During, normal inspiration. the int...

During, normal inspiration. the inter-costal muscles and diaphragm contract, enlarging the body of the thorax and decreasing, intrathoracic compressing The intercostal muscles act as a place of thoracic bellows that create a press gradient between the air passages and the alveoli. causing air to be derived into the lungs. On expiration, the intercostal muscles relax. and the natural elastic recoil of the lung increases intrathoracic urgency which causes air to be molten out of the lungs.(1)

PATHOPHYSIOLOGICAL CHANGES OF

CHRONIC PULMONARY EMPHYSEMA

Chronic pulmonary emphysema (CPE) usually flash on the minds after the lungs have been expos to a toxic agent, ofttimes tobacco smoke, for a put offed period. Tobacco smoking causes the lung to be exposed to three major pathophysiological changes:

* chronic infections caused by way of inhaling tobacco smoke that irritates the bronchi and bronchioles;

* chronic obstruction of large and small pulmonary airways from respiratory infections, exces mucus production. and bronchiolar edema; and

* entrapment of air in the alveoli that causes them to overstretch and fail to win elasticity.(2)

Physiological abnormalities. The damaged lung tissue make no use ofs elasticity, and gas exchange is compromised. Chronic bronchiolar obstruction greatly increases airway resistance and the work of breathing. Emphysematous lung tissue compresse underlying healthy lung tissue, preventing it from functioning suitably The chest cavity becomes filled with the overstretched emphysematous lung tissue, which causes the patient to have a "barrel-chested" appearance and the diaphragm to be pushed downward (Figure 1) The intercostal muscles and the diaphragm no longer can function fitly and air movement is reduc severely(3)

Patient profile. The patient experiences stiff breathlessness and can no longer participate in normal activities of daily living (ADLs). Walking across a extent may not be possible for the patient with CPE In advanced CPE the patient is confined to sitting upright in a chair, unable to exist without on supplemental oxyen ([O.sub.2]) to breathe. The patient's no room for expectation of reversal. He or she may receive limited relief from medical treatments, like as bronchodilators and corticosteroids.(4)

HISTORY OF LUNG

bulk REDUCTION SURGERY

In the past, lung transplantation was the alone surgical treatment option for patients with CPE Lung dimensions reduction surgery (LVRS) using bovine pericardium strips is a surgical treatment option that restores the mechanics of the the thoracic bellows fie. the functioning relationship of the intercostal muscles and diaphragm to the chest wall). This consequence is achieved by removing the principally damaged portions of emphysematous lung tissue; thereby downsizing hyperinflated lung tissue and allowing the chest wall and the diaphragm to assume a more normal anatomical and physiological relationship. This restores the bellows function and brings the compression of the less-diseased, underlying alveoli. The underlying, healthier lung tissue then is better able to oxygenate the family and remove carbon dioxide.

Previous surgical techniques. Previous attempts to suppress emphysematous lung tissue have not yielded satisfactory conclusions because extensive postoperative air leaks occurr from tears in the staple lines. Surgeon have tried various surgical techniques to seal the staple lines during LVR practices In 1989, an Austrian surgeon used a ribbon of polydioxanone line of junction to seal the staple lines.(5) Also in 1989 an American surgeon discussed using Teflon felt sleeve placed through the whole extent of a stapling device.(6) In 1992 a collection of surgeons in Japan used a nonwoven fabric of polyglycolic acid as a patch and manually reinforced line of junction lines for LVRS procedures.(7)

instant surgical techniques. The problem of postoperative air leaks from LVR measures has been reduced by the use of overlapping bovine pericardium strips to buttres staple lines.(8) In 1993 a surgeon at Washington University. St Louis. expanded a more satisfactory LVRS technique, which consists of reinforcing surgical staple lines with bovine pericardium strips, thereby significantly reducing the incidence of postoperative air leaks.(9) Bovine pericardium strips are advantageous to use because they are

* submissive and easy to cut,

* nonporous to intercept air leaks,

* thin enough to allow overlapping staple lines,

* hardy enough to hold the staple lines when the lung are reinflated, and

* degradable and absorbable should postoperative infections develop(10)

Our surgeon at Columbia Presbyterian Medical Center fresh York, began performing LVRS managements using bovine pericardium strips in 1994 and have had pious patient outcomes. The following is a description of our protocol for patients who are candidates for LVR procedures

SELECTION OF THORACOTOMY INCISIONS

Lung turn reduction surgery can be performed between the walls of a median sternotomy, a lateral thoracotomy, or a transverse anterior thoracotomy (ie, clamshell) incision (Figure 2) Our surgeon usually exquisite a lateral thoracotomy approach for unilateral lung reduction and a transverse anterior thoracotomy approach for bilateral lung reductions. Surgical team members place the patient in a supine position for a median sternotomy or transverse anterior thoracotomy acts or they place the patient in a lateral position onward a beanbag for a lateral thoracotomy procedure