Surgical treatment of pulmonary emphysema

Chronic obstructive pulmonary disease is an umbrella term for a range of conditions affecting the small airways (e.g. emphysema, chronic bronchitis, asthma). These are characterized by progressive, irreversible limitation of airflow, and evidence of an abnormal inflammatory response associated with inhalation of noxious gases or particles. Typically, this causes destruction of the alveolar wall, reduced elasticity, dilation of the units distal to the terminal bronchiole (resulting in hyperinflation of the chest wall), diaphragm flattening, gas trapping, and poor alveolar gas exchange compounded by a V:Q mismatch. This results in pulmonary hypertension with consequent right ventricular dysfunction in 40% of patients. Surgical procedures for emphysema were first developed more than 100 years ago, but only three have endured: bullectomy, lung-volume reduction surgery, and transplantation. This review discusses bullectomy (elective and for spontaneous secondary pneumothorax) and lung-volume reduction surgery. The indications and contraindications of surgery, technical aspects of the surgical approach, and timing of surgery are discussed. The future of surgical treatment for emphysema is considered, together with the evolving evidence base for existing treatments.