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LVRS Journal Background by
Joe Kowalski-CT
JoeKoMarKa@cs.com  

I am a 58 year old male who was diagnosed with Emphysema on Feb. 13, 1996. Although I suspected that I had problems with my lungs before that, that was the day my doctor confirmed my suspicions. I was put on 2 liters of oxygen at that time. Prior to my diagnosis I smoked 1 1/2 packs of cigarettes a day. I have not had a cigarette since. It was around that time that I heard about Lung Volume Reduction Surgery but my pulmonologist didnít know much about the procedure or where I could get more information. In March 1999 my health deteriorated to the point where I needed 4 liters of oxygen and was prescribed Prednisone to help me breathe.

The Process Begins

On May 3,1999 I made my first trip to Brigham and Womenís Hospital (BWH) in Boston (we live in north central Connecticut). I went to the Chest Clinic and had my first visit with Dr. Anne L Fuhlbrigge. We talked about the various options available (LVRS or transplantation) and opted for the LVRS if I qualified. Throughout the rest of the year we met with Doctors Fuhlbrigge, AaronDeykin and Edward P. Ingenito. I was weaned off Prednisone, started pulmonary rehab and lost weight. I underwent a battery of tests at BWH-PFTís EKGís Echocardiograms and the balloon test.  This test consisted of having a balloon passed down my trachea so they can measure air pressure.. BWH is one of three hospitals in the country that does this test as an indicator for the success of LVRS.

On Jan. 6,2000 I met with Dr. Stephan J. Mentzer of the Thoracic Surgery unit. He told me to come backand schedule the surgery when I was walking for 30 minutes twice a day. Distance and speed were not factors just duration. Exercise is essential to the success of LVRS recuperation because it minimizes the chances of contracting pneumonia. By going to rehab and using a treadmill at home I was able to meet that goal in the early spring . At this time there were a lot of family events going on in my life and I was feeling pretty good so I held off going back to BWH until the early fall.

The Surgery Is Scheduled

On Aug. 31,2000 we went back to BWH to talk to Dr. Mentzer. At that time we set Sept, 18,2000 at12:30 PM as the date and time for the surgery, which would be preceded by pre-op testing on Sept. 12th.

Pre-Op Testing

My appointment for the pre-op testing was at 10:00 AM on the 12th. We drove to Boston and arrived on time to a full waiting room at the pre-op test center. The wait however was not terribly long and I was able to conclude all the testing and consultations in about three hours. There were three phases to the pre-op testing. First I met with the Physicianís Assistant (PA) who explained the procedure and what was going to happen during the surgery and recovery. In my case the surgery consisted of removing the diseased part of the left lung and putting a gore-tex covering on it to minimize air leakage. This procedure would be done using thoroscopy. Four small incisions about one and a half inches would be made in my left side. These incisions would be used for the thoroscope, the instrument to remove the damaged lung tissue and two drainage tubes. Next we spoke with the anesthesiologist who explained a little about the sedation and pain management process including IVís and epidurals. Finally I saw a technician who did an EKG, and drew blood for testing. After that we were free to go home. We had to call on Friday to confirm the surgery schedule.

Confirming The Surgery

On Friday afternoon I called to confirm the scheduled surgery and was told that it was moved up to10:00 AM. This created a small problem for us because we had intended to drive out to Boston on Monday morning. Since they require you to be there two and a half hours before your scheduled surgery we had to scramble to come up with hotel accommodations for Sunday night. We did find a place but it was fortunate that I did not need my blood pressure checked at that time.

Lung Volume Reduction Surgery

LVRS Day 1 ( 9/18/00)

My wife and I arrived at Brigham and Womenís Hospital at 7:45 AM for the admitting process. The admitting nurse asked a few general questions, took my vitals and gave me my official hospital bracelet. About 9:15AM I was taken to the Family Liaison Area to wait to be called into pre-op.  At 10:30AM I was taken into pre-op. Other operations were running behind schedule and we found out that this was common. My wife accompanied me into pre-op where I changed into the fashionable hospital garb. The anesthesiologist came in and started setting up the IV. I was first given some numbing medication and was not bothered by the IVís. At that point my wife had to leave because they were going to put in an epidural and other lines and this required sanitary conditions. My wife returned to the Family Liaison Area and was joined by her daughter and her son-in-law. The anesthesiology team had a problem finding the right location for the epidural and some of their exploration was quite uncomfortable. They eventually got it in and I was wheeled into the operating room. I remember the clock on the wall read 12:05. The next thing I knew the clock on the wall read 2:15. The surgeon said I answered his question at the end but I have no recollection of the conversation.

I was wheeled out to the recovery room. The epidural pump was not waiting for me when I got there.  Since there was no available means of pain management I suffered the most excruciating pain of the whole procedure. It felt like my lungs were being sliced every time I took a breath. After what seemed like 30 or 45 minutes the epidural pump finally came and I received pain medication. The relief was almost instantaneous. Along with my various IVís I also had two chest tubes for fluid drainage and air. You donít want a fluid build up in the lungs for fear of pneumonia and you donít want an air build up for fear of collapsing the lung. The doctor spoke to my wife at 3:00 PM and told her that the surgery went as expected. They removed the upper portion of my left lung and there was a small air leak that would have to heal. About 4:20PM my wife was able to visit in there covery room for a few minutes I was tired but, they tell me, talking lucidly. I was brought to the Thoracic Intermediary Care Unit (TICU) at around 5:30 PM. My wife was able to visit for about 25minutes. The nurses pounded on my back and I needed the pain pump a few times (two unrelated incidents). My vitals were good BP 120/78, temp 98.7, HR 72 and Sat at 94 at 4 liters. Around7:30 PM I was allowed some ice chips which tasted like vintage champagne. I also had some ginger ale and was slightly nauseous so I was given Compazine via IV. There was a moderate amount of blood draining from the chest tube nothing to be alarmed about. My wife, daughter and son-in law left around 8:45 PM. At that time my vitals were pretty much the same as before. My wife called the nursesí station around 10:00 PM and was told I was given Lasix to prevent fluid retention. I had a catheter so that was OK by me.

LVRS Day 2 (9/19/00)

Contrary to popular belief, they donít wake you up to give you a sleeping pill in the middle of the night. They wake you up to take your vital signs. The doctors visited on morning rounds around 7AM and everything seemed to be progressing normally. My wife and daughter arrived around 8:30 AM. I was not good company as I was sleepy and dozed from time to time. With the assistance of a walker and a respiratory therapist I went for my first walk since the surgery. It was a short one and I had to stop twice when my sats went below 90, I waited a short while and resumed my walk back to my room. I didnít need to hit the pain pump during this walk. When I got back I sat in a chair for about3 1/2 hours. I went for a second walk around the nurses station and this time I only stopped once. Sats bottomed out at 91. I should mention that I took a shot from the pain pump before the walk therefore I didnít need one during the walk. The pain medication is DelAudit Previcaine (excuse the spelling) delivered through an epidural at 6 ML per hour. The PA came in and shut off the suction to the PleurEvac machine, which was hooked up to the chest tubes. I still had the tubes in but there was something called a water seal on there. This is necessary to keep air from leaking back into the lungs. I was still not able to eat solid food, I was limited to juice, jello and popsicles. At this point they all tasted like ambrosia. Around 6:30 PM I went on my third walk of the day. It was a short walk of less than 5 minutes. Throughout the day my vitals remained good..

LVRS Day 3 (9/20/00)

No major events took place today. Dr. Mentzer came in and said that it would take a while to get the Sat levels back up to presurgical levels. I went for a walk with 10 liters of O2. This walk from my room around the 11th floor was the farthest I had walked since the surgery. Each time I walked I tried to go a little farther as part of my progress. I used the pain pump before I started each walk and didnít have any problem walking. I was still on a liquid diet. The PA came in that afternoon to see what progress I had made as far as the tubes were concerned. There was still a little air leaking but very little bleeding. This was a good sign. I went for my third walk of the day in the early evening and the sat level dropped to the 70ís on 6 liters of oxygen, which was probably from fatigue. I got back into bed and everything returned to normal in a short while. My vital signs continued to be OK.

LVRS Day 4 (9/21/00)

We had reveille at 6:15 AM. Not much to do so far. The doctor came in and said that the air leak was less than yesterday. Everyday it got progressively better. I went for my first walk of the day and needed 6 liters of O2. In the late morning some other positive things took place. The epidural was removed and I was put on oral pain medication (Percocet). The chest tubes were cut and a Heimlich valve (one way) was placed on each tube end. The Heimlich valve is important because it allows fluid and air to escape but allows no fluid or air to go back into the lungs. I ate my first solid food today : a turkey sandwich with cranberry sauce. Even after waiting this long it still didn't taste that great. The pain service came in this afternoon and removed the epidural. Gradually most of the tubes were coming out. I took my second walk of the day in the early afternoon. The Sat levels dropped but with rest came back up in a short period of time, which appears to be my normal pattern. I moved out of TICU and into a semi-private room that afternoon, which was another sign of progress. Late in the afternoon I went for another walk and then had another gourmet meal. My last walk of the day came around 9PM. At this point my wife started accompanying me on these walks, which was good because when I felt like walking we could go. We didnít have to wait for a respiratory therapist to help out. My vital signs continued to look good.

LVRS Day 5 (9/22/00)

My surgeon, Dr. Mentzer, checked the tubes and said they could come out, which was the good news. The bad news was that my blood tests showed an elevated white cell count. I had more blood tests. Normal white cell blood count is 6 - 12, mine was 14. I was put on an intravenous antibiotic. I still went for a walk, my first of the day around 11:15 AM. When I got back my Sat levels were in the 70ís but they returned to the 90ís within two minutes of my resting. My wife went to the small cafeteria here at the hospital and brought me a sausage and pepper grinder for lunch. I devoured it with a bottle of fruit juice. After a while I went for my second walk. My Sat levels were erratic this time. I took a pain killer before the walk. Shortly after I returned the PA came in to take out the chest tubes. Because I had taken a pain killer earlier I couldnít have one for this fairly uncomfortable procedure, but fortunately it was over quickly. On a scale of 1 - 10, with 10 being the most severe I would rate this as a 6. The nurse on duty told me that nothing grew on the blood cultures so it looked like the antibiotic was working. The doctors would know more tomorrow. I went for another walk in the evening. My vitals were all looking OK.

LVRS Day 6 (9/23/00)

In the morning they drew blood and scheduled me for a chest x-ray (two views). All week they had been taking chest x-rays while I was in my room. This time I went down to radiology. My white blood count came back at 10 and Dr. Mentzer read the x-rays and said it was OK to go home. At 12:40 PM my Sat was 95 at 4liters, BP was 110/72 temp was 100 (slightly elevated but not enough to keep me here). I was discharged at 2:00PM and headed home. The 2 1/2 hour ride home was fairly uneventful but by the end of the journey I was starting to get uncomfortable. Fortunately we had a prescription for Percocet and had it filled upon our arrival.


LVRS Follow-up (10/05/00)

While at home I took one Percocet in the morning and one at bedtime to manage the pain for the first ten days. I had a follow up appointment with Dr. Mentzer today and he looked at my chest x-ray and pronounced me fit to go back to rehab. No other appointments necessary.

My Conclusion

Although I do not have any measurements like a PFT to prove it, I feel that the operation was a success. It has allowed me to breathe easier. My Sat levels have improved somewhat but they still drop below 90% when I exercise but rebound quickly. My goal now is to keep them above 90% and with rehab I feel that I can accomplish this goal.

While not for everyone Lung Volume Reduction Surgery has helped me. Iím particularly grateful to my wife Sandy who was a super strong pillar for me, Drs. Mentzer and Fuhlbrigge and the nurses and staff at .Brigham and Womenís Hospital in Boston MA for all their help.

JoeKoMarKa@cs.com 
Joe Kowalski-CT

December 8, 2000

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