EFFECT OF LUNG-VOLUME REDUCTION SURGERY ON DIAPHRAGM STRENGTH

Since lung volume reduction surgery (LVRS) reduces end-expiratory lung volume, we hypothesized that it may improve diaphragm strength. We ev aluated 37 patients for pulmonary rehabilitation and LVRS. Before and 8 wk after pulmonary rehabilitation, 24 patients had spirometry, lung volumes, diffusion capacity, incremental symptom limited maximum exerc ise test, 6-min walk test, maximal static inspiratory and expiratory m outh pressures, and transdiaphragmatic pressures during maximum static inspiratory efforts and bilateral supramaximal electrophrenic twitch stimulation measured. Twenty patients (including 7 patients who crosse d over after completing pulmonary rehabilitation) had baseline measure ments postrehabilitation, and 3 mo post-LVRS. Patients were 58 +/- 8 y r of age, with severe COPD and hyperinflation (FEV1, 0.69 +/- 0.21 L; RV, 4.7 +/- 1.4 L). Nineteen patients had bilateral LVRS performed via median sternotomy and stapling, and 1 patient had unilateral LVRS via thorascopy with stapling. After rehabilitation, spirometry and DLCO/V A were not different, and lung volumes showed a slight worsening in hy perinflation. Gas exchange, 6-min walk distance, maximum oxygen uptake ((V)over dot O(2)max), and breathing pattern during maximum exercise did not change after rehabilitation, but total exercise time was signi ficantly longer. Inspiratory muscle strength (PImax, Pdi(max combined) , Pdi(max sniff), Pdi(max), Pdi(twitch)), was unchanged after rehabili tation. In contrast, after LVRS, FVC increased 21%, FEV1 increased 34% , TLC decreased 13%, FRC decreased 23%, and FRCtrapped gas and RV decr eased by 57 and 28%, respectively. PCO2 was lower (44 +/- 6 versus 48 +/- 6 mm Hg, p < 0.003) and 6-min walk distance increased (343 +/- 79 versus 250 +/- 89 m, p < 0.001), as did total exercise time during max imum exercise (9.2 +/- 1.9 versus 6.9 +/- 2.7 min, p < 0.01). Minute v entilation (29 +/- 8 versus 21 +/- 6 L/min, p < 0.001) and tidal volum e (1.0 +/- 0.33 versus 0.84 +/- 0.25 L, p < 0.001) during maximum exer cise increased whereas respiratory rate was lower (28 +/- 6 versus 32 +/- 7 breaths/min, p < 0.02). Measurements of respiratory muscle stren gth (PImax, 74 +/- 28 versus 50 +/- 18 cm H2O, p < 0.002; Pdi(max comb ined), 80 +/- 25 versus 56 +/- 29 cm H2O, p < 0.01; Pdi(max sniff), 71 +/- 7 versus 46 +/- 27 cm H2O, p < 0.01; Pdi(twitch), 15 +/- 5 versus 7 +/- 5 cm H2O, p < 0.01) were all greater post-LVRS. Inspiratory mus cle workload as measured by Pdi TTI was lower following LVRS (0.07 +/- 0.02 versus 0.09 +/- 0.03, p < 0.03). On multiple regression analysis , increases in PImax correlated significantly with decreases in RV and FRCtrapped gas after LVRS (r = 0.67, p < 0.03). We conclude that LVRS significantly improves diaphragm strength that is associated with a r eduction in lung volumes and an improvement in exercise performance. F uture studies are needed to determine the relationship and stability o f these changes over time.