hronic obstructive pulmonary disease affects more than 20 million people in the United States, and kills more than 100,000 every year, making it the fourth leading cause of death. COPD is a broad term referring to three conditions: emphysema, chronic bronchitis, and asthmatic bronchitis. One of the more controversial treatments for COPD is lung reduction surgery, which means that part of the lung is actually removed. Below, a pulmonologist and a cardiothoracic surgeon talk about this surgery.
What does a COPD diagnosis mean?
BYRON THOMASHOW, MD: Chronic obstructive lung disease is broadly divided into several groups. By far the most common is the asthmatic or chronic bronchitic type. The chronic bronchitic patients, almost all of whom have been smokers, generally have cough and shortness of breath.
Emphysema is the least common of the three types, 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.
What is emphysema, 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 of a cluster of grapes that play a role with the interchange of air, 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 by the release of toxins from cigarette smoking. It's very unusual to see emphysema in patients who did not smoke.
What percentage of patients who smoke actually get emphysema, or will end up with some form of COPD?
BYRON THOMASHOW, MD: Certainly most people who smoke a significant amount over the years will develop some degree of chronic obstructive lung disease. In many patients, it may be relatively mild. But the more they smoke, the more damage there will generally be.
Asthma and chronic bronchitis are generally medically controllable diseases. Disability is the exception in asthma and chronic bronchitis, but it is the rule in progressive emphysema, in part because our medical options are so limited.
The emphysema patient tends to get more and more short of breath as the years go on. They pant doing even the most minimal of activities.
What is lung reduction surgery?
MICHAEL ARGENZIANO, MD: The operation 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 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.
Emphysematous lung is paper-thin, so 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.
Dr. Brantigan's efforts in the 1950's failed due to insufficiencies in critical care and interoperative management technology. Following improvements in surgery and operative care, Dr. Joel Cooper reintroduced the procedure in 1994. He used strips of pericardium (the sac that surrounds the heart) salvaged from animals, preserved and sterilized to buttress the staple linesand keep them from leaking.
Can anyone get lung volume reduction surgery?
MICHAEL ARGENZIANO, MD: 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 one of seventeen centers participating in the National Emphysema Treatment Trial. A patient could be referred for an evaluation, and then be randomized to either have the operation or go into the "control group."
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, under the conditions that the patient's insurance company will pay for it. Several insurance companies now are paying for the operation outside of the trial setting.
What is the selection process?
MICHAEL ARGENZIANO, MD: Patients need to meet several criteria. First, patients have to have significant disability. Furthermore, the patients need to have pure emphysema or as close to pure emphysema as possible.
BYRON THOMASHOW, MD: The older a patient is, no matter what operation they're undergoing, the greater the risk might be. But we successfully operate on patients in their 80s with bad coronary disease all the time.
We also need to make sure that these patients have cardiac function that allows them to tolerate a major surgical procedure. These patients cannot be smokers, so they have to have stopped smoking for at least six months. In addition, they have to have failed the maximum medical regimen involved in treatment. Surgery candidates have to be people who, despite everything that we have to offer, remain severely limited.
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