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Lung volume reduction surgery (LVRS) is designed to improve breathing and quality of life in patients with severe emphysema, particularly those with upper lobe predominance and low exercise capacity. By surgically removing diseased, non-functional lung tissue, LVRS reduces lung hyperinflation, enhances respiratory mechanics, and improves gas exchange. This can significantly improve symptoms, exercise tolerance, and overall survival. Despite its proven benefits, LVRS remains underutilized—partly due to the complexity of patient selection and the need for specialized surgical expertise. Clinicians participating in this course gain a comprehensive understanding of the indications, patient selection criteria, and surgical techniques for LVRS, including both median sternotomy and video-assisted thoracoscopic surgery approaches. Additionally, clinicians will learn about the latest research and advancements in minimally invasive techniques such as endobronchial valves. This knowledge will enhance their competence in managing patients with severe emphysema, improving patient care and safety. The course also covers the management of complications, postoperative care, and the role of interprofessional teams in optimizing patient outcomes. Objectives: Identify the appropriate indications for lung volume reduction surgery in patients with severe emphysema, particularly those with upper lobe predominance and low exercise capacity. Implement median sternotomy and video-assisted thoracoscopic surgery approaches for lung volume reduction surgery to optimize patient outcomes. Apply the latest research and advancements in minimally invasive techniques, such as endobronchial valves, to treat severe emphysema. Collaborate with a multidisciplinary team, including surgeons, pulmonologists, nurses, pharmacists, and respiratory therapists, to provide comprehensive care to patients undergoing lung volume reduction surgery. Access free multiple choice questions on this topic.

Lung volume reduction surgery (LVRS) is a surgical procedure primarily used to treat patients with severe emphysema, a form of chronic obstructive pulmonary disease.[1] This progressive lung condition, often caused by long-term smoking or exposure to harmful environmental factors, leads to the destruction of lung tissue, resulting in significant breathing difficulties and reduced quality of life. LVRS involves the removal of diseased, nonfunctioning lung tissue to allow the remaining healthier lung tissue to expand and function more efficiently. Although first described in the 1950s, LVRS did not gain popularity until the 1990s due to improved surgical technology and the management of complications.[2] Results from a large, collaborative, multicenter, randomized control trial for LVRS, known as the National Emphysema Treatment Trial, were published in 2003 to assess the effectiveness of LVRS on quality of life and survival advantage compared to available medical therapy.[3] This landmark study guides our current selection criteria for LVRS patients. Despite its potential benefits, LVRS is associated with substantial risks and requires careful patient selection and meticulous surgical technique. Long-term outcomes, the comparative effectiveness of unilateral versus bilateral surgery, cost-effectiveness, and the potential role of LVRS as a bridge-to-lung transplant remain active research areas.[4][5][6][7] This article provides an overview of the indications, patient selection criteria, surgical techniques, outcomes, and potential complications associated with LVRS, highlighting its role in the comprehensive management of severe emphysema.

In NETT, patient cohorts were analyzed for operative mortality and cardiopulmonary morbidity. The subanalysis found that cardiopulmonary morbidity remained high at approximately 5.5%. Major pulmonary and cardiovascular complications were also relatively high, occurring in 20% to 30% of patients (out of 511) who were considered a non-high-risk subset of LVRS patients. Naunheim et al found that patients with non-upper-lobe-predominant emphysema were 1 of the factors associated with increased mortality.[14] Other complications include: Air leaks The most common complication of LVRS is prolonged air leaks, which occur when the lung tissue does not seal appropriately after resection. This can lead to persistent pneumothorax and may require extended use of chest tubes or additional surgical interventions. Prolonged air leaks can lead to extended hospital stays, higher readmission rates, increased intensive care unit admissions, and a greater risk of postoperative pneumonia.[15] NETT estimated that 90% of patients had an air leak in the 30-day postoperative period. However, only 12% of patients had an air leak over 30 days. NETT also concluded that not having a postoperative air leak was not associated with the specific surgical technique.[16] Infection Postoperative infections, including pneumonia, wound infections, and empyema (infection of the pleural space), are significant risks. These infections can prolong hospital stays and require aggressive antibiotic therapy or surgical drainage. Cardiovascular complications These include myocardial infarction, arrhythmias, or pulmonary embolism. Pulmonary complications These include hypoxia and respiratory failure requiring reintubation, prolonged intubation, or tracheostomy.[12][14] Bleeding Intraoperative or postoperative bleeding is a potential complication that may require blood transfusions or additional surgical intervention to control. Atelectasis Partial or complete collapse of the lung can occur postoperatively, leading to reduced lung function and increased risk of infection. Pleural effusion This fluid accumulation in the pleural space may require drainage and can affect lung reexpansion. Death Although rare, mortality is a serious risk associated with LVRS, particularly in patients with severe comorbidities or poor overall health.

Effective management and successful outcomes of lung volume reduction surgery (LVRS) necessitate a comprehensive and coordinated approach by a multidisciplinary team. Physicians, including pulmonologists and thoracic surgeons, must collaborate closely to identify suitable candidates through detailed assessment and imaging studies, ensuring patients meet the criteria established by the National Emphysema Treatment Trial. Advanced clinicians and nurses play crucial roles in preoperative education, helping patients understand the procedure, potential risks, and postoperative care requirements. They also provide continuous monitoring and support during recovery, ensuring early detection and management of complications. Pharmacists contribute by optimizing medication management, addressing preexisting conditions, and ensuring appropriate use of antibiotics and pain management strategies. Respiratory therapists are integral in preoperative and postoperative pulmonary rehabilitation, helping improve patients’ lung function and exercise capacity. Effective interprofessional communication and care coordination are paramount, involving regular team meetings, shared electronic health records, and clear protocols to facilitate seamless transitions between different stages of care. This collaborative approach enhances patient-centered care and outcomes and improves patient safety and overall team performance, ultimately leading to more successful LVRS procedures and better long-term patient health.

Patients with LVRS are at high risk for cardiopulmonary morbidities. There is about a 20% to 30% morbidity rate. Since the complications are multifactorial in patients already at risk for cardiac and pulmonary complications, a well-prepared interprofessional healthcare team can improve outcomes and patient safety through appropriate monitoring, including pulse oximetry and telemetry monitoring. Interprofessional teams need to be educated about potential complications and treatment. For example, a postoperative LVRS may require pain medication, but this may also worsen respiratory status through respiratory depression that may be poorly tolerated.[14]