Faculty from the Department of Thoracic Surgery, and from the Department of Pulmonary Medicine will discuss your evaluation with you and assist in determining your best course of treatment:

• Medical management of pulmonary insufficiency and lung failure
• Other medical therapy
• Lung volume reduction surgery
• Lung transplant

This section provides an overview of medical management and lung volume reduction surgery (LVRS)

Medical Therapy

Medical therapy has been the mainstay of emphysema treatment for generations. While it cannot reverse the disease, it can help to slow its progress, minimize your symptoms, and make the most of your remaining lung function. Medical therapy has several key components:

Smoking: As difficult as it may be, you must break the smoking habit. Controlling smoking behavior is the most important strategy at all phases of the disease to prevent further progression.
Medications: You may be given inhaled medications and/or pills to manage your condition.

Oxygen: If you have low oxygen levels in your blood, long-term, continuous oxygen therapy might benefit you.

Pulmonary Rehabilitation: The primary goal is to restore you to your highest possible level of independent function. Rehabilitation involves exercising, retraining the breathing muscles, learning to conserve energy, and becoming more knowledgeable about the disease. Exercising can give you more stamina, help you to manage shortness of breath more easily, and improve your overall quality of life. You are likely to be pleased with the results if you stick with the exercise program designed for you.

Lung Volume Reduction Surgery (LVRS):

This approach to treating emphysema was first used in the 1950s, but it has not been widely practiced because of uncertainty surrounding long-term benefits. However, due to recent medical developments, more physicians have begun using LVRS in the 1990s to help people with severely disabling emphysema. The Division of Thoracic Surgery at Maryland is a leader in making this treatment option more widely available to patients. LVRS involves removing about 20 to 30 percent of the damaged lungs so that the remaining tissue and surrounding muscles are able to work more efficiently, making breathing easier.

Benefits and Risks
The surgery has been shown to improve patients' quality of life significantly, as they experience less shortness of breath and become less dependent on oxygen therapy. However, the extent of the improvement largely depends upon their level of participation in post-operative rehabilitation.
The procedure does present some risks, mainly because patients already have poor lung function and are generally older. The most common complication is air leakage from the stapled edge of the lung tissue into the chest cavity. If the air volume within the chest becomes too great, it can cause the lung to collapse. The surgical team does its best to prevent this by placing a chest tube that monitors any air leakage. Other possible complications include pneumonia or infection; stroke; bleeding; heart attack; and death. The risk varies depending upon the individual's situation and overall health. Therefore, you will need to discuss your situation with the thoracic team.

The Operation
Lung volume reduction is performed through a minimally invasive procedure called video-assisted thoracoscopy at Vanderbilt..  Thoracoscopy is  a minimally invasive technique that involves making two or three small incisions (approximately one inch) in between the ribs. A videoscope is placed through one of the incisions, which allows the surgeon to see the lungs. Instruments called a stapler and a grasper are then inserted in the other incisions to cut away the most damaged areas of the lung. The incisions are closed with sutures that eventually dissolve on their own.

At the time of surgery, chest tubes are inserted through the chest wall into the space surrounding the lungs. They are used for drainage and to monitor air leaking, and must be kept in place until neither is present. The surgical team makes every effort to minimize discomfort through intravenous medications and an epidural catheter, which is a very small tube placed in your back at the time of surgery to deliver pain medication to the spinal cord. Pain control is essential because you will need to start rehabilitation as soon as possible after the surgery.

After your Surgery
You can expect to be sitting up in a chair within hours of the surgery. You will be encouraged to cough and breathe deeply in order to keep your lungs fully expanded, which can help prevent infection and collapse. You also will receive instructions for using an incentive spirometer, which is a device that helps to increase respiratory muscle strength. Because exercise and movement are essential for a quicker and less painful recovery, pulmonary rehabilitation starts the first day after surgery. You can expect to be walking in the halls, on a treadmill or riding an exercise bicycle every day with the help of nurses and therapists. Your motivation to recover strongly influences the success of this part of the treatment, primarily because you will be asked to exercise even when you may not feel like it.
Typically, patients spend two days in the intensive care unit and at least a week in the cardiothoracic surgical unit.

After discharge
After your release from the hospital, you would participate in pulmonary rehabilitation three times per week for a minimum of six weeks. These exercises and training are a crucial part of your reconditioning and treatment plan. The exercise program is specifically designed to retrain the diaphragm and chest muscles to help you breathe easier, as well as to increase endurance. Under the close supervision of therapists, you will use treadmills, bicycles, and ergometers and do lower and upper body exercises. Therapists also pay careful attention to your breathing efforts, oxygen saturation and usage, and tolerance to exercise.

This part of the treatment plan is intended to be a lifetime change, making exercise and symptom recognition a permanent part of your daily routine. After formal pulmonary rehabilitation training, you will be ready to perform the exercise program on your own, at home or in a local gym.