Surgical procedures for the treatment of COPD

This type of surgery 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 lessen the strain on the breathing muscles, improve breathing overall and reduce shortness of breath.

There are two types of procedures to reduce lung volume:

• Lung volume reduction surgery (LVRS) is either done through a large cut in the chest or through several small cuts (keyhole surgery). The surgeon removes hyperinflated areas of the lungs that make it harder to breathe.
• Bronchoscopic lung volume reduction (BLVR), where an endoscope is inserted into the windpipe and pushed down into the branches of the bronchi (airways in the lungs). This can be done without a general anesthetic. It is normally enough to use a strong sedative that puts you into a deep sleep for a short while. The lung volume is usually reduced using valves or (less commonly) coils. Valves prevent air from flowing into the hyperinflated parts of the lungs, but allow air to escape. Coils gather the lung tissue and compress it into a smaller space.

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.

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 approaches are now more common than lung volume reduction surgery.

This procedure 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 sudden breathing difficulties (an exacerbation or flare-up).

But the surgery also had disadvantages: In the first year after the treatment, some people in the surgery group died due to consequences of the operation. And every operation is associated with risks such as infections or wound-healing problems. But the studies didn’t look into these surgery-related problems enough.

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 is not clear whether this treatment can help people to live longer, though. Most of the studies lasted one year at the 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 after the procedure. This can be caused by the endoscope that is inserted into the 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's a greater risk of pneumonia.

There are also other procedures for reducing lung volume, involving the use of things like hot steam, foam or stents. But there's a lack of research on them, so it's not clear what pros and cons they might have. They are rarely used in Germany.

This treatment is similar to lung volume reduction. Unlike the above-mentioned approaches, though, 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. Bullectomy is also 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. The transplant involves removing either one or both lungs and then replacing them with a donor lung. Due to a lack of donor lungs, this treatment isn't always possible. People who receive new lungs can usually breathe a lot better afterwards 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 medications to suppress their immune system for the rest of their lives. These medications sometimes lead to serious side effects, such as organ damage and an increased risk of infections.

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 do 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.