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• How successful are oxygen therapy and pulmonary rehabilitation in treating emphysematous COPD?
• What is lung reduction surgery?
• What sorts of patients should -- and should not -- be considered for lung reduction?

What are the risks associated with the procedure?

PARTICIPANTS Byron Thomashow, MD New York Presbyterian Hospital, Columbia University Michael Argenziano, MD New York Presbyterian Hospital, Columbia University

COPD is actually a broad term referring to three conditions: emphysema, chronic bronchitis, and asthmatic bronchitis.  As you may have guessed, the chief cause is smoking.  One of the more controversial treatments for COPD is lung reduction surgery, which means that part of the lung is actually cut out.  Here to talk about this surgery are two specialists who do the surgery and who diagnose it.

To my left, we have Dr. Byron Thomashow.  He is a pulmonologist at New York Presbyterian Hospital, and a clinical professor of medicine at Columbia University.  Doctor, thank you for being here.  We also have Dr. Michael Argenziano, who is a fellow in cardiothoracic surgery at New York Presbyterian Hospital.

Dr. Thomashow, let's begin with you.  Patients may come to you after seeing their primary care physician, and you have the distinction of diagnosing them with COPD.  We gave a very brief description.  Can you give us, with a little more detail, what this condition means?

 BYRON THOMASHOW, MD:  As you said, chronic obstructive lung disease is broadly divided into several groups, several areas.  By far the most common is the asthmatic or chronic bronchitic type.  I think most people are familiar with asthma.  The patients wheeze, they get short of breath with activity.  The chronic bronchitic patient, almost all of whom were smokers, generally have cough and recurrent sputum production, and shortness of breath.

Emphysema is the least common of the three types of chronic obstructive lung disease.  But it is potentially the most serious, because it is a disease where there is no good medical therapy.  Indeed, many of the medicines that patients with emphysema receive are medicines to treat an asthmatic, or an asthmatic/bronchitic component, in the hope that there is a component that can be improved or reversed.  The purer the emphysema, the less likely that medicines will have much of a benefit.

PAUL MONIZ:  What does emphysema refer to specifically?

BYRON THOMASHOW, MD:  Emphysema is a destructive disease of the lung, where the air spaces themselves are destroyed.  Instead of the lungs being made up, if you will, of a cluster of grapes that play a role with the interchange of air, of oxygen, the lungs in patients with emphysema become big bags of air, where those air spaces are no longer small and efficient.  There is a destruction of the parenchyma of the lung itself, caused, most people believe, by the release of toxins, if you will, from cigarette smoking.  It's very unusual to see emphysema in patients who did not smoke.

PAUL MONIZ:  What percentage of patients who smoke actually get emphysema, or will end up with some form of COPD?

BYRON THOMASHOW, MD:  That's a difficult question to answer, and I don't know that anyone knows that full answer.  Certainly most people who smoke significant amounts over the years will develop some degree of chronic obstructive lung disease.  Now in many patients, that may be relatively mild.  But the more they smoke, the more damage there will generally be.

I think it's important to recognize that asthma and chronic bronchitis, as important as they are, and they are very important, are generally medically controllable diseases.  Disability is the exception in asthma and chronic bronchitis.  On the other hand, it is the rule in progressive emphysema, in part because our medical options are so limited.

The emphysema patient, and we've all seen them, tend to get more and more short of breath as the years go on.  They pant doing even the most minimal of activities.  As the disease progresses, the quality of their life worsens.

PAUL MONIZ:  Dr. Argenziano, let's bring you into this.  Of course, you perform surgery, as lung reduction surgery.  In terms of treatments that are available, the four surgical options that are considered, what are we talking about, for emphysema?

MICHAEL ARGENZIANO, MD:  Pretty much, with patients with emphysema, whether it be moderate or severe, as Dr. Thomashow has described, the options are minimal.  Aside from the treatments that he's alluded to -- that is, trying to treat whatever components of the pulmonary dysfunction are associated with bronchitis or asthma -- the only real interventions that have been shown medically to be effective are oxygen therapy.  This has been shown to actually prolong survival and to make people feel better.  In most cases, this is done chronically on a home oxygen basis.

PAUL MONIZ:  But the technology has seemingly made things easier.  You see people who have emphysema, now walking around and not necessarily tied to their oxygen tank, so to speak, at home.  They have portable units.  Are these things helping patients with emphysema be more mobile, more independent?

MICHAEL ARGENZIANO, MD:  Certainly the mobility issues have been aided by small, portable oxygen tanks, but this is actually a question, I think, that Byron can answer a little bit more specifically, because he really does deal with these patients, medically, more than I do.

BYRON THOMASHOW, MD:  Oxygen, as Mike said, is the one modality of therapy in patients with advanced emphysema, that has been shown to be beneficial.  Part of the problem, however, is that Medicare has, for example, oxygen requirements.  In other words, to get Medicare to pay for oxygen, you have to meet some fairly stringent requirements in your patient.

Some of the newer modalities that you've mentioned, and you're clearly correct.  There have been advances.  Some of these ultralight systems, which are sort of oxygen tanks that go in a backpack.  Very light weight, very long-lasting and actually will free people up from the home base.  Some of that equipment itself is very expensive.  Most of the insurance plans will not pay for the equipment itself.  They may pay for the oxygen once you get the equipment, but you may need to make a several-thousand dollar investment to get the equipment.  That is a problem.  Oxygen does help, but its availability in the newer modalities is still somewhat stringent.

PAUL MONIZ:  When does surgery become a real option for some of these folks or, in some cases, a necessity?

MICHAEL ARGENZIANO, MD:  First of all, you should know that surgery has only become an option over the last five, six years.  The operation that we're talking about is lung volume reduction surgery and was initially conceived by Otto Brantigan in the 1950s.  Dr. Brantigan had the concept that patients with emphysema were suffering from what he termed a "loss of elastic recoil."  That is, that because of the obstruction that Byron has described in the lungs, due to the cigarette smoking, that there wasn't enough spring left in the lung for it to push air out of the patient.

By removing some of the diseased lung, he thought, in fact, it turns out, correctly, that the efficiency of the lung might be improved.  Unfortunately, Dr. Brantigan's efforts to pioneer this operation failed, mostly because in the 1950s, the degree of critical care and interoperative management technology that was available wasn't sufficient to get his patients through these operations, and there was a very high mortality rate.  Which actually led to the abandonment of the procedure.

Then, in the early 1990s, in fact, in 1994, Joel Cooper reintroduced the operation in the modern era of intra- and postoperative care.  He was able to demonstrate that the operation could be done safely, with the addition of several specific interventions that he essentially pioneered, one of which was the use of bovine pericardium to buttress the staple lines.

What I mean by that specifically is that, emphysematous lung, unlike normal lung, is paper-thin.  If you try to cut it and sew it, it just tears more and more.  One of the reasons that emphysema patients are generally very poor surgical candidates for any kind of a lung operation is because the lung is very, very delicate.  Air leaks, which refer to the passage of air from the lung out of the chest after surgery, can be a real problem.

One of the things that Dr. Cooper did was to introduce the use of strips of pericardium, which is the sac that surrounds the heart, salvaged from animals, preserved, sterilized, and used to kind of buttress the staple lines, to keep them from leaking.  And although leakage is still a problem in our patients, it's certainly become much less of a problem, to the extent that it is now possible to do the operation.

PAUL MONIZ:  It seems that Medicare stopped paying for some of these procedures, back around the same time that they were reintroduced?  What was happening?

BYRON THOMASHOW, MD:  I think we should take a step back and recognize that Dr. Cooper's attempts at surgery, even Dr. Brantigan's attempt at emphysema surgery, are just one of many.  Because medicine has had so little to offer, for over 100 years, medicine has looked at surgical options.

If you go back over the history, as I know Mike has, many operations have been tried.  Operations to try to make the chest cavity bigger, to try to make the chest cavity smaller.  Mechanical devices to try to make the diaphragms work better.  Every one of them, when they were initially introduced, were introduced enthusiastically as "This will work."  Over the course of time, because of deaths or risks or not working, they were abandoned.

As Mike says, that certainly is what happened with Dr. Brantigan's procedure in the 1950s.  I guess over the last decade we've done single lung transplantation for emphysema, with reasonable results, but risks and costs involved with that.

When Dr. Cooper reintroduced this surgery, he published some very exciting results.  Subsequently that procedure was done at Columbia and a number of other centers around the country, with similar results.  But there were real risks.  There was morbidity, so there were side effects from the operation.  There was mortality, so there were deaths from the operation.  And when Medicare, and most of these patients, because emphysema is a disease of older people, usually, when Medicare started looking at the data, it was unclear to them as to whether or not this operation really was beneficial.

Indeed, there are still questions about its role.  And so, in December of 1995, Medicare stopped paying for the operation.  Then, in the spring of 1996, for the first time ever, Medicare/HCVA actually approached the National Institute of Health and asked them to set up a randomized study, to compare surgery and medicine for this disease.  That's one of the things we're embarked on now.

PAUL MONIZ:  Dr. Argenziano, let's look for a moment at how patients are selected.  What is involved in this workup to decide who actually might benefit from lung volume reduction surgery?

MICHAEL ARGENZIANO, MD:  First of all, as we've said, the operation is still considered to be in its early stages.  Because there is currently a randomized trial underway, looking at this operation, patients currently can only have the operation in two settings.  One is to be evaluated at a center participating in the National Emphysema Treatment Trial.  There are currently 17 of these centers.  We're one of them.  So a patient could be referred to our center for an evaluation, and then, pending completion of that evaluation, be randomized, either to have the operation, or to be randomized into the control group, that is medical therapy.

The other way to have the operation would be for a patient to go to a surgeon or to a group that is performing the operation, and under the conditions that that patient's insurance company will pay for it.  In fact, there are several insurance companies now that are still paying for the operation, outside of the trial setting.

Specifically, with respect to what the workup entails, the patients need to meet several criteria.  Firstly, because this is an operation still with risk, and of unproven long-term efficacy, patients have to have significant disability.  I don't think anyone who's doing this operation is going to do the operation in patients who are a little short of breath when they're running up a hill.  This has got to be for patients who are significantly debilitated by their disease, to the extent that the risk and the uncertainties associated with the operation are going to be warranted.

Furthermore, the patients need to have pure emphysema or as close to pure emphysema as possible.  That is, if the patients have chronic bronchitis, characterized, as Dr. Thomashow described earlier, with sputum production and a lot of coughing, then those patients are not expected to do well, and in fact are at very high risk for any operation.

PAUL MONIZ:  Only four in ten patients are actually selected for this, so a lot of patients that might want the surgery actually don't get it, is that right?

MICHAEL ARGENZIANO, MD:  In fact, Byron alluded to the first reports by Dr. Cooper's group.  I think in the weeks after Dr. Cooper's first reports in the early 1990s, we received several hundred phone calls, our center, from patients who had read a Daily News article reporting the results.  It just turns out that the majority of the patients who either self-referred themselves, or even many of those that are referred by physicians are not candidates for a number of reasons.  Byron can go through those with you.

PAUL MONIZ:  How does age affect the selection process, Dr. Thomashow?

BYRON THOMASHOW, MD:  Certainly the older a patient is, no matter what operation they're undergoing, the greater the risk might be.  But certainly Mike, who does a lot of cardiothoracic surgery, will tell you that we successfully operate on patients in their eighties with bad coronary disease all the time.  There is a balance.  But the older the patient, the greater the risk.

Certainly one of the things that we found as we've reviewed our data, and has been found by other centers as well, is that one of the groups that carries the greater risk for problems with this operation are the patients over 75-80.  So, certainly 75 years and higher would be greater risk.

PAUL MONIZ:  But we're talking about a pool of patients that's in their sixties anyway, right?

BYRON THOMASHOW, MD:  That's exactly right.  And that's generally the group that we're aiming at.  The evaluation process is interesting.  It's worth stressing that whether or not a patient is being evaluated as a possible candidate for the National Emphysema Treatment Trial, or they're being evaluated through their own insurance plan to see if they're a candidate for lung volume reduction surgery, the evaluation is very similar.

We need to have somebody who is very disabled, as Mike says.  You need to have someone very limited by his disease. You need to have someone who has bad emphysema.  That is gauged by pulmonary function studies.  That is gauged by computer x-rays.

Ideally, and Mike can comment on this, perhaps, even better than I, is ideally you would like to have a patient who, while they may have diffuse emphysema, the emphysema is worse in some areas of the lung, rather than other areas, so-called target areas.  The worst areas of emphysema, where potentially those areas could be removed, allowing better areas of lung more room to function, if you will.

We need to make sure that these patients have cardiac function that allows them to tolerate a major surgical procedure.  And so we put them through echocardiograms and fancy stress tests, to make sure their heart is all right.  And, quite clearly, these patients cannot be smokers, so they have to have stopped smoking for at least six months.  And they have had to fail, basically, on what a maximum medical regimen would involve.  In other words, they have to be on everything that we have available to them, including something that we haven't talked about, and that is pulmonary rehabilitation.  Exercise programs.

Because just as oxygen has been shown to be beneficial, so has exercise.  So these have to be people who, despite everything that we have to offer, remain severely limited.

PAUL MONIZ:  Dr. Argenziano, let's give you the final word on who should be considered for this type of surgery.

MICHAEL ARGENZIANO, MD:  In our experience, and certainly in the experience of others, the ideal candidate for this operation appears to be someone who's severely limited by a very severe case of emphysema.  That is, something that a patient who, on a CAT scan, has several areas of destroyed lung.  And, as Byron described, maybe even the best candidate is someone who's got, not diffuse destruction of the lungs, but a couple of areas, typically the apical or the higher areas of the lung, that have been more exposed to cigarette smoke or other factors, and have been more destroyed.

In the operating room, we can target our resection to these more diseased areas.  That is, we can say, "Look, the whole lung looks diseased."  However, there are areas that are far more diseased.  So by removing these areas, we can let the less diseased areas re-expand and function more efficiently.

So with respect to the type of disease, we have to be sure they don't have bronchitis or asthma because those diseases do not respond to this operation.  And, if they have pure emphysema, if it's heterogeneous, which means, if it's distributed in certain areas more than others, and if the patients are otherwise good medical risks.  Meaning that they don't have severe coronary artery disease, they're not otherwise very debilitated nutritionally or otherwise.  And, as Byron has said, they've made a reasonable effort to participate in exercise programs, which have been shown, not only to improve their symptoms, but also their recovery from insults, such as surgery, then those patients can be considered candidates.

PAUL MONIZ:  You're going after something very specific here.  When you get to the operating room with these patients, you know pretty much exactly what you're dealing with, and all their options have been exhausted.

MICHAEL ARGENZIANO, MD:  Specifically with respect to what we do in the operating room, there are a number of tests that are done preoperatively, which include the tests we've discussed, and which also include other tests, which include ventilation perfusion scans and other fancy tests.  All these tests can do is help us to identify patients who are what we think good candidates.

However, the final decision about areas of resection and the extent of resection, has to be made in the operating room.  That's because, in the operating room, we perform a very simple, but very effective, test to decide which areas to resect.  That is, one of the main problems in emphysema, as we've discussed, is that the lungs do not exhale efficiently.  Because there's so much destruction, they tend to trap air, and they're big, flaccid bags.  They just can't get enough pressure to get the air out.

In the operating room, what we do is, we inflate the lung, and then we have the anesthesiologist disconnect the ventilator from the lungs.

PAUL MONIZ:  Dr. Argenziano, I'm sorry; I have to cut you off there.  If people want to see more of this, they can look at some segments that are coming up.  We certainly appreciate your time.  Dr. Michael Argenziano and Dr. Byron Thomashow.  Thank you for joining us.

I'm Paul Moniz.  Thank you for joining this webcast.  Of course, if you have any questions about this procedure, you should ask your doctor.