Surgical options in COPD - indications - Bullectomy -Lung volume reduction surgery - bronchoscopic lung volume reduction surgery - Lung transpalntation

1. Sumi Varghese
2nd year, M.Sc. Respiratory Therapy(ARC)

3. THERAPY AT EACH STAGE OF COPD

4. TABLE 1: Interventional therapy in stable COPD
Lung Volume Reduction Surgery
- Improves survival in severe emphysema patients with an upper-lobe emphysema
and low post-rehabilitation exercise capacity (Evidence A)
Bullectomy
- In selected patients, associated with decreased dyspnea, improved lung function and
exercise tolerance (Evidence C)
Transplantation
- In appropriately select patients with severe COPD, improves QoL and functional
capacity (Evidence C)
Bronchoscopic Interventions
- In selected patients with advanced emphysema, reduces EELV and improves
exercise tolerance, health status and lung function at 6-12 months following
treatment. (Evidence B)

5.  Surgical reduction of lung volume by multiple wedge excisions of emphysematous tissue
 Rationale for LVRS
- Increased elastic recoil of the lung
- Improved expiratory flow
- Improvement in the mechanical function of diaphragm
- Improved LV filling
- Reduced dynamic hyperinflation

6. bLVRS
Valves
Endobronchial
Intrabronchial
Coils
Biologic lung
volume
reduction
Thermal
airway
ablation
Airway bypass
procedure

7. PHASE APPROACH
Presurgical Comprehensive evaluation
Exercise
- Lower extremity
- Upper extremity
- Flexibility
- Strength training
- Education
- Psychosocial counselling
- Nutritional counselling
Perioperative Rapid mobilization: 2 sessions/ day, 7days /wk
Chest physiotherapy
Bronchial drainage
Postoperative Inpatient rehabilitation
Outpatient similar to presurgical

8.  Bullae > ball-valve-mechanism
 Effects of excision of bullae:
- Expansion of the underlying compressed lung.
- Raw, FRC, PVR and physiologic dead space.
- Increase in the elastic recoil pressure of the lung.
- Improvement in dynamic compliance.
- Restoration of the mechanical linkage between the chest wall and normal lung.
- Upward movement of the diaphragm to a more efficient position.
INDICATIONS EXCLUSIONS
Severe dyspnea Multiple smaller bullaes
>30% hemithorax Advanced emphysema
Pain Significant comorbidities
Spont. pneumothorax FEV1<40% of predicted
Hypercapnia
Cor-pulmonale

9. INDICATIONS
Age :
<65-70 years – single lung transplant
<60 years – bilateral lung transplant
<55 years – heart-lung transplants
Failure to respond to conventional treatment
Limited life expectancy (<2-3 years)
At least be ambulatory with O2
CONTRAINDICATIONS
Absolute contraindications:
- Smoking cessation (at least 6months)
- Psychiatric disorders
- Recent drug or alcohol abuse
- Non compliance with medical treatment
- Active malignancy
- Morbid obesity
- Systemic disease
- Progressive neuromuscular disorder
- Disabling arthritis/ limitation to exercise
- Active infection
Relative contraindications
- Coronary or other cardiac diseases
- Severe right-sided failure
- Multi-drug resistant organism
- Severe musculoskeletal disease
- Poor nutrition
- Steroid dependency

10.  Rehabilitation and lung transplantation
 Medications
- Immunosuupression
- Corticosteroids
 Complications
- Primary graft dysfunction
- Airway complications
- Acute rejection
- Chronic rejection
- Infection

11.  Hodgkin, J. E. (2009). Pulmonary Rehabilitation and Lung Transplantation. In J. E. Hodgkin,
Pulmonary Rehabilitation: Guidelines to Success (pp. 361-384).
 Hodgkin, J. E. (2009). Pulmonary Rehabilitation and Lung Volume Reduction. In J. E.
Hodgkin, Pulmonary Rehabilitation: Guidelines to Success (pp. 385-392)
 Shapiro, S. D. (2010). Chronic Bronchitis and Emphysema. In V. C. Robert J. Mason, Murray
& Nade's Textbook of Respiratory Medicine (pp. 919-967).
 2017 Global Initiative for Chronic Obstructive Lung Diseases, Inc. Pocket Guide to COPD
Diagnosis, Management and Prevention: A Guide for Health Care Professionals.