Approximately 13.5 million persons in the United States are aficted with COPD, and 3.

1 million of these
patients have emphysema (Cure Researchtm.com, http://www.cureresearch.com). Airow obstruction
associated with chronic bronchitis or emphysema occurs due to a loss of the elastic recoil properties of
the lung and chest wall. As the disease progresses, patients become increasingly debilitated. Patients
exhibit symptoms of severe dyspnea, require supplemental oxygen, and display poor exercise tolerance.
LVRS oers a select group of patients the possibility of improved exercise tolerance, reduction in
dyspnea, improved quality of life, and extended life span. It has been suggested that LVRS may provide
these patients with a beneft that otherwise cannot be achieved by any means other than lung
transplantation.

A. History of lung volume reduction surgery

1. In 1957, Otto Brantigan, M.D., described a surgical technique for patients with end-stage emphysema
that was designed to alleviate symptoms of severe dyspnea and exercise intolerance. It was Brantigans
intent to remove functionally useless areas of the lung in order to restore pulmonary elastic recoil, thus
increasing the outward traction on small airways and subsequently improve airow. Brantigan believed
that this technique could restore diaphragmatic and thoracic contours that would improve respiratory
excursion. Additionally, he reasoned that by excising the nonfunctional lung tissue, the compressive
eects exerted on normal lung tissue could be relieved and result in improved V/Q matching.
Unfortunately, the operative mortality was signifcant and no objective measures of beneft could be
documented. Tus, early LVRS was abandoned as a viable therapy for patients with end-stage
emphysema until 1993.

2. In 1996, Joel Cooper, M.D., authored an editorial advocating the technique of LVRS as a logical,
physiologically sound procedure of demonstrable beneft for a selected group of patients with no
alternative therapy [40]. He further stated that the successful application of LVRS was made possible
through an improved understanding of pulmonary physiology, improved anesthetic and surgical
techniques, and lessons learned from experience with lung transplantation. Although Dr. Cooper
touted the benefts of LVRS for certain patients, he did not minimize the surgical risk and suggested that
this was not a procedure to be performed in all healthcare centers across the country. He made the
following proposal: (1) Healthcare providers should restrict the application of this (LVRS) procedure to a
limited number of centers of excellence; (2) such centers should be required to document and report
specifed information regarding morbidity, mortality, and objective measures of outcome; and (3) these
data should be periodically reviewed and evaluated by a scientifc panel before approval to continue
performing the procedure is obtained. Additionally, he advocated that the patients who would
otherwise qualify for lung transplantation should be simultaneously evaluated for LVRS so that they
would receive the procedure proving to be most appropriate. Although Dr. Cooper did not necessarily
advocate a long-term prospective randomized trial to validate the beneft of LVRS, his proposals led to
the design and implementation of the National Emphysema Treatment Trial (NETT).

B. Te NETT was conducted from January 1998 and July 2002. It was a prospective, randomized,
multicenter trial sponsored by the National Heart, Lung, and Blood Institute in conjunction with Health
Care Financing Administration (now known as Center for Medicare and Medicaid Services [CMS]). 3,777
patients were evaluated and 1,218 patients were ultimately randomized to receive either LVRS or
medical therapy.
1. Te primary objective of the NETT was to determine if the addition of LVRS to medical therapy
improves patient survival and increases exercise capacity.

2. Secondary objectives included defning the profle of patients likely to beneft from LVRS and
determining if LVRS improves quality of life, reduces debilitating symptoms, and improves overall
pulmonary function.

3. Patients were randomized to either medical therapy alone (N = 610) or medical therapy plus surgery
(N = 608). Surgical patients were further randomized to intervention via either median sternotomy or
bilateral thoracoscopy.

4. A successful procedure was defned as a 60% to 70% increase in FEV1 by 3 months postoperatively
that is sustained for at least 1 yr; decreased total lung capacity and residual volume; improved exercise
tolerance; and signifcant reduction in supplemental oxygen requirement.

C. Results. Te fnal results of the NETT were published in the May 22, 2003 issue of the New
England Journal of Medicine [41]. Of the 608 patients assigned to LVRS, 580 underwent surgery (406 via
median sternotomy; 174 VATS). Among the 610 patients assigned to medical therapy alone, 33
underwent LVRS outside the study and 15 received lung transplantation. Overall mortality was 0.11
deaths per person-year in both treatment groups. After 24 months, exercise capacity improved more
than 10 W in 15% of patients in the surgery group compared with 3% in the medical-therapy-alone
group. After exclusion of 140 patients at high risk for death from surgery [38] according to an interim
analysis, overall mortality in the surgery group was 0.09 deaths per person-year versus 0.10 in the
medical group. Among patients with predominantly upper-lobe emphysema and low baseline exercise
capacity, mortality was lower in the surgery group than in the medical-therapy-alone group.

D. Conclusions. Te data from the trial suggested that, overall, LVRS increased the chance of
improved exercise capacity but did not demonstrate a survival advantage as compared with medical
therapy alone. Tere was a survival advantage demonstrated for those patients with both predominantly
upper-lobe emphysema and low baseline exercise capacity. Patients reported in the interim analysis [42]
and those with nonupper-lobe emphysema and high baseline exercise capacity were found to be poor
candidates for LVRS because of the increase in mortality and negligible functional gain.

E. Anesthetic management for lung volume reduction surgery. Anesthesiologists and their
expertise are essential to the continued successful outcomes for patients undergoing LVRS. Our
expertise in cardiopulmonary physiology, pharmacology, and pain management allows us to minimize
complications in the postoperative period.

1. Preoperative assessment. All patients scheduled for LVRS receive the following preoperative
physiologic studies: (a) Standard pulmonary function studies; (b) plethysmographic measurement of
lung volumes; (c) standardized 6-min walk test; (d) ABG values; (e) quantitative nuclear lung perfusion
scans; and (f) radionuclide cardiac ventriculogram and/or dobutamine stress echocardiogram.

2. Preoperative pulmonary rehabilitation program. After the initial preoperative evaluation, all patients
are enrolled into a pulmonary rehabilitation program for a minimum of 6 wks before surgical
intervention.
3. Monitors. In addition to the standard monitors, large-bore IV access and an arterial line are
recommended. Te use of central venous catheters and PA catheters should be considered on an
individual patient basis.

4. Te judicious use of TEA, both intraoperatively and postoperatively, aords advantages as follows: (a)
Preserved ability to cough and clear secretions, thus decreasing atelectasis and possibly reducing
pulmonary infection; (b) decreased airway resistance; (c) improved phrenic nerve function; (d)
stabilization of coronary endothelial function; (e) improved myocardial perfusion; (f) earlier return of
bowel function; (g) preservation of immunocompetence; and (h) decreased cost of perioperative care
through reduction of perioperative complications. Best results are obtained with catheters placed at the
T-4 to T-5 or T-5 to T-6 spinal level.

a. Intraoperative TEA. TEA can be used as an adjunct to general anesthesia. Local anesthetics, such as 2%
lidocaine or 0.5% ropivacaine, provide optimal surgical conditions. Te local anesthetics can be delivered
via intermittent bolus or as continuous infusion. (1) Because persistent air leaks may be a problem in the
postoperative period and may be exacerbated by positive-pressure ventilation, it is optimal to extubate
the patients either at the conclusion of surgery or as soon as possible thereafter. (2) Caution must be
exercised if opioids are added to the infusate because they have the potential to severely depress the
patients respiratory eorts.

b. Postoperative TEA. TEA provides superior postoperative analgesia for both median sternotomy and
bilateral thoracoscopic surgical procedures. A reduced concentration of local anesthetic plus a small
dose of opioids delivered by continuous infusion is suggested (e.g., 0.2% ropivacaine plus 0.01 mg/mL
hydromorphone).

c. Paravertebral nerve blocks (PVN) may be used as an alternative to TEA. Tey may be performed either
by multiple injections or by inserting a catheter into the paravertebral space for use with a continuous
infusion of local anesthetic. Tis technique requires the use of a multimodal analgesic regimen including
IV opioids and nonsteroidal anti-inammatory agents. Te eect of PVN on morbidity and mortality
following thoracic surgery, in particular LVRS, has yet to be determined.

5. A left-sided double-lumen EBT should be used to secure the patients airway.

6. General anesthesia. Induction of general anesthesia can be conducted with agents that promote
hemodynamic homeostasis. An example is etomidate 0.2 mg/kg plus an easily reversible
nondepolarizing neuromuscular blocking agent such as rocuronium. Maintenance anesthesia may
consist of low doses of a volatile agent (e.g., 0.2% to 0.4% isourane) and oxygen in addition to TEA. Te
anesthetic plan for each patient should be individualized appropriately.

7. Postoperative management. Problems that should be anticipated in the postoperative period include
(a) oversedation, (b) accumulation of airway secretions, (c) pneumothorax, (d) bronchospasm, (e) PE, (f)
pneumonia, (g) persistent air leaks, (h) arrhythmias, (i) myocardial infarction, and (j) PE. Re-intubation
and mechanical ventilation are associated with high morbidity and mortality. Several measures can be
taken to minimize these adverse side eects:

a. Judicious pulmonary toilet

b. Bronchodilators
c. Eective analgesia with TEA or PVN/multimodal analgesia

d. Avoidance of systemic corticosteroids

F. Endobronchial valves and blockers for lung volume reduction. Although LVRS has been shown
to beneft patients with a heterogeneous pattern of emphysema, this constitutes only about 20% of
patients who are eligible candidates for this treatment. Procedures for bronchoscopic LVRS have been
developed to treat patients with heterogeneous and homogeneous patterns of emphysema. Te
rationale for this minimally invasive approach is that by endobronchially obstructing the
emphysematous segments of the lung, collapse of these areas should occur, thereby reducing
hyperination and alleviating symptoms without the need for surgery. Currently available bronchoscopic
techniques include endobronchial blockers/valves, biologic glues, and airway bypass. Although there are
signifcant improvements achieved with endobronchial valves/blockers, the results have not been as
substantial as those obtained with surgical LVRS.

G. Conclusions. LVRS is a viable option for a select group of emphysema patients and
endobronchial valves and blockers that are undergoing clinical trials in the United States hold much
promise as a treatment alternative for all emphysema patients. Regardless of the selection of treatment
modality, the goals remain the same: Improvements in dyspnea, exercise tolerance, quality of life, and
prolonged patient survival. Te anesthesiologist must be actively engaged in the perioperative
management of these patients. Patient history and preoperative status as well as the results obtained
from the evaluation of chest radiographs, high-resolution CT scans, and right heart catheterizations
should be carefully weighed when planning for the patients care.