For some patients with chronic obstructive pulmonary disease, medications, pulmonary rehabilitation and other typical interventions may not be enough. Particularly for patients with later stage COPD, surgery may be the best option to help you manage this incurable but treatable disease.
The National Heart, Lung and Blood Institute reports that “surgery usually is a last resort for people who have severe symptoms that have not improved from taking medicines.” The dilemma is that patients must be well enough to tolerate major surgery, but advanced COPD patients may not fit this bill.
Nevertheless, surgery is a good option for some patients, and surgical treatments for the disease can take one of three forms: lung volume reduction surgery, bullectomy or lung transplantation.
Lung Volume Reduction Surgery
The name of the surgery may seem counterintuitive – if you’re having trouble breathing, why would you want to reduce the volume of air your lungs can hold? But for patients with COPD, and certain types of emphysema in particular, trapped air in the lungs is a problem that leads to the hallmark shortness of breath that COPD patients experience.
Dr. Umur Hatipoglu, director of the COPD Center at the Respiratory Institute at Cleveland Clinic, says “the big problem with emphysema patients is they get hyperinflated, they trap air.” Air gets trapped in the areas affected by the emphysema, and there’s not much lung tissue there anyway. “So they’re basically not only useless, but work against the patient making it difficult for them to breathe.”
One way surgeons have addressed this is by reducing the amount of damaged tissue in the lungs by removing this tissue, which allows air to flow more freely in and out. The Cleveland Clinic website describes the procedure as reducing “the size of an over-inflated lung,” which “allows the expansion (growth) of the remaining, often more functional lung.” According to the University of Southern California’s cardiothoracic surgery website, LVRS “removes approximately 20 to 35 percent 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. This makes breathing easier and helps patients achieve greater quality of life.”
As with all surgical procedures for COPD, “lung volume reduction surgery is not for everyone,” Hatipoglu says. “It’s useful with patients with upper lobe predominate emphysema,” a type of lung disease in which the top part of the lung has experienced significant damage. He says the surgery may also be performed on patients with “homogeneous emphysema with low exercise capacity” – in other words patients with damage throughout their lungs who are quick to become breathless with minimal exertion.
“If you look at all comers with emphysema, upper lobe emphysema with low exercise capacity would constitute about a quarter of the patients,” Hatipoglu says. “So, it’s a select group of patients. But in the end, if you do this surgery, it is associated with improved survival, so it’s one of these modalities that can improve longevity in COPD if done in the right group.”
However, LVRS is expensive and can have complications, including the risk of death. Hatipoglu says patients may “get stuck in the hospital for over a week typically with air leaks coming out of the chest through chest tubes. Therefore in the United States, this surgery is not being performed frequently anymore. And if it’s going to be done, it really should be done at a center that’s experienced with it.”
A second type of lung surgery, called bullectomy, is similar to LVRS in that it removes damaged tissue to allow the patient to breathe easier. But rather than removing emphysematous tissue, in a bullectomy, the bullae are removed. “The bullae is a very large emphysematous space that measures greater than 1 centimeter,” or about the width of the tip of your pinkie finger, Hatipoglu says. The University of Rochester Medical Center reports that individual bulla can approach 20 centimeters in size, or about 8 inches, making breathing very difficult. The NHLBI notes that “when the walls of the air sacs are destroyed, larger air spaces called bullae form. These air spaces can become so large that they interfere with breathing. In a bullectomy, doctors remove one or more very large bullae from the lungs.”
Hatipoglu says the surgery is used for patients who have lost a significant portion of their lung function to the bullae taking up space in the lung. “Particularly when bullae compress good lung, which is generally evident on imaging,” such as a chest X-ray or CT scan, Hatipoglu says. The bullae will look like a “large balloon in the chest that’s compressing normal lung tissue.”
Again, patients are carefully chosen for this surgical intervention, which can be very helpful, Hatipoglu says, “because it not only reduces the compression because you’re taking ‘the balloon’ out, it also allows the lung that’s compressed under it to expand.”
Dr. Bryan Whitson, associate professor of surgery and lead lung transplant surgeon at The Ohio State University Wexner Medical Center, says a bullectomy procedure may be useful for patients for whom an LVRS isn’t recommended for one reason or another. TheAmerican Thoracic Society reports that few patients have bullae large enough to benefit from a bullectomy. “Most people with COPD from emphysema have many small areas of damaged air sacs in their lungs. These small damaged air sacs are often scattered throughout both lungs and therefore would not benefit from a bullectomy. The Mayo Clinic reports that patients with alpha-1-antitrypsin deficiency, a genetic disorder that can lead to advanced emphysema, may also be candidates for bullectomy.
Lastly, in certain cases, a lung transplant may be a patient’s last best hope for relief from severe COPD. Whitson says “lung transplant – fortunately or unfortunately, depending on how you look at it – is the only way to cure end-stage lung disease.” For patients who’ve “maxed out on oxygen” and for whom lung function continues to decrease despite the use of inhaled or oral steroids, a transplant may be the only option, he says. The 2015 report of The Registry of the International Society for Heart and Lung Transplantation, showed that between January 1995 and June 2014, 17,141 COPD patients received lung transplants. This group accounts for 35.7 percent of all lung transplantation procedures, making COPD the most likely reason to have a lung transplant.
During a transplant, the surgeon removes the diseased lung (sometimes both) and transplants a lung or lungs from a donor. Finding a suitable donor can be challenging, and transplant patients might have to wait for a long while before a viable organ becomes available.
In addition, any kind of organ transplant is a major undertaking, and patients will be on immunosuppressant drugs for the rest of their lives to prevent rejection of the new organ. Lung transplants also requires “a lot of lifelong lifestyle changes,” Whitson says “It’s a good therapy, but as with everything in medicine, it comes with a trade-off.”
Who Qualifies for Which Surgery?
Whitson says there are numerous criteria a patient must meet before being considered for any kind of surgery. “We look at what their lung function is and how far they can walk in six minutes.” Deciding whether a patient is a good transplant candidate will also entail a look at comorbidities, or conditions such as diabetes or heart disease a patient may have, as well as the type and severity of their lung disease and their overall prognosis.
Whitson says it’s not common for a patient to have more than one of these surgeries, but it is possible that someone could have a bullectomy and then LVRS later. Or a patient could have LVRS followed by transplant several years later. The scarring that occurs as part of the LVRS procedure can make it harder to transplant a lung later, “but if you can get them 8 or 10 years down the road without immunosuppression, that’s probably a win,” he says.
If your doctor says surgery might be a good option for you, be aware that the number of hospitals approved to offer LVRS is limited. The Centers for Medicare & Medicaid Services currently lists 26 medical centers in the United States that are credentialed by the Joint Commission on Accreditation of Health Care Organizations to perform LVRS and lung or heart and lung transplants.