Nghiên cứu ứng dụng phẫu thuật nội soi cắt giảm thể tích phổi điều trị bệnh phổi tắc nghẽn mạn tính tt tiếng anh

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INTRODUCTION TO THE THESIS
QUESTION
Chronic obstructive pulmonary disease (COPD) is a global health
problem, and it is estimated that by 2020, COPD will be ranked 5th
in terms of disease burden and 3rd in mortality [1]. Emphysema is
one of the main physiological disorders of COPD. Emphysema
causes shortness of breath due to limited air flow, pulmonary
relaxation and reduced alveolar surface area.
The treatment of chronic obstructive pulmonary disease is still
primarily internal medical. With the development of science and
technology and anesthesia resuscitation in lung volume reduction
treatment in patients with COPD with severe emphysema has good
results. The principle of lung volume reduction treatment is to decrease
the mismatch between the chest and the lung volume, increase the
elasticity of the lungs and reduce airway resistance. Therefore, this
treatment method helps patients improve air flow, corresponding activity
between the respiratory muscles and the remaining lung parenchyma
leading to improve symptoms, reduce the number of flares and improve
the patient life quality with COPD [2].
At present, there are two main groups of lung volume reduction
treatment: lung volume reduction surgery and lung volume reduction
through bronchoscopy. Lung volume reduction surgery for patients
with COPD with severe emphysema has been successfully
implemented since the late twentieth century. The results of the
studies in lung volume reduction surgery have proved effective for
COPD with severe emphysema with low rates of complications and
technical complications [3], [4].
Lung volume reduction surgery is to remove the major
pulmonary emphysema in symptomatic treatment for patients with
COPD. This surgery removes at least 20-30% of the volume of one

or two lungs (in some cases, a whole lobus pulmonis or one lung is
removed), which is usually the top of the lung and it is carried out


2
with the thoracic opening along the middle sternum or lateral thoracic
or total laparoscopic surgery [5].
1. Research objectives:
In Vietnam, lung volume reduction surgery in patients with
COPD with severe emphysema has been successfully implemented at
the Thoracic Department, 103 Military Hospital in Vietnam Military
Medical University since 2014. However, research and application of
this method have not yet been systematically conducted.
Stemming from the above practice, we conduct research on the
subject: "Application of laparoscopic surgery in lung volume
reduction to treat COPD" with two following objectives:
- Comment on some clinical and subclinical characteristics of
COPD with severe emphysema which is cured by laparoscopic
surgery to reduce lung volume.
- Assess the results of treatment of chronic obstructive
pulmonary disease with severe emphysema by laparoscopic surgery
to reduce lung volume.
2. New contributions of the thesis
From the results of the clinical, subclinical characteristics study
and the effectiveness of lung volume reduction surgery for patients
with COPD, who have severe emphysema, we have the new
following contributions:
2.1. Comment on some clinical and subclinical characteristics in
patients with COPD with severe emphysema who have indicated
laparoscopic surgery to reduce lung volume.

- All 31 study patients were male, with an average age of 66,16 ±
5,62 years. The average disease duration of all patients was 6,65 ±
3,88 years. Majority of the patients have had the disease for less than
10 years (96,77%).
- All patients in the study had history of smoking, with prolonged
smoking time (average of 30,29 ± 8,62 years) and average-cigarette
packet-of-year index of 30,94 ± 12,32 packets per year.
- Body mass index (BMI) average is 20,46 ± 3,03 kg / m²;
- The number of outbreaks in a year is 3,13 ± 0,72 times.


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- The average mMRC score is 2,35 ± 0,98 points.
- Average CAT score is 19,00 ± 6,06 points, there are 83,87% of
patients with CAT ≥ 10.
- Average 6-minute walking distance is 293,90 ± 70,79 meters.
- Computerized tomography of the chest:
+ Severe emphysema in the right lower lung lobe reaches high
proportion (83,87%), emphysema entire lobes reaches 74,19%, only
1 patient (3,23%) has a sludge balloon with emphysema in whole
lobes and emphysema by the wall.
+ The average emphysema score is 2,67 ± 0,83 points
- Respiratory function:
+ The average value of VC, FVC and FEV1 are respectively
87,90 ± 21,91% predicted; 85.77 ± 20.00% predicted and 52.00 ±
18.71% predicted.
+ The average value of RV, TLC and Raw are respectively
213,84± 76,16% predicted; 140.61±21.03% predicted and 8,49±5,39
cmH2O/liter/ second.
- Arterial blood gases:

+ There were 48,39% of patients with decreased PaO 2 and
22,58% of patients with increased PaCO2 in arterial blood.
+ There were 6 patients (19,35%) with respiratory failure.
2.2. Results of treatment of chronic obstructive pulmonary disease by
lung volume reduction surgery
- Out of the 31 patients who were treated by lung volume
reduction surgery, there were 23 patients (74,19%) received
supportive laparoscopic surgery. Only 8 patients (25,81%) had
complete laparoscopic surgery.
- Average surgery time is 92,74 ± 23,69 minutes.
- Average weight of lung reduced is 31,09 ± 6,35 grams.
- The average time for drainage of pleural cavity is 4,87 ± 4,27
days.
- There were no deaths to 6 months after surgery.


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- Clinical changes at 1 month, 3 months and 6 months after
surgery: CAT scores, mMRC and average 6-minute walking distance
of the surgical group are improved better than that before surgery.
- Changing computerized tomography: emphysema scores tend to
decrease after surgery at the track time.
- Change in respiratory function:
+ VC, FVC and FEV1 increased statistically at the time of 1
month, 3 months and 6 months after surgery compared to before
surgery.
+ Average values of RV, TLC and Raw decreased after surgery.
3. The layout of the thesis
The thesis consists of 149 pages, in addition to the question,
conclusions and recommendations, the thesis includes 4 parts:

chapter 1- Document overview: 36 pages, chapter 2- Objects and
research methods: 23 pages, chapters 3- Research results: 29 pages,
chapter 4- Discussion: 26 pages. The thesis has 45 tables, 9 pictures,
12 charts. The thesis uses 121 references.


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CHAPTER 1: DOCUMENT OVERVIEW
1.1. Clinical characteristics of COPD
The main symptom is shortness of breath, persistent shortness of
breath.
Coughing chronic phlegm, increasing. At first often sputum less,
mucous sputum. During an outbreak, the number of sputum
increases, changing both color and properties.
Wheezing and a feeling of suffocation are often nonspecific and
change over time [18], [19].
- Respiratory symptoms:
+ Breathing frequency increases, then exhales for a long time,
contracting the secondary respiratory muscle such as concave
withdrawal on the breast, the intercostal space and the puncture on
the lash.
+ Stretched chest, barrel shape, wide cavity space. Pulmonary
echoes, vibration reduction and alveolar murmur reduction [18].
- Cardiovascular symptoms:
+ Symptoms of chronic heart failure and right heart failure such
as hepatomegaly, lower extremities edema, floating neck veins.
+ Chronic heart failure, heart failure may be up to 30%
1.2. Subclinical characteristics of COPD
1.2.1. X-ray image of the lung
- Image of blood vessel transformation: Sparse peripheral

pulmonary artery, decreased blood vessel size, and a rapid decrease
in the smoothness of blood vessels.
- Pictures of lung relaxation:
+ The diaphragm arch is lowered, the ribs space widens, the
morning space is wide.
+ In case of severe emphysema, the diaphragm dome can be
reversed, the heart is in the shape of water droplets and suspended on
the diaphragm dome. Cardiac/thoracic index <½[18].
- Image of air bubbles: usually focused on the top or bottom of
the lungs, images of the light areas with diameter> 1cm [22].


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1.2.2. Computerized tomography of emphysema
- Emphysema of the center of small lobes: small spots or lights of
a small size, clearly defined and reduced in intensity. Emphysema
spaces located in the center of the lobules, around the central artery
of the secondary lobes, are not directly in contact with the visceral
pleura or bronchial components and blood vessels of the lobes, subsegment and often predominate in the high areas on both sides of the
lung.
- Emphysema of the entire lobes: Large air chambers with no
clear limits and loss of central lobes of the arteries. The image of the
"black lung" is uniform, diffuse, homogeneous, the blood vessels are
sparse and often focus on the lower lobes on either side or the whole
lung. Lesions are often heterogeneous.
- Emphysema adjacent to the wall: The emphysema is located at
the periphery, there is a limited localization in the pleura or in contact
with the interstitial tissue around the blood vessels bronchus, the thin
edge corresponds to the inter-lobar septum.
- Air bubbles: are the emphysema with clear boundaries,

diameter ≥ 1 cm, thin wall <1mm [26].
1.2.3. Probe for respiratory function
Patients with chronic obstructive pulmonary disease have
irreversible or incomplete obstructive obstructive ventilation
disorders [28],[29].
Closed volume (CV) is the volume of lung when the airway starts
to close. In COPD, CV increases. Normal CV < 5% VC.
The diffusion ability and CO diffusion factor (kCO) are reduced.
1.2.4. Arterial blood gases
The reduction of PaO2 in COPD is mainly due to alveolar
hyperventilation and imbalance between ventilation and circulation.
In severe exacerbations, decreased PaO2 and increased PaCO2 can
lead to acute respiratory failure [18], [34].
1.3. Treatment of COPD
1.3.1. Medical treatment


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* Drug treatment
- The goal of treatment:
Relieving symptoms, preventing disease progression, increasing
mobility, increasing health, preventing and treating complications,
preventing and treating exacerbations, reducing mortality.
- The main medications used in COPD patients are:
bronchodilators; antibiotics: Effective against bronchopulmonary
infections, commonly used broad-spectrum antibiotics, coordinated
in 7-10 days; expectorant: Or use group containing active ingredient
N - acetylcysteine; Respiratory stimulants, pulmonary vasodilators,
medications for heart failure ...
* Respiratory support measures

- Long-term oxygen breathing
Maintain SaO2 reaching 88-92%, check arterial blood gas after
30-60 minutes.
- Non- invasive mechanical ventilation
- Invasive mechanical ventilation
1.3.2. Endoscope methods of lung volume reduction treatment of
chronic obstructive pulmonary disease
- Lung volume reduction treatment by bronchial node
Lung volume reduction treatment by bronchial node makes the
lung quickly collapse due to obstructing the drainage bronchus, but
the effect is low lung volume. Currently, this measure is rarely used
because there is often a displacement.
- Lung volume reduction treatment by twisted wires
Through bronchoscope, twisted wires are inserted into the
bronchus of segmental lobes to the lung parenchyma. Twisted wires
clog up the drainage bronchial in severe emphysema, causing the
collapse of lung.
- Lung volume reduction treatment by glue
Through bronchoscope, colloidal substances are put into the
bronchus in emphysema areas and destroyed lung areas, causing an
inflammatory reaction that causes scarring and the formation of
fibrous tissue, effectively reducing lung volume [4]


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- Lung volume reduction treatment by heat
The principle of lung volume reduction treatment by heat is that
the high-temperature steam through endoscope is put into the
bronchus leading to the emphysema area, causing inflammatory
lesions and fibrosis bronchus, leading to lung lobes with emphysema

collapsed [39].
- Lung volume reduction treatment by creating airway bridges
The principle of the technique for lung volume reduction
treatment by creating airway bridges is to use the Doppler ultrasound
probe to locate the blood vessels then locating the bronchus which
does not close to the blood vessels to poke the needle through the
bronchial wall and widen by balloon to create bladder ventilation.
The bronchial stent is put into the severe emphysema area to create
an extra airway, leaving the gas out of the severe emphysema area.
- Lung volume reduction treatment by a one-way valve
The principle of lung volume reduction treatment by a one-way
valve is that through bronchoscope, a one-way valve is put into the
bronchus in the severe emphysema area. One-way bronchial valves
open for air to pass in at second stage of breathing and close at
inspiration. Therefore, the lung corresponding to the bronchial branch
will be collapsed, reducing lung volume, making normal tissue and
respiratory muscles work.
1.3.3. Surgical treatment for chronic obstructive pulmonary
disease
* Lung volume reduction surgery
Lung volume reduction surgery has been used for few decades,
but it is a high-risk surgery so there are still many issues that need to
be further studied. These include: the choice of optimal designation,
which surgical method is appropriate, how much lung volume is
sufficient, the long-term outcome of surgery and the physiological
function of the remaining lung.
- Designation of bilateral lung volume reduction surgery [5]:
+ Clinical symptoms of emphysema do not respond or respond
little to aggressive medical treatment.

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+ Medical history and / or current examination meet enough
diagnosis criteria for COPD based on GOLD criteria 2015: FEV1 /
FVC <0.7 (after using bronchodilator).
+ Excessive lung strain on standard X-ray.
+ High resolution chest CT scan: dominant emphysema lesions
on one lung lobe
+ TLC ≥ 100% of the theoretical value after using
bronchodilators and before respiratory rehabilitation
+ RV ≥ 150% of the theoretical value after using bronchodilators
and before respiratory rehabilitation.
+ No smoking within 4 months.
- Designation single lung volume reduction surgery [5], [54].
Similar to the designation for bilateral lung volume reduction
surgery but the following criteria are added:
+ Emphysema is asymmetric, dominant on one side.
+ Inflammation of the pleura on the posterior side after disease or
interventions in the chest.
+ Unstable hemodynamics, large air leaks during lung volume
reduction surgery on the chest side that was done before.
- Contraindications
Studies generally suggest that contraindications of lung volume
reduction surgery include [5], [55]:
+ Large cocoon: diameter of cocoon is more than 5cm.
+ Bronchiectasis, sputum> ½ cup / day.
+ Pulmonary hypertension: > 45mmHg on echocardiography.
+ Arterial blood gases: PCO2> 60mmHg at room condition.
+ Daily use> 20mg prednisolon.
+ Patients at high risk group when having lung volume reduction

surgery according to NETT standards, if there is at least one of the
following criterias:
. ≥ 75 years old.
. FEV1 ≤ 20% of the theoretical value.
. DLCO ≤ 20% of theoretical value.


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. Emphysema diffuses uniformly in both lungs on high resolution
chest computerized tomography.
+ Thick pleural adhesion associated with previous chest opening.
+ Thick adhesion pleural associated pleural diseases which exist
before.
+ Patients in high-risk group when opening the chest.
Surgical methods to reduce lung volume
- Surgery by opening along the middle of the breastbone
- Endoscope surgery on both sides through the front chest
incision
- Endoscope surgery through lateral chest incision


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CHAPTER 2: SUBJECTS AND METHODS OF RESEARCH
2.1. Research subjects
Including 31 patients diagnosed with COPD with severe
emphysema who were treated at the Department of Thoracic Surgery,
Military Hospital 103 from 2013 to 2018. Patients were assigned
laparoscopic surgery to reduce lung volume, monitoring and
evaluation after surgery following a uniform procedure
Diagnosis and identification of COPD according to GOLD

standards (2013) [1]:
The diagnosis of COPD has severe emphysema as standard:
+ Shortness of breath on exertion, often and gradually.
+ The body is thin, the chest is tight, knocking, vibration is
reduced, whispering alveoli sharply decreases.
+ Standard lung X - ray: Pulmonary picture brightened, sparse
pulmonary vascular network, flat diaphragm arch and teardropshaped heart.
+ Computerized tomography of the thoracic region: the area of
the lung parenchyma increased in intensity below the threshold - 950
HU.
Indications for surgery to reduce lung volume according to
NETT (2011) [55]:
- Patients with stable COPD.
- The patient has quit smoking for more than 4 months.
- BMI <31.1 in five males and <32.3 in females.
- PaCO2 ≤ 60 mmHg and PaO2 ≥ 45 mmHg.
- Computerized tomography with severe emphysema.
- RV ≥ 150% compared to theory, TLC ≥ 100% compared to
theory.
- Left ventricular systolic function on echocardiography > 45%.
* Exclusion criteria:
General exclusion criteria
- The patient currently has other respiratory diseases: tuberculosis


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- Patients with contraindication to measuring lung function: new
myocardial infarction, pulmonary embolism, pneumothorax, severe
heart failure, limited cognitive noncooperation …[64].
- Exclusion criteria according to NETT (2011) include [55]:

- The patient refused to join the research team.
2.2. Research Methods
- Study design: Conductive research, controlled longitudinal
follow-up.
- Sample selection: From patients with COPD who have severe
emphysema, indicated for surgery to reduce lung volume.
2.3. Processing and analyzing data
Enter data into Excel software.
Data processing using SPSS 20.0 software.
The difference was statistically significant when p <0.05. Find
the correlation by Pearson correlation.
2.4. Research ethics
Patients are selected according to treatment indications and
voluntarily participate
Data of research patients are guaranteed confidentiality.
Lung volume reduction surgery for treatment of COPD with
severe emphysema has been approved by the Medical Ethics Council
of Military Hospital 103.


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CHAPTER 3: RESEARCH RESULTS
3.1. Clinical and subclinical characteristics of research subjects
3.1.1. Clinical characteristics of research subjects
All 31 study patients were male, with an average age of 66.16 ±
5.62 years. The oldest patient is 74 years old and the lowest is 55
years old.
The average duration of infection in all patients studied was 6.65
± 3.88 years. Most patients have the disease for less than 10 years
(96.77%). The rate of patients infected> 10 years is only found in

3.23% of patients.
All patients in the study had a high smoking history, with a long
smoking period (average of 30.29 ± 8.62 years) and average-year-onyear index of 30.94 ± 12.32 bags /year. All 31 patients quit, with an
average quit time of 8.52 ± 7.44 years, of which patients quit 1 year.
The average 6-minute walking distance is 293.90 ± 70.79 meters;
On average, there are 3.13 ± 0.72 outbreaks in 1 year.
The body mass index (BMI) averages 20.46 ± 3.03 kg / m²; in
which the majority of patients were in average condition (19 patients,
accounting for 61.29%); Only 2 patients (6.45%) were obese.
Table 3.1. Characteristics of systemic symptoms
Symptom
Number (n = 31)
Rate (%)
Chest barrel
16
51,61
Pneumothorax
1
3,23
Absorption of respiratory
12
38,71
muscles
Purple skin, mucous
1
3,23
membranes
Phew
5
16,13

Chest barrel is the main symptom of the study patient
(accounting for 51.66%), only 1 patient (3.23%) manifested skin,
mucous membranes. The average CAT score was 19.00 ± 6.06
points, of which the lowest patient was 8 points and the highest was
27 points.


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The average mMRC score in all patients studied was 2.35 ± 0.98
points, of which the lowest mMRC score was 1 point and the highest
was 4 points.
3.1.2. Subclinical characteristics of researched patients
Emphysema of the entire lobes alone accounts for the major
proportion (23 patients, 74.19%), only 1 patient (3.23%) has
emphysema combined with emphysema of the entire lobes and
emphysema sagging by the wall.
The average values of respiratory indicators VC, FVC and FEV1 are
87.90 ± 21.91%, respectively; 85.77±20.00% and 52.00 ± 18.71%. The
Gaensler index averages 56.13 ± 15.41%, the lowest of 14% and the
highest of 87%.
The average value of RV is 213.84±76.16% SLT and Raw is
8.49±5.39 cmH2O/liter/sec, corresponding to the increase in severity.
However, the average value of the TLC index increased at an average
level (140.61± 21.03% ).
Table 3.3. Values for arterial blood gas parameters
Index
Min
Max
X´ ± SD
PaO2 (mmHg)

81,55 ± 10,66
55
99
PaCO2 (mmHg)
39,87 ± 6,41
30
53
SaO2 (%)
95,29 ± 2,91
84
98
pH
7,39 ± 0,06
7,23
7,46
The mean values of active PaO2 and PaCO2 were 81,55±10,66
mmHg and 39,87±6,41mmHg, respectively. There were 15 patients
(48.39%) reduced arterial blood O2 but only 7 patients had arterial
hyper CO2.
Total lung capacity (TLC) was positively correlated with the
emphysema, the correlation was statistically significant (p <0.05).
There was no statistically significant correlation between
emphysema and arterial blood gas parameters (p> 0.05).
3.2. Surgical results
Table 3.4. Surgical method
Surgical method
Number (n = 31)
Rate (%)
Endoscopy support
23

74,19
Complete endoscopy
8
25,81


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Among 31 patients who had lung volume reduction surgery, 23
patients (74.19%) received supportive laparoscopic surgery. Only 8
patients (25.81%) had complete laparoscopic surgery.
The average surgery time was 92.74 ± 23.69 minutes, of which the
shortest was 60 minutes and the longest was 150 minutes. Both are
found in supportive laparoscopic surgery.
The average reduction in lung volume was 31.09 ± 6.35 grams, at
least 20 grams and a maximum of 54 grams.
3.3. Follow-up results after surgery
At 1 month postoperatively, CAT scores, mMRC scores
decreased significantly (p <0.05) compared to before the surgery,
with an average reduction of 1.97 ± 1.56 points and 0,52 ± 1.26
points.
The 6-minute walking distance for the 1-month follow-up period
increased from 293.90 ± 70.79 meters to 314.00 ± 72.24 meters, with
an average increase of 20.10 ± 39.84 meters (p <0.001). At the time
of 3-month follow-up, from 293.90 ± 70.79 meters to 330.74 ± 67.84
meters (p <0.001), with an average increase of 36.84 ± 42.19 meters,
of which 17 patients (54.84%) increased by 26 meters.
Body mass index (BMI) at 3 months after surgery tended to
increase, with an increase of 0,53 ± 1,67 kg /m2.
CAT scores at 3 months after surgery decreased significantly
compared to before surgery (p<0,001) (14,71±5,20 points compared

to 19,00±6,06 points). 100% of patients with CAT score at 3 months
decreased ≥ 2 points (mean reduction of 4,29 ± 1,83 points).
Evaluation at 3 months, 6 months after surgery compared with 1
month after surgery, scores of CAT and mMRC decreased
significantly (p<0,05). Meanwhile, the 6-minute walk distance
increased significantly (p<0,001).
At the time of follow-up 1 month after surgery, the emphysema
decreased from 2,67±0,83 points to 1,61±0,54 points, with an
average decrease of 1,06 ± 0,44 points (p<0,001). Emphysema
decreased from mainly patients with grades 3 and 4 before surgery
(38,71% of degrees 3 and 45,16% of degrees 4) decreased to mainly


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patients with grade 2 (20 patients, accounting for 64,52%). The
decrease is statistically significant (p <0,001).
Comparing at 1 month, 3 months and 6 months after surgery to 1
month after surgery, the parameters of VC, FVC and FEV1 increased
statistically (P1-3, P1-6 <0,05 ).
At the time of monitoring 3 months after surgery, there were 22
patients (70,97%) with increased VC; 25 patients (80,65%) increased
FVC and 22 patients (70,97%) increased FEV1. Only 9 patients
(29,03%) decreased VC; 6 patients (19,35%) decreased FVC and 9
patients (29,03%) decreased FEV1. In no case did not change the
indicators VC, FVC and FEV1.
FEV1 compared to before surgery at the time of monitoring mainly
increased, the increase tended to (17 patients (54,84%) at 1 month, 22
patients (70,97%) at the time of 3 months and 24 patients (77,42%) at 6
months.
At the time of follow-up 1 month after surgery, the volume of

residual gas (RV), total lung capacity (TLC) and airway resistance
(Raw) were all reduced compared to before surgery. The level of
reduction is statistically significant (p <0,05).
Table 3.39. Change of the volume parameters after surgery
Parameter
After 1
After 3 month After 6 month
(
± SD) month
p
(% SLT)
RV
163,90 ± 163,32 ± 49,44 162,52 ± 48,74 P1-3 > 0,05
56,20
P1-6 > 0,05
Change
- 0,58 ± 69,25
- 1,39 ± 69,54
TLC
122,55 ± 117,10 ± 16,89 119,61 ± 17,85 P1-3 > 0,05
17,10
P1-6 > 0,05
Change
- 5,45 ± 20,41
- 2,94 ± 20,47
Raw
6,06 ±
(cmH2O/
5,27 ± 4,51
4,39 ± 4,05

P1-3 < 0,001
4,06
liter/second)
P1-6 < 0,001
Change
- 0,79 ± 3,57
- 1,67 ± 3,62
At the time of monitoring 3 months, 6 months after surgery, the
volume of residue gas (RV) and total lung capacity (TLC)
decreased compared to the time of 1 month after surgery, but the

X


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reduction was not statistically significant (p>0,05). Meanwhile,
airway resistance decreased significantly compared to 1 month after
surgery (P1-3 <0,001; P1-6 <0,001).
At the time of follow-up 3 months after surgery, 77,42% of
patients have decreased RV; 80,65% of patients with TLC reduction;
83,87% of patients decreased Raw. In no case does not change RV,
TLC and Raw.
The degree of change in residue gas volume (RV) at the time of
monitoring was mainly reduced (83,87% decreased at 1 month,
77,42% decreased at 3 months and 74,19% decreased at 6 months).
Table 3.44. Changes in arterial blood gas parameters after
surgery
Parameters
After 1 month After 3 month After 6 month
p

(
± SD)
PaO2 (mmHg)
84,23 ± 9,66
87,94 ± 11,23
92,65 ± 5,70 P1-3 < 0,05
Change
3,71 ± 10,62
8,42 ± 10,31 P1-6 < 0,05
PaCO2
38,29 ± 5,41
38,45 ± 5,27
36,10 ± 4,95
P1-3 > 0,05
(mmHg)
P1-6 > 0,05
Change
0,16 ± 6,48
- 2,19 ± 6,06
SaO2 (%)
94,03 ± 9,41
95,16 ± 9,47
96,87 ± 1,75 P1-3 > 0,05
P1-6 > 0,05
Change
1,13 ± 13,40
2,84 ± 9,54
The arterial blood gas parameters at 3 months, 6 months
compared to 1 month after surgery, only PaO2 increased statistically
significant (p <0,05); while the reduction of PaCO2 and increase of

SaO2 was not statistically significant (p> 0,05).

X


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CHAPTER 4: DISCUSSION
4.1. Clinical and subclinical characteristics of research subjects.
All 31 study patients were male, with an average age of 66,16 ±
5,62 years. The oldest patient is 74 years old and the lowest is 55
years old. Distributed by age group in 31 patients, the group of 60-69
years old accounted for the highest proportion (41,94%), followed by
the age group> 70 accounting for 38,71% and the age group 50 - 59
accounted for 19,35%. This result is completely consistent with
previous studies.
4.1.1. Characteristics of time of illness
The average duration of infection in all patients studied was 6.65
± 3.88 years. Most patients have the disease for less than 10 years
(96.77%). The rate of patients infected> 10 years is only found in
3.23% of patients.
There is a difference in duration of illness in our patient group
with other authors.
4.1.2. Smoking characteristics
All 100% of patients had a history of smoking. The average
smoking time is 30,29 ± 8,62 years. All 31 patients quit, with an
average quit time of 8,52 ± 7,44 years. The average number of
cigarettes smoked per year was 30,94 ± 12,32 cigarettes / year,
patients smoked less. especially 10 bags/year, patients smoke up to
60 bags / year.
4.1.3. Clinical characteristics

The body mass index (BMI) averages 20,46 ± 3,03 kg / m².
Among the studied patients, only 1 patient (3,23%) had purple
skin and mucous membranes. There were 16 patients (51,61%) of
chest box shape. Expression of respiratory muscle contraction was
found in 12 patients (38,71%). Shortness of breath is seen in 100% of
patients. The average 6-minute walk distance was 293,90 ± 70,79
meters, the shortest was 197 meters and the longest patient was 440
meters.


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The average number of outbreaks in 1 year was 3,13 ± 0,72
times, in which patients had at least 2 times and patients had at most
4 times.
4.1.4. Subclinical characteristics of COPD patients with severe
emphysema
* Emphysema characteristic on chest computed tomography image
- Classification of emphysema on computerized tomography
The research results out of 31 patients with COPD, 74.19% of
emphysema of the entire lobes alone, 22.58% of emphysema of the
entire lobes combined with parietal emphysema. Only 1 patient
(3.23%) of emphysema had a combination of emphysema.
* Respiratory function characteristics in study patients
- Change living capacity, live breath volume, and maximum
exhalation volume within the first second
The results show that the average value of VC and FVC
decreases, in which FVC decreases more than VC. Maximum
exhaled volume in the first second (FEV1) decreased significantly:
on average 52,00 ± 18,71% SLT. The PEF decreased significantly,
averaging 50,87 ± 15,82% SLT. Gaensler index decreased a lot,

averaging 56,13 ± 15,41%
- Classification of airway obstruction: The degree of airway
obstruction is graded based on GOLD 2013, most patients in stage II
(51,61%).
- Changes in sludge volume and total lung capacity: Research results
indicate that the average value of RV is 213,84 ± 76,16%. The
average value of TLC is 148,13 ± 43,34%. Thus, the average value of
RV increases in severity while the average value of TLC increases in
moderation.
- Changing airway resistance
Most patients had increased airway resistance with an average
of 8,49 ± 5,39 cmH2O/liter/sec. According to the classification of
the increase in airway resistance, 12 patients (38,71%) increased the
severity of the resistance; 11 patients (35,48%) increased moderate
airway resistance. Only 2 patients (6.45%) did not increase airway
resistance.
* Change arterial blood gas parameters
The results of arterial blood gas study showed that there was a
decrease compared to normal of average value of PaO2 (81,55 ±


20
10,66 mmHg). In contrast, the average value of PaCO2 is at the
high limit of the normal value (39,87 ± 6,41 mmHg). The average
value of SaO2 and arterial blood pH within normal limits. There
were 48,39% patients with O2 and patients with arterial hyper CO2
accounted for 22,58%.
* Correlation between levels of emphysema on computerized
tomography and arterial function parameters and arterial blood
gases

Between the emphysema with VC and FVC, the inverse
correlation is weak. However, this correlation is not statistically
significant (p>0,05). FEV1 was inversely correlated with the weak
emphysema (p<0,05). MVV is positively correlated with the
emphysema (p <0.05). There was no statistically significant
correlation between emphysema and arterial blood gas
parameters (p> 0.05).
4.2. The result of surgery to reduce lung volume
4.2.1. Surgical method
Among 31 patients with lung volume reduction surgery, 23
patients (74,19%) had laparoscopic surgery. Our research results are
similar to other authors.
4.2.2. Locations of emphysema assessed during surgery
Studying the location of emphysema during surgery we
determined the right lower lobe is the most prominent emphysema
with 21 patients (67,74%).
4.2.3. Surgical time
The average surgery time was 92,74 ± 23,69 minutes, the shortest
was 60 minutes, the longest was 150 minutes, both were in the
supportive laparoscopic surgery group. Our surgery time is similar to
other authors.
4.2.4. Lung volume is reduced
The average reduction in lung volume was 31,09 ± 6,35 grams, at
least 20 grams and a maximum of 54 grams. We use cross section
with stapler. Depending on the status of the lung parenchyma, the
degree of collapse of the lung with a specific lung density will vary.
Relatively equivalent to the average right lung volume of Vietnamese
people about 150 grams, the right lung volume was reduced by
24,6%
4.2.5. Characteristics of drainage of pleural cavity

21
The average time for drainage of pleural cavity is 4,87 ± 4,27
days, the shortest for 2 days, the longest for 21 days. In which, the
first 24-hour drainage volume averages 160,61 ± 63,47 ml, at least
90 ml and at most 400 ml. Our pleural drainage time is shorter than
the results of other studies.
4.2.6. Time for mechanical ventilation and positive resuscitation
Our study found that the average mechanical ventilation time was
19,13 ±5,31 hours, the shortest was 12 hours and the longest was 36
hours. The average time of intensive resuscitation treatment was 30,19
± 10,22 hours, the shortest was 12 hours and the longest was 48 hours.
4.3. Medium-term results
4.3.1. Clinical changes after lung volume reduction surgery
Results of postoperative follow-up at 3 months with clinical
improvement. The CAT score decreased significantly from 19,00 ±
6,06 points to 14,71 ± 5,20 points (p <0,001). The walking distance
for 6 minutes increased significantly, from 293,90 ± 70,79 meters to
330,74 ± 67,84 meters (p <0,001). Expressed by 17/31 patients
(54,84%) with 6-minute walking distance increased by 26 meters.
The improvement in clinical symptoms was also shown at the mMRC
score, which decreased from 2,35 ± 0,98 points to 1,39 ± 0,88 points,
the reduction was statistically significant (p <0,001).
4.3.2. Changes in postprandial emphysema score and level
compared to before surgery
At the time of follow-up 1 month after surgery, the emphysema
decreased from 2,67±0,83 points to 1,61±0,54 points, with an
average decrease of 1,06±0,44 points (p <0,001). Emphysema
decreased from mainly patients with grades 3 and 4 before surgery

(38,71% of degrees 3 and 45,16% of degrees 4) decreased to mainly
patients with grade 2 (20 patients, accounting for 64,52%). The
decrease is statistically significant (p<0,001). However, comparing
the time after surgery 3 months, 6 months to 1 month after surgery,
the KPT score tends to increase (2,19 ± 0,62 points at the time of 3
months and 2,41 ± 0, 61 points at 6 months against 1,61 ± 0,54
points, the increase is statistically significant (p <0,001).
4.3.3. Changes in respiratory function and volume after surgery
* Changes in respiratory function after surgery
At the time of follow-up 1 month after surgery, the indicators VC,
FVC and FEV1 increased significantly compared to before surgery


22
(p<0,001). Comparing at 3 months, 6 months after surgery to 1 month
after surgery, the parameters of VC, FVC and FEV1 increased
statistically (P1-3, P1-6 <0,05). In no case did not change the
indicators VC, FVC and FEV1.
* Volume change after surgery to reduce lung volume
At the time of follow-up 1 month after surgery, the volume of
residual gas (RV), total lung capacity (TLC) and airway resistance
(Raw) were all reduced compared to before surgery. The decrease
was statistically significant (p<0,05). At the time of monitoring 3
months, 6 months after surgery, the volume of residual gas (RV) and
total lung capacity (TLC) decreased compared to time 1 months after
surgery, however, the decrease was not statistically significant (p>
0,05).
As such, surgery to reduce the volume of the lungs reduces the
volume of room air and airway resistance. The total lung capacity
decreases depending on the amount of lung removed.

4.3.4. Arterial blood gas changes after surgery to reduce lung
volume
At the time of follow-up 1 month after surgery, the level of PaO2
increase was not statistically significant compared to before surgery (p>
0,05). However, the reduction of PaCO2 compared with before surgery
was statistically significant (p<0,05). At the time of postoperative followup most patients have increased PaO2. The arterial blood gas parameters
at 3 months, 6 months compared to 1 month after surgery, only PaO2
increased statistically significant (p <0,05); while the reduction of PaCO2
and increase of SaO2 was not statistically significant (p> 0,05).


23
CONCLUDE
1. Clinical and subclinical characteristics of COPD patients with
severe emphysema
+ All patients studied were male with an average age of 66,16±5,62
years.
+ All patients have a history of smoking, the index of years-year
high is 30,94 ± 12,32.
+ Low BMI (20,46 ± 3,03 kg / m2).
+ The number of booms in a year is 3,13 ± 0,72 times.
+ The average mMRC score is 2,35 ± 0,98 points.
+ Average high CAT score is 19,00 ± 6,06 points, 83,87% of
patients with CAT ≥ 10.
+ The average 6-minute walk distance is 293,90 ± 70,79 meters.
+ Severe emphysema in the lower right lung accounts for a major
proportion (83,87%), the entire emphysema accounts for 74,19%.
+ The average emphysema is 2,67 ± 0,83 points
+ The average value of VC, FVC and FEV1 is 87,90 ± 21,91%
SLT respectively; 85,77 ± 20,00% of SLT and 52,00 ± 18,71% of

SLT.
+ The average value of RV, TLC and Raw are 213,84 ± 76,16%
SLT, respectively; 140,61±21,03% of SLT and 8,49 ± 5,39 cmH2O /
liter / second.
+ There were 48,39% of patients with decreased PaO2 and
22,58% of patients with increased arterial blood PaCO2.
+ There were 6 patients (19,35%) with respiratory failure.
2. The result of COPD treatment with lung volume reduction
surgery
- 23 patients underwent laparoscopic surgery and 8 patients
underwent laparoscopic surgery.
- Average surgery time 92.74 ± 23.69 minutes.
- Average weight of lung reduced 31.09 ± 6.35 grams.
- The average time for drainage of pleural cavity is 4.87 ± 4.27
days.


24
- Complications after surgery met 12.90%, of which 3 patients
(9.68%) prolonged gas leakage and 1 patient (3.23%) bleed the
wound.
- There were no deaths to the time of follow up 6 months
- Clinical changes at 1 month, 3 months, 6 months after surgery:
CAT scores, mMRC and average 6-minute walking distance of the
surgical group improved better than before surgery.
+ VC, FVC and FEV1 increased statistically at the time of 1
month, 3 months and 6 months compared to before surgery.
+ Average values of RV, TLC and Raw decreased after surgery.
RECOMMENDATIONS
Endoscopic thoracic surgery to reduce lung volume for patients

with chronic obstructive pulmonary disease with severe emphysema
is a safe, selectable method for treatment of patients with severe
emphysema, although However, it is necessary to select strict
indications and implement them in facilities specialized in COPD
diagnosis and treatment.
Need to monitor patients with larger numbers and longer time to
have a more accurate assessment of the effectiveness of treatment