Surgical Interventions for COPD

Max Huang, MD, FRCPC; Lianne G. Singer, MD, FRCPC

Disclosures

Geriatrics and Aging. 2005;8(3):40-46. 

In This Article

Lung Transplantation

While lung transplantation was initially used as a treatment for pulmonary fibrosis and pulmonary hypertension, the indications have evolved such that emphysema is the most common diagnosis leading to transplantation, accounting for 39% of transplants worldwide.[25] Approximately 50% of lung transplant recipients are older than 50 years, which is the age group characteristic of COPD and interstitial pulmonary fibrosis.

According to the published international guidelines for the selection of lung transplant recipients,[26] patients who are less than 65 years old with end-stage pulmonary disease in the absence of other significant organ dysfunction should be considered for lung transplant referral. Recently, some programs have been transplanting individuals older than age 65 in the absence of comorbidity. However, many older patients are found to have significant cardiac disease during lung transplant candidacy evaluation, given the high prevalence of prior smoking in this group of patients. Older patients are also more likely to have significant dysfunction of other organs.

Lung transplantation should be offered to patients with diffuse disease who have any of the following: FEV1 <20% predicted, hypercapnia, associated pulmonary hypertension, or a predicted survival of less than the expected post-transplant survival. Recent COPD survival prediction models such as the BODE score[27] may assist in identifying suitable candidates for transplantation. Potential lung transplant recipients must be ambulatory and have a preoperative weight of 70-130% of predicted. Candidates should also be motivated, have adequate social support to deal with the rigorous pre- and post-transplant activities, and have undergone a comprehensive preoperative pulmonary rehabilitation program.

Previous bullectomy or LVRS is not a contraindication to lung transplantation, and these procedures have been successfully used to bridge patients to transplantation. This is important as the early benefits of bullectomy and LVRS may not be sustained beyond a few years (Figure 4).

Figure 4.

Either single or double lung transplantation may be used for patients with emphysema. Both procedures result in substantial improvements in pulmonary function, exercise capacity, and quality of life. Disadvantages of pulmonary transplantation include a lack of available donor lungs and mortality rates of 5-15% in the first 30 days. Survivors require lifelong immunosuppression, which increases the risk of neoplasm and infection compared with nonimmunosuppressed individuals. Lung transplant recipients are also at risk of developing bronchiolitis obliterans, manifested by chronic allograft dysfunction, which reaches a cumulative incidence of 50-60% at five years post-transplantation. The cumulative five-year survival is 50%, and whether lung transplantation provides a survival benefit to COPD patients remains unclear.

In 1998, Hosenpud et al.[28] compared the survival curves of COPD patients waiting for transplant to those who underwent transplant. The study concluded that the risk of death for patients following transplant was never lower than the risk for those who continued to wait on the transplant list. This finding may have been due to premature listing of American lung transplant candidates, since European data do suggest a survival benefit of transplantation.[29,30] However, this remains an area of controversy and underscores the importance of functional and quality of life benefit in assessing outcomes of transplantation.

The choice of bilateral or unilateral transplantation for COPD patients is controversial. Numerous authors have described a higher perioperative risk from bilateral operation without a demonstrable functional benefit when compared to unilateral lung transplantation.[31,32] There were also no differences in hospital stay, ICU stay, and duration of mechanical ventilation. However, five-year survival has been reported to be 66.7% for bilateral lung transplant recipients versus 44.9% for single lung transplant recipients.[33]

Accrued from the data of 17,128 lung transplant recipients, the registry from the International Society of Heart and Lung Transplantation has demonstrated that the age of the transplant recipient does not have an effect on six-month or one-year survival.[25] Thereafter, recipients greater than 50 years of age have a more rapid decline in survival when compared to younger recipients. This is likely due to the comorbidities associated with aging and the effect of immunosuppressants on these age-related conditions.[25] These findings are similar to the experience of the Toronto Lung Transplant program, where lung transplant recipients older than 60 years had increased mortality even after adjusting for their expected higher age-related mortality.[34]

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