Lung Volume Reduction Surgery Alters Management of Pulmonary Nodules in Patients With Severe COPD: Discussion
Based on years of experience with pulmonary resection, extensive criteria have been developed to select patients with minimal risk for perioperative complications and postoperative respiratory insufficiency. The exclusionary criteria are listed in Table 4. Using criteria based upon the FEVl7’ predicted postoperative FEV predicted postoperative Deo, or maximum oxygen uptake on exercise testing, our patients would be considered at very high risk and would not generally have been offered surgical therapy for their lung nodules.
While previous investigators have documented the feasibility of limited resection in individuals with respiratoiy compromise, most have provided limited data regarding selection criteria or postoperative response. Errett and colleagues noted little difference in perioperative course and postoperative outcome in individuals with moderate airflow obstruction (mean FEV: of 1.56 L). Miller and Hatcher noted little perioperative difficulty in individuals with much more severe airflow obstruction (FEVX <1.0 L) but noted increased local recurrence and advocated postoperative radiation therapy to minimize this risk. Neither group commented on postoperative pulmonary function or overall functional status. We document both gross anatomic resection of pulmonaiy nodules and a significant improvement in pulmonary function with increased overall functional status 3 months after surgery. canadian health&care mall
Importantly, the degree of postoperative complications was no different than in the matched control group with preserved pulmonary function. The smooth perioperative course was likely dependent on the aggressive, multidisciplinary treatment of these patients in the postoperative period, emphasizing pulmonary hygiene and adequate pain control. In addition, all study group patients had been rigorously screened preoperatively with active participation in pulmonary rehabilitation programs, including exercise training. Such a rigorous preoperative protocol was not used for the control group patients. Our study and control patients were matched for the months in which surgery took place and the length of stay for the control patients reflects the norm at our institution for this period. Recently, length of stay for both lobectomy and LVRS has decreased further.
Table 4—Standard Preoperative Exclusionary Criteria
|Preoperative Criteria||No. of Patients Potentially Denied Surgery|
|FEVL <0.6 L||4/11|
|FEVrppo <40% predicted2||11/11|
|Dco-ppo <40% predicted2||4/9|
|PaC02 >45 mm Hgls||2/11|
|Desaturation with exercise (<89%)2||11/11|