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Chronic obstructive pulmonary disease

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of COPD -- emphysema and/or chronic bronchitis.

Alternative Names

COPD; Alpha-1 antitrypsin deficiency; Bronchitis - chronic; Chronic bronchitis; Emphysema

Surgical Procedures

Surgical procedures for emphysema are still investigative. They are all very expensive and often not covered by insurance. The great majority of patients cannot be helped by surgery, and no single procedure is ideal for those that can be helped.

Lung and Liver Transplantation

Advanced emphysema is responsible for over half of the lung transplants performed. Three-year survival rates after lung transplantation are about 60% for patients with either emphysema or AAT deficiencies. Techniques have been developed so that both lungs may be replaced in sequence. The increasingly long waiting time and the extraordinary expense are both significant problems.

Candidates. The best candidates are under 65 and have good general health aside from lung disease. A lung or liver transplantation may be the only hope for some patients with the alpha 1-antitrypsin (AAT) deficiency-related emphysema. AAT is produced in the liver, so a healthy transplanted liver may produce adequate supplies of this enzyme.

Waiting Time. Unfortunately, up to a third of patients awaiting lung transplantation die before a suitable donor is available. There were 1,042 lung transplantation operations in 2002, and as of this nearly 4,000 people are waiting for the operation. Not all lung transplant centers, even in major cities like New York, accept Medicare. Starting in 2005, the United Network for Organ Sharing (UNOS) is assigning lungs for transplants based on an allocation score, rather than time spent on the waiting list. The allocation score takes into account the length of time a patient is likely to survive before and after transplant. This policy applies to transplant candidates aged 12 or older.

Complications. Transplant patients must take drugs that suppress the immune system to prevent the body from rejecting the transplanted organ. Nevertheless, rejection is the primary cause of late complications and death. The mortality rate from the procedure itself is about 10%.

Lung Volume-Reduction Surgery

Lung volume-reduction surgeries (LVRS) remove over 30% of severely diseased lung tissue, and the remaining parts of the lung are joined together. Improvement in breathing after surgery appears to be largely due to the following factors:

• An improvement in the lung and chest wall's ability to spring back during breathing
• Improvement in function of the muscles, such as the diaphragm, involved with breathing

Prognosis. Two-year results of the largest study to date, called the National Emphysema Treatment Trial (NETT), indicate that patients who are good candidates for LVRS achieve better lung function with surgery, and have no higher risk of death, than those on medical therapy. Mortality rates within 90 days of surgery are almost 8% compared to about 1% in patients on medical therapy. However, in spite of the early spike in deaths after surgery, there are no overall differences in long-term survival rates.

When the operation is successful, patients report significant improvement in walking distance, weight, and quality of life. Many patients can engage in active daily events, such as golf or stair-climbing, without oxygen. Even in carefully selected candidates, however, about 15% of patients derive little or no benefit from the procedure, and about 4% get worse. Furthermore, even in successful cases, the improvement is most notable within the first 6 months, after which the condition progresses again. Beyond 2 years, lung function deteriorates to the same level as it was before the procedure. It is not clear yet if surgery is cost effective over time, compared to medical therapy.

Possible Candidates. For now, the procedure is used only in people who have severe emphysema and not chronic bronchitis. And it is applicable only to a minority of these patients. Appropriate candidates are those with the following characteristics:

• Under 75 years old
• Having severe obstruction (FEV1 less than 40% but higher than 20% of expected value)
• Carbon monoxide diffusing capacity of more than 20% of expected value
• Hyperinflated lungs (total lung capacity greater than 120% of the expected value)
• Appropriate candidates who have deficiency of alpha 1-antitrypsin, even if they have disease in the lower lobe, may do well

The most recent NETT results indicate that surgical patients who had emphysema in the upper lungs, and a low exercise capacity, may have better survival rates and outcome than the same patient group who is given medical therapy.

Comparison in Outcomes Between Surgery and Medical Treatments
	Low Exercise Capacity	High Exercise Capacity
Emphysema in Upper Lungs	Surgical group had better lung function and two-year survival rates than medical group.	Similar mortality rates but surgery group had better lung function.
Emphysema Not in the Upper Lungs	Similar survival rates and similar outcome.	Surgical group had worse survival rates, and both had low chance for improving in lung function.
Data from: A Randomized Trial Comparing Lung-Volume-Reduction Surgery with Medical Therapy for Severe Emphysema. The New England Journal of Medicine. May 22, 2003. No. 21, Vol. 348.

Poor Candidates for Surgery . Early results from NETT suggest that the following patients have a high risk of a poor prognosis , and are generally not good candidates for LVRS:

• Those with a very low FEV1 (less than 20% of expected value), plus
• Those with carbon monoxide diffusing capacity of less than 20% of expected value, or
• Those with even distribution of emphysema in the lungs

In the study, patients with these characteristics had a 16% mortality rate at 30 days after surgery compared to no deaths in similar patients who were treated with medications only. Such high-risk patients accounted for about 12.5% of the patient population in the study.

Patients may also be excluded if they have severe medical conditions that limit their life span; severe psychological problems; recent tobacco, drug, or alcohol dependence; chest wall deformity; corticosteroid dependence; or scarring around the membrane of the lung. Other indicators for a poor outlook include severe lung complications and isolated bullae (air pockets in diseased area of the lungs).

Specific Techniques. At this time, the preferred technique is bilateral lung volume reduction (surgery is done on both lungs). Surgeons use either an open approach, making a large cut in the chest area, or video-assisted thoracoscopy (VATS), which is less invasive and involves several small cuts. Either method is effective and has similar complication rates. Lines of staples are typically used to reduce lung volume.

The alternative technique is unilateral lung volume reduction . Unilateral means one-sided -- surgery is done on only one lung. Some centers believe this approach may cause fewer complications and slower decline in benefits, although not all evidence supports its use over the bilateral method.

Bullectomy

Another option for COLD is bullectomy, in which giant air pockets and surrounding lung tissue are removed. It is generally limited to younger patients, particularly those with alpha 1-antitrypsin deficiency.

• Review Date: 4/28/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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