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Medical Author:

George Schiffman, MD, FCCP

George Schiffman, MD, FCCP

Dr. Schiffman received his B.S. degree with High Honors in biology from Hobart College in 1976. He then moved to Chicago where he studied biochemistry at the University of Illinois, Chicago Circle. He attended Rush Medical College where he received his M.D. degree in 1982 and was elected to the Alpha Omega Alpha Medical Honor Society. He completed his Internal Medicine internship and residency at the University of California, Irvine.

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Medical Editor:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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

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, some bullae (giant bullae) can occupy more than 33% of the hemithorax. 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 was first performed nearly 40 years ago.

Surgeons generally remove 20% to 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% to 8%, and several complications can occur.

The criteria in determining who should undergo lung volume reduction surgery have 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 shown that patients with upper lobe disease and low exercise tolerance benefit the most from this procedure.

Newer procedures using valves and special devices placed through a bronchoscope have been developed to simulate volume reduction surgery, without any incisions. These devices have shown a minimal improvement in lung function in very select patients. Research in regard to these devices is ongoing.

Lung transplantation is a surgical option 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. New transplant criteria have moved patients with the greatest need to the top of the waiting list. It is therefore no longer necessary to try and predict the amount of life expectancy a patient has left. It probably best to be referred for transplant before long term mechanical ventilation is necessary.

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