Bone Mineral Density Improvement After Lung Volume Reduction Surgery for Severe Emphysema

doi:10.1378/chest.127.6.1960

Chest

Volume 127, Issue 6, June 2005, Pages 1960-1966

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Background

In patients with severe emphysema, bone mineral density (BMD) is reduced and the risk of osteoporosis is increased.

Study objectives

To identify the impact of lung volume reduction surgery on BMD.

Design

Prospective cohort study.

Setting

University hospital.

Patients and interventions

Forty emphysematous patients, all receiving oral steroid therapy, underwent bilateral lung volume reduction surgery. Thirty similar patients, who refused the operation, followed a standard respiratory rehabilitation program.

Measurements

All subjects were evaluated pretreatment and 12 months posttreatment for respiratory function, nutritional status, and bone-related biochemical parameters. BMD was assessed by dual-energy radiograph absorptiometry.

Results

After surgery, we observed significant improvements in respiratory function (FEV₁, + 18.8% [p < 0.01]; residual volume [RV], −29.6% [p < 0.001]; diffusing capacity of the lung for carbon monoxide [Dlco], + 21.6% [p < 0.01]) nutritional parameters (fat-free mass, + 6.0% [p < 0.01]), levels of bone-related hormones (free-testosterone, + 20.5% [p < 0.01]; parathormone, −11.2% [p < 0.01]), bone turnover markers (osteocalcin, −12.7% [p < 0.05]; bone-alkaline-phosphatase, −14.0% [p < 0.05]; β-crosslaps, −33.6% [p < 0.001]), BMD (lumbar, + 8.8% [p < 0.01]; femoral, + 5.5% [p < 0.01]), and T-score (lumbar, + 21.0% [p < 0.01]; femoral, + 12.4% [p < 0.01]) with reduction in osteoporosis rate (50 to 25%). Nineteen patients who had undergone surgery were able to discontinue treatment with oral steroids. These subjects showed a more significant improvement in BMD (lumbar, + 9.6%; femoral, + 6.8%; p < 0.001) and T-score (lumbar, + 27.3%; femoral, + 14.3%; p < 0.001). The remaining 21 patients who had undergone surgery experienced significant improvement compared to respiratory rehabilitation subjects despite continued therapy with oral steroids (BMD: lumbar, + 4.5% vs −0.7%, respectively [p < 0.01]; femoral, + 2.7% vs −1.1%, respectively [p < 0.05]; T-score: lumbar, + 14 vs −2.1, respectively [p < 0.01]; femoral, + 7.4 vs −2.7, respectively [p < 0.01]). The increase in lumbar BMD was correlated with the surgical reduction of RV (p = 0.02) and with the increase in Dlco (p = 0.01) and fat-free mass (p = 0.01).

Conclusions

Lung volume reduction surgery significantly improves BMD compared to respiratory rehabilitation therapy, even in patients requiring oral steroids. The increase in BMD correlates with RV, Dlco, and fat-free mass, suggesting that the restoration of respiratory dynamics, gas exchange, and nutritional status induces improvement in bone metabolism and mineral content.

Section snippets

Materials and Methods

The trial was designed as a prospective nonrandomized study by evaluating the effects of surgery and respiratory rehabilitation therapy on patients with severe emphysema. The analysis included intragroup evaluations (ie, from baseline to 12 months posttreatment) and intergroup evaluations (ie, surgery vs respiratory rehabilitation). The study was approved by the ethical committee of our institution and was activated in July 1999. Patients were recruited until December 2002. Written informed

Intragroup Evaluation

All patients in both groups were available for a 12-month follow-up. After surgery, significant improvements were found in the majority of respiratory, symptomatic, and nutritional parameters (Table 1). Body mass index (+5.6%; p < 0.01) and fat-free mass (+6.0%; p < 0.01) significantly increased. Bone-related hormones significantly changed, as follows: free-testosterone, +20.5% (p < 0.01); and parathormone (−11.2%; p < 0.01). The levels of bone turnover markers decreased, with the relative

Discussion

Declining bone mass and osteoporosis are common findings in patients with severe emphysema. The etiology is multifactorial, as follows: persistent flogosis²¹; chronic tissue hypoxia²²²³; impaired respiratory dynamics³; prolonged therapy with oral and inhaled steroids and β₂-agonists; and secondary hormonal and biochemical alterations.7, 8, 910, 11, 12 These factors favor a state of hypermetabolism that rapidly turns into catabolism with tissue depletion, including fat-free mass and bone tissue.⁵

Acknowledgement

We are very grateful to Mark Gallagher, MD, for his precious cooperation in reediting this article.

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Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

This study has been carried out within the Research Fellowship Program “Tecnologie e Terapie Avanzate in Chirurgia,” which was awarded by the Tor Vergata University. This research was supported by grants No.9906274194-06 and 2001061191-001 from MURST COFIN, CU0100935CT26 2002 from the CNR, and the Centro di Eccellenza 2001, Studio Rischio Genomico in Patologie Complesse Multifattoriali.

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Chest

Clinical InvestigationsBone Mineral Density Improvement After Lung Volume Reduction Surgery for Severe Emphysema

Background

Study objectives

Design

Setting

Patients and interventions

Measurements

Results

Conclusions

Section snippets

Materials and Methods

Intragroup Evaluation

Discussion

Acknowledgement

Chest

Chest

Chest

Chest

Chest

Chest

Ann Thorac Surg

Am J Clin Nutr

Respir Med

Mol Cell Endocrinol

Chest

Chest

J Thorac Cardiovasc Surg

The daily energy expenditure in stable chronic obstructive pulmonary disease

Am J Respir Crit Care Med

Total free energy expenditure in patients with severe chronic obstructive pulmonary disease

Am J Respir Crit Care Med

Clinical Investigations
Bone Mineral Density Improvement After Lung Volume Reduction Surgery for Severe Emphysema