Delay in lung volume reduction surgery due to the COVID-19 pandemic: impact on patient performance and mortality
Original Article

Delay in lung volume reduction surgery due to the COVID-19 pandemic: impact on patient performance and mortality

Alberte Lund1 ORCID logo, Henrik J. Hansen1, Kåre Hornbech1, Michael Perch2,3, Anna Kalhauge4, Jann Mortensen3,5, Kristine Jensen2, René H. Petersen1,3

1Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark; 2Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Rigshospitalet, Copenhagen, Denmark; 3Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; 4Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark; 5Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark

Contributions: (I) Conception and design: All authors; (II) Administrative support: HJ Hansen, K Hornbech, A Kalhauge, J Mortensen, K Jensen, M Perch, RH Petersen; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: A Lund; (V) Data analysis and interpretation: A Lund, RH Petersen; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Alberte Lund, MD. Department of Cardiothoracic Surgery, Rigshospitalet, Blegdamsvej 9, 2300 Copenhagen, Denmark. Email: alberte.lund@regionh.dk.

Background: Severe chronic obstructive pulmonary disease (COPD) naturally progresses over time and is associated with increased mortality. During the coronavirus disease 2019 (COVID-19) pandemic, many surgical procedures were postponed, but the full impact of these delays remains unclear. Our aim was to evaluate the consequences of delayed lung volume reduction surgery (LVRS) treatment.

Methods: This study was conducted as a retrospective observational study. Patients who had LVRS postponed six months or more due to the COVID-19 pandemic at a national university centre were included. Data were obtained from an institutional database. Patients were re-evaluated before surgery using lung function tests, a 6-minute walking test (6MWT), and blood gas analysis. Increased symptoms, mortality, and infections were recorded. All surviving patients were reassessed for treatment indication in a multidisciplinary team (MDT) meeting.

Results: A total of 67 patients had their scheduled LVRS treatment postponed due to the pandemic. Of these 16% were infected with COVID-19. Four patients (6%) died before secondary evaluation. Mean time from outpatient clinic referral to surgery date was 398 (±161) days. Forced expiratory volume in one second (FEV1) significantly decreased by 0.1 L (P<0.001), while diffusion capacity of the lung for carbon monoxide (DLCO) remained unchanged. Performance in the 6MWT worsened by 29.9 m (P<0.001), and oxygen saturation decreased by 1.3% (P=0.046). Symptom worsening was experienced in 39% of patients. Clinical deterioration rendered 5% of patients unfit for surgery, while 86% remained fit for surgery. No patients were excluded due to COVID-19 infection.

Conclusions: The delay of LVRS due to the COVID-19 pandemic led to a decrease in lung function, 6MWT performance, and oxygen saturation. Although the majority of patients remained fit for surgery, the postponement resulted in cancellation of procedures due to clinical deterioration and contributed to waiting list mortality. This patient group is vulnerable to further deterioration over time and timely treatment should be prioritized.

Keywords: Coronavirus disease 2019 (COVID-19); chronic obstructive pulmonary disease (COPD); lung volume reduction surgery (LVRS); emphysema; delay in treatment

Submitted Jul 17, 2025. Accepted for publication Oct 14, 2025. Published online Nov 26, 2025.

doi: 10.21037/jtd-2025-1453

Highlight box

Key findings

• The delay of lung volume reduction surgery (LVRS) due to the coronavirus disease 2019 (COVID-19) pandemic led to a decrease in lung function, 6-minute walking test (6MWT) performance, and oxygen saturation.

• Although the majority of patients remained fit for surgery, the postponement resulted in cancellation of procedures due to clinical deterioration and contributed to waiting list mortality.

• This patient group is vulnerable to further deterioration over time and timely treatment should be prioritized.

What is known and what is new?

• LVRS patients are a vulnerable patient group and inclusion criteria for surgery are explicit and narrow. During the COVID-19 pandemic, many surgical procedures were postponed, but the full impact of these delays remains unclear.

• Postponement of surgery had an impact on patient performance, mortality and operability in this patient group.

What is the implication, and what should change now?

• This manuscript indicates that postponement had significant consequences for this patient group, which should be considered carefully for future purposes.

Introduction

Lung volume reduction surgery (LVRS) is a surgical treatment for selected patients with severe emphysema. Surgically remodelling the lung tissue and reducing hyperinflation can reduce dyspnoea, improve exercise capacity and increase 5-year survival (1-3).

It is estimated that 400,000 patients in Denmark suffer from chronic obstructive pulmonary disease (COPD). With 3,500 deaths from COPD every year, it is the second most frequent cause of death in Denmark (4) and third leading cause of death worldwide affecting 174 million patients (5). Lung function declines over time, and symptoms progress (6). With a 16% risk of mortality within 30 days after discharge from exacerbation related admittance (4), COPD patients are vulnerable to delay in treatment. The risk of dying from exacerbation or lung function declining beyond the inclusion criteria for surgery is eminent.

During the coronavirus disease 2019 (COVID-19) pandemic from 2020–2022, staff and medical resources were reallocated to treat COVID-19 patients within our institution. Therefore, many non-malignant procedures were postponed to free these resources, and this was also the case with LVRS. All LVRS surgeries were cancelled during the pandemic at our centre.

Many patient groups were affected by the pandemic. Lung cancer patients suffered delayed access to surgery and subsequent pathological upstaging of lung cancer was documented after the COVID-19 restrictions were introduced (7,8). Studies focusing on abdominal surgery found an increase in Clavien Dindo classification and delay in access to treatment, which led to more severe clinical conditions and worse prognosis (9,10). In general, it is well established that infection with COVID-19 leads to a decrease in lung function (11) and impaired exercise capacity (12). Severe emphysema was among the documented risk factors for developing severe complications (13). However, specific knowledge on the delay in treatment and its consequences for this fragile patient group suffering from severe emphysema remains unknown.

Our aim with this study was to investigate the consequences of delayed LVRS and whether the delay in surgery led to a decline in lung function or to revocation of operability in this patient group. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1453/rc).

Methods

Patients eligible for LVRS are subjected to an extensive preoperative workup to secure all inclusion criteria, including 6 months of lung rehabilitation, are met (Table 1). Before the pandemic around 40–50 surgeries were performed a year. During the COVID-19 pandemic, all benign procedures were cancelled at our department, including all patients scheduled for LVRS. All LVRS patients postponed 6 months or more due to allocation of resources during the pandemic were included in the study. The patients were scheduled for secondary modified evaluation prior to the new scheduled date of surgery, in order to secure the patients still met the inclusion- and exclusion criteria. We evaluated the general physical fitness including recent respiratory infections or exacerbations, COVID infection with or without complications, newly emerged comorbidity and change in Medical Research Council (MRC)- and COPD assessment test (CAT)-score. Lung function test, blood samples, 6-minute walking test (6MWT) were repeated. Echocardiographic scans were repeated as needed. Furthermore, we registered whether the multidisciplinary team (MDT) decision regarding treatment strategy was changed based on the new information. Lastly, we registered how many patients died in the waiting time between the original surgery date and the secondary evaluation.

Table 1

Inclusion criteria for LVRS

Moderate to severe COPD with MRC >2
Age <75 years old
BMI >17 and <30 kg/m2
FEV1 >20% and <45% of predicted
RV >200% of predicted as a sign of relevant hyperinflation
DLCO >20% of predicted
The patient should be in ideal medical treatment and have completed rehabilitation
A high-resolution CT <3 months old should follow the referral to MDT
Absence of significant comorbidity including severe cardiovascular disease
LVEF normal
Absence of pulmonary hypertension, TI-gradient <40 mmHg
Absence of chronic or frequent lung infections
Smoking abstinence six months prior to surgery
Assessed as sufficiently physically fit to undergo surgery and rehabilitation

BMI, body mass index; COPD, chronic obstructive pulmonary disease; CT, computed tomography; DLCO, diffusion capacity for carbon monoxide; FEV1, forced expiratory volume in one second; LVEF, left ventricle ejection fraction; LVRS, lung volume reduction surgery; MDT, multidisciplinary team; MRC, Medical Research Council; RV, residual volume; TI, tricuspid insufficiency.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the regional ethics committee of the Copenhagen University Hospital (No. P-2022-930) and individual consent for this retrospective analysis was waived.

Statistical analysis

Demographic data are presented as mean and standard deviation for parametric data and as median and interquartile range (IQR) for non-parametric data, using appropriate statistical tests depending on normal distribution. P values <0.05 are considered statistically significant. To evaluate development in lung function and other tests, we applied a standard paired t-test.

Statistical calculations were performed using R Studio 2022.07.2 (The R Foundation for Statistical Computing, Vienna, Austria).

Results

During the pandemic from March 2020 to July 2022, 67 patients scheduled for LVRS were postponed. Women constituted 54% and the median age was 66 years (IQR, 60–69 years) and median smoking history was 38 (IQR, 30–49 years) pack years (Table 2).

Table 2

Demography

Variable Values (n=67)
Women 36 [54]
Age, years 66 [60–69]
BMI, kg/m2 23 [21–26]
LTOT use 8 [12]
CCI 3 [3–4]
Smoking pack years 38 [30–49]
A1AD 3 [4]

Data are shown as n [%] or median [interquartile range]. A1AD, alpha 1 antitrypsine deficiency; BMI, body mass index; CCI, Charlson comorbidity index; LTOT, long-term oxygen treatment.

Seven patients (10%) died. Four patients died awaiting surgery, two died within 30 days after surgery and one died several years later. The leading cause of death was respiratory failure, with four fatalities; the remaining three patients died from unrelated causes.

The secondary evaluation was successfully completed for 63 patients. Collectively, 16% suffered a COVID infection, but none suffered severe complications to their infection, including mechanical ventilation, pneumothorax, admission to intensive care unit (ICU), and pulmonary fibrosis. An increase in symptoms was experienced by 39% of the patients, of which 23 (89%) patients experienced increased dyspnoea.

The frequency of hospital admissions was also examined. Eight patients were admitted once due to an exacerbation of COPD, while one patient experienced four admissions. Pneumonia was less prevalent, with only five patients requiring hospitalization.

Only 19 patients (35%) had a new cardiac evaluation done. Based on these repeated echocardiographies, four patients showed signs of pulmonary hypertension of which two patients had a right heart catheterization done. One of these patients was subsequently excluded from surgery due to mean peak arterial pressure (mPAP) >35 mmHg (Table 3).

Table 3

Secondary evaluation

Outcome Values Description
Delay, days 398±161 –
COVID-19 infection 11 [16] No sequelae
Waiting list mortality 4 [6] 2 respiratory failures, 2 unknown causes of death
Increased symptoms 26 [39] –
Admitted pneumonia 5 [7] –
Admitted exacerbation 9 [13] –
New comorbidity 8 [12] ICD, STEMI, hiatus hernia, hip fracture, cervical spine pain, lung cancer, bile stasis, lung abscess
Cardiac evaluation completed 19 [35] 4 suspected pulmonal hypertension, 2 RHC, 1 excluded
Listed for LTX 3 [4] Unchanged

Data are shown as mean ± standard deviation or n [%]. COVID-19, coronavirus disease 2019; ICD, ischemic cardiac disease; LTX, lung transplant; RHC, right heart catheterization; STEMI, ST-elevation myocardial infarction.

Physical tests and dyspnoea scores were repeated at the secondary evaluation visit. CAT-score and MRC-score did not change significantly. Lung function was affected with a 0.1 L decrease in forced expiratory volume in one second (FEV1) (P<0.001). Performance in 6MWT declined with 29.9 m (P<0.001) and blood gas oxygen saturation was impaired further from 94.7% to 92.9% (P=0.046, Table 4).

Table 4

Tests

Parameters Primary evaluation Secondary evaluation Mean difference P
Respiratory parameters
   CAT score 22 [18–27] 19 [16–23] −1.7 0.07
   MRC score 3 [3–4] 3 [3–4] −0.1 0.56
   FEV1, L 0.75 [0.65–0.87] 0.71 [0.60–0.86] −0.1 <0.001
   FEV1, %predicted 28 [24–33] 27 [23–33] −1.2 0.03
   FVC, L 2.2 [1.8–2.6] 2.1 [1.7–2.6] −0.1 0.13
   FVC, %predicted 66 [59–76] 65 [54–83] −1.5 0.40
   DLCO, mmol/min/kPa 2.8 [2.2–3.5] 2.5 [2.2–3.5] −0.0 0.65
   DLCO, %predicted 37 [31–45] 35 [27–45] −0.9 0.28
   RV, L 5.2 [4.5–6.2] 5.2 [4.3–6.3] −0.1 0.63
   RV, %predicted 243 [223–265] 236 [204–261] −10.0 0.05
   TLC, L 8.1 [6.9–9.0] 7.6 [6.8–8.9] −0.2 0.12
   TLC, %predicted 134 [125–147] 132 [123–140] −2.9 0.10
   RV/TLC-ratio 0.68±0.06 0.67±0.08 −0.4 0.67
6-minute walking test
   Walking distance, m 323 [252–385] 296 [224–377] −29.9 <0.001
   Maximum heartrate during test 115 [108–124] 117 [107–124] 0.3 0.34
   Minimum blood saturation during test, % 87.3±5.0 84.3±6.7 −3.3 <0.001
Blood gas
   pH 7.43±0.03 7.41±0.03 −0.0 <0.001
   O2, kPa 9.9±1.5 9.3±1.4 −0.3 0.19
   CO2, kPa 5.4±0.5 5.7±0.8 0.2 0.06
   Oxygen saturation, % 94.7±2.6 92.9±3.7 −1.3 0.046

Data are shown as mean ± standard deviation or median [interquartile range]. CAT, COPD assessment test; COPD, chronic obstructive pulmonary disease; DLCO, diffusion capacity for carbon monoxide; FEV1, forced expiratory volume in one second; FVC, forced vital capacity; MRC, Medical Research Council; RV, residual volume; TLC, total lung capacity.

After secondary evaluation, 54 patients (86%) were deemed fit for surgery. Three patients (5%) were not fit for surgery due to physical deterioration. Six patients (9%) were excluded for other reasons. No patients were excluded due to new comorbidities or complications related to COVID-19 infection (Figure 1).

Figure 1 MDT decision after postponement and secondary evaluation. Other, aggravation of preexisting condition such as increased prednisolone use for bronchitis or increased golimumab dose for rheumatoid arthritis, etc. MDT, multidisciplinary team.

Discussion

The mean time from outpatient clinic referral to surgery date was 398 (±161) days. Prior to COVID-19, this number was a few months. With a doubled time from referral to treatment, the pandemic has caused a significant delay in treatment.

Delayed treatment caused disease progression with declining FEV1 at the secondary evaluation. FEV1 mean decrease was 0.1 L (P<0.001) in this study. This amounts to the minimal clinical difference in FEV1 to be perceived as a noticeable change by the patients (14), which corresponds with the increased experience of symptoms. Decline in lung function over time for patients with severe emphysema is known (5). However, for this patient group the consequence of this is a decline beyond the inclusion criteria for surgery and exclusion from treatment they were initially eligible for. MRC- and CAT-scores were unchanged at secondary evaluation, though the patients reported increased symptoms. At secondary evaluation with MRC-score still >2 and CAT-score >10, the patients are categorized as severely impaired COPD patients (15). This suggests that other factors may influence how the severity of dyspnoea symptoms are perceived. The variation in symptoms over time presents a major obstacle in the medical workup process for these patients with marginal lung function.

Postponement of non-malignant and elective procedures was common during the COVID-19 pandemic, with significant consequences. Wait time before surgery and cancer-related mortality increased (16). Incidence of cancer declined immediately after the beginning of the pandemic and many cancers may still be undetected as a result (17). A Canadian centre investigated consequences of delaying non-urgent surgeries during COVID-19 (18). The wait time for scheduled surgery decreased discretely but varied greatly between the different medical areas. Furthermore, the study showed increased in hospital and all-cause mortality during COVID-19 compared with before COVID-19 and suggests that attention should be drawn to the decisions constituting prioritization between patient groups. Whether the dangers of undergoing surgery with increased mortality risk outweighs the risks of delayed treatment is debateable.

A Swedish study showed that the total amount of gallstone surgeries decreased during the pandemic, though a simultaneous slight increase in acute and complicated gallstone procedures indicates postponement could have contributed to the increased share of complicated cases (10).

Hospital admission for myocardial infarction declined in this period (19,20), which could indicate patients reluctantly seeking medical treatment or access being challenging during a pandemic.

Also, reports on increased rates of perioperative complications and mortality rates following cardiac procedures (21) implies that the pandemic has had severe consequences.

The majority of patients (86%) proceeded to surgery as planned after the additional MDT conference. Five percent were excluded due to clinical deterioration, which underlines the importance of the right treatment at the right time. Postponement has resulted in disease progression beyond the inclusion criteria for surgery for 5% of the patients and thereby an inferior treatment. The burden of COPD is disproportionate in population groups with low socioeconomic status (22), leading to inequality in access to ideal medical treatment (23). The consequences of delay documented in this study contribute to this tendency of inequality, deprioritizing care for people with low socioeconomic status found in other studies (24).

Planning this study, we speculated that sequelae after COVID-19 would constitute the main reason for exclusion. Mainly because COPD is widely documented as a predictor for adverse outcomes, including mortality from COVID-19 (25). Surprisingly, no surgeries were cancelled due to COVID-19 infection and only one was cancelled due to adjacent comorbidity including pulmonary hypertension or other cardiac issues. None of the four patients who died waiting for secondary evaluation had a documented COVID-19 diagnosis and subgroup analysis revealed that the decline in lung function and performance in 6MWT was not driven by infection with COVID-19. Death related to exacerbation from COPD is a major risk in this patient group. A thorough medical examination during preoperative workup could have resulted in unknowing selection of patients more resilient than average. Therefore, the patients selected for LVRS have a certain activity level and have endured exacerbations without fatal results.

According to the Department of Health in Denmark, 3.2 million Danes were infected with COVID-19, representing 53% of the population. In this study, only 16% of the patients were infected, indicating that this patient group effectively prevented infection better than the average. However, it remains unclear how they managed to avoid sequelae.

Waiting list mortality was 6%. Before the COVID-19 pandemic, the time from referral to treatment was minimal, and thus the previous mortality rate is not comparable. For patients with COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) D mortality rates are significant with 5-year mortality as high as 30% (26). These steep numbers include overall mortality as well as cardiovascular-specific mortality (27). Patients with low FEV1 are particularly at risk. This underlines the importance of prompt treatment to prevent disease progression and reduce mortality. Though the patients did complete pulmonary rehabilitation, we speculate that many patients isolated themselves and avoided social contact and leaving their homes in order to prevent infection, which could have affected their physical fitness negatively and contributed to the decrease in lung function. The data in this study underlines, that for future purposes an important element of LVRS treatment is timing. Securing preoperative optimization with lung rehabilitation for 6 months and also preventing delay causing the patient’s disease to progress beyond the inclusion criteria for surgery.

Strengths and limitations

The unfortunate event of the COVID-19 pandemic was a threat to all patients suffering from lung disease. However, it provided a possibility to study the effects of delayed treatment in this vulnerable patient group. The study addresses a critical issue, particularly for at-risk populations during a global health crisis. COPD patients requiring LVRS are at high risk of deterioration, and delayed treatment could worsen their condition. The timing of the study during the COVID-19 pandemic makes it highly relevant to current medical practice and healthcare systems.

A key strength of this study is the inclusion of a secondary clinical evaluation, which allows for the assessment of changes in clinical status, comorbidities, and lung function. This captures the effect of the delay on disease progression and operability, making the study findings more robust and compensating for the retrospective nature of this study, which still remains a limitation. Absence of a control group is an obvious limitation and generalizability to other healthcare systems and centres with varying LVRS programs is not entirely clear. This study does not include long-term follow-up, which could clarify whether the delay associated with the pandemic had a long-term impact on this patient group.

Conclusions

The delay of LVRS due to the COVID-19 pandemic led to a decrease in lung function, 6MWT performance, and oxygen saturation. Although the majority of patients remained fit for surgery, the postponement entailed cancellation of procedures due to clinical deterioration and contributed to waiting list mortality. This patient group is vulnerable to further deterioration over time and timely treatment should be prioritized.

Acknowledgments

The abstract was presented at the 33rd ESTS meeting in Budapest from May 25–27, 2025.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1453/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1453/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1453/prf

Funding: This work was supported by Medtronic (No. ERP-2022-13071).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1453/coif). R.H.P. serves as an unpaid editorial board member of Journal of Thoracic Disease from October 2024 to September 2026. All authors report that this study was supported by a research grant from Medtronic. R.H.P. received speaker fees from Medtronic, AMBU, Medela, AstraZeneca and participated on advisory board for AstraZeneca, MSD, Roche, Bristol Meyers Squibb. K.J. received speaker fees from Medtronic. M.P. received a research grant from Roche and PulmonX, speaker fees from PulmonX, Novartis, Chiesi, AstaZeneca, Takeda, Therakos and support for congress attending from Boeringer-Ingelheim. H.J.H. received a research grant from BD and speaker fees from Medtronic. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the regional ethics committee of Copenhagen University Hospital (No. P-2022-930) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Lund A, Hansen HJ, Hornbech K, Perch M, Kalhauge A, Mortensen J, Jensen K, Petersen RH. Delay in lung volume reduction surgery due to the COVID-19 pandemic: impact on patient performance and mortality. J Thorac Dis 2025;17(11):10348-10355. doi: 10.21037/jtd-2025-1453

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