Lung Volume Reduction Surgery for Emphysema
http://www.100md.com
《新英格兰医药杂志》
The most troublesome and compelling symptom of advanced chronic obstructive pulmonary disease (COPD) with emphysema is dyspnea. Dyspnea profoundly limits the quality of life for a growing number of people worldwide who are in the advanced stages of COPD.
(Figure)
A Scanning Electron Micrograph Showing Emphysema in a Human Lung.
By permission of David Gregory and Debbie Marshall/Wellcome Photo Library.
In 1826, La?nnec, in his careful autopsies, recognized that the lungs of patients who had died from emphysema were too large — they were entrapped in the thorax. He realized that emphysema reduced elastic recoil and impaired the function of small airways in the areas that supply ventilation to destroyed tissue.
In the 1950s, Dr. Otto Brantigan, of the University of Maryland, introduced an operation that today is known as lung-volume–reduction surgery. Although he offered anecdotal and limited physiological evidence of improvement in selected patients, perioperative mortality was prohibitive, and he abandoned the operation. Brantigan attended the Eighth Aspen Emphysema Conference (the annual meeting is now known as the Aspen Lung Conference) in 1965. There he reviewed his experience in an eloquent and compelling way but did not recommend further use of the procedure. In the early 1990s, Dr. Joel Cooper, of the Washington University School of Medicine and Barnes-Jewish Hospital, resurrected the procedure, adding new approaches with the aim of forming a bridge to lung transplantation. The enthusiastic initial reports of Cooper in 1995 stimulated many thoracic surgeons to offer this procedure to their patients. But because the scientific rationale remained controversial, and because no well-designed studies had compared surgery with medical therapy, including the use of pulmonary rehabilitation and oxygen, Medicare coverage was soon denied until further studies could be conducted. These studies have now been completed.
In Lung Volume Reduction Surgery for Emphysema, 30 contributors provide 20 well-written chapters that review the scientific rationale for lung-volume–reduction surgery and the initial results of the National Emphysema Treatment Trial (NETT). This is a remarkable achievement. A historical review of the study design, which required extensive statistical assumptions and adjustments during the enrollment period, and the major outcomes of the NETT are detailed in this book. The study determined that a subgroup of patients with localized apical emphysema and poor exercise tolerance after exercise training are the most likely to benefit from lung-volume–reduction surgery.
The NETT was an unprecedented collaboration between the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) and the National Heart, Lung, and Blood Institute, along with the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). Together these agencies provided the massive financial support that was required for the successful completion of the study. What a Herculean effort!
The mechanisms of improvement after lung-volume–reduction surgery involve the restoration of elastic recoil and diaphragmatic function. The procedure can reduce the excessive respiratory drive needed for a given effort in selected patients. The result is reduced dyspnea, improved tolerance for walking, and a better quality of life. A reduction in the use of oxygen and, in some patients, in the need for corticosteroids have been secondary outcomes.
This book is a gem. It will be of great interest to all students of COPD, including clinicians, physiologists, surgeons, and radiologists. In my opinion, Lung Volume Reduction Surgery for Emphysema deserves special notice in a field that only today is receiving appropriate emphasis. COPD is the fourth most common cause of death in the United States and the only cause among the top five that is increasing in incidence. Lung-volume–reduction surgery is a breakthrough for patients who meet the established criteria, which are well outlined in this book. Although it may seem grossly overpriced, the book is worth the investment as a key historical document and reference source.
Thomas L. Petty, M.D.
University of Colorado Health Sciences Center
Denver, CO 80720((Lung Biology in Health a)
(Figure)
A Scanning Electron Micrograph Showing Emphysema in a Human Lung.
By permission of David Gregory and Debbie Marshall/Wellcome Photo Library.
In 1826, La?nnec, in his careful autopsies, recognized that the lungs of patients who had died from emphysema were too large — they were entrapped in the thorax. He realized that emphysema reduced elastic recoil and impaired the function of small airways in the areas that supply ventilation to destroyed tissue.
In the 1950s, Dr. Otto Brantigan, of the University of Maryland, introduced an operation that today is known as lung-volume–reduction surgery. Although he offered anecdotal and limited physiological evidence of improvement in selected patients, perioperative mortality was prohibitive, and he abandoned the operation. Brantigan attended the Eighth Aspen Emphysema Conference (the annual meeting is now known as the Aspen Lung Conference) in 1965. There he reviewed his experience in an eloquent and compelling way but did not recommend further use of the procedure. In the early 1990s, Dr. Joel Cooper, of the Washington University School of Medicine and Barnes-Jewish Hospital, resurrected the procedure, adding new approaches with the aim of forming a bridge to lung transplantation. The enthusiastic initial reports of Cooper in 1995 stimulated many thoracic surgeons to offer this procedure to their patients. But because the scientific rationale remained controversial, and because no well-designed studies had compared surgery with medical therapy, including the use of pulmonary rehabilitation and oxygen, Medicare coverage was soon denied until further studies could be conducted. These studies have now been completed.
In Lung Volume Reduction Surgery for Emphysema, 30 contributors provide 20 well-written chapters that review the scientific rationale for lung-volume–reduction surgery and the initial results of the National Emphysema Treatment Trial (NETT). This is a remarkable achievement. A historical review of the study design, which required extensive statistical assumptions and adjustments during the enrollment period, and the major outcomes of the NETT are detailed in this book. The study determined that a subgroup of patients with localized apical emphysema and poor exercise tolerance after exercise training are the most likely to benefit from lung-volume–reduction surgery.
The NETT was an unprecedented collaboration between the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) and the National Heart, Lung, and Blood Institute, along with the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). Together these agencies provided the massive financial support that was required for the successful completion of the study. What a Herculean effort!
The mechanisms of improvement after lung-volume–reduction surgery involve the restoration of elastic recoil and diaphragmatic function. The procedure can reduce the excessive respiratory drive needed for a given effort in selected patients. The result is reduced dyspnea, improved tolerance for walking, and a better quality of life. A reduction in the use of oxygen and, in some patients, in the need for corticosteroids have been secondary outcomes.
This book is a gem. It will be of great interest to all students of COPD, including clinicians, physiologists, surgeons, and radiologists. In my opinion, Lung Volume Reduction Surgery for Emphysema deserves special notice in a field that only today is receiving appropriate emphasis. COPD is the fourth most common cause of death in the United States and the only cause among the top five that is increasing in incidence. Lung-volume–reduction surgery is a breakthrough for patients who meet the established criteria, which are well outlined in this book. Although it may seem grossly overpriced, the book is worth the investment as a key historical document and reference source.
Thomas L. Petty, M.D.
University of Colorado Health Sciences Center
Denver, CO 80720((Lung Biology in Health a)