“I just want to be able to take a good, deep breath," says Jim Winiecke.
Winiecke was diagnosed with emphysema in 1999. A smoker for more than 40 years, he immediately quit. By 2007, his respiratory rate was 30 percent; he’s now at 23 percent Finally succumbing to a small can of oxygen as his companion, he anxiously awaits a surgery that could give him those deep breaths he longs for.
Emphysema is one of the most common types of Chronic Obstructive Pulmonary Disease (COPD). COPD took the lives of more than 3 million people in 2011, ranking it as the fourth leading cause of death. Worldwide, it is expected to become the third leading cause of death by the 2030s, according to a 2013 report from the World Health Organization. Stephen Hazelrigg, MD, professor and chief of cardiothoracic surgery along with a team of providers, in partnership with Memorial Medical Center (MMC), offer a life-saving lung volume reduction surgery (LVRS) for those suffering from end-stage emphysema. MMC is one of only six centers in the United States approved by The Joint Commission that provides this innovative surgery.
"We can take someone who can’t breathe well, take part of their lung out and they can breathe better," says Dr. Hazelrigg. "It doesn’t seem to make sense, but it works."Emphysema is a respiratory disease that progressively destroys the lungs by turning the air sacs into large, asymmetrical pockets with gaping holes in their inner walls. It also eliminates the elastic fibers that hold open the small airways leading to the air sacs. The airways collapse upon exhalation and the air in the lungs cannot escape. The lungs then increase in size and push down on the diaphragm, making it difficult to breathe.
"Many of these people are out of options; no other medications can help them," Dr. Hazelrigg says. Most of the patients with end-stage emphysema are very limited in their daily activities. Their breathing is labor intensive at under 30% of normal capacity, and, like Winiecke, they rely on supplemental oxygen. Lung volume reduction surgery is the only surgery known to help patients with end-stage emphysema, and SIU is one of the few places where this surgery is available. Dr. Hazelrigg has performed approximately 500 lung volume reduction surgeries on patients from 13 different states since 1993.
To relieve the stress on the diaphragm, the surgeon makes three small incisions for each lung and removes the most damaged part of the upper lobe of the lung. Removing the damaged areas allows the remaining healthy tissue and surrounding muscles to work more efficiently. Without the damaged area, the lungs shrink down, and the diaphragm can relax and move up and down more easily, so that the patient can breathe better. LVRS typically improves breathing by 40-50 percent. "This is a dramatic improvement in the lives of these patients," Dr. Hazelrigg says.
For Winiecke, even improving his respiratory rate to 40 percent would be a life-changing improvement. "I just want to be able to play golf, do yard work, you know, all those little things, again," Winiecke says. "I can’t lean over with this stuff; just about anything I do, is hard. If I’m going to put shoes on, I put them on, then sit back up. Then I tie them; then rest."
"Prior to LVRS, no surgical options were available to treat patients with emphysema," says Dr. Hazelrigg who averages approximately 15 LVRS surgeries a year.
The surgery has developed from using a laser to remove the diseased portion of the lung to using more precise stapled resections. In the early years of LVRS, patients had two surgeries, one lung at a time, with an approximate three-month wait-time in-between. Today, LVRS involves surgery on both lungs at once.
Approximately 15 percent of end-stage emphysema patients are candidates for LVRS, according to Dr. Hazelrigg.
"Though we’ve done almost the same technique in the surgery for over a decade now, we have gotten smarter about knowing which patients are good candidates for LVRS and better about preparing them for the surgery," says Theresa Boley, APN, CCRP, assistant professor of clinical surgery in the Division of Cardiothoracic Surgery.
Boley is one of the members of a team of 30 providers who oversees the preparation and rehabilitation of each patient and consults on patient progress and eligibility for LVRS. From occupational and physical therapy to cardiovascular and pastoral care, the team works to make sure the patient is in optimal condition for a successful surgery.
The testing is regimented and rigorous. Patients must quit smoking for at least four months and participate in at least 10 weeks of pulmonary rehabilitation before having LVRS. A battery of tests — arterial blood gas, breathing, a six-minute walk and CT scan to name a few — give the team an idea of how to best treat each individual.
"The tests have been the worst part," says Winiecke as he waits to start his walking test. "It’s hard for me to do what they want me to do. I’m used to planning things and stopping as I do them to get my breath."
Relief and breathing improvement varies from person to person. Some patients may feel like they are breathing better during the hospital stay, but typically it takes a few months. Patients report after a month that they are able to do things such as shower more easily or walk through the house without supplemental oxygen. Follow-up tests occur at six and 12 months, with annual tests thereafter.
Peggy Dillow of Effingham, 67, loves the outdoors, but her emphysema kept her from enjoying her time on her small horse ranch or being able to shop out of town with her best friend. "Anything that meant bending over was just out of the question," Dillow says. "I was also afraid someone would see me with my oxygen. I didn’t go out much."
"I know I got a second chance," says Dillow, who underwent LVRS in September 2013. Since her surgery, Dillow bought a rescue horse and spends time outside with him daily. "I believe that there was something magical about that horse and the hope he gave me to get well. We both have been fighting getting better together. I can’t believe now I’m running the sweeper, bending over to pick up sticks and scooping manure — I just love it!"
"It’s so rewarding to work with these patients," says Boley. "Their change is dramatic."
At press time, Winiecke eagerly awaits his surgery, scheduled for early February. "I’m just looking forward to being able to do those things I haven’t been able to do for a while," Winiecke says. Dr. Hazelrigg and his team are just as eager to give emphysema patients like Winiecke the best possible chance of taking that good, deep breath.
Innovation continues to help patients with emphysema
Dr. Hazelrigg and his team began their third clinical trial using a bronchoscopic technique to aid those with severe emphysema. This national study sponsored by Pulmonx Inc. evaluates the Zephyr® endobronchial valve, an investigational, minimally invasive treatment option.
"This study could lead to a less invasive treatment for emphysema for those who can’t have the surgery, resulting in improved patient breathing and quality of life," Dr. Hazelrigg says.
The qualifications for the procedure are the same for LVRS. However, one benefit to the Pulmonx device is that it can be removed if necessary. "Lung volume reduction surgery, on the other hand, is a one-time thing," Boley says. "Operating on the lung causes scar tissue to form between the lung and chest wall, so when you go back in, there’s a real possibility of tearing the lung."
In this study, the endobronchial valve is placed in the diseased part of the lung through a bronchoscope rather than surgically inserted. The tiny valve is designed to allow air to exit the portion of the lung, but blocks new air from entering. The hope is that the diseased portion of the lungs will collapse, allowing the healthy portion to work more efficiently. Relief of the individual’s symptoms will allow them to increase their activity levels and be less reliant on oxygen. "The valves may work in some patients, but they’re not as good as the surgery. At best they may improve breathing by 20 percent, but that’s still relief for the patient," Dr. Hazelrigg says.