Room to breathe – emphysema
Caroline D. Decker
For 25 years, Nedra Meiller struggled with debilitating emphysema. Today, thanks to a new surgical procedure, she leads a normal life.
A year ago, Nedra Meiller struggled for nearly every breath. Simple tasks like taking a shower and making the bed had become arduous chores, requiring frequent rests.
Meiller’s world was her home, except for doctor’s visits, she could no longer go grocery shopping or walk to the mail-box. She relied on a wheelchair to get to and from the car, which her husband drove. “I felt like I was suffocating,” Meiller says. “The only time I could breathe was when I was sitting down, doing nothing.”
Emphysema, with which Meiller had lived for 25 years, had taken hold of her lungs. At 58, suicide had become more than a fleeting thought, Meiller recalls. “I became so depressed because I couldn’t do anything,” she says. “I no longer felt like a wife or a mother. I wondered why I should go on. I wasn’t living; I was existing.”
But eight months after undergoing a new surgical procedure developed by lung transplant surgeon Joel D. Cooper, Meiller says there is virtually nothing she can’t do.
During the operation Dr. Cooper removed expanded portions of Meiller’s enlarged lungs. Decreasing the overall size of emphysema patients’ lungs literally gives the lungs more “breathing room,” Dr. Cooper says.
“I can believe the difference,” says Meiller. “I’m a new person. I have more energy now than I’ve had in years.”
Meiller now manages her St. Louis home with ease. She no longer stops to catch her breath while gardening, cooking or vacuuming. Her daily routine includes riding an exercise bike or walking on a treadmill for 30 minutes. For the first time in several years, Meiller has planted a garden.
She is one of the first 20 emphysema patients to undergo the procedure that dramatically improves lung function and helps patients breathe more easily.
“So far, we’ve seen an average improvement of 82 percent in patients, breathing capacity,” says Dr. Cooper, who performed the first procedure in January 1993 at Barnes Hospital in St. Louis. “For these severely disabled patients, this translates into a marked improvement in the quality of their lives.”
During the surgery, Dr. Cooper removes 20 to 30 percent of each lung – the most severely damaged areas. Within six months of their surgery, patients were able to resume many of the activities they had avoided for years. In the future, the surgery may be the treatment of choice for some patients with severe, debilitating emphysema who have failed to respond to medication, respiratory care, and other medical therapy.
The Disease
Emphysema, most often caused by cigarette smoking, afflicts an estimated 1.6 million Americans. The previously irreversible disease causes the lung’s tiny air sacs to overinflate, damaging their ability to expand and relax as a person breathes. Therefore, less oxygen gets into the bloodstream; to compensate, the lungs gradually enlarge until they fill the chest cavity and flatten the diaphragm, a muscle critical to breathing. Ultimately, each breath becomes a chore.
As the disease advances, emphysema patients grow weaker. At first, they experience only slight shortness of breath but, gradually, become incapable of minor physical activity. Some patients eventually become dependent upon supplemental oxygen, even while resting.
“Emphysema is like breathing in as far as you can and having to live with your chest in that position for the rest of your life,” Dr. Cooper says. “That’s what progressively happens to these patients – their lungs are fully expanded and they can barely breathe.”
Until now, lung transplants offered the only substantial relief for patients with end-stage emphysema. But transplants – which subject patients to a lifetime regimen of antirejection drugs – are risky and used only as a last resort. Moreover, the supply of donor lungs falls far short of the demand. As a result, not all suitable lung transplant candidates can get onto a transplant waiting list, some patients on the list die during the long wait for a suitable donor.
The concept of reducing the size of emphysema patients, lungs to help them breathe more easily is not new. It was first proposed some 40 years ago by the late Otto Brantigan, M.D., a surgeon at the University of Mary- land in Baltimore. Dr. Cooper learned of Dr. Brantigan’s work six years ago from a colleague in Quebec.
In the 1950s, Dr. Brantigan operated on 30 emphysema patients to remove damaged lung tissue. About one in six of the patients died following surgery, Dr. Cooper says, but 75 percent of the survivors claimed they felt better. Leading surgeons, however, dismissed the procedure, because Dr. Brantigan lacked any objective data to demonstrate that patients could breathe more easily following surgery.
Dr. Cooper’s pioneering experience with lung transplants – he is credited with performing the world’s first single- and double-lung transplants – led him to think that Dr. Brantigan may have had a good idea.
Immediately following a lung transplant, an emphysema patient’s over-extended rib cage and flattened diaphragm return to a more normal configuration, Dr. Cooper observed.
While examining emphysema patients’ lungs removed during transplantation, Dr. Cooper also noted that the severity of the disease varied throughout the lung. Removing the most damaged portion of emphysema patients’ lungs could improve overall lung function, he reasoned.
“That gave credence to the notion proposed by Brantigan – that if you can improve the ventilation of patients with severe emphysema, you can improve lung function and relieve their shortness of breath,” Dr. Cooper says.
Initially, Dr. Cooper offered the procedure only to emphysema patients who were too old or otherwise not suited for a lung transplant. After the procedure’s early success, he expanded the criteria to include some emphysema patients who would otherwise qualify for a lung transplant. Only those who had given up smoking entirely were considered for the surgery. Patients who underwent the surgery ranged in age from 37 to 76 years (mean age of 56); 11 patients were male and nine were female.
All patients underwent a six-week lung rehabilitation program before surgery to improve overall health and stamina, which helps to reduce complications afterward. The program includes walking on a treadmill or riding an exercise bike three to five times a week.
The Treatment
In surgery that takes two to three hours, Dr. Cooper and his team begin by ventilating both lungs. Then, working on one lung at a time, they stop ventilation in one of the lungs. Without oxygen, the more normal portions of the lung collapse, while severely damaged areas remain inflated. Dr. Cooper removes the inflated areas. The procedure is carried out on the other lung.
Initially, the procedure was complicated by multiple small air leaks in the lungs following surgery. The staples used to seal off the lungs leave small holes in the fragile lung tissue. Dr. Cooper solved the problem by using thin strips of tissue to buttress the staple line. The tissue is obtained from the strong, leathery pericardium of cows. The bovine tissue has helped to reduce the average hospital stay from 20 days to 13 days.
Dr. Cooper cautions that the surgery does not cure emphysema. “These individuals may continue to experience deterioration from emphysema, but if we can reset the clock by two, three, or five years, maybe more, then we think it will be very worthwhile,” he says.
So far, results have been dramatic. James Henry, 77, of Clarendon, Arkansas, the first patient to undergo the procedure, now plays golf at least three times a week and rides an exercise bicycle every day.
Before the surgery, Henry recalls, “Everything I did was an effort. I could not walk 25 yards to carry the trash to the curb without stopping to sit down. But now, my quality of life is 100 percent.”
Bonnie Gillmore, 49, of Plainville, Massachusetts, was diagnosed with emphysema 15 years ago. She says the surgery has given her a new life.
“Before the surgery, I had to keep my hair short because lifting my hands overhead to wash my hair was exhausting,” says Gillmore, whose emphysema was so severe she had to quit her job as a computer software engineer. “Walking down the block to pick up a newspaper was a major event. Now, I’m doing things I haven’t done in 15 years,” she says. “This operation has definitely given me back my life.”
Of the first 20 patients to undergo the procedure, 14 required supplemental oxygen during exercise or strenuous activities, including five who also required oxygen at rest. Three months following surgery, only two patients need supplemental oxygen during vigorous exercise, one patient requires oxygen at rest.
“Frankly, I hadn’t anticipated that so many of these patients would be able to discontinue oxygen,” Dr. Cooper says. “It was a pleasant surprise.”
While it is too early to determine the long-term effects of the operation, for most patients whose follow-up period has reached six months, lung function has continued to improve. Dr. Cooper has measured patients’ improvement objectively by administering breathing and exercise tests and subjectively by using standard evaluation of quality of life. Consistently, patients report a significant improvement in energy level and physical mobility and a reduction in health problems related to job, housework, social life, and hobbies following surgery.
Dr. Cooper attributes the success of the surgery to the skilled surgeons, anesthesiologists, respiratory therapists, and nurses who all have extensive experience working with lung transplant patients. He predicts that thousands of emphysema patients will undergo the procedure as hospitals assemble skilled surgical and support teams.
Word of the new procedure has spread since Dr. Cooper presented preliminary results in April at the annual meeting of the American Association for Thoracic Surgery. His office has fielded over 1,000 phone calls from patients around the country wanting to learn more.
If the early success of the surgery translates into a long-term benefit for emphysema patients, the procedure may become an alternative to a lung transplant for some patients and a means to postpone transplantation for others.
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