A clinician's guide to the use of lung volume reduction surgery

Abstract

The primary purpose of the National Emphysema Treatment Trial (NETT) was to evaluate the clinical efficacy of lung volume reduction surgery (LVRS) compared with medical therapy as a treatment for advanced emphysema. Transitioning the results of a complex multicenter long-term clinical trial into routine clinical practice is challenging, particularly when the therapy examined is controversial, as was the case in NETT. Aspects of the "clinical art" used by the study investigators to select and treat patients are not always transparent to practitioners reading study publications. At the last NETT Steering Committee meeting, a roundtable discussion was held with investigators, coordinators, Steering Committee leadership, and Data Coordinating Center staff regarding the clinical aspects of patient evaluation and selection and performance of LVRS in advanced emphysema. The questions posed to the meeting participants were ones that are commonly asked by patients and their treating physicians who are considering LVRS and included the following: Why recommend LVRS to a patient? When should LVRS be recommended to a patient? What types of patients are candidates for LVRS? What are the important barriers to performing LVRS? What are the major messages delivered by NETT? It is hoped that answers from NETT investigators to some of these commonly encountered questions will provide clarity and guidance to clinicians faced with the responsibility of considering and discussing LVRS with their patients. NETT investigators were also queried regarding the future directions of research in emphysema and the role that NETT played in shaping that future. The following article is a summary of the highlights of these discussions.

Figure 1.

National Emphysema Treatment Trial (NETT) subgroup treatment effects. Effect of lung volume reduction surgery (LVRS) versus medical treatment on mortality, maximal workload achieved on cardiopulmonary exercise testing (improvement of more than 10 W vs. not improved), and disease-specific quality of life as measured by the St. George's Respiratory Questionnaire (SGRQ; improvement of more than 8 units in total score vs. not improved). OR = odds ratio; RR = relative risk; *Patients not considered candidates for LVRS by the NETT or approved for LVRS by the Centers for Medicare and Medicaid Services or the Joint Commission on Accreditation of Healthcare Organizations.

Figure 2.

Suggested schema for the coordination of lung volume reduction surgery (LVRS) testing between community physicians and LVRS regional centers. 6-MWD = six-minute-walk distance; COPD = chronic obstructive pulmonary disease; CT = computed tomography; RHC = right heart catheterization; RV = residual volume.