Influence of Lung Volume Reduction LVRS (LVRS) on Health Related Quality of Life in Patients with Chronic Obstructive Pulmonary Disease
Thorax. 2003;58:405–410. Goldstein RS, Todd TRJ, Guyatt G, Keshavjee S, Dolmage TE, van Rooy S, Krip B, Maltais F, LeBlanc P, Pakhale S, Waddell TK. West Park Healthcare Centre, Lung Volume Reduction Surgery Clinic, University Health Network, University of Toronto; McMaster University Health Sciences Centre, Hamilton, Ontario; and Hopital Laval, Sainte-Foy, Quebec, Canada.
This prospective, randomized, controlled study evaluated the disease-specific quality of life in patients with severe chronic obstructive pulmonary disease (COPD). The primary outcome was disease-specific health-related quality of life. Entry criteria included age <75 years, severe stable COPD (FEV1 <40% predicted, FEV1/FVC <0.7), hyperinflation at total lung capacity (TLC; TLC by plethysmography >120% predicted), and gas trapping at TLC (TLC plethysmography minus TLC gas dilution >1.5 l), and evidence of heterogeneity on a computed tomographic (CT) or ventilation/perfusion scan. In addition, patients were nonsmokers (quit for more than 6 mo), were receiving optimal medical therapy, and had had no exacerbations for at least 6 weeks. Exclusion criteria included asthma, previous lung LVRS, pleural disease, general contraindications to LVRS, coexisting symptomatic disease that might limit exercise tolerance or health-related quality of life, inability to attend rehabilitation or follow up, pulmonary hypertension (systolic pulmonary arterial pressure >42 mm Hg or mean >35 mm Hg), hypercapnia (Paco2 >6.6 kPa), or homogeneous disease. A total of 55 patients were randomized to LVRS (n = 28) or MT (n = 27) groups after 6 weeks of pulmonary rehabilitation and monitored at 3-month intervals for 12 months with no crossover between the groups. The primary outcome was disease-specific quality of life as measured by the Chronic Respiratory Questionnaire (CRQ). The CRQ is a disease-specific measure, which focuses on 4 domains: dyspnea, fatigue, emotional function, and mastery (patients' sense of being in control of their lives and their health problem). Treatment failure was defined as death or functional decline (fall of 1 unit in any 2 domains of the CRQ). Secondary outcomes included pulmonary function and exercise capacity. The analysis of data showed that LVRS resulted in significant between-group differences in each domain of the CRQ at 12 months (change of 0.5 represents a small but important difference): dyspnea 1.9 (95% confidence interval [CI], 1.3–2.6; P < 0.0001); emotional function 1.5 (95% CI, 0.9–2.1; P < 0.0001); fatigue 2.0 (95% CI, 1.4–2.6; P < 0.0001); and mastery 1.8 (95% CI, 1.2–2.5; P < 0.0001). In the MT group, one of 27 patients died and 16 experienced functional decline over 12 months. In the LVRS group, 4 of 28 patients died and 3 experienced functional decline (hazard ratio = 3.1 [95% CI, 1.3–7.6; P = 0.01]). Between-group improvements (P < 0.05) in lung volumes, flow rates, and exercise were sustained at 12 months (RV −47% predicted [95% CI, −71–−23; P = 0.0002]; FEV1 0.3 l [95% CI. 0.1–0.5; P = 0.0003]; submaximal exercise 7.3 min [95% CI, 3.9–10.8; P < 0.0001]; 6-minute walk 66 meters [95% CI, 32–101; P = 0.0002]). The authors conclude that in patients with heterogeneous emphysema, LVRS resulted in important benefits in disease-specific quality of life compared with MT, which were sustained at 12 months after treatment. This study adds another aspect to the multiple LVRS trials being conducted in several countries. The follow up was limited to 12 months after LVRS. Whether the improved quality of life is sustained for longer periods is unclear.