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with permission.

Time (months)

Do criteria for volume reduction and transplantation overlap?

Patients with COPD who met the criteria for lung transplantation have received LVR surgery [37]. Post-hoc analysis suggested that improvements following volume reduction were equivalent to improvements seen among LVR surgery patients who were not eligible for transplants (Fig. 14.2). At 6 months, FEV1 increased by 59% in the 'transplant-eligible' group, compared to a 79% increase in the overall LVR surgery group. The 6-min walk test increased by 33% in 'transplant-eligible' subjects. This figure was intermediate between 28% for the overall group of LVR surgery patients and 47% for those who had received single-lung transplantations. The actual walking distance was 449 m for 'transplant-eligible' LVR surgery patients and 461 m post-SLT. Thus, although the LVR patients had a smaller improvement in their FEV1 (0.55-0.87 L after LVR vs. 0.48-1.59 L after SLT), the improvements in functional exercise capacity were similar with the two procedures, without the risks or complications of SLT such as rejection and immunosuppression.

What are the future directions?

The value of surgery for giant bullae is well established and without question. Short-term randomized trials have demonstrated that LVR surgery is effective in improving pulmonary mechanics, decreasing dyspnoea, increasing exercise tolerance and improving quality of life. Longer-term studies will quantify the duration of benefit, appropriate selection criteria and best techniques. Animal models of emphysema [38] enable us to evaluate several potential endo-bronchial techniques that might improve pulmonary mechanics and health-related quality of life for patients with emphysema. This is likely to become an area of very active research. Transplantation will continue to be an option for a minority of patients with end-stage emphysema. More widespread use of transplantation will depend on significant improvements in immunosuppres-sion as well as an expansion of the donor pool. Until that time, the balance for clinicians and patients remains the risk of early death or major complications, against the improvements in functional exercise capacity and health-related quality of life.

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