Pulmonary emphysema: indications for surgery

Pulmonary emphysema is defined as abnormal irreversible enlargement of airspaces distal to the terminal bronchioli, accompanied by destruction of their walls and without obvious fibrosis. It occurs usually as a consequence of smoking. Advanced stages of emphysema lead to dyspnea and are associated with airflow obstruction, hyperinflation and reduced diffusing capacity. Measures that have been shown to alter the course of the disease are smoking cessation and long-term oxygen administration to correct arterial hypoxemia. Antibiotics, bronchodilators, corticosteroids and rehabilitation may provide symptomatic relief. Surgery is another treatment option for selected cases. Recurrent pneumothoraces resulting from rupture of subpleural bullae may be prevented by thoracoscopic pleurodesis. Large bullae that compress adjacent lung and mediastinal structures may be resected. In selected cases of diffuse advanced emphysema associated with significant hyperinflation, volume reduction by resection of the most destroyed areas of the lungs may improve dyspnea, pulmonary function and exercise tolerance. In severely symptomatic patients with reduced life expectancy due to endstage emphysema, lung transplantation may provide with dramatic symptomatic and functional improvement. If the indications for operation are carefully considered and the intervention is performed by an experienced team, surgery is a valuable treatment modality in certain patients with pulmonary emphysema.