Treating emphysema - What you need to know about lung volume reduction surgery!

Author: Wang Guangfa, Chief Physician, Peking University First Hospital

Reviewer: Wu Xueyan, Chief Physician, Peking Union Medical College Hospital

For people with emphysema, breathing becomes difficult because the lungs are too full.

Lung volume reduction surgery is to cut a part of the part with severe emphysema, usually the upper lobe, so that the volume of the lung can be reduced. The diaphragm of a healthy person is like an arc-shaped dome. When it contracts, it moves downward. At the same time, the ribs become straight, the volume of the chest cavity increases, the lungs expand, and new air is inhaled. However, for patients with severe emphysema, when they are not breathing, the position of the diaphragm is low, and the ribs become straight. When inhaling, the downward movement of the diaphragm is weakened, and there is no room for the chest to expand, just like a fully inflated tire, it is difficult to pump in air. Therefore, less air is inhaled, which cannot meet the body's demand for oxygen.

After lung volume reduction surgery, the lung volume is reduced and the position of the diaphragm can be restored to a near normal state. At the same time, the chest is originally flat and straight, and the intercostal space is relatively wide. After the lung volume is reduced, the chest can also be restored to a near normal state.

Figure 1 Original copyright image, no permission to reprint

In this way, when you inhale, the lungs can take in more air, and when you exhale, they can also exhale it, which can relieve the symptoms of difficulty breathing.

1. What examinations and preparations should be done before lung volume reduction surgery for patients with emphysema?

First, we need to assess the patient's clinical characteristics to see whether the dyspnea is mainly caused by emphysema or airway obstruction. If emphysema is the main factor, this treatment can be considered.

Then we need to evaluate the lung function status. If the lung function is too good, there is no need to do it. If the lung function is too poor, the risk is too high and we can't do it. So we need to do lung function tests, including diffusion function, lung capacity, and chest CT to see the characteristics of the entire emphysema distribution to help us choose the target position.

In addition, it is required that there must be no acute exacerbation in the past three months before the operation. Second, adequate treatment is required, which includes triple therapy, respiratory rehabilitation therapy, daily exercise, and breathing exercises. After adequate treatment, re-evaluation is conducted, and if surgery is still needed, then it is performed.

Of course, patients must quit smoking. The operation will not be performed if they have not quit smoking for more than three months. If they do not quit smoking, the airway inflammation will be more severe and the risk of surgery will increase. Even if the patient is willing to take this risk, the doctor is unwilling to let the patient take this risk from the perspective of being responsible to the patient. Therefore, this is the preparation to be made before the operation.

2. What are the main risks of lung volume reduction surgery for patients with emphysema?

Lung volume reduction surgeries include surgical lung volume reduction and medical bronchoscopic lung volume reduction. In fact, except for the relatively high risk of surgical lung volume reduction, the others are still acceptable now.

The most common complication of these surgeries is infection, because these patients are very fragile and have poor sputum coughing ability, which can easily lead to infection.

In addition, some patients may have pneumothorax, which is sometimes difficult to treat. Pneumothorax often cannot close on its own and requires chest tube drainage. If chest tube drainage is still not effective, we will have some other corresponding treatment measures. However, from our experience, the incidence rate is not high. Some patients with pneumothorax will recover on their own. These patients often do not appear shortly after surgery, but appear long after surgery, and then recover on their own. Because these patients may have spontaneous pneumothorax themselves, it is hard to say whether it is related to surgery.

Of course, some patients develop pneumothorax within a short period of time after surgery, such as one week after surgery, which often indicates that the surgical treatment is effective. At this time, if the valve lung volume reduction is performed, a valve will be taken out to allow the lung to expand a little, and then the valve will be put back in after it grows. This treatment ensures both the safety and benefit of the patient.

Of course, other complications, such as local bleeding, granulation tissue hyperplasia, displacement or prolapse of the placed valve, are possible, but the overall incidence is not high.

3. How to care for patients with emphysema after lung volume reduction surgery?

After surgical lung volume reduction, postoperative care for patients with emphysema is relatively complicated.

Because of the incision, these patients often need to be observed in the intensive care unit. It is very important to deal with the sputum problem. These patients must be able to spit out sputum. If the sputum cannot be spit out, nebulization and some respiratory management must be done, such as turning over, patting the back, encouraging coughing, and strengthening nutrition, so that they can recover as soon as possible and be able to spit out sputum. Once the sputum problem is solved, the problem of postoperative infection can be reduced.

Figure 2 Original copyright image, no permission to reprint

In addition, attention should be paid to whether there is pneumothorax or chest tube drainage.

Of course, if it is bronchoscopic lung volume reduction, the care is relatively simple. These patients do not necessarily need to be admitted to the respiratory intensive care unit, it mainly depends on the recovery. If the patient is doing well after the operation, wakes up quickly, and is relatively strong, then they can be observed in the general ward.

It is not recommended to get up and do a wide range of activities right after the operation, because after the activities, this part is easy to shift, and the lungs undergo sudden changes, which will cause some mechanical effects, making it easy to have pneumothorax during exercise. For example, if there is a large bulla next to the lung, the lungs will be pulled, and the tidal volume of breathing is large, so it will be torn.

Therefore, you should do moderate activities within two or three days after surgery, but not too intense activities. After two or three days, you can strengthen rehabilitation exercises.

This is something to pay attention to after bronchoscopic lung volume reduction surgery.