Correlation of changes in quality of life after lung volume reduction surgery with changes in lung function, exercise, and gas exchange

Gender and age differences in symptom distress and functional disability one year after heart transplant surgery

OBJECTIVE

Symptoms and functional status are major concerns for heart transplant (HT) recipients. The study objective was to examine gender and age differences in symptom distress and functional disability 1 year after HT surgery.

METHODS

The sample (N = 237) consisted of 44 female and 193 male patients who were divided into younger (n = 66) and older (n = 171) groups with the breakpoint at age 50 years. Data from chart review and 2 questionnaires (Heart Transplant Symptom Checklist and Sickness Impact Profile) were analyzed with chi-square test, t tests, analysis of variance, and multivariate analysis of variance.

RESULTS

Women reported worse symptom distress (overall, plus cardiovascular, gastrointestinal, dermatologic symptoms) and more functional disability (overall, plus disability in ambulation, mobility, self-care, home management). Older patients reported more disability in ambulation and work. Gender by age interactions showed that older men reported worse genitourinary symptoms and younger women reported worse dermatologic symptoms.

CONCLUSION

There were more gender than age differences in symptoms and disability.

Taking a chance: the experience of lung volume reduction procedures for chronic obstructive pulmonary disease

OBJECTIVES

Lung Volume Reduction Surgery and Endo-Bronchial Valve(TM) insertion have expanded the therapeutic choices for chronic obstructive pulmonary disease (COPD). Controversy over efficacy, costs and risks limits access to these therapies. There are no published findings to guide our understanding of the patient's experience of surgery. The aim of this study is to understand the experience of palliative surgery for COPD.

METHODS

Merleau-Ponty's philosophy provided a framework for this Heideggerian phenomenological inquiry. Fifty-eight semi-structured interviews were conducted with 15 patients undergoing lung volume reduction procedures and 14 family members.

RESULTS

Patients and families felt they had no option but to 'take a chance' on surgery. Interventions frequently led to regaining lost tasks or easier completion of existing tasks. Where patients did not perceive an increase in things they could 'do', surgery allowed some to reclaim their sense of self. Regardless of the outcome, most did not regret their decision for surgery.

DISCUSSION

Meanings of surgery are not always tied to the visible, objective measurements of outsiders but may relate to regaining of self. Despite the concerns of some clinicians, patients and families are more likely to accept the risk of morbidity and mortality from surgery than has previously been realized.

Mortality and Functional Performance in Severe Emphysema after Lung Volume Reduction or Transplant

The purpose of this endeavor is to compare the morbidity, mortality and costs of LVRS versus transplantation in severe emphysema. This was a retrospective review of severe emphysema patients who received LVRS (n = 70) from 1994-1999, or transplant (n = 87) from 1994-2004. Change in functional status was calculated by the change in modified BODE (mBODE) score. Financial data included physician, hospital and medication costs. Preoperatively, there was no significant difference between the transplant and LVRS groups (mean +/- SD) in age (57.7 +/- 5.7 vs. 59.1 +/- 8.3 years), BMI, Borg dyspnea score, 6-minute walk distance or mBODE (10.4 +/- 2.6 vs. 9.6 +/- 2.7, p = 0.4). Preoperatively, FEV1% (23.6 +/- 8.5 vs. 31.9 +/- 17.7, p = 0.008) was significantly lower in the transplant group. One year post-operatively, transplantation patients had a significantly greater improvement in mBODE (-5.7 vs. -2.0, p = 0.0004), FEV1% (43.4 vs. 2.2%, p = 0.0004) and Borg score (-3.0 vs. -1.4, p = 0.04). Transplantation patients had lower long-term survival compared to LVRS patients (p = 0.01). The only variable that affected survival was type of surgery favoring LVRS (hazard ratio 1.7, 95% confidence limits 1.05-2.77). During a mean follow-up of 2.4 +/- 2.5 years after transplant and 5.0 +/- 3.1 years after LVRS, transplantation mean total costs were greater ($381,732 vs. $140,637, p < 0.0001). Transplantation patients spent more time in the hospital (74.3 +/- 81.3 vs. 39.5 +/- 66.7 days, p = 0.009) and had more outpatient visits (29.9 +/- 28.8 vs. 12.3 +/- 12.6 visits, p < 0.0001). In patients who survive over 1 year, transplantation provides a higher level of functional status and a greater improvement in airflow obstruction, dyspnea, exercise tolerance, and mBODE score, but costs more and carries greater mortality.

Effects of lung volume reduction surgery on gas exchange and breathing pattern during maximum exercise

BACKGROUND

The National Emphysema Treatment Trial studied lung volume reduction surgery (LVRS) for its effects on gas exchange, breathing pattern, and dyspnea during exercise in severe emphysema.

METHODS

Exercise testing was performed at baseline, and 6, 12, and 24 months. Minute ventilation (Ve), tidal volume (Vt), carbon dioxide output (Vco(2)), dyspnea rating, and workload were recorded at rest, 3 min of unloaded pedaling, and maximum exercise. Pao(2), Paco(2), pH, fraction of expired carbon dioxide, and bicarbonate were also collected in some subjects at these time points and each minute of testing. There were 1,218 patients enrolled in the study (mean [+/- SD] age, 66.6 +/- 6.1 years; mean, 61%; mean FEV(1), 0.77 +/- 0.24 L), with 238 patients participating in this substudy (mean age, 66.1 +/- 6.8 years; mean, 67%; mean FEV(1), 0.78 +/- 0.25 L).

RESULTS

At 6 months, LVRS patients had higher maximum Ve (32.8 vs 29.6 L/min, respectively; p = 0.001), Vco(2), (0.923 vs 0.820 L/min, respectively; p = 0.0003), Vt (1.18 vs 1.07 L, respectively; p = 0.001), heart rate (124 vs 121 beats/min, respectively; p = 0.02), and workload (49.3 vs 45.1 W, respectively; p = 0.04), but less breathlessness (as measured by Borg dyspnea scale score) [4.4 vs 5.2, respectively; p = 0.0001] and exercise ventilatory limitation (49.5% vs 71.9%, respectively; p = 0.001) than medical patients. LVRS patients with upper-lobe emphysema showed a downward shift in Paco(2) vs Vco(2) (p = 0.001). During exercise, LVRS patients breathed slower and deeper at 6 months (p = 0.01) and 12 months (p = 0.006), with reduced dead space at 6 months (p = 0.007) and 24 months (p = 0.006). Twelve months after patients underwent LVRS, dyspnea was less in patients with upper-lobe emphysema (p = 0.001) and non-upper-lobe emphysema (p = 0.007).

CONCLUSION

During exercise following LVRS, patients with severe emphysema improve carbon dioxide elimination and dead space, breathe slower and deeper, and report less dyspnea.

Fast onset of effect of budesonide/formoterol versus salmeterol/fluticasone and salbutamol in patients with chronic obstructive pulmonary disease and reversible airway obstruction

BACKGROUND AND OBJECTIVES

Data on the onset of action of COPD medications are lacking. This study compared the onset of bronchodilation following different inhaled therapies in patients with moderate-to-severe COPD and reversible airway obstruction.

METHODS

In this double-blind, double-dummy, crossover study, 90 patients (aged >or=40 years; FEV(1) 30-70% predicted) were randomized to a single dose (two inhalations) of budesonide/formoterol 160/4.5 microg, salmeterol/fluticasone 25/250 microg, salbutamol 100 microg or placebo (via pressurized metered-dose inhalers) on four visits. The primary end-point was change in FEV(1) 5 min after drug inhalation; secondary end-points included inspiratory capacity (IC) and perception of onset of effect.

RESULTS

Budesonide/formoterol significantly improved FEV(1) at 5 min compared with placebo (P < 0.0001) and salmeterol/fluticasone (P = 0.0001). Significant differences were first observed at 3 min. Onset of effect was similar with budesonide/formoterol and salbutamol. Improvements in FEV(1) following active treatments were superior to placebo after 180 min (all P < 0.0001); both combinations were better than salbutamol at maintaining FEV(1) improvements (P <or= 0.0001) at 180 min. Active treatments improved IC at 15 and 185 min compared with placebo (P < 0.0001). Maximal IC was greater with budesonide/formoterol than salmeterol/fluticasone (P = 0.0184) at 65 min. Patients reported a positive response to the perceptions of the onset of effect question shortly after receiving active treatments (median time to onset 5 min for active treatments vs 20 min for placebo), with no significant difference between active treatments.

CONCLUSION

Budesonide/formoterol has an onset of bronchodilatory effect in patients with COPD and reversible airway obstruction that is faster than salmeterol/fluticasone and similar to salbutamol.

Functional Status One Year After Heart Transplant

PURPOSE

Although heart transplantation (HT) increases survival of heart failure patients, many patients still experience problems afterward that affect functioning.

PURPOSES

(1) to compare the functional status of HT patients before transplant versus 1 year after transplant, (2) to identify functional problems 1 year post-transplant, and (3) to identify which variables predicted worse functional status 1 year later.

METHODS

The sample was 237 adult HT recipients who completed the 1-year post-transplant study booklet. Functional ability was assessed by the Sickness Impact Profile. Paired t tests compared Sickness Impact Profile scores before and after transplant. Medical and demographic data plus patient questionnaire data on Sickness Impact Profile, symptoms, stressors, and compliance were used in the regression.

RESULTS

Sickness Impact Profile functional scores improved significantly from pre-transplant (23.0%) to post-transplant (13.4%); however, many HT recipients still reported problems in 12 functional areas 1 year after surgery. Major problem areas were the following: work (90% of patients), eating (due to dietary restrictions, 87%), social interaction (70%), recreation (63%), home management (62%), and ambulation (54%). Only 26% were working 1 year after transplant; 59% of those working reported health-related problems performing their job. Predictors of worse functional status were greater symptom distress, more stressors, more neurologic problems, depression, female sex, older age, and lower left ventricular ejection fraction (worse cardiac function).

CONCLUSIONS

Many HT recipients were still having functional problems and had not reached their full rehabilitation potential by the 1-year anniversary after transplant.

Lung volume reduction surgery as a bridge to lung transplantation

Lung volume reduction surgery (LVRS) improves lung function, exercise capacity, and quality of life in patients with advanced emphysema. In some patients with emphysema who are candidates for lung transplantation, LVRS is an alternative treatment option to lung transplantation, or may be used as a bridge to lung transplantation. Generally accepted criteria for LVRS include severe non-reversible airflow obstruction due to emphysema associated with significant evidence of lung hyperinflation and air trapping. Both high resolution computed tomography (CT) scan of the chest and quantitative ventilation/perfusion scan are used to identify lung regions with severe emphysema which would be used as targets for lung resection. Bilateral LVRS is the preferred surgical approach compared with the unilateral procedure because of better functional outcome. Lung transplantation is the preferred surgical treatment in patients with emphysema with alpha1 antitrypsin deficiency and in patients with very severe disease who have homogeneous emphysema pattern on CT scan of the chest or very low diffusion capacity.

Determinants of health-related quality of life in patients with pulmonary emphysema

QUESTION OF THE STUDY

The aim of our study was to examine the relationship between health-related quality of life (HRQL), lung function parameters and intensity of dyspnea in order to determinate what variables influence the HRQL in patients with pulmonary emphysema.

PATIENTS AND METHODS

Forty (mean aged 66+/-9) consecutive male patients with pulmonary emphysema were evaluated. All patients underwent spirometry, measurement of lung volumes, inspiratory and expiratory respiratory pressure (MIP and MEP), measurement of corrected carbon monoxide diffusing capacity (KCO), and 6-min walking test (6MWT). The scale of dyspnea by the baseline dyspnea index (BDI) and British Medical Council Research (MCR), and the quality of life by Chronic Respiratory Question Disease (CRQD) were also assessed.

RESULTS

FEV1, FVC, 6MWT, KCO, MEP, MIP, BDI and MCR were correlated with dimensions of CRQD. Factor analysis reduced these variables to four factors, which accounted for 86.2% of the total variance: (1) airway obstruction, (2) dyspnea, (3) capacity of effort, (4) maximum static respiratory pressure. In the multiple regression model BDI and MEP explained the 64% of the total variance of CRQD.

CONCLUSIONS

Quality of life measured by CRQD in patients with emphysema is predominantly determined by dyspnea, and in minor degree by expiratory muscle strength. Our results underscore the usefulness of dyspnea scales and MEP in the evaluation of HRQL in patients with emphysema.

Pulmonary exercise testing predicts prognosis in patients with chronic obstructive pulmonary disease

OBJECTIVE

In patients with chronic obstructive pulmonary disease (COPD), patient age and initial value of forced expiratory volume in 1 second (FEV1) have been considered the most accurate predictors of mortality among the parameters obtained from pulmonary exercise tests. However, few studies have examined the predictive variables of prognosis among exercise parameters in COPD. We therefore attempted to identify the best index for predicting long-term survival in patients with COPD among the cardiopulmonary variables obtained during exercise testing.

PATIENTS AND METHODS

Fifty-eight patients with COPD (50 men and 8 women) without hypoxemia at rest or other serious complications performed resting pulmonary function tests followed by a symptom-limited ramp exercise test on a cycle ergometer with breath-by-breath gas analysis and arterial blood gas sampling.

RESULTS

After 3,570+/-1,373 days follow-up (mean+/-SD), 21 died because of deaths by respiratory failure. The overall survival rates calculated by the Kaplan-Meier method were 92.9% and 75.8% at 5 years and 10 years, respectively. In univariate Cox hazards analysis, age, FEV1, VC, RV/TLC, VEmax, VO2max, VCO2max, PaO2max, PacO2max, and PaO2 at rest were found to be significant prognostic indices of survival. However, multivariate analysis revealed only FEV1, PaO2max, and age as independent predictors of mortality. In severe COPD patients (FEV1 <50% predicted, n=35), PaO2max and age also correlated with prognosis, whereas FEV1 did not.

CONCLUSION

Pulmonary exercise testing is useful in predicting prognosis in patients with COPD.

Quality of life after lung volume reduction surgery

The common physiologic and functional variables that quantify limitation in emphysema patients have been the most common outcomes measured after LVRS. Spirometric values and exercise capacity are merely surrogates, however, for their impact on symptoms and QOL in patients with severe emphysema. Because LVRS has been developed as a surgery to palliate disabling symptoms of emphysema, many studies now have included HRQOL outcomes along with the commonly measured physiologic and functional outcomes. Some studies have centered on the QOL as the primary outcome instead of physiologic variables. Many symptom scales and disease-specific and general instruments of HRQOL have been used for evaluating emphysema patients before and after LVRS. Case-control studies and randomized studies have shown a consistent improvement in symptoms related to emphysema and general QOL. These studies validate the use of LVRS as a palliative therapy for selected patients with emphysema. The NETT suggests that this benefit is applicable primarily to patients with an upper lobe-predominant pattern of emphysema or patients with low exercise capacity. Validation or refinement of these criteria depends on the continued contributions of the many investigators performing LVRS.

[Surgery for emphysema: recent advances]

INTRODUCTION

The treatment of chronic obstructive pulmonary disease has progressed considerably over the past 40 Years but, for most patients with advanced disease, medical management does not often produce more than limited benefits, particularly in terms of quality of life.

STATE OF ART

Over the last decade the surgical treatment of emphysema, which was previously limited to bullectomy, has seen important developments: for carefully selected patients lung Volume reduction surgery and lung transplantation now offer the possibility of real symptomatic improvement and even prolonged survival. Thanks to the thousands of patients who have received these treatments our understanding of the pathophysiological mechanisms, surgical techniques, risks and benefits, medium and long-term results, and selection criteria has improved considerably.

PERSPECTIVES AND CONCLUSIONS

This review summarises the most important aspects of these developments and discusses the role of Volume reduction and lung transplantation in the treatment of advanced emphysema.

Le réentraînement à l’effort des BPCO : bases physiologiques et résultats

INTRODUCTION

In the last decade pulmonary rehabilitation has become a well accepted treatment for patients with chronic obstructive pulmonary disease (COPD) suffering from persistent dyspnea and fatigue, despite appropriate medical treatment.

STATE OF ART

Patients with COPD frequently have muscular dysfunction that can be corrected by appropriate exercise training programmes. Muscle function as measured by strength and endurance tests exercise capacity and also the health status and quality of life are improved by exercise and endurance training. However, integration of exercise training in a multidisciplinary management programme is necessary to take account of all aspects of the illness.

PERSPECTIVES

Methods of exercise training need to be adapted for patients with severe COPD who are unable to undertake endurance training and for patients who obtain little benefit.

CONCLUSIONS

Pulmonary rehabilitation, thanks to its multidisciplinary nature, seems to be an effective modality of management for patients with COPD. However, the improvements in physical ability, quality of life and general health require an exercise training programme that is adapted for the individual patient.

Effects of lung volume reduction surgery on left ventricular diastolic filling and dimensions in patients with severe emphysema

STUDY OBJECTIVES

Data on the influence of lung volume reduction surgery (LVRS) on cardiac function and hemodynamics are scarce and controversial. Previous studies have focused mainly on right ventricular function and pulmonary hemodynamics. Here, we evaluated the effects of LVRS on left ventricular (LV) end-diastolic filling pattern, dimensions, stiffness, and performance, as well as pulmonary and systemic hemodynamics.

DESIGN

A prospective, open, controlled study.

PATIENTS

Patients with severe emphysema undergoing LVRS (10 patients). Patients scheduled for pulmonary lobectomy due to carcinoma (ie, the lobectomy group) served as control subjects (10 patients).

MEASUREMENTS

LV dimensions and mitral flow velocities were measured by transesophageal, two-dimensional, Doppler echocardiography, and central hemodynamics were measured by a pulmonary artery thermodilution catheter. Measurements were performed during anesthesia in the supine position, before and after surgery, without and with passive leg elevation.

RESULTS

Baseline cardiac index (CI) [- 21%], stroke volume index (SVI) [- 31%], stroke work index (SWI) [- 26%], and LV end-diastolic area index (EDAI) [- 15%] were significantly (p < 0.001) lower, whereas LV end-diastolic stiffness (LVEDS) did not differ in the LVRS group compared to the lobectomy group. The time from peak early diastolic filling to zero flow (E-dec time) [58%] and the deceleration slope of early diastolic filling (E-dec slope) [45%] were significantly higher (p < 0.01), whereas peak early diastolic filling velocity (E-max) [- 31%; p < 0.01] and the proportion of E-max vs peak late diastolic filling velocity (A-max) [ie, the E/A ratio] (- 27%; p < 0.001) were significantly lower compared to the lobectomy group. LVRS significantly increased CI (40%; p < 0.001), SVI (34%; p < 0.001), SWI (58%; p < 0.001), LV EDAI (18%; p < 0.001), E-max (44%; p < 0.01), A-max (15%; p < 0.05) and E/A ratio (28%; p < 0.01), decreased E-dec time (- 31%; p < 0.05) and E-dec slope (- 98%; p < 0.01), and had no effect on LVEDS. In the lobectomy group, surgery affected none of these variables.

CONCLUSIONS

LV function is impaired in patients with severe emphysema due to small end-diastolic dimensions. LVRS increases LV end-diastolic dimensions and filling, and improves LV function.

Improvement in resting inspiratory capacity and hyperinflation with tiotropium in COPD patients with increased static lung volumes

BACKGROUND

In patients with COPD, changes in inspiratory capacity (IC) have shown a higher correlation to patient-focused outcomes, such as dyspnea with exercise, than other standard spirometric measurements. Changes in IC reflect changes in hyperinflation. Tiotropium is a once-daily inhaled anticholinergic that has its effect through prolonged M3 muscarinic receptor antagonism and has demonstrated sustained improvements in spirometric and health outcomes. We sought to evaluate changes in resting IC and lung volumes after long-term administration of tiotropium.

METHODS

To evaluate the effect of tiotropium, 18 micro g/d, on IC, a 4-week, randomized, double-blind, placebo-controlled study was conducted in 81 patients with stable COPD. At each of the visits (weeks 0, 2, and 4) FEV(1), FVC, IC, slow vital capacity (SVC), and thoracic gas volume (TGV) were measured prior to study drug (- 60 and - 15 min) and after study drug (30 min, 60 min, 120 min, and 180 min).

RESULTS

Mean age was 64 years; 62% were men. Mean baseline FEV(1) was 1.12 L (43% predicted). The mean differences (tiotropium - placebo) in FEV(1) trough (morning before drug), peak, and area under the curve over 3 h values (adjusted for baseline and center differences) at week 4 were 0.16 L, 0.22 L, and 0.22 L, respectively (p < 0.01 for all); differences in IC for these variables were 0.22 L, 0.35 L, and 0.30 L (p < 0.01 for all). Differences in TGV were - 0.54 L, - 0.60 L, and - 0.70 L, respectively (p < 0.01 for all). The percentage improvement in area under the curve above baseline with tiotropium was similar among FEV(1) and lung volumes (FEV(1), 18%; FVC, 20%; SVC, 16%; IC, 16%; TGV, 14%).

CONCLUSIONS

Observed improvements in IC and reductions in TGV with once-daily tiotropium reflect improvements in hyperinflation that are maintained over 24 h.

Quality of life after tailored combined surgery for stage I non–small-cell lung cancer and severe emphysema

BACKGROUND

We analyzed the early and long-term quality of life changes occurring in 16 patients undergoing tailored combined surgery for stage I non-small-cell lung cancer (NSCLC) and severe emphysema.

METHODS

Mean age was 65 +/- 5 years. All patients had severe emphysema with severely impaired respiratory function and quality of life. Tumor resection was performed with sole lung volume reduction (LVR) in 5 patients, separate wedge resection in 3 patients, segmentectomy in 2 patients, and lobectomy in 6 patients. A bilateral LVR was performed in 5 patients. Quality of life was assessed at baseline and every 6 months postoperatively by the Short-form 36 (SF-36) item questionnaire.

RESULTS

Mean follow-up was 44 +/- 21 months. All tumors were pathologic stage I. There was no hospital mortality nor major morbidity. Significant improvements occurred for up to 36 months in the general health (p = 0.02) domain and for up to 24 months in physical functioning (p = 0.02), role physical (p = 0.005), and general health (p = 0.01) SF-36 domains. Associated improvements regarded dyspnea index (-1.3 +/- 0.6) forced expiratory volume in one second (+0.28 +/- 0.2L), residual volume (-1.18 +/- 0.5L) and 6-minute-walking test distance (+86 +/- 67 m). Actuarial 5-year survival was similar to that of patients with no cancer undergoing LVRS during the same period (68% vs 82%, p = not significant).

CONCLUSIONS

Our study suggests that selected patients with stage I NSCLC and severe emphysema may significantly benefit from tailored combined surgery in terms of long-term quality of life and survival.

Patient selection for lung volume reduction surgery

LVRS represents a valid surgical option for a limited number of patients who have symptomatic emphysema. The results of recent controlled studies have provided a realistic view of LVRS outcomes and yielded a validated algorithm for selection of optimal candidates for surgery. Furthermore, the NETT has provided simultaneously collected cost data that have provided a unique view of the costs and benefits of LVRS in patients who have advanced emphysema. Additional data collection will better define the long-term benefits of such surgical intervention in patients who have COPD.

Sustained improvements in dyspnea and pulmonary function 3 to 5 years after lung volume reduction surgery

OBJECTIVES

To determine long-term survival rates of patients who underwent lung volume reduction surgery (LVRS) for emphysema and the factors associated with longer survival, and to evaluate levels of perceived dyspnea and health-related quality of life (HRQL) after a follow-up period of 3 to 5.5 years.

DESIGN

Retrospective observational study.

SETTING

Academic medical center

METHODS

Telephone and postal surveys were used to obtain patient dyspnea scores and HRQL scores. Hospital databases and state registries were searched to determine patient survival and pulmonary function.

RESULTS

Of 54 patients undergoing LVRS, 29 patients (18 men and 11 women) were available for follow-up, which ranged from 36 to 66 months (mean +/- SE, 51 +/- 1.5 months). There was significant sustained improvement in modified Medical Research Council scores compared to pre-LVRS: 2.19 +/- 0.19 vs 2.88 +/- 0.14 (p = 0.0000). Eleven of 22 patients demonstrated an increase in all three Mahler baseline dyspnea index grades of at least one level. Baseline body mass index (BMI) and post-LVRS length of stay (LOS) were significantly associated with survival: survivor vs deceased baseline BMI, 24.2 +/- 0.6 vs 21.4 +/- 0.5 (p = 0.002), and post-LVRS LOS, 15.4 +/- 1.7 days vs 28.7 +/- 5.3 days (p = 0.015). Compared to pre-LVRS, 20 patients with mean follow-up time of 45 months demonstrated significant sustained improvements in FEV(1) percentage of predicted (31.4 +/- 2.1% vs 39.8 +/- 3.5%, p = 0.038), total lung capacity percentage of predicted (136 +/- 4% vs 122 +/- 3%, p = 0.0004), and residual volume percentage of predicted (237 +/- 14% vs 172 +/- 11%, p = 0.0001). Patient HRQL measured using the Dartmouth Primary Care Co-operative Quality of Life questionnaire was more favorable than that reported in aged-care settings. Caregiver burden scale scores indicate caring for a recipient of LVRS carries similar burden to that for caring for individuals with other chronic illnesses.

CONCLUSIONS

In this population, a majority of the LVRS patients survived for >/= 3 years. Among survivors, dyspnea and lung function benefits were seen. Baseline BMI and postoperative LOS were significantly associated with survival.

A prospective evaluation of lung volume reduction surgery in 200 consecutive patients

OBJECTIVES

Though numerous studies have demonstrated the short-term efficacy of lung volume reduction surgery (LVRS) in select patients with emphysema, the longer-term follow-up studies are just being reported. The primary objectives of this study were to assess long-term health-related quality of life, satisfaction, physiologic status, and survival of patients following LVRS.

DESIGN

We used a prospective cohort study design to assess the first 200 patients undergoing bilateral LVRS (from 1993 to 1998), with follow-up through the year 2000. Each patient served as his own control, initially receiving optimal medical management including exercise rehabilitation before undergoing surgery. Preoperative postrehabilitation data were used as the baseline for comparisons with postoperative data. The primary end points were the effects of LVRS on dyspnea (modified Medical Research Council dyspnea sale), general health-related quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]), patient satisfaction, and survival. The secondary end points were the effects of LVRS on pulmonary function, exercise capacity, and supplemental oxygen requirements.

SETTING

A tertiary care urban university-based referral center.

PATIENTS

Eligibility requirements for LVRS included disabling dyspnea due to marked airflow obstruction, thoracic hyperinflation, and heterogeneously distributed emphysema that provided target areas for resection. Patients were assessed at 6 months, 3 years, and 5 years after surgery.

INTERVENTIONS

Preoperative pulmonary rehabilitation and bilateral stapling LVRS.

MEASUREMENTS AND RESULTS

The 200 patients accrued 735 person-years (mean +/- SD, 3.7 +/- 1.6 years; median, 4.0 years) of follow-up. Over the three follow-up periods, an average of > 90% of evaluable patients completed testing. Six months, 3 years, and 5 years after surgery, dyspnea scores were improved in 81%, 52%, and 40% of patients, respectively. Dyspnea scores were the same or improved in 96% (6 months), 82% (3 years), and 74% (5 years) of patients. Improvements in SF-36 physical functioning were demonstrated in 93% (6 months), 78% (3 years), and 69% (5 years) of patients. Good-to-excellent satisfaction with the outcomes was reported by 96% (6 months), 89% (3 years), and 77% (5 years) of patients. The FEV(1) was improved in 92% (6 months), 72% (3 years), and 58% (5 years) of patients. Changes in dyspnea and general health-related quality-of-life scores, and patient satisfaction scores were all significantly correlated with changes in FEV(1). Following surgery, the median length of hospital stay in survivors was 9 days. The 90-day postoperative mortality was 4.5%. Annual Kaplan-Meier survival through 5 years after surgery was 93%, 88%, 83%, 74%, and 63%, respectively. During follow-up, 15 patients underwent subsequent lung transplantation.

CONCLUSIONS

In stringently selected patients, LVRS resulted in substantial beneficial effects over and above those achieved with optimized medical therapy. The duration of improvement was at least 5 years in the majority of survivors.

Treatment of patients with lung cancer and severe emphysema: lessons from lung volume reduction surgery

Lung volume reduction surgery (LVRS) is effective therapy for selected patients with end-stage emphysema. Surgery produces improved pulmonary function, increased exercise tolerance and enhanced quality of life. It has been shown to be superior to medical management over the short-term in randomized controlled trials. The experience gained by dealing with this select group of patients has had a substantial impact on management of lung cancer in some patients with advanced lung disease. Numerous surgical, anaesthetic, and nursing advances gained in dealing with lung volume reduction surgery (LVRS) procedures now allow surgery to be considered as the optimal cancer management technique. For some carefully selected candidates, cancer resection and LVRS can be performed simultaneously, with dual benefits. The physiologic principles underlying LVRS and selection guidelines will be reviewed. The impact on cancer management and the current strategy at Toronto General Hospital will also be presented.

Health-related quality of life after lung volume reduction surgery

Many studies have demonstrated short-term physiologic benefits and improvements in various measures of health-related quality of life (HRQOL) after lung volume reduction surgery (LVRS). However, LVRS involves short-term risks of morbidity, disability, and mortality. Few reports describe the long-term effects of LVRS on patients with emphysema. Rational decision making about LVRS depends on whether the expected improvement in quality of life from LVRS outweighs the expected disability and morbidity and the potential mortality from the procedure. This report describes the HRQOL and survival outcomes of patients with emphysema after LVRS.

An evaluation of two approaches to exercise conditioning in pulmonary rehabilitation

STUDY OBJECTIVES

To compare the effectiveness of two forms of exercise training in pulmonary rehabilitation.

DESIGN

A prospective, randomized, unblinded, 8-week trial.

SETTING

A hospital-based outpatient pulmonary rehabilitation program.

PATIENTS

Forty patients (20 patients in each group) with COPD who were referred for pulmonary rehabilitation.

INTERVENTIONS

We compared the short-term effectiveness of a high-intensity, lower-extremity endurance program with a low-intensity, multicomponent calisthenics program for the rehabilitation of patients with COPD. The high-intensity group trained predominately on the stationary bicycle and treadmill, with a goal of exercising at > or = 80% of maximal level determined from incremental testing for 30 min per session. The low-intensity group performed predominately classroom exercises for approximately 30 min per session. For both groups, twice-weekly sessions were held for 8 weeks. The primary outcome measure was health status, measured using the Chronic Respiratory Disease Questionnaire. Other outcomes included peak oxygen consumption on incremental treadmill exercise testing, exertional dyspnea, treadmill endurance time, the number of sit-to-stand repetitions and arm lifts in 1 min, overall dyspnea, and questionnaire-rated functional status.

MEASUREMENTS AND RESULTS

Both groups showed significant postrehabilitation improvement in exercise variables, exertional and overall dyspnea, functional performance, and health status. Patients in the high-intensity group showed greater increases in treadmill endurance and greater reductions in exertional dyspnea, whereas those in the low-intensity group showed greater increases in arm-endurance testing. Both groups had similar improvements in overall dyspnea, functional performance, and health status.

CONCLUSIONS

Despite differences in exercise performance, both high-intensity, lower-extremity endurance training and low-intensity calisthenics led to similar short-term improvements in questionnaire-rated dyspnea, functional performance, and health status.

Psychiatric issues in pulmonary disease

This article has attempted to provide an overview of the clinical literature regarding the psychological issues facing patients with pulmonary disease, depending on when the illness begins in the life span, because different developmental tasks are disrupted. Patients must contend with side effects of medication that may mimic or exacerbate psychiatric disorders. The main drug interactions for psychiatrists to be aware of in this patient population occur between rifampin, or theophylline and psychotropic medications. In lung transplant recipients on cyclosporine therapy, the antidepressant drug nefazadone may cause increased cyclosporine levels. Psychiatrists must be aware of the risks, benefits, and survival statistics; educate patients; and ascertain whether the patient is competent to make medical decisions regarding treatment procedures.