The document discusses various interventional therapies for managing chronic obstructive pulmonary disease (COPD), including lung volume reduction surgery and transplantation, emphasizing their benefits and criteria for selection based on patient's condition. It outlines preoperative and postoperative rehabilitation strategies, highlighting the importance of comprehensive evaluations and various contraindications for surgical options. Additionally, it addresses potential complications associated with lung transplantation and the necessity for immunosuppression post-surgery.

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.