Surgery for Emphysema Flashcards
Pathophysiology of emphysema
Degredation of elastin-collagen matrix in airway, resulting in loss of elastic recoil that limits airflow and respiratory mechanics.
Ultimately results in irreversable destruction and permanent enlargement of distal airspaces and lung parenchyma
Goals of surgical intervention for emphysema
Palliation of symptoms
Improvement in survival
Diagnostic criteria for emphysema
- Decreased FEV1:FVC ratio
- Absolute decrease in FEV1
- Hyperinflation of lungs
- Flattening of diaphragm
- Increased WOB
Preoperative evalution and planning essential for LVRS
- Cardiopulmonary clearance
- Rigerous pulmonary rehab program
- Weaning of steriods
- Optimization of bronchodilators
- Nicotine abstinence
- Physical re-conditioning
- CT scan (chest)
- Characterize distribution and extent of disease
Indications for LVRS
Body mass index (BMI) less than 32 kg/m2
Forced-expiratory volume in 1 second (FEV1) of less than 45% predicted but > 20
Dlco > 20
The arterial partial pressure of carbon dioxide (PaCO2) of less than 60 mm Hg
The arterial partial pressure of oxygen (PaO2) of greater than 45 mm Hg
A 6-min walk test distance of greater than 140 m
No smoking for at least 4 months before initial screening
* Acceptable cardiac risk
* Compiance with rigerous pulmonary rehabiliation (preop and postop)
SIgnificant (Absolute) Contraindications for LVRS
- Bronchiectasis
- Hypercarbia (PCO2 > 60 mmHg on RA)
- Pulmonary HTN
- Prior lobectomy on ipsilateral side
- Interstitial lung disease
- Ventilator dependence
Relative Contraindications for LVRS
- Chronic bronchitis
- Asthma
- Use of >= 20 mg Prednisone daily
- Oxygen dependence
- Active nicotine (smoking) use
- Morbid obesity
Historical surgical techniques for emphysema
- Techniques designed to enlarge thoracic cavity
- costochondrectomy
- transverse sternotomies
- paravertebral thoracoplasties
- Diaphragmatic plication
- Pleurectomy
- incrase collateral circulation to lung parenchyma
- Bullectomy
- Pneumonectomy
Contemporary definition (goal) of LVRS
Resection of non-anatomic, poorly perfused lung tissue by median sternotomy, thoracotomy, or VATS
Surgical principles of LVRS
- Inspect/palpate entire lung
- Observe and preserve ares of fastest desaturation and determine tissue for resection
- Mobilize entire lung - divide inferior pulmonary ligament
- Resect target area with reinforced stapler
- Use Gortex or bovine pericardium to reinforce stapler
- Avoid over resection to minimize space problems and air leaks
- Use synthetic glues/sealent, pleural tents, or pleurodesis to reduce air leaks
- Chest tube placement to water seal immediately
Perioperative managment principles following LVRS
- Aggressive pulmonary toilet
- Medical optimization
- Physical therapy
- Use of inhaled bronchodilators
- Avoid steroids
- Aggressive bronchoscopy strategy for pulmonary hygiene
Expected results after LVRS
- Improvement:
- FEV1
- Respiratory muscle function
- Expercise capacity
- Dyspnea
Common postoperative complicatons following LVRS
- Prolonged air leak
- Respiratory failure
- MI
- PNA
- Stroke
Perioperative mortaltiy after LVRS
5-15%
T/F:
Studies have demonstrated superior outcomes following VATS vs. open (median sternotomy, thoracotomy) LVRS?
False:
no differences in functional outcomes
however, VATS patients are able to return to independent living sooner
