New hope for patients with emphysema: lung volume reduction surgery.

HEART & LUNG VOL. 28, NO. 6 455 Section Editor’s Note: Chronic obstructive pulmonary disease (COPD) is a disease characterized by a chronic, progressive air flow obstruction that, as it progresses, becomes devastating to the lives of many. In the United States, approximately 13 million people have COPD,1 and COPD is the fourth leading cause of death, preceded only by heart disease, cancer, and stroke.2 It is the second leading cause of disability in adults younger than 65 years of age.3 The number of patients with COPD has increased by 41.5% since 1982, making it one of the fastest-growing diseases in the world. It claims more than 90,000 lives each year in the United States alone.1,4 Whereas traditional management of the disease has focused on pharmacologic interventions, such as bronchodilators and the use of supplemental oxygen, a newer approach has been introduced that involves surgery. This surgery, called lung volume reduction surgery, involves the removal of 20% to 30% of the patient’s lung through either a midsternal incision or the use of video thoracoscopy. The surgery presents the risk of postoperative complications,5 which vary depending on the status of the patient and the surgical approach used. Preliminary studies, however, have shown this surgery to be of benefit, with improvement in the forced expiratory volume in 1 second (FEV1) and significant reductions in total lung capacity, residual volume, and air trapping 3 and 6 months after the surgery.6 Patients have also reported an improvement in their quality of life after lung volume reduction surgery. Others have shown that the benefits of surgery, when combined with postoperative pulmonary rehabilitation, continue for 6 to 12 months.7,8 None of these studies, however, were done in large numbers of subjects, and none used a randomized control design, making the benefits shown open to question. There were also concerns about the high costs of the surgery. To address these many concerns, a unique partnership was formed in 1997 between the Health Care Financing Administration and the National Institutes of Health. They put out a call for proposals and selected 20 sites to participate in a multicenter randomized clinical trial comparing the effectiveness of one of two approaches to lung volume reduction surgery with that of an extended program of pulmonary rehabilitation.4 This trial, now called the National Emphysema Treatment Trial, involves some sites testing rehabilitation against one surgical approach and others having a second random assignment to one of two surgical procedures. In this well-designed trial, however, research concerning the nursing management of the patients is lacking. Yet nurses are caring for these patients before and after surgery and in a variety of settings with little to guide them. What follows is a case study written by nurses who care for these patients during the immediate postoperative phase. Their expertise in the care of these patients is what is needed at this time. In their communication regarding this one patient they indicate many of the challenges they and the patients face both before and immediately after surgery. Audrey Gift, PhD, RN, FAAN