Society of Cardiovascular Anesthesiologists

Literature Reviews

A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.

National Emphysema Treatment Trial Research Group. N Engl J Med 2003; 348: 2059-2073.

Reviewer: Rose Christopherson, MD, PhD
Staff Anesthesiologist
Portland VA Medical Center
Associate Professor, Anesthesiology
Oregon Health & Science University
Portland, OR

Background: It is unclear whether patients undergoing lung volume reduction surgery for severe emphysema benefit in terms of mortality or improvement in medical status. Patient selection criteria are important since some patients may benefit while others may be harmed.

Methods: A total of 1218 patients with severe emphysema underwent pulmonary rehabilitation. They were then randomized to receive either lung-volume-reduction surgery or to continue with medical treatment, as part of a multicenter trial.

Results: Overall mortality was 0.11 deaths per person-year in both the surgical and the medical groups. After 24 months, exercise capacity had improved by over 10 W in 15 % of the surgery group, compared with 3 % of patients in the medical group (P < 0.001). When 140 very high risk patients were excluded from the analysis, the mortality was 0.09 deaths / person-year in the surgery group, and 0.10 deaths / person-year in the medical management group (NS). Among patients with emphysema predominantly affecting the upper lobes of the lungs who also had low exercise capacity, mortality was lower in the surgery group (risk ratio for death, 0.47; P = 0.005). Among patients with non-upper-lobe emphysema and good exercise capacity, mortality was higher in the surgery group (risk ratio, 2.06; P = 0.02).

Conclusions: Overall, lung-volume-reduction surgery did not confer a survival benefit, although it increased the probability that patients would have improved exercise capacity. Among patients with predominantly upper-lobe emphysema and poor exercise tolerance (defined as less than 15 watts expended energy) at baseline, it improved survival. Those who were very high risk, or who had either diffuse emphysema or lower lobe emphysema had increased mortality if they were randomized to the surgical group.

Discussion: This large study is of obvious clinical relevance. If the findings are to be applied in practice, however, we should remember that the group that showed a survival benefit, those with upper-lobe emphysema and poor exercise tolerance, had undergone pulmonary rehabilitation for 6-10 weeds prior to being randomized. After rehabilitation, those who had an FEV1 or a carbon monoxide diffusing capacity of 20% or less of the predicted value were not randomized. Thus, the people who might be expected to have a survival benefit are those who have disease localized in the upper lobes; have poor exercise capacity even after systematic pulmonary treatment; and have both an FEV1 and a CO diffusing capacity of more than 20 % of the predicted value.

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