Medical Edge Newspaper Column

Emphysema: Buying Time Through Surgery

Jan. 28, 2007
Dear Mayo Clinic:
My husband is 66 years old and has emphysema that only continues to get worse. Doctors are talking to him about lung volume reduction surgery. What is that and how much benefit can it bring? -- Duluth, Minn.

Answer:
Emphysema, a chronic and progressive disease, causes the tiny air sacs in the lungs to lose their elasticity. They ultimately break down and form larger sacs, which not only retain air, making it more difficult for the patient to exhale, but also take up more space in the chest cavity. These hyperinflated lungs worsen the situation by flattening the main respiratory muscle -- the diaphragm -- so breathing becomes increasingly labored.

Because smoking is the major cause of emphysema (responsible for more than 90 percent of cases), the highest priority for a patient is to quit. This won't reverse damage already incurred, but it should slow the disease's progression and reduce or prevent other tobacco-related problems.

In mild to moderate cases of emphysema, symptoms usually can be managed reasonably well without resorting to surgery. Drugs, including bronchodilators and inhaled corticosteroids, help relieve coughing, shortness of breath and breathing difficulty. Supplemental oxygen can help offset low blood-oxygen levels. Immunization against infectious diseases -- such as flu and pneumonia -- can prevent some respiratory complications. And pulmonary rehabilitation programs that combine education (special breathing techniques and ways to conserve energy, for example), exercise training (to maximize fitness), and behavioral interventions (including smoking cessation and nutritional counseling) can be very helpful.

However, if patients progress to a severe state of emphysema that no longer responds to such measures, and their shortness of breath is disabling, they should consider being evaluated for lung volume reduction surgery (LVRS) by a multidisciplinary team at a major medical center that routinely performs this operation.

In LVRS, surgeons remove the most damaged lung tissue, usually some 15 percent of each lung, while maintaining the shape of the original lung. Although it might seem counterintuitive to treat diminished lung capacity by further reducing the size of the lungs, the extra space created in the chest cavity restores the curvature of the diaphragm, helping it work more efficiently. Also, the remaining lung tissue will trap less air. After LVRS, patients experience some relief from shortness of breath, may have a decreased need for supplemental oxygen, and enjoy a better quality of life -- that is, they can pursue a wider range of activities and function more independently.

But LVRS isn't for everyone. Researchers in the National Emphysema Treatment Trial (NETT), a federally funded, five-year, multi-center (including Mayo Clinic) study, concluded it is beneficial for some patients but less so for others. It depends on "topography" (is the emphysema present throughout the lungs, say, or mostly in the upper lobes?) and the patient's exercise capacity after having participated in pulmonary rehabilitation. The best candidates, NETT found, are those with upper-lobe emphysema and a low exercise capacity. After LVRS these patients tend to function better and survive longer (though both benefits can be modest).

Given emphysema's inexorable progression, these benefits will likely last only a few years -- patients ultimately revert to their pre-operation status. However, if they choose not to undergo LVRS, they will be appreciably worse off at that later date. Thus many doctors believe the surgery basically buys patients time, improves their quality of life, and, for some, increases longevity.

For breathing-disabled patients who aren't good candidates for LVRS, lung transplantation may be an option. But it's essential that the person is young and fit enough to undergo the operation (typical patients are in their mid-60s) and fortunate enough to be matched with a donor organ, as demand exceeds supply.

Implantable devices -- one-way valves, placed in the airways, that prevent air from entering the most diseased parts of the lungs, thereby deflating them -- are another potential option. They are still in clinical trials, but we hope they will provide an effect similar to that of LVRS, creating more room in the chest cavity so the remaining, healthier portions of the lung may better function.

-- Claude Deschamps, M.D., Thoracic Surgery, Mayo Clinic, Rochester, Minn.