User login
Case Presentation
A 65-year-old man with severe chronic obstructive disease (COPD; forced expiratory volume in 1 second/forced vital capacity ratio [FEV1/FVC], 27; FEV1 25% of predicted; residual volume 170% of predicted for his age and height) was seen in the pulmonary clinic. His medications include a long-acting beta agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination that he uses twice daily as advised. He uses his rescue albuterol inhaler roughly once a week. The patient complains of severe disabling shortness of breath with exertion and severe limitation of his quality of life because of his inability to lead a normal active life. He is on 2 L/min of oxygen at all times. He has received pulmonary rehabilitation in hopes of improving his quality of life but can only climb a flight of stairs before he must stop to rest. He asks about options but does not want to consider lung transplantation today. His most recent chest computed tomography (CT) scan demonstrates upper lobe predominant emphysematous changes with no masses or nodules.
What are the patient's options at this time?
Lung volume reduction surgery (LVRS) attempts to reduce space-occupying severely diseased, hyperexpanded lung, thus allowing the relatively normal adjoining lung parenchyma to expand into the vacated space and function effectively.1 Hence, such therapies are suitable for patients with emphysematous lungs and not those with bronchitic-predominant COPD. LVRS offers a greater chance of improvement in exercise capacity, lung function, quality of life, and dyspnea in the correctly chosen patient population, as compared with pharmacologic management alone.2 However, the procedure is associated with risks, including higher short-term morbidity and mortality.2 Patients with predominantly upper-lobe emphysema and a low maximal workload after rehabilitation were noted to have lower mortality, a greater probability of improvement in exercise capacity, and a greater probability of improvement in symptoms if they underwent surgery compared to medical therapy alone.2 On the contrary, patients with predominantly non–upper-lobe emphysema and a high maximal workload after rehabilitation had higher mortality if they underwent surgery compared to receiving medical therapy alone.2 Thus, a subgroup of patients with homogeneous emphysema symmetrically affecting the upper and lower lobes are considered to be unlikely to benefit from this surgery.2,3
Valves and other methods of lung volume reduction such as coils, sealants, intrapulmonary vents, and thermal vapor in the bronchi or subsegmental airways have emerged as new techniques for nonsurgical lung volume reduction.4-9 Endobronchial-valve therapy is associated with improvement in lung function and with clinical benefits that are greatest in the presence of heterogeneous lung involvement. This works by the same principle as LVRS, by reduction of the most severely diseased lung units, expansion of the more viable, less emphysematous lung results in substantial improvements in lung mechanics.10,11 The most important complications of this procedure include pneumonia, pneumothorax, hemoptysis, and increased frequency of COPD exacerbation in the following 30 days. The fact that a high-heterogeneity subgroup had greater improvements in both the FEV1 and distance on the 6-minute walk test than did patients with lower heterogeneity supports the use of quantitative high-resolution computed tomography (HRCT) in selecting patients for endobronchial-valve therapy.12 The HRCT scans also help in identifying those with complete fissures, a marker of lack of collateral ventilation (CV+) between different lobes. Presence of CV+ state predicts failure of endobronchial valve and all forms of endoscopic LVRS.13 Bronchoscopic thermal vapor ablation (BTVA) therapy can potentially work on a subsegmental level and be successful for treatment of emphysema with lack of intact fissures on CT scans. Other methods that have the potential to be effective in those with collateral ventilation would be endoscopic coil therapy and polymeric lung volume reduction.11,14 Unfortunately, there are no randomized controlled trial data demonstrating clinically meaningful improvement following coil therapy or polymeric lung volume reduction in this CV+ patient population. Vapor therapy is perhaps the only technique that has been found to be effective in upper lobe predominant emphysema even with CV+ status.13
Our patient has evidence of air trapping and emphysema based on a high residual volume. A CT scan of the chest can determine the nature of the emphysema (heterogeneous versus homogenous) and based on these findings, further determination of the best strategy for lung volume reduction can be made.
Is there a role for long-term oxygen therapy?
Long-term oxygen therapy (LTOT) used for more than 15 hours a day is thought to reduce mortality among patients with COPD and severe resting hypoxemia.15-18 More recent studies have failed to show similar beneficial effects of LTOT. A recent study examined the effects of LTOT in randomized fashion and determined that supplemental oxygen for patients with stable COPD and resting or exercise-induced moderate desaturation did not affect the time to death or first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, the rate of all hospitalizations, the rate of all COPD exacerbations, or changes in measures of quality of life, depression, anxiety, or functional status.19
Our patient is currently on long-term oxygen therapy and in spite of some uncertainty as to its benefit, it is prudent to order oxygen therapy until further clarification is available.
What is the role of pulmonary rehabilitation?
Pulmonary rehabilitation is an established treatment for patients with chronic lung disease.20 Benefits include improvement in exercise tolerance, symptoms, and quality of life, with a reduction in the use of health care resources.21 A Spanish population-based cohort study that looked at the influence of regular physical activity on COPD showed that patients who reported low, moderate, or high physical activity had a lower risk of COPD admissions and all-cause mortality than patients with very low physical activity after adjusting for all confounders.22
As previously mentioned, patients in GOLD categories B, C, and D should be offered pulmonary rehabilitation as part of their treatment.23 The ideal patient is one who is not too sick to undergo rehabilitation and is motivated to improve his or her quality of life.
What is the current scope of lung transplantation in the management of severe COPD?
There is an indisputable role for lung transplantation in end-stage COPD. However, lung transplantation does not benefit all COPD patients. There is a subset of patients for whom the treatment provides a survival benefit. It has been reported that 79% of patients with an FEV1 < 16% predicted will survive at least 1 additional year after transplant, but only 11% of patients with an FEV1 > 25% will do so.24 The pre-transplant BODE (body mass index, airflow obstruction/FEV1, dyspnea, and exercise capacity) index score is used to identify patients who will benefit from lung transplantation.25,26 International guidelines for the selection of lung transplant candidates identify the following patient characteristics:27
- The disease is progressive, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy;
- The patient is not a candidate for endoscopic or surgical LVRS;
- BODE index is 5 to 6;
- The PCO2 is greater than 50 mm Hg (6.6 kPa) and/or PO2 is less than 60 mm Hg (8 kPa);
- FEV1 is 25% predicted.
The perioperative mortality of lung transplantation surgery has been reduced to less than 10%. Risk of complications from surgery in the perioperative period, such as bronchial dehiscence, infectious complications, and acute rejection, have also been reduced but do occur. Chronic allograft dysfunction and the risk of lung cancer in cases of single lung transplant should be discussed with the patient before surgery.28
How can we incorporate palliative care into the management plan for patients with COPD?
Among patients with end-stage COPD on home oxygen therapy who have required mechanical ventilation for an exacerbation, only 55% are alive at 1 year.29 COPD patients at high risk of death within the next year of life as well as patients with refractory symptoms and unmet needs are candidates for early palliative care. Palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members, and palliative care is recommended by multiple international societies for patients with advanced COPD.30,31 In spite of these recommendations, the utilization of palliative care resources has been dismally low.32,33 Improving physician-patient communication regarding palliative services and patients’ unmet care needs will help ensure that COPD patients receive adequate palliative care services at the appropriate time.
Conclusion
COPD is a leading cause of morbidity and mortality in the United States and represents a significant economic burden for both individuals and society. The goals in COPD management are to provide symptom relief, improve the quality of life, preserve lung function, and reduce the frequency of exacerbations and mortality. COPD management is guided by disease severity that is measured using the GOLD multimodal staging system and requires a multidisciplinary approach. Several classes of medication are available for treatment, and a step-wise approach should be applied in building an effective pharmacologic regimen. In addition to pharmacologic therapies, nonpharmacologic therapies, including smoking cessation, vaccinations, proper nutrition, and maintaining physical activity, are an important part of long-term management. Those who continue to be symptomatic despite appropriate maximal therapy may be candidates for lung volume reduction. Palliative care services for COPD patients, which can aid in reducing symptom burden and improving quality of life, should not be overlooked.
1. Sabanathan A, Sabanathan S, Shah R, Richardson J. Lung volume reduction surgery for emphysema: a review. J Cardiovasc Surg. 1998;39:237.
2. Group NETTR. Patients at high risk of death after lung-volume–reduction surgery. N Engl J Med. 2001;345:1075-1083.
3. Group NETTR. A randomized trial comparing lung-volume–reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348:2059-2073.
4. Decker MR, Leverson GE, Jaoude WA, Maloney JD. Lung volume reduction surgery since the National Emphysema Treatment Trial: study of Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg. 2014;148:2651-2658.
5. Deslée G, Mal H, Dutau H, et al. Lung volume reduction coil treatment vs usual care in patients with severe emphysema: the REVOLENS randomized clinical trial. JAMA. 2016;315:175-184.
6. Hartman JE, Klooster K, Gortzak K, et al. Long-term follow-up after bronchoscopic lung volume reduction treatment with coils in patients with severe emphysema. Respirology. 2015;20:319-326.
7. Snell GI, Hopkins P, Westall G, et al. A feasibility and safety study of bronchoscopic thermal vapor ablation: a novel emphysema therapy. Ann Thorac Surg. 2009;88:1993-1998.
8. Ingenito EP, Berger RL, Henderson AC, et al. Bronchoscopic lung volume reduction using tissue engineering principles. Am J Respir Crit Care Med. 2003;167:771-778.
9. Ingenito EP, Loring SH, Moy ML, et al. Comparison of physiological and radiological screening for lung volume reduction surgery. Am J Respir Crit Care Med. 2001;163:1068-1073.
10. Shah P, Slebos D, Cardoso P, et al. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial. Lancet. 2011;378:997-1005.
11. Sciurba FC, Ernst A, Herth FJ, et al. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med. 2010;363:1233-1244.
12. Wan IY, Toma TP, Geddes DM, et al. Bronchoscopic lung volume reduction for end-stage emphysema: report on the first 98 patients. Chest. 2006;129:518-526.
13. Gompelmann D, Eberhardt R, Schuhmann M, et al. Lung volume reduction with vapor ablation in the presence of incomplete fissures: 12-month results from the STEP-UP randomized controlled study. Respiration. 2016;92:397-403.
14. Come CE, Kramer MR, Dransfield MT, et al. A randomised trial of lung sealant versus medical therapy for advanced emphysema. Eur Respir J. 2015;46:651-662.
15. Group NOTT. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med. 1980;93:391-398.
16. Council M. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet. 1981;1:681-686.
17. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179-191.
18. Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187:347-365.
19. Group L-TOTTR. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016;375:1617-1627.
20. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015(2):CD003793.
21. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;355:362-368.
22. Garcia-Aymerich J, Lange P, Benet M, et al. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. 2006;61:772-778.
23. Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org. Accessed July 9, 2019.
24. Thabut G, Ravaud P, Christie JD, et al. Determinants of the survival benefit of lung transplantation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2008;177:1156-1163.
25. Lahzami S, Bridevaux PO, Soccal PM, et al. Survival impact of lung transplantation for COPD. Eur Respir J. 2010;36:74-80.
26. Cerón Navarro J, de Aguiar Quevedo K, Ansótegui Barrera E, et al. Functional outcomes after lung transplant in chronic obstructive pulmonary disease. Arch Bronconeumol. 2015;51:109-114.
27. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34:1-15.
28. Minai OA, Shah S, Mazzone P, et al. Bronchogenic carcinoma after lung transplantation: characteristics and outcomes. J Thorac Oncol. 2008;3:1404-1409.
29. Hajizadeh N, Goldfeld K, Crothers K. What happens to patients with COPD with long-term oxygen treatment who receive mechanical ventilation for COPD exacerbation? A 1-year retrospective follow- up study. Thorax. 2015;70:294-296.
30. Siouta N, van Beek K, Preston N, et al. Towards integration of palliative care in patients with chronic heart failure and chronic obstructive pulmonary disease: a systematic literature review of European guidelines and pathways. BMC Palliat Care. 2016;15:18.
31. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.
32. Szekendi MK, Vaughn J, Lal A, et al. The prevalence of inpatients at thirty-three U.S. hospitals appropriate for and receiving referral to palliative care. J Palliat Med. 2016;19:360-372.
33. Rush B, Hertz P, Bond A, et al. Use of palliative care in patients with end-stage COPD and receiving home oxygen: national trends and barriers to care in the United States. Chest. 2017;151:41-46.
Case Presentation
A 65-year-old man with severe chronic obstructive disease (COPD; forced expiratory volume in 1 second/forced vital capacity ratio [FEV1/FVC], 27; FEV1 25% of predicted; residual volume 170% of predicted for his age and height) was seen in the pulmonary clinic. His medications include a long-acting beta agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination that he uses twice daily as advised. He uses his rescue albuterol inhaler roughly once a week. The patient complains of severe disabling shortness of breath with exertion and severe limitation of his quality of life because of his inability to lead a normal active life. He is on 2 L/min of oxygen at all times. He has received pulmonary rehabilitation in hopes of improving his quality of life but can only climb a flight of stairs before he must stop to rest. He asks about options but does not want to consider lung transplantation today. His most recent chest computed tomography (CT) scan demonstrates upper lobe predominant emphysematous changes with no masses or nodules.
What are the patient's options at this time?
Lung volume reduction surgery (LVRS) attempts to reduce space-occupying severely diseased, hyperexpanded lung, thus allowing the relatively normal adjoining lung parenchyma to expand into the vacated space and function effectively.1 Hence, such therapies are suitable for patients with emphysematous lungs and not those with bronchitic-predominant COPD. LVRS offers a greater chance of improvement in exercise capacity, lung function, quality of life, and dyspnea in the correctly chosen patient population, as compared with pharmacologic management alone.2 However, the procedure is associated with risks, including higher short-term morbidity and mortality.2 Patients with predominantly upper-lobe emphysema and a low maximal workload after rehabilitation were noted to have lower mortality, a greater probability of improvement in exercise capacity, and a greater probability of improvement in symptoms if they underwent surgery compared to medical therapy alone.2 On the contrary, patients with predominantly non–upper-lobe emphysema and a high maximal workload after rehabilitation had higher mortality if they underwent surgery compared to receiving medical therapy alone.2 Thus, a subgroup of patients with homogeneous emphysema symmetrically affecting the upper and lower lobes are considered to be unlikely to benefit from this surgery.2,3
Valves and other methods of lung volume reduction such as coils, sealants, intrapulmonary vents, and thermal vapor in the bronchi or subsegmental airways have emerged as new techniques for nonsurgical lung volume reduction.4-9 Endobronchial-valve therapy is associated with improvement in lung function and with clinical benefits that are greatest in the presence of heterogeneous lung involvement. This works by the same principle as LVRS, by reduction of the most severely diseased lung units, expansion of the more viable, less emphysematous lung results in substantial improvements in lung mechanics.10,11 The most important complications of this procedure include pneumonia, pneumothorax, hemoptysis, and increased frequency of COPD exacerbation in the following 30 days. The fact that a high-heterogeneity subgroup had greater improvements in both the FEV1 and distance on the 6-minute walk test than did patients with lower heterogeneity supports the use of quantitative high-resolution computed tomography (HRCT) in selecting patients for endobronchial-valve therapy.12 The HRCT scans also help in identifying those with complete fissures, a marker of lack of collateral ventilation (CV+) between different lobes. Presence of CV+ state predicts failure of endobronchial valve and all forms of endoscopic LVRS.13 Bronchoscopic thermal vapor ablation (BTVA) therapy can potentially work on a subsegmental level and be successful for treatment of emphysema with lack of intact fissures on CT scans. Other methods that have the potential to be effective in those with collateral ventilation would be endoscopic coil therapy and polymeric lung volume reduction.11,14 Unfortunately, there are no randomized controlled trial data demonstrating clinically meaningful improvement following coil therapy or polymeric lung volume reduction in this CV+ patient population. Vapor therapy is perhaps the only technique that has been found to be effective in upper lobe predominant emphysema even with CV+ status.13
Our patient has evidence of air trapping and emphysema based on a high residual volume. A CT scan of the chest can determine the nature of the emphysema (heterogeneous versus homogenous) and based on these findings, further determination of the best strategy for lung volume reduction can be made.
Is there a role for long-term oxygen therapy?
Long-term oxygen therapy (LTOT) used for more than 15 hours a day is thought to reduce mortality among patients with COPD and severe resting hypoxemia.15-18 More recent studies have failed to show similar beneficial effects of LTOT. A recent study examined the effects of LTOT in randomized fashion and determined that supplemental oxygen for patients with stable COPD and resting or exercise-induced moderate desaturation did not affect the time to death or first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, the rate of all hospitalizations, the rate of all COPD exacerbations, or changes in measures of quality of life, depression, anxiety, or functional status.19
Our patient is currently on long-term oxygen therapy and in spite of some uncertainty as to its benefit, it is prudent to order oxygen therapy until further clarification is available.
What is the role of pulmonary rehabilitation?
Pulmonary rehabilitation is an established treatment for patients with chronic lung disease.20 Benefits include improvement in exercise tolerance, symptoms, and quality of life, with a reduction in the use of health care resources.21 A Spanish population-based cohort study that looked at the influence of regular physical activity on COPD showed that patients who reported low, moderate, or high physical activity had a lower risk of COPD admissions and all-cause mortality than patients with very low physical activity after adjusting for all confounders.22
As previously mentioned, patients in GOLD categories B, C, and D should be offered pulmonary rehabilitation as part of their treatment.23 The ideal patient is one who is not too sick to undergo rehabilitation and is motivated to improve his or her quality of life.
What is the current scope of lung transplantation in the management of severe COPD?
There is an indisputable role for lung transplantation in end-stage COPD. However, lung transplantation does not benefit all COPD patients. There is a subset of patients for whom the treatment provides a survival benefit. It has been reported that 79% of patients with an FEV1 < 16% predicted will survive at least 1 additional year after transplant, but only 11% of patients with an FEV1 > 25% will do so.24 The pre-transplant BODE (body mass index, airflow obstruction/FEV1, dyspnea, and exercise capacity) index score is used to identify patients who will benefit from lung transplantation.25,26 International guidelines for the selection of lung transplant candidates identify the following patient characteristics:27
- The disease is progressive, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy;
- The patient is not a candidate for endoscopic or surgical LVRS;
- BODE index is 5 to 6;
- The PCO2 is greater than 50 mm Hg (6.6 kPa) and/or PO2 is less than 60 mm Hg (8 kPa);
- FEV1 is 25% predicted.
The perioperative mortality of lung transplantation surgery has been reduced to less than 10%. Risk of complications from surgery in the perioperative period, such as bronchial dehiscence, infectious complications, and acute rejection, have also been reduced but do occur. Chronic allograft dysfunction and the risk of lung cancer in cases of single lung transplant should be discussed with the patient before surgery.28
How can we incorporate palliative care into the management plan for patients with COPD?
Among patients with end-stage COPD on home oxygen therapy who have required mechanical ventilation for an exacerbation, only 55% are alive at 1 year.29 COPD patients at high risk of death within the next year of life as well as patients with refractory symptoms and unmet needs are candidates for early palliative care. Palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members, and palliative care is recommended by multiple international societies for patients with advanced COPD.30,31 In spite of these recommendations, the utilization of palliative care resources has been dismally low.32,33 Improving physician-patient communication regarding palliative services and patients’ unmet care needs will help ensure that COPD patients receive adequate palliative care services at the appropriate time.
Conclusion
COPD is a leading cause of morbidity and mortality in the United States and represents a significant economic burden for both individuals and society. The goals in COPD management are to provide symptom relief, improve the quality of life, preserve lung function, and reduce the frequency of exacerbations and mortality. COPD management is guided by disease severity that is measured using the GOLD multimodal staging system and requires a multidisciplinary approach. Several classes of medication are available for treatment, and a step-wise approach should be applied in building an effective pharmacologic regimen. In addition to pharmacologic therapies, nonpharmacologic therapies, including smoking cessation, vaccinations, proper nutrition, and maintaining physical activity, are an important part of long-term management. Those who continue to be symptomatic despite appropriate maximal therapy may be candidates for lung volume reduction. Palliative care services for COPD patients, which can aid in reducing symptom burden and improving quality of life, should not be overlooked.
Case Presentation
A 65-year-old man with severe chronic obstructive disease (COPD; forced expiratory volume in 1 second/forced vital capacity ratio [FEV1/FVC], 27; FEV1 25% of predicted; residual volume 170% of predicted for his age and height) was seen in the pulmonary clinic. His medications include a long-acting beta agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination that he uses twice daily as advised. He uses his rescue albuterol inhaler roughly once a week. The patient complains of severe disabling shortness of breath with exertion and severe limitation of his quality of life because of his inability to lead a normal active life. He is on 2 L/min of oxygen at all times. He has received pulmonary rehabilitation in hopes of improving his quality of life but can only climb a flight of stairs before he must stop to rest. He asks about options but does not want to consider lung transplantation today. His most recent chest computed tomography (CT) scan demonstrates upper lobe predominant emphysematous changes with no masses or nodules.
What are the patient's options at this time?
Lung volume reduction surgery (LVRS) attempts to reduce space-occupying severely diseased, hyperexpanded lung, thus allowing the relatively normal adjoining lung parenchyma to expand into the vacated space and function effectively.1 Hence, such therapies are suitable for patients with emphysematous lungs and not those with bronchitic-predominant COPD. LVRS offers a greater chance of improvement in exercise capacity, lung function, quality of life, and dyspnea in the correctly chosen patient population, as compared with pharmacologic management alone.2 However, the procedure is associated with risks, including higher short-term morbidity and mortality.2 Patients with predominantly upper-lobe emphysema and a low maximal workload after rehabilitation were noted to have lower mortality, a greater probability of improvement in exercise capacity, and a greater probability of improvement in symptoms if they underwent surgery compared to medical therapy alone.2 On the contrary, patients with predominantly non–upper-lobe emphysema and a high maximal workload after rehabilitation had higher mortality if they underwent surgery compared to receiving medical therapy alone.2 Thus, a subgroup of patients with homogeneous emphysema symmetrically affecting the upper and lower lobes are considered to be unlikely to benefit from this surgery.2,3
Valves and other methods of lung volume reduction such as coils, sealants, intrapulmonary vents, and thermal vapor in the bronchi or subsegmental airways have emerged as new techniques for nonsurgical lung volume reduction.4-9 Endobronchial-valve therapy is associated with improvement in lung function and with clinical benefits that are greatest in the presence of heterogeneous lung involvement. This works by the same principle as LVRS, by reduction of the most severely diseased lung units, expansion of the more viable, less emphysematous lung results in substantial improvements in lung mechanics.10,11 The most important complications of this procedure include pneumonia, pneumothorax, hemoptysis, and increased frequency of COPD exacerbation in the following 30 days. The fact that a high-heterogeneity subgroup had greater improvements in both the FEV1 and distance on the 6-minute walk test than did patients with lower heterogeneity supports the use of quantitative high-resolution computed tomography (HRCT) in selecting patients for endobronchial-valve therapy.12 The HRCT scans also help in identifying those with complete fissures, a marker of lack of collateral ventilation (CV+) between different lobes. Presence of CV+ state predicts failure of endobronchial valve and all forms of endoscopic LVRS.13 Bronchoscopic thermal vapor ablation (BTVA) therapy can potentially work on a subsegmental level and be successful for treatment of emphysema with lack of intact fissures on CT scans. Other methods that have the potential to be effective in those with collateral ventilation would be endoscopic coil therapy and polymeric lung volume reduction.11,14 Unfortunately, there are no randomized controlled trial data demonstrating clinically meaningful improvement following coil therapy or polymeric lung volume reduction in this CV+ patient population. Vapor therapy is perhaps the only technique that has been found to be effective in upper lobe predominant emphysema even with CV+ status.13
Our patient has evidence of air trapping and emphysema based on a high residual volume. A CT scan of the chest can determine the nature of the emphysema (heterogeneous versus homogenous) and based on these findings, further determination of the best strategy for lung volume reduction can be made.
Is there a role for long-term oxygen therapy?
Long-term oxygen therapy (LTOT) used for more than 15 hours a day is thought to reduce mortality among patients with COPD and severe resting hypoxemia.15-18 More recent studies have failed to show similar beneficial effects of LTOT. A recent study examined the effects of LTOT in randomized fashion and determined that supplemental oxygen for patients with stable COPD and resting or exercise-induced moderate desaturation did not affect the time to death or first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, the rate of all hospitalizations, the rate of all COPD exacerbations, or changes in measures of quality of life, depression, anxiety, or functional status.19
Our patient is currently on long-term oxygen therapy and in spite of some uncertainty as to its benefit, it is prudent to order oxygen therapy until further clarification is available.
What is the role of pulmonary rehabilitation?
Pulmonary rehabilitation is an established treatment for patients with chronic lung disease.20 Benefits include improvement in exercise tolerance, symptoms, and quality of life, with a reduction in the use of health care resources.21 A Spanish population-based cohort study that looked at the influence of regular physical activity on COPD showed that patients who reported low, moderate, or high physical activity had a lower risk of COPD admissions and all-cause mortality than patients with very low physical activity after adjusting for all confounders.22
As previously mentioned, patients in GOLD categories B, C, and D should be offered pulmonary rehabilitation as part of their treatment.23 The ideal patient is one who is not too sick to undergo rehabilitation and is motivated to improve his or her quality of life.
What is the current scope of lung transplantation in the management of severe COPD?
There is an indisputable role for lung transplantation in end-stage COPD. However, lung transplantation does not benefit all COPD patients. There is a subset of patients for whom the treatment provides a survival benefit. It has been reported that 79% of patients with an FEV1 < 16% predicted will survive at least 1 additional year after transplant, but only 11% of patients with an FEV1 > 25% will do so.24 The pre-transplant BODE (body mass index, airflow obstruction/FEV1, dyspnea, and exercise capacity) index score is used to identify patients who will benefit from lung transplantation.25,26 International guidelines for the selection of lung transplant candidates identify the following patient characteristics:27
- The disease is progressive, despite maximal treatment including medication, pulmonary rehabilitation, and oxygen therapy;
- The patient is not a candidate for endoscopic or surgical LVRS;
- BODE index is 5 to 6;
- The PCO2 is greater than 50 mm Hg (6.6 kPa) and/or PO2 is less than 60 mm Hg (8 kPa);
- FEV1 is 25% predicted.
The perioperative mortality of lung transplantation surgery has been reduced to less than 10%. Risk of complications from surgery in the perioperative period, such as bronchial dehiscence, infectious complications, and acute rejection, have also been reduced but do occur. Chronic allograft dysfunction and the risk of lung cancer in cases of single lung transplant should be discussed with the patient before surgery.28
How can we incorporate palliative care into the management plan for patients with COPD?
Among patients with end-stage COPD on home oxygen therapy who have required mechanical ventilation for an exacerbation, only 55% are alive at 1 year.29 COPD patients at high risk of death within the next year of life as well as patients with refractory symptoms and unmet needs are candidates for early palliative care. Palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members, and palliative care is recommended by multiple international societies for patients with advanced COPD.30,31 In spite of these recommendations, the utilization of palliative care resources has been dismally low.32,33 Improving physician-patient communication regarding palliative services and patients’ unmet care needs will help ensure that COPD patients receive adequate palliative care services at the appropriate time.
Conclusion
COPD is a leading cause of morbidity and mortality in the United States and represents a significant economic burden for both individuals and society. The goals in COPD management are to provide symptom relief, improve the quality of life, preserve lung function, and reduce the frequency of exacerbations and mortality. COPD management is guided by disease severity that is measured using the GOLD multimodal staging system and requires a multidisciplinary approach. Several classes of medication are available for treatment, and a step-wise approach should be applied in building an effective pharmacologic regimen. In addition to pharmacologic therapies, nonpharmacologic therapies, including smoking cessation, vaccinations, proper nutrition, and maintaining physical activity, are an important part of long-term management. Those who continue to be symptomatic despite appropriate maximal therapy may be candidates for lung volume reduction. Palliative care services for COPD patients, which can aid in reducing symptom burden and improving quality of life, should not be overlooked.
1. Sabanathan A, Sabanathan S, Shah R, Richardson J. Lung volume reduction surgery for emphysema: a review. J Cardiovasc Surg. 1998;39:237.
2. Group NETTR. Patients at high risk of death after lung-volume–reduction surgery. N Engl J Med. 2001;345:1075-1083.
3. Group NETTR. A randomized trial comparing lung-volume–reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348:2059-2073.
4. Decker MR, Leverson GE, Jaoude WA, Maloney JD. Lung volume reduction surgery since the National Emphysema Treatment Trial: study of Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg. 2014;148:2651-2658.
5. Deslée G, Mal H, Dutau H, et al. Lung volume reduction coil treatment vs usual care in patients with severe emphysema: the REVOLENS randomized clinical trial. JAMA. 2016;315:175-184.
6. Hartman JE, Klooster K, Gortzak K, et al. Long-term follow-up after bronchoscopic lung volume reduction treatment with coils in patients with severe emphysema. Respirology. 2015;20:319-326.
7. Snell GI, Hopkins P, Westall G, et al. A feasibility and safety study of bronchoscopic thermal vapor ablation: a novel emphysema therapy. Ann Thorac Surg. 2009;88:1993-1998.
8. Ingenito EP, Berger RL, Henderson AC, et al. Bronchoscopic lung volume reduction using tissue engineering principles. Am J Respir Crit Care Med. 2003;167:771-778.
9. Ingenito EP, Loring SH, Moy ML, et al. Comparison of physiological and radiological screening for lung volume reduction surgery. Am J Respir Crit Care Med. 2001;163:1068-1073.
10. Shah P, Slebos D, Cardoso P, et al. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial. Lancet. 2011;378:997-1005.
11. Sciurba FC, Ernst A, Herth FJ, et al. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med. 2010;363:1233-1244.
12. Wan IY, Toma TP, Geddes DM, et al. Bronchoscopic lung volume reduction for end-stage emphysema: report on the first 98 patients. Chest. 2006;129:518-526.
13. Gompelmann D, Eberhardt R, Schuhmann M, et al. Lung volume reduction with vapor ablation in the presence of incomplete fissures: 12-month results from the STEP-UP randomized controlled study. Respiration. 2016;92:397-403.
14. Come CE, Kramer MR, Dransfield MT, et al. A randomised trial of lung sealant versus medical therapy for advanced emphysema. Eur Respir J. 2015;46:651-662.
15. Group NOTT. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med. 1980;93:391-398.
16. Council M. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet. 1981;1:681-686.
17. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179-191.
18. Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187:347-365.
19. Group L-TOTTR. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016;375:1617-1627.
20. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015(2):CD003793.
21. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;355:362-368.
22. Garcia-Aymerich J, Lange P, Benet M, et al. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. 2006;61:772-778.
23. Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org. Accessed July 9, 2019.
24. Thabut G, Ravaud P, Christie JD, et al. Determinants of the survival benefit of lung transplantation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2008;177:1156-1163.
25. Lahzami S, Bridevaux PO, Soccal PM, et al. Survival impact of lung transplantation for COPD. Eur Respir J. 2010;36:74-80.
26. Cerón Navarro J, de Aguiar Quevedo K, Ansótegui Barrera E, et al. Functional outcomes after lung transplant in chronic obstructive pulmonary disease. Arch Bronconeumol. 2015;51:109-114.
27. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34:1-15.
28. Minai OA, Shah S, Mazzone P, et al. Bronchogenic carcinoma after lung transplantation: characteristics and outcomes. J Thorac Oncol. 2008;3:1404-1409.
29. Hajizadeh N, Goldfeld K, Crothers K. What happens to patients with COPD with long-term oxygen treatment who receive mechanical ventilation for COPD exacerbation? A 1-year retrospective follow- up study. Thorax. 2015;70:294-296.
30. Siouta N, van Beek K, Preston N, et al. Towards integration of palliative care in patients with chronic heart failure and chronic obstructive pulmonary disease: a systematic literature review of European guidelines and pathways. BMC Palliat Care. 2016;15:18.
31. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.
32. Szekendi MK, Vaughn J, Lal A, et al. The prevalence of inpatients at thirty-three U.S. hospitals appropriate for and receiving referral to palliative care. J Palliat Med. 2016;19:360-372.
33. Rush B, Hertz P, Bond A, et al. Use of palliative care in patients with end-stage COPD and receiving home oxygen: national trends and barriers to care in the United States. Chest. 2017;151:41-46.
1. Sabanathan A, Sabanathan S, Shah R, Richardson J. Lung volume reduction surgery for emphysema: a review. J Cardiovasc Surg. 1998;39:237.
2. Group NETTR. Patients at high risk of death after lung-volume–reduction surgery. N Engl J Med. 2001;345:1075-1083.
3. Group NETTR. A randomized trial comparing lung-volume–reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348:2059-2073.
4. Decker MR, Leverson GE, Jaoude WA, Maloney JD. Lung volume reduction surgery since the National Emphysema Treatment Trial: study of Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg. 2014;148:2651-2658.
5. Deslée G, Mal H, Dutau H, et al. Lung volume reduction coil treatment vs usual care in patients with severe emphysema: the REVOLENS randomized clinical trial. JAMA. 2016;315:175-184.
6. Hartman JE, Klooster K, Gortzak K, et al. Long-term follow-up after bronchoscopic lung volume reduction treatment with coils in patients with severe emphysema. Respirology. 2015;20:319-326.
7. Snell GI, Hopkins P, Westall G, et al. A feasibility and safety study of bronchoscopic thermal vapor ablation: a novel emphysema therapy. Ann Thorac Surg. 2009;88:1993-1998.
8. Ingenito EP, Berger RL, Henderson AC, et al. Bronchoscopic lung volume reduction using tissue engineering principles. Am J Respir Crit Care Med. 2003;167:771-778.
9. Ingenito EP, Loring SH, Moy ML, et al. Comparison of physiological and radiological screening for lung volume reduction surgery. Am J Respir Crit Care Med. 2001;163:1068-1073.
10. Shah P, Slebos D, Cardoso P, et al. Bronchoscopic lung-volume reduction with Exhale airway stents for emphysema (EASE trial): randomised, sham-controlled, multicentre trial. Lancet. 2011;378:997-1005.
11. Sciurba FC, Ernst A, Herth FJ, et al. A randomized study of endobronchial valves for advanced emphysema. N Engl J Med. 2010;363:1233-1244.
12. Wan IY, Toma TP, Geddes DM, et al. Bronchoscopic lung volume reduction for end-stage emphysema: report on the first 98 patients. Chest. 2006;129:518-526.
13. Gompelmann D, Eberhardt R, Schuhmann M, et al. Lung volume reduction with vapor ablation in the presence of incomplete fissures: 12-month results from the STEP-UP randomized controlled study. Respiration. 2016;92:397-403.
14. Come CE, Kramer MR, Dransfield MT, et al. A randomised trial of lung sealant versus medical therapy for advanced emphysema. Eur Respir J. 2015;46:651-662.
15. Group NOTT. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med. 1980;93:391-398.
16. Council M. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema: Report of the Medical Research Council Working Party. Lancet. 1981;1:681-686.
17. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155:179-191.
18. Vestbo J, Hurd SS, Agustí AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187:347-365.
19. Group L-TOTTR. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016;375:1617-1627.
20. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015(2):CD003793.
21. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;355:362-368.
22. Garcia-Aymerich J, Lange P, Benet M, et al. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. 2006;61:772-778.
23. Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org. Accessed July 9, 2019.
24. Thabut G, Ravaud P, Christie JD, et al. Determinants of the survival benefit of lung transplantation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2008;177:1156-1163.
25. Lahzami S, Bridevaux PO, Soccal PM, et al. Survival impact of lung transplantation for COPD. Eur Respir J. 2010;36:74-80.
26. Cerón Navarro J, de Aguiar Quevedo K, Ansótegui Barrera E, et al. Functional outcomes after lung transplant in chronic obstructive pulmonary disease. Arch Bronconeumol. 2015;51:109-114.
27. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2015;34:1-15.
28. Minai OA, Shah S, Mazzone P, et al. Bronchogenic carcinoma after lung transplantation: characteristics and outcomes. J Thorac Oncol. 2008;3:1404-1409.
29. Hajizadeh N, Goldfeld K, Crothers K. What happens to patients with COPD with long-term oxygen treatment who receive mechanical ventilation for COPD exacerbation? A 1-year retrospective follow- up study. Thorax. 2015;70:294-296.
30. Siouta N, van Beek K, Preston N, et al. Towards integration of palliative care in patients with chronic heart failure and chronic obstructive pulmonary disease: a systematic literature review of European guidelines and pathways. BMC Palliat Care. 2016;15:18.
31. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23:932-946.
32. Szekendi MK, Vaughn J, Lal A, et al. The prevalence of inpatients at thirty-three U.S. hospitals appropriate for and receiving referral to palliative care. J Palliat Med. 2016;19:360-372.
33. Rush B, Hertz P, Bond A, et al. Use of palliative care in patients with end-stage COPD and receiving home oxygen: national trends and barriers to care in the United States. Chest. 2017;151:41-46.