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* From the Division of Pulmonary & Critical Care Medicine, Department of Medicine (Drs. Leyenson, Cordova, Travaline, and Criner and Ms. Kuzma), Division of Cardiothoracic Surgery, Department of Surgery (Dr. Furukawa), Temple University School of Medicine, Philadelphia, PA.
Correspondence to: Gerard J. Criner, MD, FCCP, Professor of Medicine and Director, Pulmonary & Critical Care Medicine, Temple University School of Medicine, Pulmonary & Critical Care Medicine, 3401 N Broad St, Suite 785, Philadelphia, PA 19140
Study objectives: To evaluate correlations between improvement in quality of life (QOL) in patients with severe COPD before and after they undergo lung volume reduction surgery (LVRS) with changes in pulmonary function tests, gas exchange, exercise performance, and alterations in medical management.
Design: Case-series analysis.
Setting: University hospital.
Patients: Forty-two patients (mean [± SD] age, 56 ± 8 years; 53% women) with severe airflow obstruction (FEV1, 0.62 ± 0.2 L), and moderate to severe hyperinflation (total lung capacity [TLC], 6.9 ± 1.7 L).
Intervention and measurements: All patients underwent bilateral LVRS via median sternotomy. Measurements of lung function, symptom-limited cardiopulmonary exercise testing, the total distance the patient was able to walk in 6 min in a corridor, and sickness impact profile (SIP) scores were made before and 3 months after LVRS. SIP scores are inversely proportional to the level of function and QOL.
Results: Compared to baseline,
FEV1 increased (0.87 ± 0.3 vs 0.62 ± 0.2 L,
respectively; p < 0.01) while residual volume significantly
decreased (3.2 ± 1.8 vs 6.3 ± 1.2 L, respectively; p < 0.004)
at 3 months post-LVRS. On cardiopulmonary exercise testing, values
increased from baseline to post-LVRS for total exercise time
(9.0 ± 2.2 vs 6.0 ± 1.5 min, respectively; p = 0.045), maximum
oxygen uptake (
O2) (16 ± 3 vs
11 ± 2 mL/kg/min, respectively; p = 0.01), and maximum minute
ventilation (E) (33 ± 9 vs 28 ± 5 L/min,
respectively; p = 0.03). The percentage change in the oxygen cost of
breathing (O2/E
ratio) from low to high workloads during exercise was
significantly lower after LVRS (p = 0.002). There was no significant
change in oxygenation after LVRS (PaO2/fraction
of inspired oxygen, 331 ± 27 vs 337 ± 39, respectively;
p = 0.76), but PaCO2 tended to be lower
(41 ± 9 vs 48 ± 6 mm Hg, respectively; p = 0.07). Overall SIP
scores were significantly lower after LVRS than before (8 ± 4 vs
15 ± 2, respectively; p = 0.002). Changes in SIP scores correlated
with the change in
O2/E ratio from low
to high workloads, with patients having the smallest changes in
O2/E ratio having the
smallest changes in SIP scores after LVRS (r = 0.6;
p = 0.01). Improved or lower SIP scores also tended to correlate with
a reduction in residual volume/TLC ratio (r = 0.45;
p = 0.09), and there was a linear correlation with a statistically
significant Pearson r value with decreased steroid
requirements (r = 0.7; p = 0.001). Moreover, changes
in psychological SIP subscore tended to correlate with diminished
oxygen requirements post-LVRS (r = 0.45; p = 0.09).
However, there was no significant correlation between changes in SIP
scores and routine measurements of lung function, exercise performance,
or gas exchange.
Conclusion: There is an association between an improvement in QOL and reduced hyperinflation after LVRS. Reduced hyperinflation may lead to more efficient work of breathing during exercise and, therefore, to an increased ability to perform daily activities. Changes in QOL scores correlate best with behaviorally based variables that directly affect the patient’s well-being, such as systemic steroid administration.
Key Words: cardiopulmonary exercise testing • COPD • emphysema • lung volume reduction surgery • quality of life
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