Lung Volume Resection Surgery - Indications, Contraindications, and Procedure

Introduction:

Lung volume reduction surgery is a surgical procedure performed to remove the damaged tissues of the lungs. This procedure improves breathing ability and lung capacity, improving life quality. The main aim of this surgery is to remove the damaged portion of the lungs, allowing the remaining healthy tissues to function normally. Severe cases of lung damage require lung transplantation.

What Is Lung Volume Reduction Surgery?

Lung volume reduction is a surgical procedure performed for patients with end-stage lung diseases. It involves the surgical removal of severely affected areas of the lungs. This allows the healthy portion of the lungs to function normally. About 20 % - 30 % of damaged portions of the lungs are removed, reducing the size of over-expanded lungs. The diaphragm, chest wall, and rib cage resume normal shape and function efficiently after the surgical resection. This is performed when there is no improvement in the lung condition with medical treatments.

Why Is Lung Volume Reduction Surgery Performed?

Emphysema is a chronic disease that affects the walls of the alveoli (air sacs). Emphysema always coexists with chronic obstructive pulmonary disease. Individuals with severe emphysema, a type of chronic obstructive pulmonary disease (COPD), individuals with reducing the elastic recoil of the lungs and result in hyperinflation of the lungs from air trapping. Air is trapped in the lungs and cannot get out, causing shortness of breath. It is a progressive disease that affects the lung tissues and causes breathing difficulty. It causes shortness of breath, coughing, fatigue, and weight loss. Lung volume reduction surgery is performed to improve the strength of respiratory muscles, respiratory mechanics, lung capacity, and breathing ability.

What Are the Indications of Lung Volume Reduction Surgery?

The national emphysema treatment trial (NETT) study published criteria for lung volume reduction surgery. According to these criteria, lung volume reduction surgery is indicated in selected patients. It is indicated for patients with upper lobe emphysema and low exercise capacity because these patients function well after the surgery. It is also indicated in patients with upper lobe emphysema and high exercise capacity and diffuse emphysema and low exercise capacity. The patients with the following criteria are eligible for the lung volume reduction surgery:

• Body mass index (BMI) should be less than 32 kg/m².

• Forced-expiratory volume in one second should be less than 45 %.

• The arterial partial pressure of carbon dioxide should be less than 60 mm Hg.

• A six-minute walk test is done for a distance greater than 140 m.

• Smoking should not be done for at least four months before the initial screening.

What Are the Contraindications for Lung Volume Reduction Surgery?

Lung volume reduction surgery is not indicated for patients with diffuse emphysema and high exercise capacity because these patients have poor survival rates after surgery. According to NETT criteria, lung volume reduction surgery is not indicated for patients with the following disabilities:

• The forced-expiratory volume is less than 20 %.

• The diffusion capacity for carbon dioxide is less than 20 %.

• The appearance of homogenous emphysema on computed tomography (CT) scan.

The patients with the above risks or no benefit from the surgery are at higher risk for death after lung volume reduction surgery.

What Are the Tests Performed Before Lung Volume Reduction Surgery?

The following tests are performed to determine if the lung volume reduction surgery is appropriate for that patient.

• Chest X-ray to visualize the damaged portion of the lungs.

• Pulmonary function tests are performed to measure the functioning of the lungs.

• Cardiac stress test.

• Arterial blood gas test to measure the level of oxygen and carbon dioxide in the blood.

• Electrocardiogram to visualize the heart’s electrical system.

• Echocardiogram to identify cardiac abnormalities.

• High-resolution computed tomography scan.

• Oxygen titration.

• Six-minute walk test to measure exercise tolerance.

• Cardiopulmonary exercise test to evaluate the heart and lung function.

• Right heart catheterization.

How Is Lung Volume Reduction Surgery Performed?

The main aim of lung volume reduction surgery is to remove 30 % of diseased tissues from each lung to allow the healthy tissues to function better. Sternotomy or thoracoscopy techniques are followed to perform this surgery.

• Sternotomy - The sternotomy technique is performed by cutting through the breastbone or sternum and opening the chest. Both the lungs are approached simultaneously, and the damaged tissues are removed.

• Thoracotomy - Incisions are made on either side of the chest. The ribs are spread to approach the lungs, and the diseased portion of the lungs is removed.

• Thoracoscopy - It is a minimally invasive video-assisted surgical technique in which three to five incisions are made on both sides of the chest between the ribs. A videoscope is inserted through one of the incisions to visualize the lungs. A stapler and grasper are inserted into another incision to remove the damaged tissues of the lungs. The remaining healthy tissues are resealed with the stapler. It can be used to approach one lung or both lungs at the same time.

What Are the Complications of Lung Volume Reduction Surgery?

Patients undergoing this surgery are at high risk for cardiopulmonary morbidities. The other complications associated with lung volume reduction surgery include:

• Air leakage from the suture line into the chest cavity.

• Pneumonia or other infections.

• Cardiovascular complications like arrhythmias, myocardial infarction, or pulmonary embolus.

• Hypoxia.

• Pulmonary complications like respiratory failure require prolonged intubation, reintubation, or tracheostomy.

What Is the Significance of Lung Volume Reduction Surgery?

Lung volume reduction surgery can be performed as an adjunct to adult and pediatric lung transplantation. Investigations are going on regarding the use of endobronchial valves in lung volume reduction without the need for incisions. The valves are placed inside the lungs through a bronchoscopy. A bronchoscope is used to visualize the lungs.

What to Expect With Lung Volume Reduction Surgery?

Patients with predominantly upper lobe disease and low exercise capacity perform well, and the prognosis is good. Pulmonary rehabilitation is a significant part of recovery. It should begin within the first four to six weeks after surgery.

Conclusion:

Lung volume reduction surgery improves breathing ability, lung capacity, and quality of life. The success rate depends on the location and extent of the diseased tissues, the patient’s exercise tolerance, and the ability to tolerate surgery. It is a surgical procedure that restores lung function and improves the healthy living of the patients.