Lung volume reduction surgery for diffuse emphysema

Lung volume reduction surgery (LVRS) has been re-introduced for treating patients with severe diffuse emphysema. It is a procedure that aims to improve long-term daily functioning, although it is costly and may also be associated with a high risk of mortality.

To assemble evidence from randomised controlled trials for the effectiveness of LVRS, and identify optimal surgical techniques.

Randomised controlled trials were identified using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register. Searches are current to September 2005.

Randomised controlled trials that studied the safety and efficacy of LVRS in patients with diffuse emphysema were included. Studies were excluded if they investigated giant or bullous emphysema.

Two independent review authors assessed trials for inclusion and extracted data. Where possible, data from more than one study were combined using RevMan 4.2 software.

Eight studies (1663 participants) met the entry criteria of the review. One study accounted for 73% of the participants recruited. Study quality was high, although blinding in studies was not possible. Ninety day mortality was significantly greater in all those who underwent LVRS (odds ratio 6.57 (95% CI 3.34 to 12.95), four studies, N = 1415). A subgroup analysis by risk status suggested that there was a subgroup of participants who were consistently at a significant risk of death, although this was only measured in one large study. The ninety day mortality data indicated that death was more likely with LVRS irrespective of risk status identified in one large study. Improvements in lung function, quality of life and exercise capacity were more likely with LVRS than with usual follow-up.

The evidence summarised in this review is drawn from one large study, and several smaller trials. The findings from the large study indicated that in patients who survive up to three months post-surgery, there were significantly better health status and lung function outcomes in favour of surgery compared with usual medical care. Patients identified post hoc as being of high risk of death from surgery were those with particularly impaired lung function and poor diffusing capacity and/or homogenous emphysema. Further research should address the effect of this intervention on exacerbations and rate of decline in lung function and health status.