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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

- 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:

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

diameter ≥ 1 cm, thin wall
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.


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

- 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 10 years is only found in

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)

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
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
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

(
± 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
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,

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
(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
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.


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- 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