title: Mechanisms of relief of exertional breathlessness following unilateral bullectomy and lung volume reduction surgery in emphysema.
abstract: OBJECTIVE
  To explore mechanisms of relief of exertional breathlessness following surgery to reduce thoracic gas volume in patients with emphysema.
  
  
  METHODS
  We studied 8 patients with emphysema (FEV1 = 39 +/- 3% predicted; residual volume [RV] = 234 +/- 12% predicted; mean +/- SEM) who were severely breathless despite optimal pharmacotherapy and who underwent unilateral bullectomy for giant bullae (greater than one third hemithorax); 4 of these also had ipsilateral lung reduction (pneumectomy). Pulmonary function and cycle exercise performance (n = 6) were evaluated before and 13 +/- 3 weeks after surgery. Chronic breathlessness was measured with the Baseline Dyspnea Index and the Medical Research Council dyspnea scale. Exertional breathlessness was measured using Borg ratings at a standardized work rate (BorgSTD).
  
  
  RESULTS
  FEV1, FVC, and maximal inspiratory pressures increased postsurgery by 29 +/- 7% (p < 0.05), 24 +/- 10% (p = 0.06), and 39 +/- 12% (p < 0.01), respectively. Plethysmographic total lung capacity, RV, and functional residual capacity fell by 14 +/- 2%, 30 +/- 4%, and 18 +/- 3%, respectively (p < 0.001). All measures of chronic breathlessness improved significantly (p < 0.05). During exercise at a standardized work rate, BorgSTD fell 45% (p < 0.05), end-expiratory lung volume (EELV) fell 22% (p < 0.01), and breathing frequency (F) fell 25% (p = 0.08). By multiple stepwise regression analysis, 99% (p = 0.007) of the variance in symptom relief (delta BorgSTD) was explained by the combination of decreased ratio of the end-expiratory lung volume to total lung capacity, decreased F, and diminished mechanical constraints on tidal volume (tidal volume to vital capacity ratio).
  
  
  CONCLUSIONS
  Reduced exertional breathlessness at a given workload after volume reduction surgery was attributed to a combination of reduced thoracic hyperinflation, reduced F, and reduced mechanical constraints on lung volume expansion.
authors.affiliation: Department of Medicine, Queen's University, Kingston, Ontario, Canada.
authors.forename: D E
authors.initials: DE
authors.lastname: O'Donnell
authors.forename: K A
authors.initials: KA
authors.lastname: Webb
authors.forename: J C
authors.initials: JC
authors.lastname: Bertley
authors.forename: L K
authors.initials: LK
authors.lastname: Chau
authors.forename: A A
authors.initials: AA
authors.lastname: Conlan
mesh_terms: D004417:Dyspnea / Q000209:etiology / Q000503:physiopathology*; D005080:Exercise Test; D005260:Female; D005541:Forced Expiratory Volume; D005652:Functional Residual Capacity; D006801:Humans; D008297:Male; D008875:Middle Aged; D011656:Pulmonary Emphysema / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D012115:Residual Volume; D015656:Respiratory Mechanics; D014109:Total Lung Capacity; D014797:Vital Capacity