The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on lung volume reduction surgery for advanced emphysema.
Emphysema is a chronic lung disease, whereby walls of the air sacs (alveoli) in the lung weaken and disintegrate, leaving behind abnormally large air spaces that remain filled with air even when the patient breathes out. The most common symptoms of emphysema are shortness of breath (dyspnoea), coughing, fatigue and weight loss. Emphysema often coexists with chronic obstructive pulmonary disease (COPD).
Treatment involves a multidisciplinary approach, which includes education, exercise, breathing retraining, smoking cessation, oral and inhaled medications, oxygen therapy, and lung transplantation. Lung volume reduction surgery may be an option for patients who experience breathlessness, and have pulmonary function tests that show severe obstruction and enlarged lungs.
Lung volume reduction surgery (LVRS) aims to remove the least functional part of the lungs in order to improve airflow, diaphragm and chest wall mechanics and alveolar gas exchange in the remaining portion of the lung. The diseased part of the lung can be accessed by various techniques including median sternotomy, video assisted thoracoscopy (VATS) for unilateral or bilateral surgery, or thoracotomy (unilateral surgery). Median sternotomy involves cutting through the sternum to open the chest. The video assisted procedure involves making a number of small incisions in both sides of the chest to allow the insertion of instruments into the chest between the ribs.
Surgery aims to reduce the volume of each lung by between 20 and 30%. This is done by using a surgical stapling device to cut and seal the tissue, laser ablation to shrink lung volume or a combination of both. Once the tissue has been removed the lung is re-inflated and the chest closed.
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.