Stability of Improvements in Exercise Performance and Quality of Life Following Bilateral Lung Volume Reduction Surgery in Severe COPD

doi:10.1378/chest.112.4.907

Chest

Volume 112, Issue 4, October 1997, Pages 907-915

https://doi.org/10.1378/chest.112.4.907 Get rights and content

Study objective

To evaluate the long-term stability of improvements in exercise capacity and quality of life (QOL) after lung volume reduction surgery (LVRS).

Design

Case-series analysis.

Setting

University hospital.

Patients

Twenty-six patients with severe airflow obstruction (mean FEV₁ of 0.67±0.18 L) and moderate to severe hyperinflation (mean total lung capacity of 7.30±1.90 L).

Intervention and measurements

All patients underwent bilateral LVRS via median sternotomy. Serial measurement of lung function, symptom-limited cardiopulmonary exercise tests, 6-min walk distances (6MWD), and sickness impact profile (SIP) scores were done before, and at 3, 6, 12, and 18 months after surgery.

Results

FEV₁ (0.93±0.29 vs 0.68±0.19 L, p<0.001) increased while residual volume (3.47±1.2 vs 4.77±1.5 L, p<0.001) decreased significantly at 3 months post-LVRS compared to baseline, and these changes were maintained at 12 to 18 months follow-up. Similarly, the increase in 6MWD at 3 months post-LVRS (340±84 vs 251±114 m, p<0.001) was sustained at all follow-up times. On cardiopulmonary exercise testing, total exercise time (9.0±1.8 vs 6.1±1.9 min, p<0.001), oxygen uptake at peak exercise ( $\dot{V}$ O₂O₂ peak) (14.9±4 vs 11.9±3 mL/kg/min, p<0.001), maximum oxygen pulse (7.43±2.37 vs 5.85±1.96 mL/beat, p<0.005), and maximum minute ventilation ( $\dot{V}$ O₂Emax) (30.3±10 vs 23.5±7.1 L/min, p<0.001) increased significantly at 3 months post-LVRS. On serial study following LVRS, total exercise time remained significantly greater at 6 (8.5±1.38 min) and 12 months (8.71±2.0 min) post-LVRS compared to baseline (5.81±1.9 min, p<0.05). $\dot{V}$ O₂O₂ peak tended to be higher at all follow-up periods (3 months, 16.1±4.3; 6 months, 14.5±2.6; 12 months, 14.1±3.5 mL/kg) compared to baseline (12.6±3.9 mL/kg, p=0.08). Similarly, maximum O₂ pulse tended to be higher in all follow-up studies (3 months, 8.45±2.7; 6 months, 7.6±1.7; 12 months, 7.42±2.1 mL/beat) compared to baseline (6.39±2.5 mL/beat, p=0.06). Higher $\dot{V}$ O₂Emax continued to be observed at 6 (30±10 L/min) and 12 months (28±10 L/min) post-LVRS, compared to baseline (23±7 L/min, p=0.02). VEmax post-LVRS was significantly higher at 3 and 6 months compared to baseline on post-hoc analysis (p<0.05). Overall SIP scores were lower at 3 months (7 vs 18, p<0.0002) post-LVRS and were sustained in long-term follow-up.

Conclusion

We conclude that bilateral LVRS via median sternotomy in selected patients with severe, diffuse emphysema improves exercise performance and QOL at 3 months following LVRS and these improvements are maintained for at least 12 to 18 months in follow-up.

Section snippets

Patient Selection

Patients with severe emphysema meeting criteria shown in Table 1 were enrolled in this study. Patients had stopped smoking for at least 6 months and remained seriously symptomatic despite optimal medical therapy (bronchodilators, inhaled and/or oral corticosteroids, home oxygen therapy, and comprehensive outpatient pulmonary rehabilitation). All patients had the study protocol and LVRS explained to them in detail and gave written informed consent. The study was approved by our Institutional

Patient Characteristics

From November 1994 to October 1996, 180 patients with severe COPD were evaluated for LVRS. Following an initial evaluation, 69 patients had LVRS. Twenty-five patients had complete physiologic data and 19 patients had quality of life assessments at 3 months post-LVRS. Thirteen patients had repeated complete physiologic testing before and 3, 6, and 12 months post-LVRS, 11 of whom had repeated quality of life evaluations. Six patients had repeated testings for up to 18 months post-LVRS.

The age of

Discussion

This investigation clearly demonstrates that bilateral LVRS via median sternotomy in selected patients with severe, diffuse emphysema improves lung function, exercise performance, and quality of life. These improvements seem to peak at 3 to 6 months following surgery and are maintained for at least 12 months postoperatively. Moreover, based on data obtained in a small number of patients with 18 months of follow-up, it appears that these beneficial changes in lung function, exercise performance,

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Cited by (84)

Lung deflation and oxygen pulse in COPD: Results from the NETT randomized trial
2012, Respiratory Medicine
Citation Excerpt :
The extent to which impaired cardiac function can be improved by reducing hyperinflation may have implications in patient management. Several prior investigations in limited numbers of patients have studied this question with mixed results3,9–13; however, the general consensus is that reducing the degree of hyperinflation may improve cardiac function. We postulated that data from the patients enrolled in the National Emphysema Treatment Trial (NETT),14 provided the best available source of information to answer this question, because patients had lung volumes and cardiopulmonary exercise testing measured over time and were randomized to lung volume reduction surgery (LVRS) or medical therapy.
In COPD patients, hyperinflation impairs cardiac function. We examined whether lung deflation improves oxygen pulse, a surrogate marker of stroke volume.
In 129 NETT patients with cardiopulmonary exercise testing (CPET) and arterial blood gases (ABG substudy), hyperinflation was assessed with residual volume to total lung capacity ratio (RV/TLC), and cardiac function with oxygen pulse (O₂ pulse = VO₂/HR) at baseline and 6 months. Medical and surgical patients were divided into “deflators” and “non-deflators” based on change in RV/TLC from baseline (∆RV/TLC). We defined deflation as the ∆RV/TLC experienced by 75% of surgical patients. We examined changes in O₂ pulse at peak and similar (iso-work) exercise. Findings were validated in 718 patients who underwent CPET without ABGs.
In the ABG substudy, surgical and medical deflators improved their RV/TLC and peak O₂ pulse (median ∆RV/TLC −18.0% vs. −9.3%, p = 0.0003; median ∆O₂ pulse 13.6% vs. 1.8%, p = 0.12). Surgical deflators also improved iso-work O₂ pulse (0.53 mL/beat, p = 0.04 at 20 W). In the validation cohort, surgical deflators experienced a greater improvement in peak O₂ pulse than medical deflators (mean 18.9% vs. 1.1%). In surgical deflators improvements in O₂ pulse at rest and during unloaded pedaling (0.32 mL/beat, p < 0.0001 and 0.47 mL/beat, p < 0.0001, respectively) corresponded with significant reductions in HR and improvements in VO₂. On multivariate analysis, deflators were 88% more likely than non-deflators to have an improvement in O₂ pulse (OR 1.88, 95% CI 1.30–2.72, p = 0.0008).
In COPD, decreased hyperinflation through lung volume reduction is associated with improved O₂ pulse.
Dynamic lung hyperinflation and its clinical implication in COPD
2008, Revue des Maladies Respiratoires
Static lung hyperinflation is defined as the elevation of end- expiratory lung volume above its predicted value, with no increase in end-expiratory alveolar pressure, which remains equal to atmospheric pressure. Dynamic hyperinflation is the transient increase of this volume above the relaxation volume. In patients with COPD, dynamic hyperinflation is mainly determined by the mechanical properties of the respiratory system. Its measurement relies on plethysmography and, during exercise, inspiratory capacity. During exercise, dynamic hyperinflation attenuates expiratory flow limitation but increases the inspiratory loading and induces functional weakness of the diaphragm. It also has haemodynamic consequences and results in more rapid, shallow breathing and progressive reduction in dynamic lung compliance. These events explain exercise intolerance. Several approaches may help combat dynamic hyperinflation and its deleterious clinical effects: bronchodilators, hyperoxia, helium-oxygen mixtures, lung volume reduction surgery…
La distension statique est définie par l’élévation du volume télé- expiratoire au-dessus de sa valeur prédite, mais sans modification de la pression alvéolaire de fin d’expiration, qui reste égale à la pression atmosphérique. La distension dynamique est l’augmentation temporaire de ce volume au-dessus du volume de relaxation. Dans la BPCO, elle est principalement déterminée par les caractéristiques mécaniques du système respiratoire. Sa mesure repose avant tout sur la pléthysmographie et, au cours de l’exercice, le suivi de la capacité inspiratoire. Au cours de l’exercice, la distension dynamique s’oppose à la limitation de débit expiratoire mais augmente la charge élastique et, donc, l’effort inspiratoire tout en induisant une faiblesse fonctionnelle du diaphragme. Elle a un retentissement hémodynamique et s’accompagne d’une polypnée, associée à une baisse de compliance pulmonaire dynamique. Ces phénomènes expliquent l’intolérance à l’exercice. Plusieurs approches peuvent être envisagées pour combattre la distension dynamique : bronchodilatateurs, hyperoxie, mélange hélium-oxygène, chirurgie de réduction de volume pulmonaire.
Lessons from the National Emphysema Treatment Trial
2007, Seminars in Thoracic and Cardiovascular Surgery
Citation Excerpt :
This group also demonstrated an increase in maximal achieved wattage during oxygen-supplemented cycle ergometry in surgical patients; lesser improvement was noted in patients receiving aggressive medical management. NETT investigators noted that surgical patients, in contrast with medically treated patients, were more likely to maintain improved maximal wattage during oxygen-supplemented cardiopulmonary exercise testing during long-term follow-up (Fig. 2),13 corroborating previous reports of sustained improvement in 6MWD,32 even despite documented spirometric decrement.28 A variety of quality-of-life measures have been used to assess the response to LVRS, as has been reviewed elsewhere.8,33
Medicare coverage for lung volume reduction surgery has been approved recently by the Centers for Medicare and Medicaid Services for the treatment of severe emphysema. The scientific basis for this approval stems largely from findings of the National Emphysema Treatment Trial (NETT). The purpose of this article is to review the contributions of the NETT to the management of chronic obstructive pulmonary disease.
Longitudinal changes in hyperinflation parameters and exercise capacity after giant bullous emphysema surgery
2006, Journal of Thoracic and Cardiovascular Surgery
Although resection of giant bullae for the purpose of improving the function of underlying compressed lung is an accepted form of surgery for emphysema, there is only limited information regarding long-term improvement in dynamic hyperinflation and exercise tolerance. Our major goal was to investigate the effects of lung resection for giant bullae on pulmonary function, dynamic hyperinflation, and exercise capacity in patients with chronic obstructive pulmonary disease characterized by emphysema.
Pulmonary function and exercise testing were assessed prospectively before and 3, 6, 12, 24, and 48 months after surgery in 12 patients who had chronic obstructive pulmonary disease with emphysema who underwent lung resection of giant bullae.
Forced expiratory volume, diffusing capacity for carbon monoxide, arterial partial pressure of oxygen, and exercise capacity were significantly increased after resection of surgical bullae. Dynamic hyperinflation, as assessed by reduction in inspiratory capacity and dyspnea Borg scale, were significantly decreased during exercise. Improvement in baseline and exercise functional capacity slightly decreased over time, remaining, however, far above the value before surgery.
Altogether, these findings suggest that surgery for resection of giant bullae is an effective procedure for improving airflow, limiting gas exchange, and limiting exercise dynamic hyperinflation over time.
Surgical management of emphysema
2004, Revue de Pneumologie Clinique
Tout patient emphysémateux présentant une dyspnée invalidante, dégradant sa qualité de vie, et ceci en dépit d’un traitement maximal, doit bénéficier d’un bilan en vue d’une éventuelle intervention. Ce bilan associe : l’appréciation de la gêne fonctionnelle perçue (échelle de dyspnée, test de marche, qualité de vie), l’évaluation de la réversibilité des lésions (imagerie, EFR, TLCO, gazométrie, scintigraphie, micro-cathétérisme droit), et enfin l’évaluation du terrain.
En dehors de la transplantation pulmonaire, la seule alternative chirurgicale est la résection qui, selon le parenchyme qu’elle concerne, s’appelle « résection bulleuse » ou « réduction de volume ». Ses modalités sont multiples : résection atypique des deux sommets par sternotomie, résection atypique multiple mais unilatérale, ou enfin simple lobectomie. Le choix de la technique dépend en priorité de la répartition des zones de déstructuration parenchymateuse et, accessoirement, de la gravité de la maladie emphysémateuse et de l’âge du patient.
Avec une mortalité opératoire maintenant largement inférieure à 10 %, la réduction de volume entraîne une amélioration significative de la gêne fonctionnelle (80 % des patients) mais temporaire (4 à 5 ans).
Une mention toute particulière doit être faite pour la chirurgie des bulles qui est source d’une récupération des paramètres fonctionnels et spirométriques précoce, constante et durable.
Surgery is an important therapeutic option for emphysema patients with invalidating dyspnea and poor quality-of-life. Preoperative tests must determine the degree of functional impairment (dyspnea score, walking test, quality-of-life) and evaluate lesion reversibility (imaging, function tests, TLCO, blood gases, scintigraphy, right microcatheterism) and assess the patient's general health status.
Besides lung transplantation, the only surgical alternative is resection which, depending on the type of parenchymal damage, can involve excision of bullae or volume reduction. Several modalities can be proposed: atypical resection of the apexes via sternotomy, multiple unilateral atypical resection, simple lobectomy. The choice depends on the distribution of the parenchymal destruction and also on the severity of the emphysema and the patient's age.
Operative mortality is now well below 10%. Volume reduction provides significant functional improvement in 80% of patients but with a temporary effect (4-5 years).
Bullae excision is particularly important since functional recovery is achieved early and persists.
Improvement after lung volume reduction surgery: A role for inspiratory muscle adaptation
2004, Respiratory Physiology and Neurobiology
In severe emphysema, lung volume reduction surgery (LVRS) can improve lung function and exercise tolerance. The maximal changes of forced expiratory volume in 1 s (FEV₁) and lung volume occur early after surgery, whereas maximal improvement of exercise tolerance occurs later. We tested the hypothesis that secondary adaptation of inspiratory muscles could explain this delayed clinical improvement.
In that purpose, we evaluated nine consecutive patients before LVRS and up to 9 months post-operatively. Six weeks after LVRS, we observed an increase in FEV₁ and 6 min walk distance (6MWD). The gain in sniff nasal inspiratory pressure (SNIP) was inversely proportional to lung volume loss. Values of FEV₁ and lung volume were maintained throughout follow-up whereas SNIP values significantly increased from 6 weeks to 6 months post-LVRS. In the meantime, we observed an increase in 6MWD correlated with the SNIP increase.
This suggests that in patients undergoing LVRS, early improvement of SNIP is proportional to decrease in lung volume whereas the further delayed improvement may be due, at least in part, to adaptation of the inspiratory muscles.

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Chest

Clinical Investigations: Lung Volume Reduction SurgeryStability of Improvements in Exercise Performance and Quality of Life Following Bilateral Lung Volume Reduction Surgery in Severe COPD

Study objective

Design

Setting

Patients

Intervention and measurements

Results

Conclusion

Section snippets

Patient Selection

Patient Characteristics

Discussion

Ann Thorac Surg

J Thorac Cardiovasc Surg

Clin Chest Med

J Thorac Cardiovasc Surg

Bilateral lung volume reduction surgery for advanced emphysema

Chest

Lung volume reduction surgery: case selection, operative techniques, and clinical results

Ann Surg

Lung function testing: selection of reference values and interpretative strategies

Am Rev Respir Dis

The perception of breathlessness in asthma

Am Rev Respir Dis

Effects of encouragement on walking test performance

Thorax

The sickness impact profile: development and final revision of a health status measure

Med Care

Principles of interpretation

Principles of exercise testing and interpretation

Relation of Vo2max to cardiopulmonary function in patients with chronic obstructive lung disease

Am J Respir Crit Care Med

Clinical Investigations: Lung Volume Reduction Surgery
Stability of Improvements in Exercise Performance and Quality of Life Following Bilateral Lung Volume Reduction Surgery in Severe COPD

Relation of Vo₂max to cardiopulmonary function in patients with chronic obstructive lung disease