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Over the past 50-75 years, various surgical approaches have been tried to improve symptoms and to restore lung function in people with emphysema. Only giant bullectomy and, possibly, lung volume reduction surgery have proven useful.

Bullectomy

Bullectomy is the removal of giant bullae, which are air-filled spaces affected by emphysema located in the lung periphery. Bullectomy has been a standard approach for many years. The bullae in patients with emphysema generally range in size from 1-4 cm in diameter; however, bullae can occupy more than 33% of the hemithorax (eg, giant bullae). The hemithorax is one side of the chest.

Giant bullae may compress adjacent lung tissue, reducing blood flow and ventilation to healthy tissue. Removal of these bullae can result in the expansion of compressed lungs and improved function.

Lung volume reduction surgery

Lung volume reduction surgery was first performed nearly 40 years ago.

Surgeons generally remove 20-30% from the upper part of each lung, the area typically most damaged by tobacco smoking. The theory is that the removal of a portion of the diseased lung increases the airway diameter in the remaining lung and thereby improving lung function and airflow, which, in turn, reduces the symptoms.

This procedure has a death rate of 0-8%, and several complications can occur.

The criteria in determining who should undergo lung volume reduction surgery have recently been defined. Generally speaking, those who do undergo this surgery have symptoms due to severe emphysema, marked hyperinflation (enlargement of airways and air spaces indicative of emphysema), and evidence of emphysema as seen on an HRCT scan.

A large multicenter prospective study has just been completed and has shown that patients with upper lobe disease and low exercise tolerance benefit the most from this procedure.

Lung transplantation

Lung transplantation is a relatively new surgical therapy for people with advanced lung disease.

Those with COPD are the largest single category of people who undergo this process. The timing of transplant is difficult to determine, but those selected to receive a transplant should have a life expectancy without transplant of 2 years or less due to COPD.

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