Lung Volume Reduction Surgery (LVRS)

For individuals living with severe emphysema, a debilitating form of chronic obstructive pulmonary disease (COPD), the simple act of breathing can become a profound struggle. While many treatments aim to manage symptoms, lung volume reduction surgery (LVRS) offers a unique and powerful approach to significantly improve breathing and enhance quality of life for carefully selected patients. 

Originally developed to form a bridge to a lung transplant, LVRS has itself become a successful treatment for select patients with chronic obstructive pulmonary disease (COPD), emphysema and disabling shortness of breath. It can significantly improve your health and reduce feelings of breathlessness. In some cases, LVRS may negate the need for lung transplant rather than serving as an interim treatment while awaiting transplant. 

LVRS is a specialized emphysema treatment that, for the right patient, can transform how they experience their daily lives, offering renewed energy and a greater capacity for activity.

How LVRS Works

Lung volume reduction surgery (LVRS) is a surgical procedure designed to improve breathing for individuals with severe emphysema. The core principle behind LVRS is to remove the most diseased, non-functioning and hyperinflated parts of the lung. By taking out these damaged sections, the remaining healthier lung tissue has more space within the chest cavity to expand and work more efficiently. This strategic reduction of lung volume allows the diaphragm, the primary muscle for breathing, to regain its natural dome shape and function more effectively, leading to easier and more productive breaths.

Imagine your lungs as two large, spongy organs. In severe emphysema, certain areas become stretched out and filled with stagnant air. These areas occupy valuable space, but do not help with oxygen exchange. The hyperinflated areas act like dead weight, hindering the healthier parts of the lung and making it harder for the diaphragm to move. LVRS directly addresses this problem by carefully excising these damaged sections. Typically, 20% to 30% of the diseased lung tissue is removed, often from the upper lobes — frequently the most affected. This lung reduction surgery aims to make a significant difference in how you breathe. 

There are two primary surgical approaches for performing LVRS: 

1. Sternotomy: This traditional method involves a larger incision in the chest, typically splitting the breast bone, to directly access and remove the damaged lung tissue. While highly effective, it is a more invasive procedure with a longer recovery period. 
2. Robotic-assisted thoracoscopic surgery (RATS): This minimally invasive approach, often preferred when suitable, uses several small incisions. A tiny camera (thoracoscope) and specialized surgical instruments are inserted through these small openings. The surgeon views the procedure on a monitor, precisely identifying and removing the diseased lung tissue. RATS generally results in less pain, smaller scars and a quicker recovery compared to a sternotomy. 

The choice between an open or RATS approach depends on your specific lung disease pattern and overall health. 

It's important to distinguish LVRS from other procedures like bullectomy. While both involve removing lung tissue, a bullectomy specifically targets very large, isolated air sacs (bullae) that are often larger than 1 centimeter and directly compress healthy lung tissue. LVRS, on the other hand, typically addresses diffuse emphysema, where the damage is more widespread across a larger region of the lung, requiring the removal of more general areas of nonfunctional tissue. 

The objective of LVRS treatment is not to cure emphysema, but to significantly alleviate symptoms, improve respiratory mechanics and enhance the your capacity for daily activities. The goal is to offer a substantial improvement in quality of life for those who meet the strict selection criteria.

Who Can Have Lung Volume Reduction Surgery (LVRS)

Determining who is a candidate for LVRS is a process that involves a comprehensive evaluation by our multidisciplinary team of specialists. This detailed screening ensures that only patients who are most likely to benefit and tolerate the procedure are considered, minimizing risks and maximizing potential positive outcomes. LVRS is specifically for individuals with severe emphysema where conventional medical therapies are no longer sufficient to manage their symptoms.

Key criteria and factors considered for candidacy include: 

• Diagnosis of severe emphysema: You must have a confirmed diagnosis of severe emphysema, often with significant hyperinflation and a specific pattern of lung damage. Imaging studies, particularly high-resolution CT scans, are critical to assess the distribution of emphysema. LVRS is typically most effective when the emphysema is predominantly in the upper lobes of the lungs, as removing these damaged areas creates more space for the healthier lower lobes to function. 
• Optimal medical management: Candidates must have already undergone and maximized all other forms of nonsurgical emphysema treatment, including medication regimens and completion of an intensive pulmonary rehabilitation program. This ensures that surgery is considered only when other less invasive options have been fully exhausted. 
• Smoking cessation: A non-negotiable requirement is a commitment to permanent smoking cessation. You must have stopped smoking for at least six months before evaluation, as continued smoking significantly increases surgical risks and compromises long-term outcomes. 
• Overall health and age: While there is no strict age cutoff, candidates must be in relatively good overall health and free from other severe medical conditions that would significantly increase the risks of major surgery. Coexisting conditions such as significant heart disease, kidney failure or cancer may eliminate you as a candidate. The multidisciplinary team, including a thoracic surgeon, pulmonologist, cardiologist and anesthesiologist, will thoroughly assess all aspects of your health. 
• Pulmonary function tests: Extensive lung function tests, including spirometry and lung volume measurements, are essential to quantify the severity of the lung disease and assess the potential for improvement. These tests help identify the degree of airflow obstruction and hyperinflation. 
• Exercise capacity: An exercise capacity assessment, such as a 6-minute walk test, helps determine your current functional limitation and provides a baseline to measure postoperative improvement. 
• Nutritional status: Good nutritional status is crucial for recovery. Patients who are significantly underweight or obese may need to address these issues prior to surgery. 
• Psychological evaluation: A psychological assessment may be conducted to ensure you have realistic expectations about the surgery and recovery and has adequate support systems in place. 

Our highly trained specialists take a comprehensive approach, bringing together experts from various specialties to thoroughly evaluate each potential LVRS candidate. This includes pulmonologists specializing in lung disease, thoracic surgeons, physical therapists, respiratory therapists and nutritionists. We consider every aspect of your health and lifestyle to determine if LVRS is the right path forward, ensuring that your safety and the potential for significant improvement are at the forefront of our decision-making. If you are struggling with advanced emphysema and have exhausted other options, a referral for an LVRS evaluation could open the door to a new phase of relief and improved breathing.

Benefits of LVRS: Improving Life With Emphysema 

LVRS can offer life-changing benefits, significantly improving not just physical symptoms but also overall quality of life. The primary goal of this specialized emphysema treatment is to alleviate the severe shortness of breath that characterizes advanced emphysema, enabling you to engage in activities that you once found impossible. 

The key benefits observed after successful LVRS include:

• Significant improvement in breathing: Patients consistently report feeling less breathless, both at rest and during exertion. By removing the hyperinflated, diseased parts of the lung, the remaining healthier lung tissue can expand more effectively, and the diaphragm can return to a more optimal position, making each breath more efficient. This directly addresses the critical issue of trapped air, allowing for better ventilation and gas exchange. Many patients describe feeling like they can finally take a full, deep breath again. 
• Enhanced exercise capacity: One of the most profound benefits is the increased ability to perform physical activities. Before LVRS, many patients struggle with simple tasks like walking across a room, climbing stairs or performing daily chores. After surgery, a significant portion of patients experience a dramatic improvement in their exercise capacity, often measured by an increased distance in a 6-minute walk test. This newfound physical stamina translates into greater independence and the ability to enjoy hobbies and social interactions that were previously out of reach. 
• Reduced need for oxygen therapy: If you are dependent on supplemental oxygen, LVRS can often lead to a reduction in your oxygen requirements and, in some cases, even complete liberation from oxygen therapy. This offers tremendous freedom and convenience, allowing you to move more freely without the constraints of an oxygen tank. 
• Decreased hospitalizations and COPD exacerbations: Severe emphysema often leads to recurrent flare-ups or exacerbations, which can necessitate frequent hospital visits. By improving lung mechanics and overall respiratory health, LVRS can reduce the frequency and severity of these acute episodes, leading to fewer hospitalizations and a more stable health trajectory. 
• Improved quality of life: Beyond specific physiological improvements, the overarching benefit of LVRS is a substantial enhancement in quality of life. Patients often report improved energy levels, better sleep, reduced anxiety and depression related to their breathing difficulties and a greater sense of well-being. The ability to participate more fully in daily life and reconnect with loved ones is a common and cherished outcome. 
• Long-term outcomes and survival: Studies have shown that for carefully selected patients, LVRS can improve survival rates and provide durable benefits lasting for many years. While the lung disease itself is chronic and not cured by surgery, the impact of LVRS on lung function can be long-lasting, significantly extending both the quantity and quality of life for suitable candidates. At Froedtert & MCW health network, our commitment to thorough patient selection and expert surgical techniques contributes to these favorable long-term results. The success rate of LVRS, when performed on appropriate candidates by experienced teams, is considerable in terms of symptomatic relief and functional improvement. While individual results vary, many patients experience sustained benefits for 5 to 10 years or more after the procedure, highlighting its long-term impact on the progression of severe emphysema. 

The decision to undergo LVRS is significant, but if you meet the stringent criteria, the potential to reclaim a more active and comfortable life makes it a truly transformative option. Our team will thoroughly discuss all potential benefits and help you set realistic expectations for your recovery and long-term outlook. 

The LVRS Process: From Evaluation to Recovery 

We start with a carefully structured process, designed to ensure your safety, optimize outcomes and provide comprehensive support every step of the way. From your initial evaluation to long-term recovery, our multidisciplinary team guides you through each phase.

Phase 1: Comprehensive Evaluation 

The first and most critical step is a thorough evaluation to determine if you are a suitable candidate for LVRS. This phase is extensive and may take several weeks to complete. It involves: 

• Detailed medical history and physical exam: We review your entire health record, focusing on your lung disease, other medical conditions and lifestyle habits, including your smoking history. 
• Advanced lung function tests: A battery of tests, including spirometry, lung volume measurements and diffusion capacity, precisely quantifies the severity and distribution of your emphysema and overall lung function. 
• High-resolution CT scan of the chest: This imaging provides detailed pictures of your lungs, allowing our thoracic surgeons and pulmonologists to identify the most damaged areas for removal and to assess the presence of any other lung abnormalities. 
• Exercise testing: Typically, a 6-minute walk test or a cardiopulmonary exercise test (CPET) measures your current exercise capacity and oxygen consumption, providing a baseline for comparison after surgery.
• Cardiovascular assessment: Evaluation of your heart health through tests like an echocardiogram and possibly a cardiac stress test ensures your heart can tolerate the surgery. 
• Nutritional and psychological assessment: Our team assesses your nutritional status and psychological well-being, as both play a crucial role in surgical recovery and long-term success.

Phase 2: Presurgical Preparation and Pulmonary Rehabilitation 

Once deemed a candidate, preparing your body for surgery is paramount. A vital component of this preparation is an intensive pulmonary rehabilitation program. This is not just exercise; it's a comprehensive program that includes: 

• Education: Understanding your lung condition, medications and self-management techniques
• Supervised exercise training: Tailored exercises to strengthen your respiratory muscles and overall physical endurance
• Nutritional counseling: Guidance to achieve and maintain optimal weight and muscle mass, which are critical for recovery
• Breathing strategies: Learning techniques to breathe more efficiently and manage shortness of breath

Completing a preoperative pulmonary rehabilitation program has been shown to significantly improve outcomes and reduce complications after LVRS. 

Phase 3: Lung Volume Reduction Surgery 

Our surgical team will carefully prepare you for surgery. The lung reduction surgery itself typically takes 2 to 3 hours, depending on the complexity and the surgical approach (sternotomy or robotic surgery). During the procedure, we remove the diseased, hyperinflated lung tissue. Our experienced thoracic surgeons use advanced techniques to ensure precision and minimize trauma to healthy tissues. 

After the surgery, you will be transferred to a recovery area, then to an intensive care unit (ICU) or specialized surgical ward for close monitoring. 

Phase 4: Hospital Stay and Immediate Postoperative Care 

Your hospital stay after LVRS typically ranges from 5 to 10 days, though this can vary based on your individual recovery. During this time, you can expect:

• Pain management: Our team will ensure your pain is well-controlled through various methods, allowing you to move and participate in recovery activities. 
• Chest tubes: You will have one or more chest tubes inserted during surgery to drain fluid and air from your chest cavity, helping the remaining lung to re-expand. These are typically removed once your lung fully expands and drains adequately. 
• Early mobilization: You will be encouraged to get out of bed and walk as soon as safely possible, often within 24 to 48 hours. Early activity is crucial for preventing complications like pneumonia and blood clots. 
• Respiratory therapy: Respiratory therapists will guide you through breathing exercises and techniques to help clear your lungs and improve function. 

Phase 5: Recovery and Long-Term Rehabilitation

Recovery from lung reduction surgery is a gradual process that continues for several months after discharge. You will continue with a structured pulmonary rehabilitation program after you are discharged. This ongoing rehabilitation is vital for solidifying the gains made from surgery, improving your strength and endurance and helping you adapt to your new breathing capacity. Most patients find that significant improvements in their breathing and exercise capacity become noticeable within 3 to 6 months post-surgery. Full recovery, including regaining strength and endurance, can take up to a year. Regular follow-up appointments with your pulmonologist and surgeon are essential to monitor your progress, adjust medications and ensure the best possible long-term outcomes. The commitment to this comprehensive recovery plan is key to maximizing the benefits of LVRS. 

Risks and Potential Complications of LVRS 

While LVRS offers significant benefits for eligible patients with severe emphysema, it is important to acknowledge that it is a major surgical procedure carrying inherent risks. Our team is dedicated to thoroughly discussing these potential complications with you, to ensure you are fully informed and prepared. We use advanced techniques and rigorous patient selection to minimize these risks, but it is crucial for both you and your referring physician to understand them. 

Common Risks and Complications

• Prolonged air leaks: This is one of the most common complications after LVRS. Air can leak from the sutured lung tissue, requiring chest tubes to remain in place for an extended period (sometimes several weeks) until the leak resolves. In some cases, additional interventions might be needed. 
• Pneumonia or other lung infections: As with any chest surgery, there is a risk of developing lung infections postoperatively, which may require antibiotics or other treatments. 
• Bleeding: While less common, surgical bleeding can occur, potentially requiring blood transfusions or, in rare instances, further surgery. 
• Cardiac complications: Patients with underlying heart conditions may be at increased risk for heart rhythm disturbances, heart attack or heart failure, particularly in the immediate postoperative period. Comprehensive cardiac evaluation before surgery helps to identify and mitigate these risks. 
• Respiratory failure: In some cases, despite the surgery, your respiratory function may not improve as expected or may even worsen temporarily, potentially requiring mechanical ventilation. 
• Deep vein thrombosis (DVT) and pulmonary embolism (PE): Blood clots can form in the legs (DVT) and potentially travel to the lungs (PE), which can be life-threatening. We use prophylactic measures, such as blood thinners and compression devices, to prevent these. 
• Wound infection: Infection at the surgical incision sites can occur, but is generally treatable with antibiotics.
• Persistent pain: Some patients may experience chronic pain or discomfort around the incision sites. 

Less Serious Common

• Stroke: Stroke is a rare but serious complication, especially in older patients or those with pre-existing cardiovascular risk factors. 
• Kidney failure: Acute kidney injury can occur, particularly in patients with pre-existing kidney problems.
• Adverse reaction to anesthesia: While rare, complications related to general anesthesia can occur. 

Factors Influencing Risk

The severity of these risks can vary significantly depending on several factors, including: 

• Your overall health and the presence of other medical conditions
• The severity of your emphysema and specific lung anatomy
• Age and nutritional status
• Adherence to pre- and postoperative instructions, particularly smoking cessation

Our specialized team works diligently to identify and manage these potential risks. Through meticulous preoperative assessment, precise surgical techniques and comprehensive postoperative care, we strive to achieve the best possible outcomes while ensuring patient safety. 

It is important to have an open and honest discussion with your surgical team about all potential risks and benefits, as this will help you make an informed decision about whether LVRS is the right treatment path for you. Our team is here to answer all your questions and provide the support you need through this serious, yet potentially life-changing, procedure. 

Beyond Surgery: Long-Term Management and Support 

Undergoing LVRS is a significant milestone in managing severe emphysema, but it is not a cure for the underlying lung disease. Emphysema remains a chronic condition that requires ongoing care and commitment. Froedtert & MCW support extends far beyond the operating room, focusing on long-term management to help you maximize and sustain the benefits of your surgery, promoting a healthier and more active life. 

Key aspects of long-term management and support include: 

• Continued pulmonary rehabilitation: This remains a cornerstone of post-LVRS care. Regular participation in a pulmonary rehabilitation program, whether in an outpatient setting or through home-based exercises, helps to maintain and improve your lung function, build physical stamina and reinforce efficient breathing techniques. This ongoing engagement is crucial for long-term success and continued gains in exercise capacity. 
• Medication management: Your pulmonologist will continue to manage your medications, including bronchodilators, inhaled corticosteroids and any other COPD therapies. These medications play a vital role in controlling inflammation, preventing exacerbations and optimizing your lung health alongside the surgical improvements. 
• Smoking cessation support: For individuals with emphysema, maintaining lifelong smoking cessation is absolutely critical. Our team provides resources and support to help you stay smoke-free, as continued smoking can rapidly negate the benefits of LVRS and accelerate disease progression. 
• Regular follow-up care: Consistent follow-up appointments with your pulmonologist and thoracic surgeon are essential. These visits allow our team to monitor your lung function, assess your overall health, identify any potential issues early and adjust your treatment plan as needed. We will periodically perform imaging studies and lung function tests to track your progress. 
• Vaccinations and infection prevention: Staying up-to-date on vaccinations, especially for influenza and pneumonia, is crucial for individuals with chronic lung disease to prevent infections that can severely impact respiratory health. 
• Nutritional support: Maintaining good nutrition is important for overall health and energy levels. Our dietitians can provide ongoing guidance to ensure you are meeting your nutritional needs. 
• Emotional and psychological well-being: Living with a chronic lung disease and undergoing major surgery can take an emotional toll. Our team offers resources for psychological support, helping you manage anxiety, depression and any challenges that may arise during your recovery and beyond. 

While LVRS cannot "cure" low lung volume, it significantly reduces the volume of diseased lung, allowing the healthier parts to work better. With comprehensive care and patient commitment, many individuals can have a much more normal and fulfilling life, actively managing their emphysema rather than being severely limited by it. 

Our dedicated Froedtert & MCW team is committed to partnering with you to provide the expertise, compassion and resources necessary to help you achieve the best possible quality of life after LVRS treatment, ensuring you continue to breathe easier and live more fully.