lung elastic recoil 12 and decreases end-expiratory lung volume, 3,6,13,14 thereby improving lung [15][16][17][18] and respiratory muscle mechanics 5,7 and overall exercise tolerOriginal Research CARDIOTHORACIC SURGERY ance. 19 -24 However, most of the published reports are uncontrolled, unicenter trials involving small numbers of patients with short-term follow-up.…”

“…19 -24 However, most of the published reports are uncontrolled, unicenter trials involving small numbers of patients with short-term follow-up. 3,5,[17][18][19]22,23,[25][26][27] The National Emphysema Treatment Trial (NETT) represents the most extensively characterized patient cohort with severe emphysema undergoing repeated exercise testing. Here we report the effects of optimal medical therapy plus LVRS vs optimal medical therapy alone on maximum exercise after outpatient rehabilitation and through 2 years postrandomization to treatment.…”

Effects of lung volume reduction surgery in hamsters with elastase-induced emphysema

“…Lung volume reduction surgery (LVRS) has been shown to have a beneficial effect on lung function, submaximal exercise capacity and quality of life in selected patients with severe emphysema [1][2][3], although individual results classically demonstrate large scatter [1]. Initially, it was proposed that the increase in maximal expiratory flow (MEF) observed after LVRS was mainly due to an improvement in lung elastic recoil after the surgical procedure [4].…”

Lung volume reduction surgery: what can we learn from the National Emphysema Treatment Trial?: Fig. 1.—

“…Several large case series from centres with considerable experience have demonstrated a low operative mortality (v5%) and significant improvements in symptoms, pulmonary function, and exercise capacity in the short and intermediate term after LVRS [3][4][5][6][7]. Three prospective randomised studies confirmed functional improvements in the operated group, whereas this was not observed in the conservativelytreated control arm [8][9][10]. Nonetheless, controversy remained with respect to potential benefits and risk of the procedure [11,12].…”