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September 20, 2004
Emory Hospital approved for lung surgery

By ERIC RANGUS

Emphysema is a disabling condition that affects approximately 2 million Americans, most of them over age 50, and treatment options are few. Typically caused by cigarette smoking, the disabling and deadly condition costs more than $2.5 billion in annual health care expenses and kills more than 16,000 people in the United States each year, according to a 2001 National Institutes of Health report.

Emory Hospital has been approved by the federal Centers for Medicare and Medicaid Services (CMS) to receive reimbursement for lung-volume reduction surgery as a treatment for emphysema. Currently, only 46 centers in the country are eligible for this reimbursement; now, recipients who meet certain guidelines will have their surgeries covered by Medicare if they are done at Emory Hospital.

Lung-volume reduction surgery (LVRS) is a procedure aimed at targeted areas of severe emphysema in the upper lobes of the lung. Approximately 30–40 percent of each upper lobe is removed.

“This allows the remaining lung to expand, plus it allows the restoration of the normal contour of the diaphragm,” said Joseph Miller, professor and chief of general thoracic surgery in the School of Medicine.
In emphysema patients, the walls between the tiny air sacs in their lungs are damaged. While healthy lungs expand with each inhalation and collapse with each exhalation, helping to move air in and out, lungs damaged by emphysema gradually lose their elasticity.

The airways, normally held open by the elastic pull of the lungs, also become floppy and collapse on exhalation. As a result, patients with emphysema have increasing difficulty moving air in and out of their lungs.

“By reducing the lung size, airways are opened. This allows the breathing muscles to return to a more normal and comfortable position, making breathing easier,” Miller said. “[LVRS] has been shown to improve patients’ quality of life significantly, as they experience less shortness of breath and generally become less dependent on oxygen therapy.

“The surgery is available under rigid, specified guidelines and will probably be open to only about 10–15 percent of the Medicare population with emphysema,” Miller added.

Eligible patients have to meet defined physiological, anatomical and rehabilitation guidelines. Pulmonary function studies and arterial blood gases must fall within specified limits; some can be too good or too poor. Those who do not meet the guidelines might be considered candidates for lung transplant. Individuals also must have disease in specified target zones in upper lobes of the lung and must meet specified rehab requirements, including 30 minutes on the exercise bike or treadmill at certain resistance levels, for 10–12 weeks.

“Patients are tested before they are approved for surgery and then retested immediately prior to surgery,” Miller said of the criteria.

From 1994–97, Emory performed LVRS on 86 patients, the most in the Southeast. The procedure was closed to Medicare patients from 1997 until January of this year.

“During this time, we treated 25–30 [non-Medicare] patients, all with positive outcomes. Now, with the re-emergence of LVRS for Medicare patients, Emory is again prepared to be a national leader,” Miller said.
LVRS was suspended from Medicare coverage because of a lack of sufficient medical evidence supporting the health benefit of the procedure. But the National Emphysema Treatment Trial, a five-year, multicenter, randomized study, provided new evidence regarding the effectiveness, safety and cost-effectiveness of adding LVRS to medical therapy for patients with advanced emphysema.

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