Lung volume reduction surgery for patientswith COPD with severe emphysema has been successfullyimplemented since the late twentieth century.. Stemming from the above practice, we conduct
Trang 1INTRODUCTION TO THE THESIS QUESTION
Chronic obstructive pulmonary disease (COPD) is a global healthproblem, and it is estimated that by 2020, COPD will be ranked 5th
in terms of disease burden and 3rd in mortality [1] Emphysema isone of the main physiological disorders of COPD Emphysemacauses shortness of breath due to limited air flow, pulmonaryrelaxation and reduced alveolar surface area
The treatment of chronic obstructive pulmonary disease is stillprimarily internal medical With the development of science andtechnology and anesthesia resuscitation in lung volume reductiontreatment in patients with COPD with severe emphysema has goodresults The principle of lung volume reduction treatment is to decreasethe mismatch between the chest and the lung volume, increase theelasticity of the lungs and reduce airway resistance Therefore, thistreatment method helps patients improve air flow, corresponding activitybetween the respiratory muscles and the remaining lung parenchymaleading to improve symptoms, reduce the number of flares and improvethe patient life quality with COPD [2]
At present, there are two main groups of lung volume reductiontreatment: lung volume reduction surgery and lung volume reductionthrough bronchoscopy Lung volume reduction surgery for patientswith COPD with severe emphysema has been successfullyimplemented since the late twentieth century The results of thestudies in lung volume reduction surgery have proved effective forCOPD with severe emphysema with low rates of complications andtechnical complications [3], [4]
Lung volume reduction surgery is to remove the majorpulmonary emphysema in symptomatic treatment for patients withCOPD This surgery removes at least 20-30% of the volume of one
or two lungs (in some cases, a whole lobus pulmonis or one lung isremoved), which is usually the top of the lung and it is carried out
Trang 2with the thoracic opening along the middle sternum or lateral thoracic
or total laparoscopic surgery [5]
1 Research objectives:
In Vietnam, lung volume reduction surgery in patients withCOPD with severe emphysema has been successfully implemented atthe Thoracic Department, 103 Military Hospital in Vietnam MilitaryMedical University since 2014 However, research and application ofthis method have not yet been systematically conducted
Stemming from the above practice, we conduct research on the
subject: "Application of laparoscopic surgery in lung volume reduction to treat COPD" with two following objectives:
- Comment on some clinical and subclinical characteristics ofCOPD with severe emphysema which is cured by laparoscopicsurgery to reduce lung volume
- Assess the results of treatment of chronic obstructivepulmonary disease with severe emphysema by laparoscopic surgery
to reduce lung volume
2 New contributions of the thesis
From the results of the clinical, subclinical characteristics studyand the effectiveness of lung volume reduction surgery for patientswith COPD, who have severe emphysema, we have the newfollowing contributions:
2.1 Comment on some clinical and subclinical characteristics in patients with COPD with severe emphysema who have indicated laparoscopic surgery to reduce lung volume.
- All 31 study patients were male, with an average age of 66,16 ±5,62 years The average disease duration of all patients was 6,65 ±3,88 years Majority of the patients have had the disease for less than
10 years (96,77%)
- All patients in the study had history of smoking, with prolongedsmoking time (average of 30,29 ± 8,62 years) and average-cigarettepacket-of-year index of 30,94 ± 12,32 packets per year
- Body mass index (BMI) average is 20,46 ± 3,03 kg / m²;
- The number of outbreaks in a year is 3,13 ± 0,72 times
Trang 3- The average mMRC score is 2,35 ± 0,98 points.
- Average CAT score is 19,00 ± 6,06 points, there are 83,87% ofpatients with CAT ≥ 10
- Average 6-minute walking distance is 293,90 ± 70,79 meters
- Computerized tomography of the chest:
+ Severe emphysema in the right lower lung lobe reaches highproportion (83,87%), emphysema entire lobes reaches 74,19%, only
1 patient (3,23%) has a sludge balloon with emphysema in wholelobes and emphysema by the wall
+ The average emphysema score is 2,67 ± 0,83 points
- Respiratory function:
+ The average value of VC, FVC and FEV1 are respectively87,90 ± 21,91% predicted; 85.77 ± 20.00% predicted and 52.00 ±18.71% predicted
+ The average value of RV, TLC and Raw are respectively213,84± 76,16% predicted; 140.61±21.03% predicted and 8,49±5,39cmH2O/liter/ second
- Arterial blood gases:
+ There were 48,39% of patients with decreased PaO2 and22,58% of patients with increased PaCO2 in arterial blood
+ There were 6 patients (19,35%) with respiratory failure
2.2 Results of treatment of chronic obstructive pulmonary disease by lung volume reduction surgery
- Out of the 31 patients who were treated by lung volumereduction surgery, there were 23 patients (74,19%) receivedsupportive laparoscopic surgery Only 8 patients (25,81%) hadcomplete laparoscopic surgery
- Average surgery time is 92,74 ± 23,69 minutes
- Average weight of lung reduced is 31,09 ± 6,35 grams
- The average time for drainage of pleural cavity is 4,87 ± 4,27days
- There were no deaths to 6 months after surgery
Trang 4- Clinical changes at 1 month, 3 months and 6 months aftersurgery: CAT scores, mMRC and average 6-minute walking distance
of the surgical group are improved better than that before surgery
- Changing computerized tomography: emphysema scores tend todecrease after surgery at the track time
- Change in respiratory function:
+ VC, FVC and FEV1 increased statistically at the time of 1month, 3 months and 6 months after surgery compared to beforesurgery
+ Average values of RV, TLC and Raw decreased after surgery
3 The layout of the thesis
The thesis consists of 149 pages, in addition to the question,conclusions and recommendations, the thesis includes 4 parts:chapter 1- Document overview: 36 pages, chapter 2- Objects andresearch methods: 23 pages, chapters 3- Research results: 29 pages,chapter 4- Discussion: 26 pages The thesis has 45 tables, 9 pictures,
12 charts The thesis uses 121 references
Trang 5CHAPTER 1: DOCUMENT OVERVIEW
1.1 Clinical characteristics of COPD
The main symptom is shortness of breath, persistent shortness ofbreath
Coughing chronic phlegm, increasing At first often sputum less,mucous sputum During an outbreak, the number of sputumincreases, changing both color and properties
Wheezing and a feeling of suffocation are often nonspecific andchange over time [18], [19]
- Respiratory symptoms:
+ Breathing frequency increases, then exhales for a long time,contracting the secondary respiratory muscle such as concavewithdrawal on the breast, the intercostal space and the puncture onthe lash
+ Stretched chest, barrel shape, wide cavity space Pulmonaryechoes, vibration reduction and alveolar murmur reduction [18]
- Cardiovascular symptoms:
+ Symptoms of chronic heart failure and right heart failure such
as hepatomegaly, lower extremities edema, floating neck veins.+ Chronic heart failure, heart failure may be up to 30%
1.2 Subclinical characteristics of COPD
1.2.1 X-ray image of the lung
- Image of blood vessel transformation: Sparse peripheralpulmonary artery, decreased blood vessel size, and a rapid decrease
in the smoothness of blood vessels
- Pictures of lung relaxation:
+ The diaphragm arch is lowered, the ribs space widens, themorning space is wide
+ In case of severe emphysema, the diaphragm dome can bereversed, the heart is in the shape of water droplets and suspended onthe diaphragm dome Cardiac/thoracic index <½[18]
- Image of air bubbles: usually focused on the top or bottom ofthe lungs, images of the light areas with diameter> 1cm [22]
Trang 61.2.2 Computerized tomography of emphysema
- Emphysema of the center of small lobes: small spots or lights of
a small size, clearly defined and reduced in intensity Emphysemaspaces located in the center of the lobules, around the central artery
of the secondary lobes, are not directly in contact with the visceralpleura or bronchial components and blood vessels of the lobes, sub-segment and often predominate in the high areas on both sides of thelung
- Emphysema of the entire lobes: Large air chambers with noclear limits and loss of central lobes of the arteries The image of the
"black lung" is uniform, diffuse, homogeneous, the blood vessels aresparse and often focus on the lower lobes on either side or the wholelung Lesions are often heterogeneous
- Emphysema adjacent to the wall: The emphysema is located atthe periphery, there is a limited localization in the pleura or in contactwith the interstitial tissue around the blood vessels bronchus, the thinedge corresponds to the inter-lobar septum
- Air bubbles: are the emphysema with clear boundaries,diameter ≥ 1 cm, thin wall <1mm [26]
1.2.3 Probe for respiratory function
Patients with chronic obstructive pulmonary disease haveirreversible or incomplete obstructive obstructive ventilationdisorders [28],[29]
Closed volume (CV) is the volume of lung when the airway starts
to close In COPD, CV increases Normal CV < 5% VC
The diffusion ability and CO diffusion factor (kCO) are reduced
1.2.4 Arterial blood gases
The reduction of PaO2 in COPD is mainly due to alveolarhyperventilation and imbalance between ventilation and circulation
In severe exacerbations, decreased PaO2 and increased PaCO2 canlead to acute respiratory failure [18], [34]
1.3 Treatment of COPD
1.3.1 Medical treatment
Trang 7* Drug treatment
- The goal of treatment:
Relieving symptoms, preventing disease progression, increasingmobility, increasing health, preventing and treating complications,preventing and treating exacerbations, reducing mortality
- The main medications used in COPD patients are:bronchodilators; antibiotics: Effective against bronchopulmonaryinfections, commonly used broad-spectrum antibiotics, coordinated
in 7-10 days; expectorant: Or use group containing active ingredient
N - acetylcysteine; Respiratory stimulants, pulmonary vasodilators,medications for heart failure
* Respiratory support measures
- Long-term oxygen breathing
Maintain SaO2 reaching 88-92%, check arterial blood gas after30-60 minutes
- Non- invasive mechanical ventilation
- Invasive mechanical ventilation
1.3.2 Endoscope methods of lung volume reduction treatment of chronic obstructive pulmonary disease
- Lung volume reduction treatment by bronchial node
Lung volume reduction treatment by bronchial node makes thelung quickly collapse due to obstructing the drainage bronchus, butthe effect is low lung volume Currently, this measure is rarely usedbecause there is often a displacement
- Lung volume reduction treatment by twisted wires
Through bronchoscope, twisted wires are inserted into thebronchus of segmental lobes to the lung parenchyma Twisted wiresclog up the drainage bronchial in severe emphysema, causing thecollapse of lung
- Lung volume reduction treatment by glue
Through bronchoscope, colloidal substances are put into thebronchus in emphysema areas and destroyed lung areas, causing aninflammatory reaction that causes scarring and the formation offibrous tissue, effectively reducing lung volume [4]
Trang 8- Lung volume reduction treatment by heat
The principle of lung volume reduction treatment by heat is thatthe high-temperature steam through endoscope is put into thebronchus leading to the emphysema area, causing inflammatorylesions and fibrosis bronchus, leading to lung lobes with emphysemacollapsed [39]
- Lung volume reduction treatment by creating airway bridges
The principle of the technique for lung volume reductiontreatment by creating airway bridges is to use the Doppler ultrasoundprobe to locate the blood vessels then locating the bronchus whichdoes not close to the blood vessels to poke the needle through thebronchial wall and widen by balloon to create bladder ventilation.The bronchial stent is put into the severe emphysema area to create
an extra airway, leaving the gas out of the severe emphysema area
- Lung volume reduction treatment by a one-way valve
The principle of lung volume reduction treatment by a one-wayvalve is that through bronchoscope, a one-way valve is put into thebronchus in the severe emphysema area One-way bronchial valvesopen for air to pass in at second stage of breathing and close atinspiration Therefore, the lung corresponding to the bronchial branchwill be collapsed, reducing lung volume, making normal tissue andrespiratory muscles work
1.3.3 Surgical treatment for chronic obstructive pulmonary disease
* Lung volume reduction surgery
Lung volume reduction surgery has been used for few decades,but it is a high-risk surgery so there are still many issues that need to
be further studied These include: the choice of optimal designation,which surgical method is appropriate, how much lung volume issufficient, the long-term outcome of surgery and the physiologicalfunction of the remaining lung
- Designation of bilateral lung volume reduction surgery [5]:
+ Clinical symptoms of emphysema do not respond or respondlittle to aggressive medical treatment
Trang 9+ Medical history and / or current examination meet enoughdiagnosis criteria for COPD based on GOLD criteria 2015: FEV1 /FVC <0.7 (after using bronchodilator).
+ Excessive lung strain on standard X-ray
+ High resolution chest CT scan: dominant emphysema lesions
on one lung lobe
+ TLC ≥ 100% of the theoretical value after usingbronchodilators and before respiratory rehabilitation
+ RV ≥ 150% of the theoretical value after using bronchodilatorsand before respiratory rehabilitation
+ No smoking within 4 months
- Designation single lung volume reduction surgery [5], [54].
Similar to the designation for bilateral lung volume reductionsurgery but the following criteria are added:
+ Emphysema is asymmetric, dominant on one side
+ Inflammation of the pleura on the posterior side after disease orinterventions in the chest
+ Unstable hemodynamics, large air leaks during lung volumereduction surgery on the chest side that was done before
- Contraindications
Studies generally suggest that contraindications of lung volumereduction surgery include [5], [55]:
+ Large cocoon: diameter of cocoon is more than 5cm
+ Bronchiectasis, sputum> ½ cup / day
+ Pulmonary hypertension: > 45mmHg on echocardiography.+ Arterial blood gases: PCO2> 60mmHg at room condition.+ Daily use> 20mg prednisolon
+ Patients at high risk group when having lung volume reductionsurgery according to NETT standards, if there is at least one of thefollowing criterias:
≥ 75 years old
FEV1 ≤ 20% of the theoretical value
DLCO ≤ 20% of theoretical value
Trang 10Emphysema diffuses uniformly in both lungs on high resolutionchest computerized tomography.
+ Thick pleural adhesion associated with previous chest opening.+ Thick adhesion pleural associated pleural diseases which existbefore
+ Patients in high-risk group when opening the chest
Surgical methods to reduce lung volume
- Surgery by opening along the middle of the breastbone
- Endoscope surgery on both sides through the front chest incision
- Endoscope surgery through lateral chest incision
Trang 11CHAPTER 2: SUBJECTS AND METHODS OF RESEARCH 2.1 Research subjects
Including 31 patients diagnosed with COPD with severeemphysema who were treated at the Department of Thoracic Surgery,Military Hospital 103 from 2013 to 2018 Patients were assignedlaparoscopic surgery to reduce lung volume, monitoring andevaluation after surgery following a uniform procedure
Diagnosis and identification of COPD according to GOLDstandards (2013) [1]:
The diagnosis of COPD has severe emphysema as standard:+ Shortness of breath on exertion, often and gradually
+ The body is thin, the chest is tight, knocking, vibration isreduced, whispering alveoli sharply decreases
+ Standard lung X - ray: Pulmonary picture brightened, sparsepulmonary vascular network, flat diaphragm arch and teardrop-shaped heart
+ Computerized tomography of the thoracic region: the area ofthe lung parenchyma increased in intensity below the threshold - 950
HU
Indications for surgery to reduce lung volume according toNETT (2011) [55]:
- Patients with stable COPD
- The patient has quit smoking for more than 4 months
- BMI <31.1 in five males and <32.3 in females
- PaCO2 ≤ 60 mmHg and PaO2 ≥ 45 mmHg
- Computerized tomography with severe emphysema
- RV ≥ 150% compared to theory, TLC ≥ 100% compared totheory
- Left ventricular systolic function on echocardiography > 45%
* Exclusion criteria:
General exclusion criteria
- The patient currently has other respiratory diseases: tuberculosis
Trang 12- Patients with contraindication to measuring lung function: newmyocardial infarction, pulmonary embolism, pneumothorax, severeheart failure, limited cognitive noncooperation …[64]
- Exclusion criteria according to NETT (2011) include [55]:
- The patient refused to join the research team
2.3 Processing and analyzing data
Enter data into Excel software
Data processing using SPSS 20.0 software
The difference was statistically significant when p <0.05 Findthe correlation by Pearson correlation
2.4 Research ethics
Patients are selected according to treatment indications andvoluntarily participate
Data of research patients are guaranteed confidentiality
Lung volume reduction surgery for treatment of COPD withsevere emphysema has been approved by the Medical Ethics Council
of Military Hospital 103