Characteristics of included studies
| Reference | Study design strengths and weaknesses (n = sample size) | Criteria for entry to study | Intervention | Outcomes | Additional information | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Inclusion | Exclusion | ||||||||||
| Argenziano24 | Consecutive case series within a controlled comparison (n = 92). 75% reached the 3–6 month follow up point and were treated as a discrete cohort with 96% follow up. No information on assessment of outcome. | Hyperinflation Poor diaphragmatic excursion Pulmonary perfusion and ventilation deficits Significant functional disability | Morbid obesity Chronic bronchitis Excessive sputum production Metastatic cancer Continued or recent smoking Less than severe functional disability | Stapling with BPS buttressing Bilateral and unilateral Mainly open procedures | Pulmonary function tests Morbidity and mortality Dyspnoea | Baseline data: unclear when these were obtained Setting/experience: part of a 2 year programme at Columbia-Presbyterian Medical Centre, New York, USA NB. Population includes some very ill cases | |||||
| Bagley25 | Consecutive case series (n = 55). 82% followed up for three months. No information on assessment of outcome | Advanced emphysema unhappy with the limits imposed by the disease Small amounts of airways inflammation Recent completion of a pulmonary rehabilitation programme RV >150% of predicted PA systolic pressure <50 mm Hg Smoking cessation for at least 1 year | Recent high dose steroid use Other active medical problems | Stapling with BPS buttressing Bilateral via median sternotomy 8 weeks pulmonary rehabilitation pre-op. | Pulmonary function tests 6 MWD Chronic Respiratory Diseases Questionnaire | Baseline data: 6MWD and subjective data obtained post-rehabilitation Pulmonary function test baseline data collected at various points particularly for very ill cases Setting/experience: early experience in a 320 bed community hospital in the USA NB. Results presented as numbers of patients achieving a significant improvement postoperatively | |||||
| Benditt41 | Consenting cases of a consecutive series: included cases studied compared with those excluded and shown not to be significantly different (n = 21 (of 47)). 100% follow up to 3 months. No information on assessment of outcome. | Evidence of emphysema on CT scan Severe airflow limitation FEV1>15% and <35% predicted TLC >120% RV >150% Air trapping and hyperinflation Smoking cessation for at least 3 months | Age >75 years Excessive daily sputum production Significant co-morbidity | Stapling with BPS buttressing Bilateral via median sternotomy | Pulmonary function tests to ATS standards | Baseline data: no detail on when these were obtained Setting/experience: part of a year long programme at the University of Washington in Seattle, USA | |||||
| Bousamra26 | Consecutive case series (n = 45). 93% followed up to 3 months. No information on assessment of outcome. | Marked hyperexpansion Heterogeneous emphysema Large RV Significant trapped gas volume | Previous major thoracic surgery Prominent component of bronchospasm Copious sputum production or congestive cardiac failure Inability to undertake pulmonary rehabilitation | Mainly stapling Bilateral via median sternotomy or thoracotomy Pulmonary rehabilitation 6 weeks pre-op continuing post-op | Pulmonary function tests. Dyspnoea (Mahler index), follow up inadequate 6MWD (follow up inadequate) Mortality and morbidity | Baseline data: obtained pre and post rehabilitation Setting/experience: first 45 cases treated at the Medical College of Wisconsin Hospitals, USA | |||||
| Cooper39 | Consecutive case series (n = 150). 67% followed up to 6 months; 37% to 1 year; and 13% to 2years; all treated as discrete cohorts. No information on assessment of outcome. | Emphysema with hyperinflation and heterogeneity Marked physiological impairment (FEV1 <35% predicted) Marked restriction in activities of daily living despite maximal medical therapy Age <75 years Acceptable nutritional status (70–130% of ideal body weight) Ability to participate in vigorous pulmonary rehabilitation programme No co-existing major medical problems that would significantly increase operative risk Willingness to undertake risk of morbidity and mortality associated with the procedure Smoking cessation for at least 6 months | Diffuse disease with no target areas Insufficient thoracic distension, advanced age or associated medical problems FEV1 too good Pleural disease Better suited to lung transplantation Paco 2 >55 mm Hg in association with other problems Marked kyphosis | Stapling with BPS buttressing Bilateral via median sternotomy 6 weeks pulmonary rehabilitation pre-op. | Pulmonary function tests Exercise testing 6 MWD Morbidity and mortality Dyspnoea (Mahler index and MMRC) Quality of life (Nottingham Health Profile and SF36) | Baseline data: generally obtained pre and post rehabilitation but presented separately Setting/experience: the most recent results of a large programme at Washington University, Missouri, USA which commenced in 1993 | |||||
| Cordova40 | Consecutive case series (n = 69). 25 patients reached 3 months, 13 reached 1 year and 6 reached 2 years with 100% follow up and all were treated as discrete cohorts. No information on assessment of outcome. | New York Heart Association class III–IV Evidence of airflow obstruction and hyperinflation by pulmonary function studies (i.e. post-bronchodilator FEV130% predicted) FRC or TLC >120% of predicted Discrepancy between helium dilution and FRC body box determination of lung volumes by >500 ml Documented hyperinflation on chest radiograph Diffuse emphysema documented on CT scan Ventilation-perfusion mismatch documented in planned resected lung by VQ scan | Patients with severe and refractory hypoxaemia Severe hypercapnic respiratory failure requiring mechanical ventilation Presence of severe cardiovascular disease Presence of severe pulmonary hypertension (mean Pa pressure >500 mm Hg). Severe debilitated state with total body weight <70% of ideal Presence of significant extrapulmonary end organ dysfunction expected to limit survival Psychosocial dysfunction Continued smoking | Stapling Bilateral via median sternotomy All patients underwent pulmonary rehabilitation for 8 weeks pre-op and 3 months post-op | Pulmonary function tests to ATS standards Exercise testing 6MWD Quality of life (Sickness Impact Profile) | Baseline data: measurements were obtained after pulmonary rehabilitation Setting/experience: first 25 cases of 69 treated in a 2-year programme at Temple University Hospital, Philadelphia, USA | |||||
| Criner27 | Consecutive case series (n = 3). 100% followed up for at least 3 months. No information on assessment of outcome. |
Severe COPD and respiratory failure Ventilator dependent Poor mobility Severe hypercapnia and cor pulmonale | Not stated | Stapling Bilateral via thoracotomy or sternotomy No pulmonary rehabilitation | Pulmonary function tests to ATS standards Arterial blood gas analysis Bedside maximum inspired pressure and ventilation. | Baseline data: obtained 1–4 months prior to intubation (not available for one subject) Setting/experience: part of a 2 year programme at Temple University Hospital Philadelphia, USA NB. All very ill cases | |||||
| Daniel28 | Consecutive case series (n = 26). 65% followed up to 3 months but treated as a discrete cohort (n=17). No information on assessment of outcome. | Diagnosis of COPD No smoking for more than 1 month Age <75 years FEV115– 35% predicted Paco 2 <55 mm Hg Prednisone dosage <20 mg daily Pa <55 mm Hg by echocardiography Commitment to preoperative and postoperative supervised pulmonary rehabilitation for 6 weeks | Previous thoracotomy or pleurodesis Symptomatic coronary heart disease, chronic asthma or bronchitis | Stapling with BPS buttressing Bilateral via median sternotomy Pulmonary rehabilitation pre and post- op for 6 weeks | Pulmonary function tests Quality of life (tool not stated) | Baseline data: no information as to when baseline measurements were obtained Setting/experience: 1 year experience at the University of Virginia, USA | |||||
| Eugene29 | Consecutive case series (n = 44). 91% followed up to 3 months and 86% followed up to 6 months. No information on assessment of outcome. | Severely impaired pulmonary function (FEV1<0.5 l) Lifestyle limiting dyspnoea Reduced pulmonary function (FEV1 20–40% predicted) RV >250% predicted Hyperexpansion Diffuse bullous emphysema Target areas | Advanced age Hypercarbia Irreversible pulmonary hypertension Prior operation or thoracic deformities Significant co-morbidity Poor patient compliance | Stapling with BPS buttressing and laser Unilateral and bilateral via thoracoscopy and median sternotomy No pre-op pulmonary rehabilitation (40 patients underwent rehabilitation post-op) | Pulmonary function tests Dyspnoea (Borg and MMRC scores) | Baseline data: no information on when baseline data were obtained Setting/experience: part of an 18 month experience at the Western Medical Centre, Anaheim, California, USA NB. All very ill cases | |||||
| Eugene30 | Consecutive case series (n = 28). 100% followed up to 3 months. No information on assessment of outcome. | Dyspnoea severely impairing lifestyle Inability to work or self care No improvement on maximal medical management Bullous or diffuse emphysema with hyperinflation on CT scan Markedly low FVC and FEV1 and high lung volumes | Not stated | Laser and/or stapling with BPS buttressing Unilateral via thoracoscopy No information on pulmonary rehabilitation | Pulmonary function tests Dyspnoea (tool not stated) | Baseline data: no information Setting/experience: early experience (Nov 1993–July 1994) at the Western Medical Centre, Anaheim and the University of California, Irvine, USA | |||||
| Keller31 | Consecutive case series (n = 25). 100% followed up to 6 months. No information on assessment of outcome. | Established diagnosis of severe emphysema Significant air trapping Impaired diffusion capacity Demonstrated distinct target areas for surgical resection Ventilation/perfusion mismatch | Coronary heart disease or left ventricular failure Chronic bronchitis Severe hypercapnia (Paco 2 >55 mm Hg) Significant PA hypertension (mean >35 mm Hg) | Stapling Unilateral via thoracoscopy Pre-op pulmonary rehabilitation for at least 6 weeks | Pulmonary function tests Dyspnoea (Mahler index) Exercise testing 6 MWD (all to ATS standards) | Baseline data: measurements obtained after pulmonary rehabilitation Setting/experience: first 25 cases in a series of 75 at St Louis University, Missouri, USA | |||||
| Kotloff32 | Consecutive case series within a controlled comparison. Thoracoscopic procedure (n = 40). 89% followed up for 3–6 months. Closed procedure (n = 80). 81% followed up for 3–6 months. No information on assessment of outcome. | FEV1 20–30% predicted Severe hyperinflation RV >200% predicted Heterogeneous disease Large zones of hypoventilated and hypoperfused lung on VQ scan | Giant bullectomy Paco 2 >50 mm Hg PA systolic pressure >50 mm Hg Continued smoking Body weight over or under 20% of ideal Prior surgery or pleurodesis Significant bronchospasm with wide fluctuations in FEV1 Copious daily sputum production Poor functional status | Stapling with BPS buttressing Bilateral (some staged) via median sternotomy or thoracoscopy 6 weeks pulmonary rehabilitation pre and post-op | Pulmonary function tests Exercise testing 6MWD Mortality and morbidity | Baseline data: obtained after pulmonary rehabilitation Setting/experience: part of a programme at the University of Pennsylvania, USA (duration not stated) | |||||
| Little33 | Consecutive case series (n = 55). 51% followed up to 3 months and treated as a discrete cohort. No information on assessment of outcome. | Diffuse emphysema Cessation of smoking | Severe bronchitis Carbon dioxide retention >50 mm Hg Congestive cardiac failure or cor pulmonale End stage COPD Inability to ambulate FEV1 <35% predicted despite pulmonary rehabilitation | Mixed, mainly laser Unilateral via thoracoscopy Includes some open procedures and 3 resection of giant bullae No routine pulmonary rehabilitation although some did 6 weeks pre-op | Pulmonary function tests 6MWD Dyspnoea | Baseline data: when pulmonary rehabilitation was undertaken baseline data were obtained after this Setting/experience: part of a wider programme at the University of Nevada, USA | |||||
| McKenna42 | Consecutive case series within a controlled comparison (n = 166). 87% followed up for 6–12 months. No information on assessment of outcome. | Marked symptoms despite maximal medical management Hyperexpansion of the thorax and flattening of the diaphragm on chest radiograph Severe heterogeneous emphysema on CT scan | Current smoking Age >80 years Severe carbon dioxide retention (Paco 2 >55 mm Hg) Severe heart disease History of cancer in the last 5 years Ventilator dependency Presence of a lung mass Prior thoracic surgery | Stapling with BPS buttressing Unilateral or bilateral Thoracoscopic Pulmonary rehabilitation not routine pre-op but all underwent this for 2–3 weeks post-op | Mortality and morbidity Pulmonary function tests Dyspnoea (MMRC) Steroid and oxygen dependence | Baseline data: unclear when these were obtained Setting/experience: results of a year long programme at the Lung Centre, Chapman Medical Centre, California, USA | |||||
| Miller34 | Consecutive case series (n = 53). 84% followed up to 6 months. No information on assessment of outcome. | Advanced generalised emphysema No bullae over 5 cm Failure of maximum medical therapy No significant coronary heart disease or psychiatric problems No life threatening illness Ability to perform pulmonary rehabilitation Smoking cessation for 6 months Steroid dosage >15 mg a day No generalised osteoporosis | Predominately bullous emphysema Smoking Too good physiological state Significant coronary heart disease PA pressure >35 mm Hg Inability to participate in pulmonary rehabilitation Steroid dosage >15 mg a day Use of multiple psychiatric drugs Significant bronchitis or asthma Previous pulmonary operation or sclerosis Age <75 FEV1 <30% predicted Paco 2<50 mm Hg, Pao2 >40 mm Hg on room air | Stapling with BPS buttressing Bilateral via median sternotomy 6 weeks pulmonary rehabilitation pre-op and post-op | Pulmonary function tests Dyspnoea (tool not stated) 6MWD | Baseline data: no information on when baseline measurements were obtained Setting/experience: early results of an 18 month programme at Emory University Medical School, Georgia, USA | |||||
| Sciurbia35 | Consecutive case series (n = 20). 100% followed up to 3 months. Outcome assessment by trained independent assessor. | Diffuse emphysema on the CT scan | Giant bullae Dominant bronchiectasis, chronic bronchitis or clinical cor pulmonale Systolic PA pressure >50 mm Hg Severe epistaxis or inability to tolerate oesophageal balloon placement Severe dyspnoea despite maximal medical therapy Clinically stable for 1 month pre-study FEV1 <0.5 and RV >140% predicted after bronchodilators | Laser and stapling Unilateral and bilateral Open and closed procedures No information on pulmonary rehabilitation | 6MWD (standardised) Dyspnoea (Mahler index) Pressure/volume relations Elastic recoil | Baseline data: obtained 1–4 weeks preoperatively Setting/experience: first 20 cases in the University of Pittsburgh, USA programme from October 1994 to February 1995 | |||||
| Snell36 | Consecutive case series (n = 20). 95% followed up to 3 months. No information on assessment of outcome. | Diagnosis of emphysema in patients receiving optimal management Bronchodilator FEV1 <40% predicted RV >150% predicted Apical functionless emphysematous lung on CT and VQ with relative preservation of basal lung function | Inability to complete pulmonary rehabilitation Age >75 years Body mass index <16 kg/m2 or 27 kg/m2 Previous thoracotomy or extensive pleural disease Alpha-1 antitrypsin deficiency, bronchiectasis or asthma Tobacco use within the last 3 months Other major medical illness including psychiatric disorders Prednisolone dosage >10 mg/day Paco 2 >55 mm Hg or Pao2 <45 mm Hg on air 6MWD <150 m PA pressure >50 mm Hg | Stapling with BPS buttressing Bilateral via median sternotomy 8 weeks pulmonary rehabilitation pre-op | Pulmonary function tests 6MWD Dyspnoea (MMRC score) | Baseline data: used best results obtained preoperatively Setting/experience: early experience in Australia, September 1995 to February 1997 | |||||
| Stammerberger37 | Consecutive case series (n = 42). 85% followed up to 3 months. 69% to 6 months (data not included). No information on assessment of outcome. | Severe COPD FEV1 <35% predicted Considerable hyperinflation TLC >130% and RV >200% Flattened diaphragm High motivation No smoking for 6 months No further improvement possible on medical management | Age >75 years Paco 2 >55 mm Hg Diffusing capacity for carbon monoxide <20% predicted Bronchiectasis, acute bronchopulmonary infection, neoplastic disease with a life expectancy of 2 years or psychiatric disturbance Significant coronary heart disease or marked pulmonary hypertension (mean PA pressure 30 mm Hg) | Stapling Bilateral via thoracoscopy No systematic pulmonary rehabilitation | Pulmonary function tests 6MWD Dyspnoea (MMRC scale) | Baseline data: no information Setting/experience: results of experience in Switzerland which began in Jan 1994 to Sept 1996 NB. 12MWD results halved to give 6MWD. | |||||
| Zenati38 | Consecutive case series (n = 35). 86% followed up to 3 months. No information on assessment of outcome. | Patients who met the criteria for LVRS and lung transplantation End stage diffuse emphysema Severely impaired quality of life despite maximal medical therapy Post bronchodilator FEV1 <30% predicted Disabling dyspnoea at <50 yards walking | PA pressure >55 mm Hg Smoking within the last 3 months Large bullae with underlying compressed lung on CT scan Morbid obesity >1.5 lean body weight Unstable coronary heart disease End stage cancer Non-ambulatory Ventilator dependent Previous thoracic surgery | Laser and stapling with BPS buttressing Bilateral and unilateral Open and closed No pulmonary rehabilitation | Pulmonary function tests 6MWD Dyspnoea (Mahler index and Borg scale) | Baseline data: no information. Setting/experience: 18 month experience at Pittsburgh Medical Centre, USA from July 1994 to December 1995 | |||||
6MWD = six minute walking distance; CT = computerised tomography; VQ = ventilation perfusion; BPS = bovine pericardial strips; FRC = functional residual capacity; RV = residual volume; FVC = forced vital capacity; Paco 2, Pao 2 = arterial carbon dioxide and oxygen tensions; PA = pulmonary artery; FEV1 = forced expiratory volume in one second; TLC = total lung capacity; MMRC = modified Medical Research Council; ATS = American Thoracic Society.