LVRS (Lung Volume Reduction Surgery)
Jane M. Martin, BA, LRT, CRT
What is LVRS?
LVRS stands for Lung Volume Reduction Surgery, an operation that reduces the size of the lungs to help them work better. The idea is to remove over-expanded, useless lung tissue allowing for the more healthy lung tissue to have room to move and function more effectively.
What is wrong in lungs with COPD?
In COPD the lungs lose their elastic quality, becoming too stretched out. Just as a balloon that’s been filled many times becomes floppy and unable to get rid of air, lungs with COPD (some much more than others) tend to trap stale air that no matter how hard you try, you cannot blow out. In individuals whose emphysema component of their COPD is very severe, the lungs are extremely stretched out and large. When this happens the chest cavity is crowded and the lungs cannot effectively do the work of breathing and oxygen exchange. In short, it takes a lot of work to move the air in and out, with not much benefit.
How does LVRS help?
In Lung Volume Reduction Surgery, the non-working, or poorly working, areas of the lungs are removed, allowing the less damaged areas to expand into that space. The desired result is more efficient lung function.
The diaphragm, the main muscle of breathing, works best when, at rest, it is in the shape of a dome. When the dome flattens and pulls on the bottoms of the lungs, the lungs expand and air comes in easily. When the diaphragm goes back into a dome shape, it pushes up on the bottoms of the lungs and the air goes out.
In some people with COPD, with the lungs extremely over expanded, the diaphragm is flat all the time. There is such a small degree of movement, this makes it hard to push air of out of the lungs. Reducing lung volume (making the lungs smaller) allows the diaphragm to get back to a dome shape again.
In addition to a flattened diaphragm, when lungs are too big, the ribs are swiveled up and forward. Reducing the volume of the lungs will help the ribs drop to their normal position. This improves the movement of the respiratory muscles, resulting in less work of breathing with a much better effect.
Is LVRS something new?
LVRS is not a new procedure. It was first tried decades ago. In fact, a procedure called “bullectomy” has been around for 50 years. “Bullae / blebs,” are names for sections of lungs that are so stretched out, they are like bulging blisters. Blebs can be small, but some can be as big as a softball, doing nothing to assist in oxygen exchange, but taking up a lot of room in the chest, pressing on more healthy lung tissue.
The National Emphysema Treatment Trial (NETT)
The revival of LVRS was based on removing not just blebs, but the upper areas of both lungs. Having a successful surgical outcome on delicate lung tissue that is badly damaged and full of air does not come easily. And as LVRS became more widely performed, it was not unusual for people who had this surgery to have no improvement at all. Sadly, some became even worse. Air leaks persisted in some patients, keeping them in the hospital for months. Some people never recovered. Some even died. But, desperate to breathe better, people continued to seek this surgery wherever they could get it. Because of this, the National Institutes of Health (NIH) and the agency in charge of Medicare (CMS) organized a study to learn what type of lungs and what types of patients, would have the best chance to benefit from LVRS. This study was called the National Emphysema Treatment Trial (NETT).
What did the study find?
The NETT study found that certain types of patients with COPD have a good chance of benefiting from LVRS and recovering quite well from surgery. It also found that some types of patients are likely to be harmed by this surgery.
It found that people who have COPD with diffuse disease (the same amount of damage spread throughout the lungs and not just in one area), those with significant lower lobe lung disease, and those with a very low oxygen diffusion level are not likely to benefit from LVRS, but in fact, could be harmed by it. Those who have these types of COPD are more likely to live longer and have a better quality life with the usual medical treatment (pulmonary rehabilitation, oxygen, and medications) rather than LVRS.
Who qualifies for LVRS?
The following criteria make LVRS an option worth considering.
- Emphysema that is mainly in the tops of the lungs
- People with exercise capacity that is very limited
- People with exercise capacity not improved by pulmonary rehabilitation
- People who are committed to never smoking again and have been smoke free for at least six months
Today, LVRS is permitted only in select medical centers with doctors who are very experienced in doing this surgery. Improved outcomes have also resulted from advances in keeping a lasting, airtight seal where the lungs have been operated on. Therefore, carefully selected COPD patients who undergo LVRS in approved facilities have a greater chance of a successful outcome and improved quality of life, exercise capacity and survival.
What if I don’t qualify for LVRS? Is there still hope for me?
Yes! Although COPD is not curable and it is progressive—it is treatable! And medical treatment is better than ever. Pulmonary Rehabilitation, portable oxygen, optimal use of medications as well as education on avoiding lung infection—or at least catching it early—can help people with even severe COPD live well for many years.
Reference for this article: COPD Foundation Big Fat Reference Guide (BFRG) version 2.0 http://www.copdfoundation.org
For more information:
COPD Foundation, Big Fat Reference Guide (click on Resources, BFRG)
Lung Volume Reduction Surgery - University of Michigan Health System
Cleveland Clinic – Lung Volume Reduction Surgery
National Emphysema Treatment Trial (NETT)
© Copyright 2012, Jane M. Martin, CRT
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