tuesday case conference
TRANSCRIPT
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Tuesday Case Conference
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History:
54 yr old man with progressive dyspnea over the last few years. Now only able to walk 100 feet or climb one flight of stairs. Also complains of an occasional wheeze.
Patient denies chest pain, cough, fevers, orthopnea, PND. ROS otherwise negative.
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PMHx:HTNGERD
SHx:50 pk yr, ¼ ppdNo EtOH/IVDUNo recent travel
FHx:Father died of emphysema
at 65 yrs old, otherwise negative
NKDA
MedicationsHCTZ
Zantac prn
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Labs:
14.5 normal diff
7.2 311
45.8
141 99 11
4.0 32 1.0
Physical Exam:
BP 146/95 HR 90
sat 90% wt 160 lbs
NAD A+O
HEENT-normal
CV-RRR no MRG
Lungs-decreased BS, prolonged expiration
Abd-benign
Ext-no CCE
115
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Pulmonary Function:
Pre-BD Post-BD
FVC 1.77 (37%) 2.44 (Δ 37%)
FEV1 0.82 (23%) 0.83 (Δ 1%)
FEV1/FVC 46%
TLC 7.79 (110%)
RV 5.62 (247%)
DLCO 8.31 (30%)
DL/VA 2.68 (68%)
ABG = 7.4 / 52 / 58 on RA
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History (continued):
Patient is started on albuterol, atrovent, serevent and azmacort. He is also started on oxygen and undergoes pulmonary rehabilitation with only slight improvement in symptoms and stable PFT’s.
Patient also quits smoking and is interested in other potential therapeutic options.
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Exercise Test:
A non-invasive exercise study is performed
• Patient achieves 40 watts (22%)
• VO2 max is 0.62 liters/min (24%)
• Maximum HR is 117 (67%)
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History continued:
After extensive evaluation, the patient is electively admitted and undergoes left bullectomy and bilateral lung volume reduction surgery.
The patients is able to come off oxygen and notes a dramatic improvement in symptoms which has been sustained over the last four years.
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Pre-Op POD #500
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Change in Pulmonary Function:Lung Volumes
0
2
4
6
8
10
0 10 20 30 40
Months
Lite
rs
TLC
RV
FVC
FEV1
LVRS
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Change in Pulmonary Function:Diffusion Capacity
810121416182022
0 10 20 30 40
Months
mL/
min
/mm
HG
LVRS
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0
20
40
60
80
100
0 5 10 15 20
MonthsW
atts
0
0.5
1
1.5
2
0 5 10 15 20
Months
Lite
rs/M
in
Maximum Work Load
Maximum VO2
LVRS
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Lung Volume Reduction Surgery
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A Surgical Approach to Emphysema:
• LVRS described by Brantigan in the 1950’s. Post-operative mortality was 18%. Problems with persistent air leaks.
• Better surgical techniques and use of material to reinforce the staple line lead to renewed interest in the 1990’s.
Brantigan et al, ARRD 1959, 80:194-202
Cooper et al, J Th and CV Surg 1995, 109:106-119
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Physiologic Rationale
By removing areas of emphysematous lung, elastic recoil will improve leading to open airways and increased flow .
Brantigan et al, ARRD 1959, 80:194-202
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LVRS Improves Elastic Recoil
Sciurba et al, NEJM 1996, 334:1095-1099
The pressure-volume relationship was measured for 10 patients before and 3 months after LVRS.
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Small randomized trial of 48 patients shows improvement in FEV1 and FVC in the LVRS group.
LVRS vs Medical Therapy
Geddes et al, NEJM 2000, 343:239-245
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LVRS vs Medical Therapy
This study also showed improvement in exercise and quality of life score.
Geddes et al, NEJM 2000, 343:239-245
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High Risk Patients Do Poorly with LVRSEarly Results from NETT
High Risk:
• FEV1 <20%
• DLCO <20%
• Homogeneous
NETT, NEJM 2001, 345:1075-1083
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Patient Selection Criteria for LVRS
Upper (n=106)
Non-Upper (n=32)
p Value
Δ FEV1
(Liters)0.43 0.22 0.0013
Δ Dyspnea (Score 0-4)
1.63 1.88 0.34
McKenna et al, J Th and CV Surg 1997, 114:957-967
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Questions about LVRS:
• Does LVRS improve survival?
• Is there a subset of patients that benefits more from LVRS?
• Is there a subset of patients that should not undergo LVRS?
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NETT Study Design
Multi-center, randomized trial
1218 patients enrolled from 1/1998 to 7/2002• FEV1 ≤45%, TLC ≥100%, RV≥150%• PaCO2 ≤60 mmHg, PaO2 ≥45 mmHg on room air• 6 minute walk ≥140 meteres• Emphysema on HRCT• Disease stable on ≤20 mg prednisone
All received pulmonary rehab for 6 to 10 weeks then randomized to receive medical therapy or LVRS
NETT, J Th and CV Surg 1999, 118:518-528
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NETT ResultsOverall Survival
NETT, NEJM 2003, 348:2059-2073
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NETT ResultsSurvival: High Risk vs Non-high Risk
NETT, NEJM 2003, 348:2059-2073
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NETT Study Design
The non-high risk patients were further characterized for subgroup analysis based on:
• Distribution (upper vs non-upper lobe)
• Exercise Capacity (Sex-specific 40th percentile)
Yielding four subgroups:(1) Upper lobe, low exercise
(2) Upper lobe, high exercise
(3) Non-upper lobe, low exercise
(4) Non-upper lobe, high exercise
NETT, NEJM 2003, 348:2059-2073
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NETT ResultsSurvival: Upper Lobe
NETT, NEJM 2003, 348:2059-2073
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NETT ResultsSurvival: Non-Upper Lobe
NETT, NEJM 2003, 348:2059-2073
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Change in Maximal Workload, FEV1 and Quality of Life at 24 Months
NETT, NEJM 2003, 348:2059-2073
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Change in Maximal Workload Upper lobe and Low Exercise Subgroup
NETT, NEJM 2003, 348:2059-2073
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Is LVRS Cost-Effective?Dollars per Quality-Adjusted Life Year Gained
NETT, NEJM 2003, 348:2092-2102
OverallUpper Lobe
Low Exercise
3 Years $190,000 $98,000
10 Years $53,000 $21,000
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Conclusions from the NETT:
• Overall, LVRS does not improve survival, but does improve exercise capacity and quality of life.
• LVRS does improve survival in patients with upper lobe disease and low exercise capacity.
• LVRS is cost-effective.
• High risk patients and patients with non-upper lobe disease and high exercise capacity are poor candidates for LVRS
NETT, NEJM 2003, 348:2059-2073
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LVRS versus Lung Transplant:
Retrospective, single-center analysis
• LVRS: 33 patients• Single Lung TXP: 39 patients• Double Lung TXP: 25 patients
Compared changes in physiologic parameters and survival.
Gaissert et al, J Th CV Surg 1996, 111:296-307
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LVRS versus Lung Transplant:Change in FEV1 and FVC
BLT
SLT
BLT
SLT
LVRS LVRS
Gaissert et al, J Th CV Surg 1996, 111:296-307
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LVRS versus Lung Transplant:Change in PaO2 and PaCO2
BLT
SLT
LVRS
BLT
LVRS
SLT
Gaissert et al, J Th CV Surg 1996, 111:296-307
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LVRS versus Lung Transplant:Change in Six Minute Walk
BLT
SLT
LVRS
Gaissert et al, J Th CV Surg 1996, 111:296-307
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LVRS versus Lung Transplant:Oxygen Requirement
Gaissert et al, J Th CV Surg 1996, 111:296-307
0
20
40
60
80
100
1 2 3
LVRS
Single TXP
Double TXP
Pre-Op 3 Mo 6 Mo
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LVRS versus Lung Transplant:Mortality
Gaissert et al, J Th CV Surg 1996, 111:296-307
LVRS Single TXP Double TXP
Early Deaths 0 - 30 days
0% 2.5% 8.0%
Late Deaths 30 d - 1 yr
3.0% 7.7% 8.0%
Total 3.0% 10.2% 16.0%
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LVRS versus Lung Transplant:12 LVRS Patients Who Were TXP
Candidates
0
20
40
60
80
0 3 6
Months
% C
ha
ng
e FEV1
6min walk
PaO2
Gaissert et al, J Th CV Surg 1996, 111:296-307
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LVRS versus Lung Transplant:Authors Conclusions
“Although single and bilateral lung transplantation results in superior lung function, volume reduction achieves satisfactory improvement in disabling symptoms early after operation while avoiding immunosuppression and transplant-specific complications.”
Gaissert et al, J Th CV Surg 1996, 111:296-307
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LVRS as a Bridge to Transplant?
Retrospective study of 27 patients who underwent LVRS followed by transplant (22.9 months later).
A subgroup of patients had physiologic improvement and improvement in nutritional status.
Senbaklaviaci et al, Eur J CT Surg 2002, 22:363-367
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LVRS as a Bridge to Transplant?
Retrospective study of 15 patients who underwent LVRS followed by transplant (28.1 months later).
No difference in survival in this group compared to matched transplant alone group.
Burns et al, Ann Th Surg 2002, 73:1587-1593
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Conclusions:
• LVRS improves physiologic parameters, exercise capacity and quality of life in some patients with emphysema.
• LVRS improves survival in patients with upper lobe disease and low exercise capacity
• The role of LVRS and lung transplant in patients with emphysema is not well studied.
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References:
Brantigan et al, ARRD 1959, 80:194-202Cooper et al, J Th and CV Surg 1995, 109:106-119Sciurba et al, NEJM 1996, 334:1095-1099Geddes et al, NEJM 2000, 343:239-245NETT, NEJM 2001, 345:1075-1083NETT, J Th and CV Surg 1999, 118:518-528NETT, NEJM 2003, 348:2059-2073NETT, NEJM 2003, 348:2092-2102Gaissert et al, J Th CV Surg 1996, 111:296-307Senbaklaviaci et al, Eur J CT Surg 2002, 22:363-367Burns et al, Ann Th Surg 2002, 73:1587-1593