Lung volume reduction surgery in ventilator-dependent COPD patients

Background: Lung volume reduction surgery has been advocated recently as adjunctive surgical therapy to improve lung and chest wall mechanics in selected patients with diffuse emphysema, Although clear-cut guidelines to select candidates have not been fully established, patients decompensated with significant pulmonary artery hypertension and hypercapnic respiratory failure are currently not considered suitable subjects. Accordingly, ventilator-dependent COPD patients are not considered candidates for this procedure. However, because ventilator-dependent COPD patients have an exceptionally poor prognosis, we elected to offer them this promising, but unproved surgical intervention. Herein, we describe the outcome of these three patients. Patients: The 3 patients had recurrent exacerbations of COPD precipitating respiratory failure, and following aggressive medical therapy remained mechanically ventilated for 11 to 16 weeks (1 patient had a brief period of successful weaning before returning to mechanical ventilation). Prior to surgery, the patients had severe hypercapnia and cor pulmonale. Compared with preoperative values, surgery resulted in improvements in PaO2/FIo(2), 304+/-80 (SD) vs 229+/-48 mm Hg, reductions in PaCO2, 44+/-3 vs 60+/-9 mm Hg, increases in FVC, 1.63+/-0.52 vs 1.09+/-0.05 L, and maximum inspiratory pressure, 57+/-22 vs 29+/-12 cm H2O. Postoperative complications included persistent air leaks and one tension pneumothorax. Patients weaned from mechanical ventilation after 10 to 21 days all were discharged home and they continue to demonstrate improved gas exchange and functional status. Conclusions: Lung volume reduction surgery in select, ventilator-dependent COPD patients can result in improved gas exchange and respiratory mechanics that enable successful weaning and overall improved functional status.