A 72 Year Old Man With Emphysema and Severe Symptoms.

A 72-year-old man with emphysema, an ex-smoker for 4 years, continues to be symptomatic on minimal exertion despite maximal medical therapy, including long-term oxygen

treatment. A 6-week pulmonary rehabilitation programme has also failed to palliate his symptoms.His forced expiratory volume in 1 second is 0.6 L (28% of predicted)

and his gas transfer is 45%. His CT chest scan shows severe heterogeneous emphysema with almost completely destroyed upper lobes.

Question:  Which one of the following treatment options would you consider?
A Single lung transplantation
B Bilateral lung transplantation
C Heart–lung transplantation
D Lung volume reduction surgery
E Nebulised morphine.

Answer:
D Lung volume reduction surgery

Discussion: This patient is too old for either bilateral lung transplantation or heart–lung transplantation. Single lung transplantation is highlyunlikely because of the shortage of donors. He should be considered for lung volume reduction surgery (LVRS). The goal of LVRS is to reduce lung volume by 20–30%, which probably improves pulmonary and chest wall mechanics at rest and

during exercise. Several randomised trials have compared LVRS with optimal medical treatment and have shown that patients with upper lobe-predominant emphysema and a low exercise capacity benefit the most from LVRS. 

Contraindications include forced expiratory volume in 1 second <20% of predicted,diffusing capacity of the lungs for carbon monoxide <20% of predicted and homogeneous changes on CT chest scan, because this group of patients is at high risk of death after surgery and is also unlikely to benefit from LVRS