Bullectomy, lung volume reduction surgery (LVRS) and lung transplantation have all been used to treat patients with COPD.Treatment with LVRS and transplantation are usually considered in patients who do not respond to medical therapy (1)
Bullectomy
- usually involves the removal of a single large bulla that leads to collapse of surrounding lung tissue
Patients who are breathless, and have a single large bulla on a CT scan and an FEV1 less than 50% predicted should be referred for consideration of bullectomy
- is indicated for the relief of dyspnoea or for the management of complications of the bulla:
- recurrent or persistent pneumothorax
- infection with failure of medical treatment and evidence of abscess formation in bulla
- suspicion of carcinoma
- massive haemoptysis LVRS
- LVRS aims to improve breathlessness by removing areas of poorly functioning lung, thereby decreasing the intra-thoracic volume and reducing the mechanical disadvantage faced by the respiratory muscles.
- patients with severe COPD who remain breathless with marked restriction of their activities of daily living, despite maximal medical therapy (including rehabilitation), should be referred for consideration of lung volume reduction surgery if they meet all of the following criteria:
- FEV1 more than 20% predicted
- PaCO2 less than 7.3 kPa
- upper lobe predominant emphysema
- TLCO more than 20% predicted Transplantation
- patients with severe COPD who remain breathless with marked restriction of their activities of daily living despite maximal medical therapy should be considered for referral for assessment for lung transplantation bearing in mind comorbidities and local surgical protocols.
Considerations include
- age
- FEV1
- PaCO2
- homogeneously distributed emphysema on CT scan
- elevated pulmonary artery pressures with progressive deterioration
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