Management of COPD: surgical options

Dyspnoea on exertion and exercise intolerance are the hallmarks of chronic obstructive pulmonary disease (COPD); the primary causes appear to be respectively, increased airway resistance with reduced maximal ventilatory capacity and peripheral skeletal muscle dysfunction with early onset of anaerobic metabolism. Patients with end-stage COPD usually show little or no benefit from conventional medical treatment. Physical training is capable of ameliorating exercise tolerance, but improvement is usually modest in the advanced disease state. Two surgical options are generally accepted for carefully selected patients with emphysema: resection of large bullae, when identified, and lung transplantation. Transplantation, the only effective cure for advanced COPD, is of limited use primarily because of age, comorbidity, limited availability of organs and cost. A different approach for severe emphysema, lung volume reduction surgery (LVRS), has been increasingly utilized during the past several years. In carefully selected emphysematous patients, LVRS improves lung volumes and mechanics, and reduces exertional dyspnoea. Unfortunately, surgical mortality still remains high and some patients show no measurable improvement after surgery. There is an urgent need for data on long-term effects of LVRS; the results of large, randomized trials will soon be forthcoming. The aim of this brief review is to summarize the available knowledge on the effects of LVRS, the criteria for patient selection, short- versus long-term effects and, finally, to propose future directions in this field.