Lung volume reduction surgery: from National Emphysema Treatment Trial to non-intubated awake video-assisted thoracoscopic surgery

Abstract

Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.

Current overview of awake, non-intubated, video-assisted thoracic surgery.

“…Considering the haemodynamic consequences of deep anaesthesia, the deterioration of cardiac performance, the need for muscle paralysis, delayed recovery, increased risk of pneumonia, and the inherent risks of intubation, an operation with sedoanalgesia should be considered as an option [ 23 ]. Because intubation is not required in thoracoscopic procedures performed with sedation and local anaesthesia, possible fatal complications are avoided [ 24 ].…”

Lung volume reduction for severe emphysema: scalpel or bronchoscope?

“…So, if LVR is considered, in most settings-like in the German health care system-LVRS and EBV are the only available approaches in clinical routine. In properly selected patients both can improve pulmonary function, exercise capacity, quality of life and survival (2,3). So far, however, both methods have only been studied in large clinical trials against optimized standard care including smoking cessation, pharmacotherapy and pulmonary rehabilitation, but not compared with each other.…”