Effects of emphysema and lung volume reduction surgery on transdiaphragmatic pressure and diaphragm length

Study objectives: To determine the effect of emphysema and lung volume reduction surgery (LVRS) on diaphragm length (Ldi) and its capacity to generate transdiaphragmatic pressure (Pdi). Design: Prospective clinical trial with a parallel group design. Setting: Laboratory investigations in normal volunteers recruited by advertisement and in emphysema outpatients being evaluated for elective LVRS. Study population: Thirteen normal subjects and 13 emphysema patients matched for age and sex. Six emphysema patients underwent LVRS. Measurements: Ldi and maximal Pdi during static inspiratory efforts (PdiMax) were measured at three different lung volumes (LVs). Pdi during maximal bilateral phrenic nerve twitch stimulation (PdiTw) was measured at functional residual capacity (FRC). All measurements were repeated at 3, 6, and 12 months postoperatively. Results: Ldi, PdiMax, and PdiTw were lower in emphysema patients than in normal subjects at their respective LVs. PdiMax and PdiTw at FRC returned within the normal range after LVRS in emphysema patients. The relationships between PdiMax and LV or Ldi were shifted respectively to higher LV and shorter Ldi in emphysema patients relative to normal subjects, both before and after LVRS. LVRS effected craniad displacement of the diaphragm but no change in rib cage dimensions. Improvements in dyspnea and quality of life after LVRS correlated with changes in LV and Ldi but not with changes in airway caliber. Conclusion: Adaptive mechanisms, consistent with sarcomere deletion, tend to restore diaphragm strength in emphysema patients at FRC, which are fully expressed after LVRS. Lung remodeling by LVRS may alter pleural surface pressure distribution, causing a sustained change in chest wall shape.