Surgical procedures for the treatment of COPD
Surgical procedures for COPD are only considered at very advanced stages of the disease. Various techniques can be used to reduce the volume of the lungs, making it easier to breathe. In very severe cases of COPD a lung transplant may be possible.
Advanced chronic obstructive pulmonary disease (COPD) can lead to pulmonary emphysema. This is where the walls of the air sacs (alveoli) in the lungs are destroyed, resulting in larger air sacs that sometimes burst. Because of this “hyperinflation” of the air sacs, the volume of the lungs increases too. The healthy part of the lung gets smaller and less oxygen enters the blood. The breathing muscles have to work harder too. As a result, people get out of breath more easily, are less fit and more often have coughs with sputum (coughed-up phlegm).
If the symptoms can no longer be effectively relieved with other treatments, an operation or smaller surgical procedure may be possible under certain circumstances. This type of treatment generally isn’t used very often.
Lung volume reduction
This type of treatment involves removing or reducing the size of hyperinflated parts of the lungs. As a result, the overall volume of the lungs is reduced to start off with. But then there’s more room for the healthy parts of the lungs, which makes it easier for them to supply the blood with oxygen. The aim of this treatment is to reduce the strain on the breathing muscles, improve breathing overall and reduce shortness of breath.
There are two types of lung volume reduction treatment:
- Surgery: This is either done through a large cut in the chest to open up the rib cage or through several small openings (keyhole surgery). The surgeon removes hyperinflated areas of the lungs that make it harder to breathe.
- Bronchoscopic procedures: In this approach, an endoscope is inserted into the trachea (windpipe) and pushed down into the bronchial tubes (airways in the lungs). This can be done without a general anesthetic; it is usually enough to use a strong sedative that puts you into a deep sleep for a short while. The lung volume can then be reduced using, for instance, valves or coils. In other techniques, hyperinflated areas of the lungs are treated with hot steam or foam in order to shrink the enlarged air sacs. Small tubes known as stents can be used too, but that isn’t common practice in Germany.
These procedures are only suitable for people with severe COPD who
- haven’t smoked for several months,
- don’t have any other serious medical conditions,
- aren’t extremely underweight, and
- have already tried out all of the other treatment options.
Different procedures will be more suitable for different people, depending on factors such as the type of pulmonary emphysema.
How effective is lung volume reduction treatment?
Lung volume reduction treatment can help people who have COPD but it is also associated with certain risks. Each procedure has its own pros and cons. Bronchoscopic procedures are more common than surgery nowadays, but there has been less research on them.
Lung volume reduction surgery can increase the chances of living longer. In the largest study on this treatment, the following was found after five years:
- Without the surgery, 49 out of 100 people had passed away.
- With the surgery, 42 out of 100 people had passed away.
What’s more, the patients who had the surgery were physically fitter, had a better quality of life and fewer episodes of breathing difficulties. They were also less likely to have to go to hospital due to a sudden worsening of their symptoms (exacerbation).
But the surgery also had disadvantages: In the first year after the treatment, more people in the surgery group died (due to consequences of the operation). Like all operations, the surgery is also associated with risks such as inflammations and wound-healing problems. The studies didn’t look into these adverse effects enough, though.
Bronchoscopic procedures using valves or coils can improve your physical fitness and quality of life. Coils were also found to reduce the likelihood of breathing difficulties. It’s not clear whether this treatment can help people to live longer. The studies so far have lasted one year at most. That's too short to be able to answer this question.
One disadvantage of this treatment is that people's breathing sometimes suddenly gets worse afterwards. This can be caused by the endoscope that is inserted into the bronchi (air tubes in the lungs). It can lead to a collapsed lung (pneumothorax) too. People often cough up a bit of blood after the procedure, and the treatment is associated with the usual surgery-related risks. If coils are used, there is a greater risk of pneumonia.
Less is known about the pros and cons of procedures that use steam, foam and stents because there’s a lack of research on these approaches.
This treatment is similar to lung volume reduction. It specifically gets rid of large air-filled spaces (known as bullae). Bullectomy is considered as a treatment option if individual air pockets take up more than a third of a lung and put pressure on nearby tissue. Like other treatments mentioned above, bullectomy is a minimally invasive procedure. In other words, it is done through small cuts in the chest area (keyhole surgery).
Lung transplants are only considered for people who have advanced pulmonary emphysema, and only if they have already tried out all other treatment options. Due to a lack of donor lungs, this treatment isn't always possible. People who receive new lungs can usually breathe a lot better and their quality of life improves.
Transplants are associated with special risks because they involve major surgery and the body’s immune system might attack the new organ afterwards. To lower the risk of the body rejecting the organ, people have to take medication to suppress their immune system for the rest of their lives. But this medication sometimes has serious side effects.
Lung transplants are only considered as a treatment option if someone is very likely to die of COPD in the next few years – and if they don’t have any other serious illnesses. They have to stop smoking quite a long time before having the transplant, and they have to be prepared to actively take part in rehabilitation activities and exercises. Because people over the age of 65 are more likely to have other serious illnesses, most patients who have a lung transplant are younger.
Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), Deutsche Atemwegsliga, Österreichische Gesellschaft für Pneumologie (ÖGP). S2k-Leitlinie zur Diagnostik und Therapie von Patienten mit chronisch obstruktiver Bronchitis und Lungenemphysem (COPD). AWMF-Registernr.: 020-006. January 24, 2018.
Institute for Quality and Efficiency in Health Care (IQWIG, Germany). Procedure for lung volume reduction in severe lung emphysema: Final report; Commission N14-04. February 07, 2017. (IQWiG Reports; Volume 487).
Van Agteren JE, Carson KV, Tiong LU, Smith BJ. Lung volume reduction surgery for diffuse emphysema. Cochrane Database Syst Rev 2016; (10): CD001001.
Van Agteren JE, Hnin K, Grosser D, Carson KV, Smith BJ. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; (2): CD012158.
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