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J Thorac Cardiovasc Surg 1997;114:957-967
© 1997 Mosby, Inc.

GENERAL THORACIC SURGERY

PATIENT SELECTION CRITERIA FOR LUNG VOLUME REDUCTION SURGERY

Supported in part by DOE grant DE-f603-91 ER61227, National Institutes of Health grant R01192, and the Heart and Lung Surgery Foundation.

Received for publication July 3, 1996 Revisions requested Feb. 13, 1997 Revisions received June 16, 1997 Accepted for publication July 31, 1997 Address for reprints: Robert J. McKenna, Jr., MD, 8635 Third, Suite 975W, Los Angeles, CA 90048.

Abstract

Objective: Our intent was to refine the patient selection criteria for lung volume reduction surgery because various centers have different criteria and not all patients benefit from the procedure. Methods: Patient information, x-ray results, arterial blood gases, and plethysmographic pulmonary function tests in 154 consecutive patients who underwent bilateral thoracoscopic staple lung volume reduction surgery were compared with clinical outcome (change in forced expiratory volume in 1 second and dyspnea scale) with t tests and analysis of variance. Results: Three hundred thirty-three of 487 (69%) patients evaluated for lung volume reduction surgery were rejected for lack of heterogeneous emphysema ( n = 212), medical contraindications ( n = 88), hypercapnia ( n = 20), uncontrolled anxiety or depression ( n = 10), or pulmonary hypertension ( n = 1). Two patients died during the evaluation process. When tested by analysis of variance, there was no difference in clinical outcome associated with preoperative forced expiratory volume in 1 second, residual volume, total lung capacity, single-breath diffusing, and arterial oxygen or carbon dioxide tension. All patients selected for the operation had a heterogeneous pattern of emphysema. The upper lobe heterogeneous pattern of emphysema on chest computed tomography and lung perfusion scan was strongly associated with improved outcome with a mean (95% confidence interval) improvement in forced expiratory volume in 1 second of 73.2% (63.3 to 83.1) for the upper lobe compared with a mean (95% confidence interval) improvement of 37.9% (22.9 to 53.0) for the lower lobe or diffuse pattern of emphysema. Conclusion: The most important selection criteria for lung volume reduction surgery is the presence of a bilateral upper lobe heterogeneous pattern of emphysema on chest computed tomography and lung perfusion scan. After patients have been selected on the basis of a heterogeneous pattern of emphysema, clinical factors and physiology are not associated with clinical outcome well enough to further refine patient selection criteria. These results do not support the arbitrary patient selection criteria for lung volume reduction surgery reported in the literature.

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