Lung Volume Reduction Surgery vs Medical Treatment* For Patients With Advanced Emphysema John D. Miller, MD, FCCP; Robert L. Berger, MD; Richard A. Malthaner, MD, FCCP; Bartolome R. Celli, MD, FCCP; Charles H. Goldsmith, PhD; Edward P. Ingenito, MD, FCCP; David Higgins, MD; Peter Bagley, MD, FCCP; Gerard Cox, MB, FCCP; and Cameron D. Wright, MD, FCCP† Objective: To contribute to the knowledge on the therapeutic value of lung volume reduction surgery (LVRS). Design: Two similar, independently conceived and conducted, multicenter, randomized clinical trials. Setting: The Canadian Lung Volume Reduction (CLVR) study and the Overholt-Blue Cross Emphysema Surgery Trial (OBEST). Methods: Using a fixed-effects meta-analysis, the 6-month results produced by the addition of LVRS to optimal medical therapy were compared to those obtained from optimal medical therapy alone. Patients were required to have severe emphysema, marked airflow limitation (ie, FEV 1 , 15 to 40% predicted), hyperinflation (total lung capacity [TLC], > 120% predicted), CO 2 , < 55 mm Hg, and measurable dyspnea (chronic respiratory disease questionnaire [CRDQ] scores < 4 for the CLVR study, or Medical Research Council dyspnea scale > 1 for the OBEST). Optimal medical therapy included pulmonary rehabilitation in both arms of both studies. Results: The CLVR study randomized 58 patients and the OBEST randomized 35 patients for a total of 93 patients. Of these, 54 patients were randomized to undergo surgery, and 39 patients were randomized to receive medical treatment. The 6-month mortality rate (including operative mortality) in the surgical and medical cohorts was similar (5.6% vs 5.1%, respectively). A comparison of the medical and surgical arms of the combined CLVR study/OBEST population showed that LVRS was associated with a higher FEV 1 (167 mL or 24% predicted; 95% confidence interval [CI], 29 to 304; p  0.017), lower residual volume (1,342 mL or 24.5% predicted; 95% CI, 1,844 to 840; p < 0.001), lower TLC (1,044 mL or 13% predicted; 95% CI, 1483 to 605; p < 0.001), and higher 6-min walk distance (148.8 feet; 95% CI, 24.3 to 273.2; p  0.019). Each domain of the CRDQ showed statistically significant improvement in the surgical arm of the study, but not in the medical arm. The summary physical component scale of the Medical Outcomes Study 36-item short form (SF-36) was also more favorable in the LVRS cohort (6.9; 95% CI, 2.86 to 10.90; p < 0.001). The summary mental component scale of the SF-36 did not show a statistically significant difference between the two groups. Conclusion: Six months after randomization, LVRS produced better palliation than optimal medical therapy in patients with advanced emphysema. (CHEST 2005; 127:1166 –1177) Key words: chronic obstructive lung disease; COPD; emphysema; lung volume reduction; pneumectomy; quality of life; randomized multicentered clinical trial; surgery Abbreviations: CI = confidence interval; CLVR = Canadian Lung Volume Reduction; CRDQ = Chronic Respiratory Disease Questionnaire; DCC = data coordination center; Dlco = diffusing capacity of the lung for carbon monoxide; HUI = health utility index; LVRS = lung volume reduction surgery; 6MWD = 6-min walk distance; NETT = National Emphysema Treatment Trial; OBEST = Overholt-Blue Cross Blue Shield Emphysema Surgery Trial; RV = residual volume; SF-36 Medical Outcomes Study 36-item short form; TLC = total lung capacity T he report by Cooper et al 1 in 1995 on the beneficial influence of lung volume reduction surgery (LVRS) for the treatment of advanced em- physema was followed by enthusiastic utilization of the operation. During the early experience with LVRS, functional results, and operative mortality as well as morbidity had been highly variable. 2 However, as the indications for the procedure and principles of management evolved and became stan- dardized, the results were favorable and relatively 1166 Clinical Investigations Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/22024/ on 04/19/2017