Lung volume reduction surgery
Some people with emphysema may benefit from an operation called lung volume reduction surgery to remove diseased lung tissue.
The procedure is believed to create more space in the chest cavity for the working lung tissue to expand. This appears to prolong life for people whose emphysema predominantly affects the upper lobes and reduces exercise capacity. Medicare covers this procedure for people who fulfill these criteria.
Another option for people with emphysema is lung transplantation. More than 1,600 lung transplants were performed in 2009 in the United States. About 34 percent of these procedures involve a single lung (unilateral), while 66 percent involve both lungs (bilateral).
Unilateral transplants are reserved for people with emphysema or pulmonary fibrosis (chronic inflammation and progressive scarring of the walls of the air sacs); bilateral transplants are performed primarily in selected emphysema patients, people who have bronchiectasis, and those who have cystic fibrosis, a hereditary disease in which abnormally thick, sticky mucus clogs the lungs and may lead to life-threatening lung infections.
Because donor lungs are scarce and transplants are risky, potential candidates for transplantation must undergo extensive evaluation. Successful candidates must meet disease-specific criteria for severe (end-stage) lung disease, yet be able to survive the wait for one or both donor lungs and to endure the rigors of the operation itself and the postoperative period. Recent changes to the rules for organ allocation have reduced waiting times for lung transplants in people who are seriously ill.
Also, international guidelines have established an upper age limit of 65 years for unilateral and bilateral transplants. However, a number of medical centers have performed transplants in people who exceed these age limits. Guidelines from the International Society for Heart and Lung Transplants note that while older patients are less likely to survive than younger patients, because they often have a number of coexisting illnesses, advanced age alone in an otherwise acceptable candidate with few other health problems does not necessarily imply a less successful result.
Transplants cannot be performed in people with major disease in other organs, including HIV infection, cancer (other than basal or squamous cell skin cancers) diagnosed within the past two years, positive tests for hepatitis B antigen, or hepatitis C infection with liver disease. Lung transplantation may not be suitable for people who are obese or have severe osteoporosis.
People who undergo a lung transplant are required to take medications for the rest of their life to suppress the immune system and prevent it from rejecting the transplanted lung(s). After successful transplantation, patients may experience some limitations in exercise tolerance, but usually not enough to interfere with normal daily activities or to reduce quality of life.
The five-year survival rate after lung transplantation is approximately 44 percent for a single-lung transplant and 50 percent for a double-lung transplant. The survival rate is highest in those who receive transplants for underlying emphysema and lowest in those treated for idiopathic pulmonary fibrosis (progressive scarring of the lungs for which the cause is unknown) or pulmonary hypertension.
The most common problem related to rejection—and the most dangerous complication of transplantation—is a condition called bronchiolitis obliterans, in which the bronchioles become blocked.
Other common complications are infections and adverse effects of the immunosuppressive drugs.
Experimental treatments for COPD
Several new experimental procedures are being studied as possible alternatives to lung volume reduction surgery or lung transplantation. These treatments include minimally invasive surgical procedures as well as a nonsurgical option known as biologic lung volume reduction. Researchers are also studying new drug treatments for COPD.