Ann Thorac Surg 2001;71:1037-1038
© 2001 The Society of Thoracic Surgeons
Case report
Lung volume reduction surgery in a ventilated patient with severe pulmonary emphysema
Bari Murtuza, FRCSa,
Brian F. Keogh, FRCAa,
Anita K. Simonds, FRCPa,
John R. Pepper, FRCSa
a Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, England, United Kingdom
Accepted for publication September 6, 2000.
Address reprint requests to Mr Murtuza, Department of Cardiothoracic Surgery, Royal Brompton Hospital, Sydney St, London SW3 6NP, England
e-mail: dr_bm1{at}hotmail.com
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Abstract
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There are a limited number of reports in the literature cocerning lung volume reduction surgery in patients receiving mechanical ventilation. We present a case in which a ventilator-dependent patient with apparent end-stage pulmonary emphysema underwent lung volume reduction with a successful outcome. Although the role of this procedure for selected nonventilated patients has been widely discussed its use in ventilated patients is still not clearly defined. We show that lung volume reduction surgery may facilitate ventilatory weaning in such cases and improve functional status.
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Introduction
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Lung volume reduction surgery (LVRS) was originally described in 1957 as a procedure to improve symptoms by correcting the mechanical aspects of severe diffuse emphysema [1]. Recently the technique has been revived and involves uni- or bilateral resection of 20% to 30% of the lung volume in such patients [2]. Although various reports have described the use of LVRS in ventilated patients [3], clear selection criteria and the optimal surgical approach will emerge only with further data.
A 48-year-old woman with a history of smoking and severe chronic obstructive pulmonary disease (COPD) was admitted with acute type II respiratory failure. Her history also included hypertension and Graves’ disease, which had been treated with radioiodine. Medications included salbutamol, ipratropium, valsartan, and paroxetine. She had been ventilated twice previously and had been on home oxygen and nocturnal nasal intermittent positive pressure ventilation (NIPPV) for 12 months. The patient had not wished to be considered for lung transplantation. Having been intubated and ventilated at another hospital, she was transferred to our institution with hybercarbia and acidosis (Table 1). Percutaneous tracheostomy was performed after her arrival.
There was no obvious precipitant for her deterioration; bronchoscopy and lavage were normal and transesophageal echocardiography demonstrated mild biventricular hypertrophy with good ventricular function. Right heart catheterization showed a mean pulmonary artery pressure of 27 mm Hg and a pulmonary vascular resistance of 109 dyne · s · cm-5. Initial therapy included intravenous steroids, empiric antibiotics, and aminophylline. Ventilatory management was difficult despite permissive hypercapnea and the patient deteriorated over the next 15 days, requiring inotropic agents to maintain cardiac output. Computed tomography showed regional heterogeneity with predominant emphysematous changes in the apical and posterior upper lobe segments, suggesting that LVRS might be a reasonable option.
The patient underwent bilateral LVRS on day 18 through a fourth intercostal space "clam-shell" incision. The apical and posterior upper lobe segments were resected and bilateral apicolateral pleurectomy performed. Subsequent progress was surprisingly good, with only minor air leaks, and the patient was able to tolerate extended periods without ventilatory support by postoperative day 12. Weaning was not attempted until the patient was pain-free given her borderline pulmonary function. She was transferred to the ward on postoperative day 19 on ipratropium, salbutamol and budesonide nebulizers, and oral aminophylline. There was a significant initial improvement in PACO2, with spontaneous breathing, but no change in FEV1 (Table 1). The patient was discharged home, independently mobile, on postoperative day 30 and requiring only nocturnal NIPPV and oxygen therapy. Three months after LVRS respiratory function tests had declined (Table 1), although she had a shuttle walking test distance of 70 m and remained ventilator-independent.
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Comment
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Lung volume reduction surgery has previously been shown to be effective in a limited number of mechanically ventilated patients [3]. The proposed mechanism is an improvement in lung and chest wall mechanics. This surgery may lengthen the diaphragm by reducing end-expiratory volume, thus improving its contraction. Other benefits include improved ventilation-perfusion matching, lowering of small airway resistance by restoration of lung elastic recoil, and restoration of normal outward chest wall recoil [4].
Preoperative assessment of these patients is difficult as they are clearly unable to perform standard spirometry. In our patient, formal respiratory function tests had last been performed 8 months before surgery (Table 1) and would have underestimated the severity of pulmonary dysfunction immediately before LVRS. Additional investigations included chest radiography, arterial blood gas analysis, computed tomography, and right heart catheterization. Patients normally considered to be poor candidates for LVRS are those with ventilator-dependent hypercapneic respiratory failure and significant pulmonary hypertension. The significance of hypercarbia is less clear in ventilated patients and its level depends on the ventilatory protocol and trapped volume. A key selection criterion for LVRS is heterogeneity on CT, particularly with predominant upper zone disease. Surgical approaches advocated for LVRS have included laser and stapled techniques [5]. Our patient underwent an open bilateral technique using a linear stapler and bovine pericardial strips as previously described by Cooper [6]. The "clam-shell" incision was used to maximize surgical access to the posterior segments of the upper lobes and to improve postoperative healing in view of the tracheostomy site and known methicillin-resistant Staphylococcus aureus contact. Mulitidisciplinary care involving surgeons, anesthesiologists, intensivists, respiratory physicians, and physiotherapists was a key factor in this patient’s rehabilitation.
Our patient had no significant perioperative complications and showed a marked improvement in PACO2, suggesting reduced energy expenditure for breathing (Table 1). Associated morbidity may, however, include prolonged air leak, tension pneumothorax, pneumonia, and generalized sepsis. Outcome measures used to assess the benefit of surgery were ventilator-independence, functional improvement, and lowered PACO2 (Table 1). Although one cannot account specifically for the apparent lack of improvement in FEV1, it is difficult to acquire meaningful comparative data for the ventilated preoperative versus nonventilated postoperative state. The sequential postoperative respiratory function tests in this patient (Table 1) show a trend of deteriorating pulmonary function that is likely to reflect progressive pulmonary pathophysiology. Despite this, after successful ventilatory weaning she did not require reventilation over 90 days of follow-up.
In accordance with previous reports we conclude that mechanical ventilation should not be a contraindication to LVRS in patients with severe emphysema. Surgery in these patients offers the prospect of ventilatory weaning and may serve as an alternative to lung transplantation, although long-term follow-up data will be needed to determine the best selection criteria and approach to LVRS in ventilated patients.
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References
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Brantigan O.C., Mueller E. Surgical treatment of emphysema. Am Surg 1957;23:789-804.[Medline]
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Cooper J.D., Trulock E.P., Triantafillou A.N., et al. Bilateral pneumonectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106-119.[Abstract/Free Full Text]
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Criner G.J., O’Brien G., Furukawa S., et al. Lung volume reduction surgery in ventilator-dependent COPD patients. Chest 1996;110:877-884.[Abstract/Free Full Text]
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Sciurba F.C., Rogers R.M., Keenan R.L., et al. Improvement in pulmonary function and elastic recoil after lung volume reduction surgery for diffuse emphysema. N Engl J Med 1996;334:1095-1099.[Abstract/Free Full Text]
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McKenna R.J., Brenner M., Gelb A.F., et al. A randomized trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:317-322.[Abstract/Free Full Text]
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Cooper J. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038-1039.[Abstract]
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I. Baeyens, M. F. Maguire, C. D. Sheldon, and R. G. Berrisford
Lung volume reduction surgery in a ventilator-dependent patient
Interactive CardioVascular and Thoracic Surgery,
June 1, 2004;
3(2):
237 - 239.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
