Indications for surgical intervention in COPD

Chronic obstructive pulmonary disease (COPD) is a progressive disease with substantial associated morbidity and mortality. While numerous surgical modalities have been tried as solutions to this debilitating disease, only three - bullectomy, lung volume reduction surgery (LVRS), and transplantation - have been demonstrated to have any benefit towards either survival or improvement in quality of life. These interventions are viable options in a select group of patients with severe, incapacitating emphysema. Only those patients that have failed to progress despite optimized medical therapy and a rigorous pulmonary rehabilitation regiment should be considered for operative planning. Pulmonary function tests, chest radiography, computed tomography, and nuclear ventilation-perfusion scans then further delineate those patients who are most likely to benefit from the operation, as well as determining which intervention is most likely to have a good outcome. The surgical options available to the patient depend upon the spectrum of the distribution of their disease - isolated bullae can be treated with bullectomy, heterogeneous emphysema lends itself to LVRS, while homogenous disease is best treated by lung transplantation. The ideal indicators for LVRS also include hyperinflation, a FEV₁ greater that 20%, and a normal PaCO₂. In contrast, patients with a low FEV₁, hypercapnia, and associated pulmonary hypertension are directed towards transplantation. Using these criteria, there are few patients that are serious candidates for surgical intervention.