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Lung volume reduction surgery ( LVRS )
- 1. Mashail AlRayes 4th yearRT student UOD LUNG VOLUME REDUCTION SURGERY โLVRSโ
- 2. OBJECTIVES ๏ฒ Introduction anddefinition ๏ฒ NETT ๏ฒ Mechanisms of improvement ๏ฒ One-Stage Bilateral LVRS ๏ฒ Mortality and Morbidity ๏ฒ What to expect? ๏ฒ LVRS and Lung Transplantation ๏ฒ Articles
- 3. LVRS / reductionpneumoplasty / lung shaving / lung contouring . ๏ฒ It is performed on patients with severe emphysema in order to allow the remaining compressed lung to expand and thus improve respiratory function. LVRS
- 4. ๏ก A formof (COPD) that is defined by abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles and is associated with destruction of the alveolar walls. ๏ก In advanced stages of emphysema there is a sequence of events : EMPHYSEMA Hyperinflation Diaphragm mobility Pleural pressure Elastic recoil
- 5. ๏ฒ Dr. Brantiganin 1957 was the first person to present the concept of LVRS . ๏ฒ He proposed ( Resection of the most useless area and down sizing the lung would help to restore the outward pull on the small airway) HISTORY
- 6. The first multi-centerclinical trial 5 years to complete. Recruitment ended on schedule in July 2002, and follow up in December 2002.
- 7. There were 3groups of patients that tend to benefit from LVRS : ๏ฒ Group 1: Patients with predominantly upper lobe emphysema and low exercise capacity. Results: Improved survival and functional outcomes. ๏ฒ Group 2: Patients with predominantly upper lobe emphysema and high exercise capacity. Results : Improved functional outcomes. ๏ฒ Group 3: Patients with non-upper lobe emphysema and low exercise capacity. Results : Improved survival. THE NATIONAL EMPHYSEMA TREATMENT TRIAL NETT
- 8. CRITERIA FOR THECANDIDATES
- 9. THE IDEAL CANDIDATESFOR LVRS Patients with upper-lobe predominant emphysema and low exercise capacity
- 10. MECHANISMS OF IMPROVEMENT CardiocirculatoryFunction Gas Exchange Chest Wall and Diaphragm Configuration Lung Elastic Recoil
- 11. LUNG ELASTIC RECOIL lungelastic recoil dynamic complianceIntrinsic PEEPwork of breathing Residual volume exercise tolerance ventilatory mechanics
- 12. CHEST WALL ANDDIAPHRAGM CONFIGURATION Decreases rib cage diameter Strength of inspiratory muscles The diaphragm movement
- 13. A recent meta-analysisof randomized trials indicated that following LVRS : In an analysis of the NETT cohort : Patients with upper-lobe emphysema on maximal exercise showed: ๏ฒ higher output of CO2. ๏ฒ greater tidal volume. ๏ฒ increased hearth rate --------> slower and deeper breathing patterns lasting for up to 24 months. GAS EXCHANGE Significant improvements occur both in PaO2 and PaCO2 (Huang et al., 2011) (Criner, 2009)
- 14. ๏ฒ Improvement inboth right and left ventricular function. In an analysis from the NETT on pulmonary hemodynamic changes at rest : ๏ฒ Except for a smaller change in end-expiratory capillary wedge pressure, compared with medical treatment, LVRS was not associated with an increase in pulmonary artery pressures. CARDIOCIRCULATORY FUNCTION ( Criner et al., 2007 )
- 15. ๏ฒ It isthe most widely adopted approach since it produced : ๏ฒ The standard technique entails nonanatomical staple resection of the most emphysematous lung tissue (resectional LVRS) carried out on both lungs by : ๏ฒ median sternotomy ๏ฒ or VATS through general anesthesia and single-lung ventilation. ONE-STAGE BILATERAL LVRS Greater functional and clinical improvements
- 16. MORTALITY AND MORBIDITY mortalityrates ranged between 0 and 17% morbidity rate of 59% has been reported in the NETT Pulmonary morbidity within 90 days 30% Cardiac arrhythmia 23.5% Cardiovascular morbidity within 90 days 20% Pneumonia 18% Reintubation 22% (DeCamp et al., 2008)
- 17. The benefits ofLVRS include significant improvements in : BENEFITS Exercise capacity Respiratory function Subjective dyspnea Quality of life measures Survival
- 18. ๏ฒ Patients mustparticipate in a 6 to 10 weeks pulmonary rehabilitation program prior to surgery. ๏ฒ Immediately after the procedure, patients are allowed to breath on their own. ๏ฒ Pain medication is given through an epidural catheter. ๏ฒ Drainage tubes are left in the chest. ๏ฒ Physical therapy is reinstituted early during the recovery phase during the hospitalization. WHAT TO EXPECT
- 19. Lung transplantation andLVRS both have advantages for patients with severe emphysema. LVRS AND LUNG TRANSPLANTATION According to the age LVRS For older patients Lung transplantation is commonly 60โ65 years In young patients LVRS - transplantation
- 20. ๏ฒ LVRS provedto be able to delay the need for lung transplantation by 3โ6 years. ๏ฒ As a rule, lung transplantation can be performed safely after LVRS Findings of : ๏ฒ homogeneous or -1-antitrypsin-deficiency-related emphysema. ๏ฒ FEV1 < 20% predicted. ๏ฒ DLCO < 20% predicted. ๏ฒ Elevated pulmonary artery pressure. ๏ฒ The presence of scarring of the lungs or chronic inflammatory changes. LVRS AND LUNG TRANSPLANTATION lung transplantation
- 21.
- 22. Baseline demographics, Respiratoryfunction and emphysema distribution
- 23. Measurements During MaximumExercise at Baseline and 6, 12 and 24 Months
- 24. Pao2 During RestfulBreathing, Unloaded Pedaling, and Maximum Exercise at Baseline and at 6, 12, and 24 Months
- 25. CONCLUSION During exercise followingLVRS, patients with severe emphysema improve carbon dioxide elimination and dead space, breathe slower and deeper, and report less dyspnea.
- 26.
- 27.
- 28. Baseline Hemodynamic VariablesIn Medical and Lung Volume Reduction Surgery Groups
- 29. CONCLUSION In comparison tomedical therapy, LVRS was not associated with an increase in pulmonary artery pressures.
- 30.
- 31. CONCLUSION In selected patientswith homogeneous pulmonary emphysema, LVRS can be successfully performed with low perioperative mortality. Significant improvements in dyspnea, lung function and exercise capacity are maintained for several years
- 32.
Editor's Notes
- #4ย (LVRS) is a procedure which removes approximately 20-35% of the poorly functioning, space occupying lung tissue from each lung By reducing the lung size, the remaining lung and surrounding muscles (intercostals and diaphragm) are able to work more efficiently.
- #5ย That intensifies expiratory muscle recruitment
- #7ย is the first multi-center clinical trial designed to determine the role, safety, and effectiveness of bilateral lung volume reduction surgery (LVRS) in the treatment of emphysema. A secondary objective is to develop criteria for identifying patients who are likely to benefit from the procedure.
- #8ย randomized, multicenter trial which compared the results of LVRS to medical therapy These patients have improved survival and functional outcomes after LVRS compared to medical therapy. These patients have improved functional outcomes after LVRS but no difference in survival compared to medical therapy These patients have improved survival after LVRS but no difference in survival compared to medical therapy.
- #10ย represent the ideal candidates for LVRS in terms of expected magnitude and duration of benefits
- #13ย reported that LVRS decreases middle-to-lower anterior-to-posterior rib cage diameter as assessed by chest radiography and CT whereas, in another elegant study, Cassart et al. [62] have found that by decreasing the overall lung volume, LVRS makes the diaphragm dome move upwards and increases the area of muscle juxtaposed to the rib cage. Lower operating lung volumes have been reported to eventually lead to improvements in strength and efficiency of inspiratory muscles.
- #14ย In an analysis of the NETT cohort, Criner and coworkers [68] reported that following LVRS, patients with upper-lobe emphysema on maximal exercise showed higher output of CO2, greater tidal volume, and increased hearth rate, which were associated with slower and deeper breathing patterns lasting for up to 24 months
- #15ย Right and left ventricular function can be impaired in patients with advanced emphysema due to reduced end-diastolic volumes beneficial effects of LVRS on right ventricular filling and performance have been hypothesized by our group [71] who reported that improvements in right ventricular function indexes occurred on exercise after LVRS and correlated with a reduction in RV/TLC. In a similar manner, Jรถrgensen et al. [72] reported post-LVRS increases in left ventricular end-diastolic dimensions and filling, eventually resulting in improved left ventricular function.
- #16ย One-stage bilateral LVRS is the most widely adopted approach since it produced greater functional and clinical improvements than unilateral treatment Median sternotomy is one of many incisions that can be made in the thorax and gives a wide view of the thoracic cavity video-assisted thoracoscopic procedures: Video-assisted thoracoscopic surgery (VATS) is minimally invasive thoracic surgery that does not use a formal thoracotomy incision.
- #17ย mortality rates ranged between 0 and 17% in previous studies (Table 2) whereas an overall morbidity rate of 59% has been reported in the NETT major pulmonary and cardiovascular morbidity within 90 days post-LVRS occurred in 30% and 20% of patients, respectively Cardiac arrhythmia was the most common complication with a rate of 23.5% . Rates for pneumonia and need of reintubation were 18% and 22%, respectively
- #19ย To optimize exercise capacity and improve early postoperative recovery, Immediately after the procedure, patients are awakened from the general anesthetic and allowed to breath on their own. to help control postoperative discomfort. . to drain any excess air or fluid from the chest after surgery Patients are discharged from the hospital once the patient is mobile, tolerating a regular diet and drainage tubes have been removed.
- #20ย patients demonstrated to improve dyspnea, respiratory function, exercise capacity, and quality of life in patients with severe emphysema. For older patients, LVRS remains the only surgical option to achieve a significant clinical benefit whereas patients aged 55โ60 are more difficult to address since the benefits of LVRS may be lost over time when they reach an age limit which may be critical for lung transplantation. In young patients who fulfill the criteria for both surgical treatments, LVRS can be performed first to postpone lung transplantation
- #21ย preferably addressed to