Communications to the Editor |

Elastic Recoil of Lung and Lung Reduction Surgery FREE TO VIEW

Herman F. Froeb, MD, FCCP
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La Jolla, CA

Correspondence to: Herman F. Froeb, MD, FCCP, Scripps Memorial Hospital Campus, 9834 Genesee Ave, Suite 416, La Jolla, CA 92037

Chest. 2001;119(6):1981. doi:10.1378/chest.119.6.1981
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To the Editor:

At a recent meeting of the American College of Chest Physicians in San Francisco in October, there were several sessions concerning lung volume reduction surgery. In two of these sessions that I attended, the concept of emphysematous lung “bulging out the chest wall and pushing down the diaphragms and even compressing the heart” was discussed by surgeons and pulmonologists present. The beneficial effect of the surgery was thought to be due to “removal of the bulging emphysematous lung to allow good lung to expand and to allow the chest to assume a less distended position and the diaphragms to ascend once the downward pressure by the bulging lung was relieved.” Indeed, this does happen, but for an entirely different reason.

It has to do with retractile elastic recoil of the lung being opposed by the expansive force of the chest wall. When these two opposing forces equal one another and cancel out, the diaphragms come to rest.

In emphysema, the loss of elastic recoil of the lung allows the chest wall to expand and hence the diaphragm becomes low. Now when the surgeon removes the areas of emphysematous lung, the elastic recoil increases, the chest wall is drawn in, and the diaphragm rises. This increase in elastic recoil of the lung also keeps the airways open longer during expiration, and they become larger on inspiration, improving ventilation/perfusion ratios and reducing the airway’s resistance and work of breathing.

Another analogy is that of a rubber band with several flabby sections in it. If these sections are removed, the rubber band has better elastic recoil.

To appreciate the expansive qualities of the chest wall, consider the following: if a pneumothorax is present (nontension, noncommunicating) and the chest wall is opened, air rushes in as the chest wall expands.

One of the surgeons at the meeting, who stressed the forceful expansile properties of the emphysematous lung pushing down the diaphragm, claimed support for his theory by observing the bulging of the emphysematous lung through a thoracotomy incision at the time of lung volume reduction surgery. When this point of view was presented to Dr. Jerry Mead during his “Distinguished Lecture in Physiology—Thoracic Kinetics,” he thought this was due to the pressure involved in the administration of the anesthesia.

A more sophisticated discussion of this can be found in Chapter 13,“ Statics of the Respiratory System” by Emil Agostini and Jere Mead in Handbook of Physiology, Section 3, Respiration, Vol. I, pages 387–407 (see pages 390–391), published by the American Physiologic Society, Washington, DC, 1964.




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