Loris CeronSC Pneumologia

ULSS 12 Veneziana

BPCO e chirurgia

• Chirurgia nella BPCO• Chirurgia per la BPCO

Chirurgia nella BPCO

• Il paziente con BPCO ha un rischio di 2,7-4,7 volte aumentato di complicanze respiratorie dopo un intervento chirurgico

• La complicazione più comune è la polmonite, associata ad un rischio significativo di mortalità (20% entro un mese dall’intervento)

Celli BR et al. Standards for the diagnosis and treatment of patients with COPD. Eur Respir J 2004; 23: 932–946

Arozullah AM, Khuri SF, Henderson WG, Daley J. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major

noncardiac surgery. Ann Intern Med 2001 Nov 20;135(10):847-57

RESULTS: A total of 2466 patients (1.5%) developed pneumonia, and the 30-day postoperative mortality rate was 21%. A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair, thoracic, upper abdominal, neck, vascular, and neurosurgery), age, functional status, weight loss, chronic obstructive pulmonary disease, general anthesia, impaired sensorium, cerebral vascular accident, blood urea nitrogen level, transfusion, emergency surgery, long-term steroid use, smoking, and alcohol use. Patients were divided into five risk classes by using risk index scores. Pneumonia rates were 0.2% among those with 0 to 15 risk points, 1.2% for those with 16 to 25 risk points, 4.0% for those with 26 to 40 risk points, 9.4% for those with 41 to 55 risk points, and 15.3% for those with more than 55 risk points. The C-statistic was 0.805 for the development cohort and 0.817 for the validation cohort.

CONCLUSIONS:The postoperative pneumonia risk index identifies patients at risk for postoperative pneumonia and may be useful in guiding perioperative respiratory care

N Engl J Med 1999; 340: 937–944

N Engl J Med 1999; 340: 937–944

N Engl J Med 1999; 340: 937–944

Provvedimenti

• cessazione del fumo 4-8 settimane prima dell'intervento• ottimizzazione della terapia• mobilizzazione precoce• respiri profondi• uso di IPPB e di spirometria incentivante• buona analgesia

L'intervento va rinviato in presenza di riacutizzazione

Celli BR et al. Standards for the diagnosis and treatment of patients with COPD. Eur Respir J 2004; 23: 932–946

ConclusionsIn the present study, the efficacy of isolated conventional physical therapy, incentive spirometry, EPAP or early mobilization was not evaluated. However, it was possible to demonstrate that the physiotherapeutic approach based on packages of interventions resulted in reduced incidence of atelectasis and reduced length of hospital stay amongpatients undergoing elective open UAS.

• If the % PPO FEV 1 and % PPO DLCO values are both > 60%, the patient is considered at low risk of anatomic lung resection, and no further tests are indicated

• If either the % PPO FEV 1 or % PPO DLCO are within 60% and 30% predicted, a low technology exercise test should be performed as a screening test

• If performance on the low technology exercise test is satisfactory (stair climbing altitude > 22 m or shuttle walk distance > 400 m), patients are regarded as at low risk of anatomic resection

• A cardiopulmonary exercise test is indicated when the PPO FEV 1 or PPO DLCO (or both) are < 30% or when the performance of the stair-climbing test or the shuttle walk test is not satisfactory

• A peak oxygen consumption ( O2 peak) < 10 mL/kg/min or 35% predicted indicates a high risk of mortality and long-term disability for major anatomic resection. Conversely, a O2 peak > 20 mL/kg/min or 75% predicted indicates a low risk.

Chirurgia per la BPCO

• Bullectomia• Riduzione polmonare chirurgica (LVRS)• Trapianto polmonare

• Riduzione polmonare endoscopica (ELVR)

Chirurgia per la BPCO

Bullectomia• In pazienti molto selezionati, la procedura può essere efficace

nell’alleviare la dispnea e migliorare la funzione respiratoria (evidenza C).

Celli BR et al. Standards for the diagnosis and treatment of patients with COPD. Eur Respir J 2004; 23: 932–946Rabe KF et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. GOLD Executive Summary. Am J Respir Crit Care Med 2007;176:532–555

Chirurgia per la BPCO

Celli BR et al. Standards for the diagnosis and treatment of patients with COPD. Eur Respir J 2004; 23: 932–946

Mehran RJ, Deslauriers J. Indications for surgery and patient work-up for bullectomy. Chest Surg Clin N Am 1995;5(4):717-34. 

If a patient has a smaller bulla, which is less than 30% of the volume of the hemithorax, the dyspnea is unlikely to be related to the bulla and its excision is probably not indicated.

The bulla must occupy at least 50% of the hemithorax and show definite displacement of adjacent lung tissue.

There must be no vanishing lung syndrome nor chronic purulent bronchitis.

Radiologic evidence of compressed lung tissue that can be re-expanded by removal of the bulla

Evidence of regional imbalance with poor perfusion on the side of the bulla and relatively good perfusion on the contralateral side.

Chirurgia per la BPCO

Riduzione polmonare chirurgica (LVRS)• Lo studio NETT (National Enphysema Therapy Trial) ha dimostrato che i

pazienti con enfisema non omogeneo, prevalente ai lobi superiori, con FEV1 o DLCO >20% e con scarsa capacità di esercizio dopo un trattamento riabilitativo preoperatorio avevano una migliore sopravvivenza e una migliore qualità di vita.

• Il follow-up a lungo termine conferma un miglioramento della sopravvivenza a 5 anni.

• La procedura è molto costosa e va valutata con molta attenzione

National Emphysema Treatment Trial Research Group. A Randomized Trial Comparing Lung-Volume–Reduction Surgery with Medical Therapy for Severe Emphysema. N Engl J Med 2003;348:2059-73Naunheim KS et al. Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group. Ann Thorac Surg 2006 Aug;82(2):431-43

Naunheim KS,  Wood DE, Mohsenifar Z, Sternberg AL, Criner GJ, DeCamp MM, Deschamps CC, Martinez FJ, Sciurba FC, Tonascia J, Fishman AP; National Emphysema Treatment Trial Research Group.

Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group.

Ann Thorac Surg 2006 Aug;82(2):431-43

RESULTS:• The intention-to-treat analysis of 1218 randomized patients demonstrates an

overall survival advantage for LVRS, with a 5-year risk ratio (RR) for death of 0.86 (p = 0.02). Improvement was more likely in the LVRS than in the medical group for maximal exercise through 3 years and for health-related quality of life (St. George's Respiratory Questionnaire [SGRQ]) through 4 years. Updated comparisons of survival and functional improvement were consistent with initial results for four clinical subgroups of non-high-risk patients defined by upper-lobe predominance and exercise capacity. After LVRS, the upper-lobe patients with low exercise capacity demonstrated improved survival (5-year RR, 0.67; p = 0.003), exercise throughout 3 years (p < 0.001), and symptoms (SGRQ) through 5 years (p < 0.001 years 1 to 3, p = 0.01 year 5). Upper-lobe-predominant and high-exercise-capacity LVRS patients obtained no survival advantage but were likely to improve exercise capacity (p < 0.01 years 1 to 3) and SGRQ (p < 0.01 years 1 to 4).

Total H.H. (>10%) H.H.+ L.E. H.H.+ L.E.+C.F.0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

0

1

2

3

4

5

6

7

8

7.2%

10.5%

15.2%

25.6%

5.8%

8.8%

10.6%9.6%

FEV1 % Change 6MWT % Change SGRQ Delta (abs)

H.H. = High Heterogeneity L.E. = Lobar Exclusion C.F. = Collateral Flow

VENT Responder Summary (Delta Treatment & Control @ 6mons)

N=179 N=91 N=74 N=30

Soggetti candidabili a intervento (protocollo VENT) 153-344

Nuovi casi di BPCO candidabili a intervento (protocollo VENT)

12-18/anno

Un solo Centro per l‘interventoRete Pneumologica per la selezione dei candidati

Creazione di un registro

Selezione dei candidati

In a prospective study of 625 COPD patients, a BODE index of 7 to 10 (on a scale from 0 to 10) was associated with a median survival of about 3 years, which is less than would be expected after transplantation. Patients with a BODE score of 5 to 6 would likely not derive a survival benefit from transplantation but may be candidates for early referral.

Orens JB, et al.International Guidelines for the Selection of Lung Transplant Candidates: 2006 Update—A Consensus Report From the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. The Journal of Heart and Lung Transplantation, 2006

Sopravvivenza nel trapianto di polmoneRegistro Italiano Trapianti

Absolute contraindications.

● Malignancy in the last 2 years, with the exception of cutaneous squamous and basal cell tumors. In general, a 5-year disease-free interval is prudent. The role of lung transplantation for localized bronchioalveolar cell carcinoma remains controversial.

● Untreatable advanced dysfunction of another major organ system (e.g., heart, liver, or kidney). Coronary artery disease not amenable to percutaneous intervention or bypass grafting, or associated with significant impairment of left ventricular function, is an absolute contraindication to lung transplantation, but heart-lung transplantation could be considered in highly selected cases.

● Non-curable chronic extrapulmonary infection including chronic active viral hepatitis B, hepatitis C, and human immunodeficiency virus.

● Significant chest wall/spinal deformity.● Documented nonadherence or inability to follow through with medical therapy or office follow-up, or

both.● Untreatable psychiatric or psychologic condition associated with the inability to cooperate or comply with

medical therapy.● Absence of a consistent or reliable social support system.● Substance addiction (e.g., alcohol, tobacco, or narcotics) that is either active or within the last 6 months.

Relative contraindications.

● Age older than 65 years. Older patients have less optimal survival, likely due to comorbidities, and therefore, recipient age should be a factor in candidate selection. Although there cannot be endorsement of an upper age limit as an absolute contraindication

● Critical or unstable clinical condition (e.g., shock, mechanical ventilation or extra-corporeal membrane Oxygenation)

● Severely limited functional status with poor rehabilitation potential.● Colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria.● Severe obesity defined as a body mass index (BMI) exceeding 30 kg/m2.12● Severe or symptomatic osteoporosis. ● Mechanical ventilation. Carefully selected candidates on mechanical ventilation without other acute or

chronic organ dysfunction, who are able to actively participate in a meaningful rehabilitation program, may be successfully transplanted.

● Other medical conditions that have not resulted in end-stage organ damage, such as diabetes mellitus, systemic hypertension, peptic ulcer disease, or gastroesophageal reflux should be optimally treated before transplantation. Patients with coronary artery disease may undergo percutaneous intervention before transplantation or coronary artery bypass grafting concurrent with the procedure