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© 2004 European Association of Cardio-Thoracic Surgery
Lung volume reduction surgery in a ventilator-dependent patientRoyal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK
* Corresponding author. Tel.: +44-1392-402689; fax: +44-1392-402175 Received June 11, 2003; received in revised form November 18, 2003; accepted November 28, 2003
In recent years lung volume reduction surgery (LVRS) has been advocated in a selected group of severe chronic obstructive pulmonary disease (COPD) patients. There are few reports of successful surgical intervention on ventilator-dependent patients. We present our own experience with a 53-year-old male who suffered an acute exacerbation of COPD and who could not be weaned off ventilation after 22 days. He underwent bilateral LVRS after which he was successfully weaned from ventilation. He is alive 4 years later with a satisfactory quality of life.
Key Words: Lung volume reduction surgery; Chronic obstructive pulmonary disease; Mechanical ventilation; Ventilator dependency
A 53-year-old accountant with chronic obstructive pulmonary disease (COPD) was seen in the respiratory medicine clinic with a 2-year history of dyspnoea, orthopnoea and a reduced exercise tolerance of 100 yards. He was an ex-smoker of 36 pack-years. His oxygen saturation then was 88% on air with an FEV1/FVC (ratio of forced expiratory volume in the first one second to forced vital capacity) of 26% (33% of predicted) and a residual volume of 5.70 l (266% of predicted; Table 1).
Two weeks later he was admitted with increasing dyspnoea, wheezing and pyrexia. His oxygen saturation was 87% on 2 l O2. His condition deteriorated with PO2 of 7.7 (normal 11.3–14.0)kPa and PCO2 of 9.13 (normal 4.7–6.0)kPa on 24% O2. Twelve hours later he developed a right-sided pneumothorax and an intercostal chest drain was inserted. He developed severe surgical emphysema, oxygen saturation fell to 70% and PCO2 rose to 12.0kPa. He was intubated and transferred to the intensive care unit (ICU). The patient was treated for 31 days on the ICU with repeated attempts at weaning from ventilatory support proving unsuccessful. His initial chest drain and two more subsequent drains intermittently controlled his air leak and improved his surgical emphysema. Tracheostomy became unavoidable by day 12. Weaning was further complicated by pneumonia that was treated with appropriate antibiotics. CT scan showed cystic changes in both lungs consistent with heterogeneous emphysema, predominantly in the upper lobes. On the 24th day, after several further unsuccessful attempts at weaning, lung volume reduction surgery (LVRS) was undertaken under general anaesthesia. A trans-thoracic cardiac ECHO prior to the operation showed a normal left ventricle though views were limited; PA pressures could not be measured. Pre-operatively his ventilation parameters were IPAP 10cmH2O and EPAP 5cmH2O; his arterial blood gases on Fi O2 0.45 were pH 7.41, PO2 8.2, PCO2 6.93, oxygen saturation 93%. At median sternotomy both upper lobes appeared grossly emphysematous with severe destruction. Severe bullous emphysematous changes within the right upper lobe had appearances typical of a recent air leak; this was the likely cause for his pneumothorax. The middle lobe was relatively spared and there was emphysematous destruction in the right lower lobe. Approximately two-thirds of both upper lobes including the ruptured emphysematous area and a hyperinflated area of the right lower lobe were stapled off and an apical chest drain was left on each side. Staple lines were reinforced with Gore-tex (Seamguard) strips. A thoracic epidural catheter was used for post-operative analgaesia. The patient was gradually weaned from ventilation and was discharged from ICU within a week. On the ward he struggled with swallowing due to laryngeal dysfunction and also had some memory deficit. He remained on intermittent bilevel positive airway pressure for 5 weeks post-operatively because of recurrent pneumothorax and aspiration pneumonias. He finally went home with domestic oxygen 47 days after his operation. Four years after the operation he remains on home oxygen and his quality of life is satisfactory. Repeat pulmonary function testing showed FEV1 has remained stable since the operation, FVC is reduced but not worsening and total lung capacity (TLC) and residual volume (RV) are increased but not progressively (Table 1).
Patient selection for elective LVRS can be difficult since mortality rate can be as high as 19% and morbidity rates higher [1]. The justification and indications for ‘urgent’ LVRS (in ventilator-dependent patients) are even more difficult to establish. LVRS is not a definite curative procedure and gives only partial improvement as the remaining lung tissue is diseased and prone to further deterioration. Patients who are ventilator-dependent already have a poor prognosis so it may be difficult to justify LVRS in this subgroup. However LVRS may be the only remaining option to achieve successful weaning in these patients. LVRS has been advocated as a bridge to lung transplantation, which may be a further therapeutic option for these patients. The main indication for this patient's surgery was failure to wean from ventilation on account of his severe emphysema. His air leak contributed to this but was not the principle indication for surgery. His pulmonary function was such that a bilateral procedure was felt to be the best option; a unilateral procedure may not have made sufficient improvement to have allowed successful weaning from ventilation. There are four publications reporting cases of successful weaning following LVRS in ventilator-dependent patients (Table 2). Follow-up in these patients is short, but all patients' quality of life improved and all showed the expected improvements in lung volumes.
An open approach was chosen to enable easy identification of the site of bronchopleural fistula in severely emphysematous lungs. Median sternotomy for bilateral LVRS is well supported in the literature [2,3] and in our case provided excellent exposure. Excision of the site of air leak, increased diaphragm mobility and a reduction in residual volume all probably contributed to the clinical improvement. This case report adds to the literature reporting LVRS as an appropriate manoeuvre in selected ventilator-dependent COPD patients and highlights the potential for long-term survival. Our primary goal was not to improve respiratory function but to improve chances of survival. The procedure enabled us to wean the patient from ventilatory support and to avoid further complications of long-term ventilation. He went home and has remained ventilator-independent for 4 years. He is on home oxygen and although he rarely leaves his house his mood remains euthymic and he is glad he had LVRS. There is a need for a prospective trial of LVRS in ventilator-dependent patients. This would be difficult to achieve but could be accomplished using strict criteria in a multi-centre protocol. doi:10.1016/j.icvts.2003.11.007
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Abstract
1. Case report