Advanced COPD Treatment: Do You Need Surgery?

Living with chronic obstructive pulmonary disease (COPD) can feel overwhelming, especially when standard inhalers and medications aren't providing adequate relief. If you're struggling to catch your breath despite taking your medications as prescribed, you may be wondering: what comes next? Do I need surgery?

The good news is that the landscape of advanced COPD treatment has undergone a dramatic transformation in recent years. Today, patients have access to innovative non-surgical options, minimally invasive procedures and targeted biologic therapies unavailable just a few years ago.

"If there someone is not getting controlled on routine inhalers and the fundamentals, then there are many more effective and safer options," explains Faisal Khan, MD, an interventional pulmonologist at Franciscan Health Indianapolis.

Dr. Khan explained current COPD treatment options in a recent episode of the Franciscan DocPod podcast.

Key Takeaways: Advanced COPD Treatment

• Surgery is no longer the only option for advanced COPD.
• Biologic therapies can be effective not just in symptom control, but also in reduced frequency of dangerous flare-ups.
• Endobronchial valve therapy, a minimally invasive alternative to lung volume reduction surgery, is a new option for patients living with advanced COPD.

Lung Surgery Among Growing Options For Advanced COPD

For decades, lung surgery was one of the few treatment options for patients with severe COPD.

Lung volume reduction surgery (LVRS) involved surgeons removing damaged portions of the lung, but this approach had high postoperative mortality and morbidity rates, making many patients and physicians hesitant to pursue it.

Lung transplantation remains another surgical option, but it's typically reserved for younger COPD patients (generally under 70 years old) who meet strict criteria. Many patients with severe COPD don't qualify for a lung transplant due to age or other medical conditions.

The reality is that most patients with advanced COPD today can find relief through non-surgical and minimally invasive approaches.

New Biologic Therapies Target the Root Cause of Inflammation

New medications, called biologic therapies, can help many COPD patients address the underlying inflammatory processes driving the disease. Recent research has shown a decrease in COPD flare-ups for people treated with biologic medicine.

"Lately, there has been a focus on, again, the pathways that drive the inflammation," Dr. Khan said. "The inflammation drivers in the COPD are variable, and some people with COPD have the same cells that drive their COPD and bronchoconstriction as the asthmatics."

These biologic therapies have shown remarkable effectiveness not just in symptom control, but more importantly, in reducing the frequency of dangerous flare-ups.

"Those events of exacerbations have been significantly cut down, thereby leading to a good quality of life and not having the fear of having a flare-up," Dr. Khan explains.

Dr. Khan emphasizes that identifying the right candidates for biologic therapies is crucial.

"The key is to identify those individuals that have COPD and are on regular inhaler, and they're adhering to it, and still not getting control,” Dr. Khan said, “then to identify whether these immunologic or biologic options are valid for them or not."

Other Innovative COPD Medications

Beyond biologics, several new medication options have emerged for treating more advanced COPD.  These have shown an impact on reducing hospitalization and flare-ups and improving quality of life.

“There are other set of medications that target a different pathway,” Dr. Khan said. “They come both as oral medications and inhaled medications. But they fundamentally are more useful for people who have predominantly Chronic bronchitis, typically manifesting with symptoms of productive cough, in contrast to emphysema that presents predominantly as shortness of breath. These are nuances within the bigger picture of COPD. So, people who generate a lot of phlegm, there are medications now that help reduce phlegm and the rate of flare-ups.”

Minimally Invasive Valve Therapy Offers Hope Without Surgery

For patients with severe COPD, one of the most significant advances has been the development of endobronchial valve therapy, a minimally invasive alternative to surgical lung volume reduction.

"Now, we have a bronchoscopic approach to deal with this, where there's no incision involved," Dr. Khan explains. "You identify areas in the lung that have the most wasted airspace and least amount of contribution to their breathing. And then, you block those areas by putting one-way valves, which does not allow the air to go into those segments and causes a collapse of those segments."

Rather than requiring surgery, physicians can now address this problem through bronchoscopy.

The Zephyr® Valve System

The Zephyr® Valve system has been FDA-approved and in use for more than five years with excellent outcomes. This minimally invasive procedure offers several advantages:

• No incisions or cutting required
• 30-to-60 minute bronchoscopy procedure
• Placement of approximately four tiny valves
• Three-day hospital stay
• Significant improvements in quality of life

"We are grateful to offer this new treatment because our severe COPD and emphysema patients struggle with each breath," Dr. Khan said when introducing the Zephyr program at Franciscan Health Indianapolis in spring 2020. "Until now, the only other options for these patients were highly-invasive procedures such as lung transplants. Zephyr has the potential to be a life-changer for many patients."

A second valve system, Spiration valves, is also available, giving physicians options to customize treatment based on individual patient anatomy and needs.

By redirecting air to healthier lung segments and reducing hyperinflation, these valves help restore more efficient breathing mechanics. The diaphragm and chest wall muscles can return to a more advantageous position, improving the sensation of breathing and overall quality of life.

Candidates for endobronchial valve therapy

Endobronchial valve therapy isn't for everyone. Ideal candidates typically have:

• Predominant COPD or emphysema with significant air trapping
• Severe symptoms despite optimal medical therapy
• Specific anatomical characteristics identified through CT imaging
• Commitment to remaining tobacco-free

"It's not for everyone, but people with emphysema who have a lot of air trapping," Dr. Khan said. “There's a selection criteria. But should someone qualify for those, then you identify areas in the lung that have the most wasted airspace.”

Pulmonary Rehabilitation Remains Critical To Care

Regardless of which treatments for advanced COPD you pursue, pulmonary rehabilitation plays an essential part in maintaining long-term benefits.

These comprehensive programs help improve exercise tolerance, reduce symptoms and enhance overall quality of life. They're recommended for all COPD patients experiencing functional limitations, not just those undergoing advanced procedures.

Making The Decision: What's Right For You?

The explosion of treatment options for advanced COPD means there's hope beyond traditional inhalers, and surgery is rarely the first—or even second—line of treatment anymore.

"This is making a lot of impact in improving people's quality of life and kind of overall sense of confidence and not have that impending doom of struggling to breathe all the time," Dr. Khan said.

If you're living with advanced COPD and struggling despite your current medications, don't assume surgery is your only option—or that you have no options at all. Schedule a consultation with a pulmonologist experienced in advanced COPD therapies to discuss whether biologic medications, endobronchial valve therapy, or other emerging treatments might be right for you.

Working with a pulmonologist can help:

• Assess your specific COPD phenotype: Through blood tests and imaging, your doctor can determine whether you have eosinophilic inflammation, predominant emphysema, or chronic bronchitis features that might respond to targeted therapies.
• Evaluate your exacerbation patterns: Frequent hospitalizations or the need for repeated steroids and antibiotics may indicate you're a candidate for biologics or other advanced therapies.
• Consider minimally invasive procedures: If you have severe emphysema with air trapping, endobronchial valve therapy might offer significant relief without the risks of major surgery.
• Optimize your complete treatment plan: This includes ensuring proper inhaler technique, addressing comorbid conditions, incorporating pulmonary rehabilitation, and considering emerging therapies.

The goal is no longer just managing COPD symptoms. It's about reducing COPD flare-ups, improving your quality of life and giving you back the confidence to breathe easier and live more fully.