Evaluation and Testing

Step 1: Consultation and Initial Evaluation

The first step prior to entering the surgical process is a consultation appointment for an initial evaluation to determine if the patient meets the criteria for benefit from LVRS. You should bring your most recent medical records from your primary care provider and/or pulmonologist, including chest X-rays, chest CT scans and recent pulmonary function testing. The thoracic surgeon and nurse will review these tests with you, take a complete medical history, perform a physical examination and ask you several questions about your current exercise capacities and breathing difficulties. At the end of the consultation, the physician will make recommendations for further testing or medical management, almost invariably prescribing a pulmonary rehab program. The office will contact you to schedule any additional testing or your pulmonary rehabilitation plan.

The effects of LVRS can vary among patients depending on the location or extent of their disease and their exercise capacity. These two characteristics have been found to help predict whether a patient would benefit from LVRS. The National Emphysema Treatment Trial (NETT) study results have identified four sub-groups of patients who had different risks and benefits from LVRS. Specifically:

  • Group 1: Mostly upper-lobe emphysema and low exercise capacity. These patients were more likely to live longer and were more likely to function better after LVRS than after medical treatment.
  • Group 2: Mostly upper-lobe emphysema and high exercise capacity. These patients are more likely to function better after LVRS than after medical treatment, but there was no difference between the LVRS and Medical participants in survival.
  • Group 3: Mostly non upper-lobe emphysema and low exercise capacity. These patients had similar survival and function after LVRS as after medical treatment.
  • Group 4: Mostly non upper-lobe emphysema and high exercise capacity. These patients had worse survival after LVRS than after medical treatment; both LVRS and medical participants had similar low chance of functioning better.

LVRS candidates who fall into Groups 1, 2 or 3 are the best candidates for LVRS. All LVRS candidates are encouraged to discuss their individual characteristics with their primary care provider or pulmonologist to determine if they are likely to benefit from LVRS.

Step 2: Testing

You will undergo a series of tests that help define your illness and determine the extent of disease. Testing may include:

  • Chest X-ray: Used to determine the areas where tissue has collapsed, depression of the diaphragm, and overinflation as well as to detect other conditions that may accompany emphysema, such as pneumonia, heart problems or lung cancer.

  • Pulmonary Function Tests: Breathing tests that measure how well your lungs are functioning, their volume, whether or not you respond to inhaler medications, and the strength of your respiratory muscles.

  • Arterial Blood Gas: A blood test that measures levels of carbon dioxide and oxygen in your blood.

  • Electrocardiogram (EKG): A test that measures the electrical activity of the heart.

  • High Resolution CT Scan: Detailed pictures of the lung tissue, heart and diaphragm taken to determine the location and severity of emphysema in your lungs.

  • Oxygen Titration: While on a treadmill, oxygen levels are monitored to determine if your level of oxygen falls with exercise. This will help identify the amount of oxygen needed for the six-minute walk.

  • Six-minute walk: A test that requires you to walk on a designated path for six minutes while the distance you cover and your level of breathlessness are recorded.

  • Cardiopulmonary Exercise Test: An exercise test that measures endurance and the ability of your lungs to compensate during physical activity. Your heart and oxygen levels are monitored while you ride an exercise bike.

  • Right Heart Catheterization: This outpatient procedure will be done only if the doctors feel you need further work-up. A catheter is inserted into a leg or neck vein and passed into the right side of your heart to measure the pressures in your heart.

  • Cardiac Stress Test: a test used to provide information about how the heart responds to exertion.

  • Pulmonologist Consultation: a consultation with a pulmonologist will also be completed during this step.

Step 3: Case Presentation

Your test results will be presented at our bi-monthly multi-disciplinary Emphysema Conference, which is attended by members of the thoracic team. Based on this information, the team may recommend non-surgical medical management, which involves medication and rehabilitation, lung volume reduction surgery, or, in special cases, lung transplantation. You will be contacted by phone five to seven days after the conference as to your specific treatment plan.

Step 4: Pulmonary Rehabilitation

If a patient is accepted for surgery, he or she will be referred to a pulmonary rehabilitation program three times a week for a minimum of 16 visits. The University of Maryland Medical Center offers pulmonary rehabilitation services at the University of Maryland Rehabilitation & Orthopaedics Institute, formerly Kernan Hospital. These exercises are a crucial part of the patient's reconditioning and treatment plan. The exercise program is specifically designed to retrain the diaphragm and chest muscles to help the patient breathe easier, as well as to increase endurance. Under the close supervision of therapists, the patient will learn to use treadmills, bicycles and ergometers in addition to upper and lower body exercises. Therapists also pay careful attention to the patient's breathing efforts, oxygen saturation and usage, and tolerance to exercise.

This part of the treatment plan is intended to be a lifelong change, making exercise and symptom recognition a permanent part of the patient's daily routine. After formal pulmonary rehabilitation, the patient will be ready for perform the exercise program on his or her own, at home or in a local gym.

Step 5: Surgical Preparation

Once the pulmonary rehabilitation is complete, the patient will return for a final pre-operative check in about one week prior to the termination of the rehab program. At this check, surgery will be scheduled, surgical consent will be obtained and preoperative testing is performed. The preoperative testing will include an evaluation by an anesthesiologist.

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