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Important Note: The following information
is provided for your education. It should not be relied upon for
personal diagnosis or treatment. If you believe that a
particular therapy applies to you or someone you care about, be
sure to consult a doctor before trying it.
Emphysema/COPD Research:
2002-2006
Eur J Cardiothorac Surg. 2006 May 1; [Epub ahead of print]
Assessment of pulmonary function after lobectomy for lung cancer—upper lobectomy might have the same effect as lung volume reduction surgery.
Kushibe K, Takahama M, Tojo T, Kawaguchi T, Kimura M, Taniguchi S.
Department of Thoracic and Cardiovascular Surgery, Nara Medical University
School of Medicine, Kashihara, Nara 634-8522, Japan.
Objective: Lung volume reduction surgery (LVRS) in well-selected patients with
severe emphysema results in postoperative improvement in symptoms and pulmonary
function. Experience with LVRS suggests that predicted postoperative FEV(1.0)
may be underestimated after lobectomy in patients with lung cancer and
emphysema. As most of the patients with lung cancer have more or less
emphysematous changes in the lungs, we assumed that lobectomy would achieve the
same effect as LVRS even in patients without chronic obstructive pulmonary
disease on the pulmonary function test. We assessed changes in pulmonary
function in terms of 'volume reduction effect' after lobectomy for lung cancer.
Methods: Forty-three patients underwent right upper lobectomy (RUL), 38 patients
left upper lobectomy (LUL), 39 patients right lower lobectomy (RLL), and 38
patients left lower lobectomy (LLL). Pulmonary function tests were performed
preoperatively and 6 months to 1 year after surgery. Results: Percent change in
FEV(1.0) after lobectomy was -6.9+/-16.1% in RUL group, -11.2+/-16.9% in LUL
group, -14.7+/-9.8% in RLL group, and -12.8+/-9.5% in LLL group. We evaluated
the correlation between a preoperative FEV(1.0)% of predicted and percentage
change in FEV(1.0) after lobectomy. There were no significant relationships
between these variables in RLL or LLL group. In contrast, there were significant
negative relationships between these variables in RUL and LUL groups.
Correlation coefficients were r=-0.667, p<0.0001 for RUL and r=-0.712, p<0.0001
for LUL. In RUL and LUL groups, patients with a higher preoperative FEV(1.0)% of
predicted had a more adverse percentage change in FEV(1.0) after surgery. In
addition, all 13 patients with a preoperative FEV(1.0)% of predicted <60% in RUL
and LUL groups had an increase in FEV(1.0) postoperatively. Patients with a
lower preoperative FEV(1.0)% of predicted had a greater 'volume reduction
effect' with an increase in FEV(1.0) after upper lobectomy. Conclusion: Upper
lobectomy might have a volume reduction effect.
-----
Proc Am Thorac Soc. 2006 Apr;3(2):176-9.
Why does the lung hyperinflate?
Ferguson GT.
Pulmonary Research Institute of Southeast Michigan, Livonia, Michigan 48152,
USA. garytferguson@msn.com
Patients with chronic obstructive pulmonary disease (COPD) often have some
degree of hyperinflation of the lungs. Hyperinflated lungs can produce
significant detrimental effects on breathing, as highlighted by improvements in
patient symptoms after lung volume reduction surgery. Measures of lung volumes
correlate better with impairment of patient functional capabilities than do
measures of airflow. Understanding the mechanisms by which hyperinflation occurs
in COPD provides better insight into how treatments can improve patients'
health. Both static and dynamic processes can contribute to lung hyperinflation
in COPD. Static hyperinflation is caused by a decrease in elasticity of the lung
due to emphysema. The lungs exert less recoil pressure to counter the recoil
pressure of the chest wall, resulting in an equilibrium of recoil forces at a
higher resting volume than normal. Dynamic hyperinflation is more common and can
occur independent of or in addition to static hyperinflation. It results from
air being trapped within the lungs after each breath due to a disequilibrium
between the volumes inhaled and exhaled. The ability to fully exhale depends on
the degree of airflow limitation and the time available for exhalation. These
can both vary, causing greater hyperinflation during exacerbations or increased
respiratory demand, such as during exercise. Reversibility of dynamic
hyperinflation offers the possibility for intervention. Use of bronchodilators
with prolonged durations of action, such as tiotropium, can sustain significant
reductions in lung inflation similar in effect to lung volume reduction surgery.
How efficacy of bronchodilators is assessed may, therefore, need to be
reevaluated.
-----
Am J Transplant. 2006;6(5 Pt 2):1188-97.
Thoracic organ transplantation in the United States, 1995-2004.
Orens JB, Shearon TH, Freudenburger RS, Conte JV, Bhorade SM, Ardehali A.
Johns Hopkins University School of Medicine, Baltimore, MD, USA. jorens@jhmi.edu
This article reviews trends in thoracic organ transplantation based on OPTN/SRTR
data from 1995 to 2004. The number of active waiting list patients for heart
transplants continues to decline, primarily because there are fewer patients
with coronary artery disease listed for transplantation. Waiting times for heart
transplantation have decreased, and waiting list deaths also have declined, from
259 per 1000 patient-years at risk in 1995 to 156 in 2004. Fewer heart
transplants were performed in 2004 than in 1995, but adjusted patient survival
increased to 88% at 1 year and 73% at 5 years. Emphysema, idiopathic pulmonary
fibrosis and cystic fibrosis were the most common indications among lung
transplant recipients in 2004. Waiting time for lung transplantation decreased
between 1999 and 2004. Waiting list mortality decreased to 134 per 1000
patient-years at risk in 2004. One-year survival following transplantation has
improved significantly in the past decade. The number of combined heart-lung
transplants performed in the United States remains low, with only 39 performed
in 2004. Overall unadjusted survival, at 58% at 1 year and 40% at 5 years, is
lower among heart-lung recipients than among either heart or lung recipients
alone.
-----
J Cardiopulm Rehabil. 2006 Mar-Apr;26(2):112-7.
Impact of customized videotape education on quality of life in
patients with chronic obstructive pulmonary disease.
Petty TL, Dempsey EC, Collins T, Pluss W, Lipkus I, Cutter GR, Chalmers R,
Mitchell A, Weil KC.
University of Colorado Health Sciences Center, Denver, USA.
PURPOSE: To compare the impact of a library of pulmonary rehabilitation
videotapes versus an older videotape and usual care on quality of life and
ability to perform activities of daily living in persons with chronic
obstructive pulmonary disease. METHODS: Two hundred fourteen patients diagnosed
with chronic obstructive pulmonary disease, emphysema, or chronic bronchitis
were recruited and randomized to receive customized videotapes, standard
videotapes, or usual care. Outcome measures included the Fatigue Impact Scale,
Seattle Obstructive Lung Disease Questionnaire, and the SF-36(R) Health Survey.
RESULTS: Differences in coping skills and emotional functioning on the Seattle
Obstructive Lung Disease Questionnaire were found among the 174 subjects who
completed the study. The customized videotape group improved by 8.6 and 4.8
points, respectively, whereas the score of the other groups decreased by less
than 1 point for the coping skills, and the scores of the standard video and the
control groups decreased by 3.0 and 2.1 points, respectively, for emotional
functioning (P < .05, all comparisons). The scores using the Fatigue Impact
Scale also improved for the customized videotape group, whereas the scores of
the others remained unchanged. Videotape users demonstrated better conversion to
and retention of exercise habits, with over 80% of customized videotape subjects
who reported exercise habits at baseline continuing the habits as compared with
40% in the usual care group. Sedentary subjects at baseline were more likely to
begin and maintain exercise if randomized to videotapes. CONCLUSIONS: These
findings demonstrate increased quality of life, lower fatigue, and better
compliance with a prescribed exercise regimen among subjects using the
customized videotapes. There was a significant improvement in emotional
functioning and coping skills among customized videotape subjects.
-----
Proc Am Thorac Soc. 2006;3(1):58-65.
Chronic obstructive pulmonary disease: from unjustified nihilism
to evidence-based optimism.
Celli BR.
Department of Medicine, Tufts University. bcelli@cchcs.org
Chronic obstructive pulmonary disease (COPD) has been associated with a
nihilistic attitude. On the basis of current evidence, this nihilistic attitude
is totally unjustified. The disease must be viewed through the lens of a new
paradigm: one that accepts COPD as not only a pulmonary disease but also as one
with important measurable systemic consequences. COPD is not only preventable
but also treatable. Smoking cessation, oxygen for hypoxemic patients, lung
reduction surgery for selected patients with emphysema, and noninvasive
ventilation during severe exacerbations have all been shown to impact on
mortality. In addition, pulmonary rehabilitation, pharmacologic therapy, and
lung transplantation improve patient-centered outcomes such as health-related
quality of life, dyspnea, exercise capacity, and even exacerbations and
hospitalizations. Caregivers should familiarize themselves with the multiple
complementary forms of treatment and individualize therapy to the particular
situation of each patient. The future for patients with this disease is bright
as its pathogenesis and clinical and phenotypic manifestations are unraveled.
The advent of newer and more effective therapies will lead to a decline in the
contribution of this disease to poor world health.
-----
Eur J Cardiothorac Surg. 2006 May 1; [Epub ahead of print]
Assessment of pulmonary function after lobectomy for lung cancer
- upper lobectomy might have the same effect as lung volume reduction surgery.
Kushibe K, Takahama M, Tojo T, Kawaguchi T, Kimura M, Taniguchi S.
Department of Thoracic and Cardiovascular Surgery, Nara Medical University
School of Medicine, Kashihara, Nara 634-8522, Japan.
Objective: Lung volume reduction surgery (LVRS) in well-selected patients with
severe emphysema results in postoperative improvement in symptoms and pulmonary
function. Experience with LVRS suggests that predicted postoperative FEV(1.0)
may be underestimated after lobectomy in patients with lung cancer and
emphysema. As most of the patients with lung cancer have more or less
emphysematous changes in the lungs, we assumed that lobectomy would achieve the
same effect as LVRS even in patients without chronic obstructive pulmonary
disease on the pulmonary function test. We assessed changes in pulmonary
function in terms of 'volume reduction effect' after lobectomy for lung cancer.
Methods: Forty-three patients underwent right upper lobectomy (RUL), 38 patients
left upper lobectomy (LUL), 39 patients right lower lobectomy (RLL), and 38
patients left lower lobectomy (LLL). Pulmonary function tests were performed
preoperatively and 6 months to 1 year after surgery. Results: Percent change in
FEV(1.0) after lobectomy was -6.9+/-16.1% in RUL group, -11.2+/-16.9% in LUL
group, -14.7+/-9.8% in RLL group, and -12.8+/-9.5% in LLL group. We evaluated
the correlation between a preoperative FEV(1.0)% of predicted and percentage
change in FEV(1.0) after lobectomy. There were no significant relationships
between these variables in RLL or LLL group. In contrast, there were significant
negative relationships between these variables in RUL and LUL groups.
Correlation coefficients were r=-0.667, p<0.0001 for RUL and r=-0.712, p<0.0001
for LUL. In RUL and LUL groups, patients with a higher preoperative FEV(1.0)% of
predicted had a more adverse percentage change in FEV(1.0) after surgery. In
addition, all 13 patients with a preoperative FEV(1.0)% of predicted <60% in RUL
and LUL groups had an increase in FEV(1.0) postoperatively. Patients with a
lower preoperative FEV(1.0)% of predicted had a greater 'volume reduction
effect' with an increase in FEV(1.0) after upper lobectomy. Conclusion: Upper
lobectomy might have a volume reduction effect.
-----
Proc Am Thorac Soc. 2006 Apr;3(2):176-9.
Why does the lung hyperinflate?
Ferguson GT.
Pulmonary Research Institute of Southeast Michigan, Livonia, Michigan 48152,
USA. garytferguson@msn.com
Patients with chronic obstructive pulmonary disease (COPD) often have some
degree of hyperinflation of the lungs. Hyperinflated lungs can produce
significant detrimental effects on breathing, as highlighted by improvements in
patient symptoms after lung volume reduction surgery. Measures of lung volumes
correlate better with impairment of patient functional capabilities than do
measures of airflow. Understanding the mechanisms by which hyperinflation occurs
in COPD provides better insight into how treatments can improve patients'
health. Both static and dynamic processes can contribute to lung hyperinflation
in COPD. Static hyperinflation is caused by a decrease in elasticity of the lung
due to emphysema. The lungs exert less recoil pressure to counter the recoil
pressure of the chest wall, resulting in an equilibrium of recoil forces at a
higher resting volume than normal. Dynamic hyperinflation is more common and can
occur independent of or in addition to static hyperinflation. It results from
air being trapped within the lungs after each breath due to a disequilibrium
between the volumes inhaled and exhaled. The ability to fully exhale depends on
the degree of airflow limitation and the time available for exhalation. These
can both vary, causing greater hyperinflation during exacerbations or increased
respiratory demand, such as during exercise. Reversibility of dynamic
hyperinflation offers the possibility for intervention. Use of bronchodilators
with prolonged durations of action, such as tiotropium, can sustain significant
reductions in lung inflation similar in effect to lung volume reduction surgery.
How efficacy of bronchodilators is assessed may, therefore, need to be
reevaluated.
-----
Am J Transplant. 2006;6(5 Pt 2):1188-97.
Thoracic organ transplantation in the United States, 1995-2004.
Orens JB, Shearon TH, Freudenburger RS, Conte JV, Bhorade SM, Ardehali A.
Johns Hopkins University School of Medicine, Baltimore, MD, USA. jorens@jhmi.edu
This article reviews trends in thoracic organ transplantation based on OPTN/SRTR
data from 1995 to 2004. The number of active waiting list patients for heart
transplants continues to decline, primarily because there are fewer patients
with coronary artery disease listed for transplantation. Waiting times for heart
transplantation have decreased, and waiting list deaths also have declined, from
259 per 1000 patient-years at risk in 1995 to 156 in 2004. Fewer heart
transplants were performed in 2004 than in 1995, but adjusted patient survival
increased to 88% at 1 year and 73% at 5 years. Emphysema, idiopathic pulmonary
fibrosis and cystic fibrosis were the most common indications among lung
transplant recipients in 2004. Waiting time for lung transplantation decreased
between 1999 and 2004. Waiting list mortality decreased to 134 per 1000
patient-years at risk in 2004. One-year survival following transplantation has
improved significantly in the past decade. The number of combined heart-lung
transplants performed in the United States remains low, with only 39 performed
in 2004. Overall unadjusted survival, at 58% at 1 year and 40% at 5 years, is
lower among heart-lung recipients than among either heart or lung recipients
alone.
-----
J Cardiopulm Rehabil. 2006 Mar-Apr;26(2):112-7.
Impact of customized videotape education on quality of life in
patients with chronic obstructive pulmonary disease.
Petty TL, Dempsey EC, Collins T, Pluss W, Lipkus I, Cutter GR, Chalmers R,
Mitchell A, Weil KC.
University of Colorado Health Sciences Center, Denver, USA.
PURPOSE: To compare the impact of a library of pulmonary rehabilitation
videotapes versus an older videotape and usual care on quality of life and
ability to perform activities of daily living in persons with chronic
obstructive pulmonary disease. METHODS: Two hundred fourteen patients diagnosed
with chronic obstructive pulmonary disease, emphysema, or chronic bronchitis
were recruited and randomized to receive customized videotapes, standard
videotapes, or usual care. Outcome measures included the Fatigue Impact Scale,
Seattle Obstructive Lung Disease Questionnaire, and the SF-36(R) Health Survey.
RESULTS: Differences in coping skills and emotional functioning on the Seattle
Obstructive Lung Disease Questionnaire were found among the 174 subjects who
completed the study. The customized videotape group improved by 8.6 and 4.8
points, respectively, whereas the score of the other groups decreased by less
than 1 point for the coping skills, and the scores of the standard video and the
control groups decreased by 3.0 and 2.1 points, respectively, for emotional
functioning (P < .05, all comparisons). The scores using the Fatigue Impact
Scale also improved for the customized videotape group, whereas the scores of
the others remained unchanged. Videotape users demonstrated better conversion to
and retention of exercise habits, with over 80% of customized videotape subjects
who reported exercise habits at baseline continuing the habits as compared with
40% in the usual care group. Sedentary subjects at baseline were more likely to
begin and maintain exercise if randomized to videotapes. CONCLUSIONS: These
findings demonstrate increased quality of life, lower fatigue, and better
compliance with a prescribed exercise regimen among subjects using the
customized videotapes. There was a significant improvement in emotional
functioning and coping skills among customized videotape subjects.
-----
Proc Am Thorac Soc. 2006;3(1):58-65.
Chronic obstructive pulmonary disease: from unjustified nihilism
to evidence-based optimism.
Celli BR.
Department of Medicine, Tufts University. bcelli@cchcs.org
Chronic obstructive pulmonary disease (COPD) has been associated with a
nihilistic attitude. On the basis of current evidence, this nihilistic attitude
is totally unjustified. The disease must be viewed through the lens of a new
paradigm: one that accepts COPD as not only a pulmonary disease but also as one
with important measurable systemic consequences. COPD is not only preventable
but also treatable. Smoking cessation, oxygen for hypoxemic patients, lung
reduction surgery for selected patients with emphysema, and noninvasive
ventilation during severe exacerbations have all been shown to impact on
mortality. In addition, pulmonary rehabilitation, pharmacologic therapy, and
lung transplantation improve patient-centered outcomes such as health-related
quality of life, dyspnea, exercise capacity, and even exacerbations and
hospitalizations. Caregivers should familiarize themselves with the multiple
complementary forms of treatment and individualize therapy to the particular
situation of each patient. The future for patients with this disease is bright
as its pathogenesis and clinical and phenotypic manifestations are unraveled.
The advent of newer and more effective therapies will lead to a decline in the
contribution of this disease to poor world health.
-----
Curr Opin Pulm Med. 2006 Mar;12(2):125-31.
Alpha-1-antitrypsin replacement therapy: current status.
Abusriwil H, Stockley RA.
Lung Investigation Unit, Nuffield House, Queen Elizabeth Hospital, University
Hospital Birmingham NHS Trust, Birmingham, UK.
PURPOSE OF REVIEW: Alpha-1-antitrypsin deficiency is a relatively common genetic
disease that predisposes to the development of early-onset emphysema and, in
some instances, liver disease. The use of alpha-1-antitrypsin replacement
therapy in the treatment of alpha-1-antitrypsin deficiency related emphysema is
much debated and the purpose of this review is to examine the results of recent
studies. We will comment briefly on the pathogenesis and epidemiology of the
disease together with new therapeutic approaches currently under intense
research. RECENT FINDINGS: Several nonrandomized observational studies and one
metaanalysis on the clinical effectiveness of alpha-1-antitrypsin replacement
treatment showed a favourable result towards reducing forced expiratory volume
in 1 s (FEV1) deterioration in alpha-1-antitrypsin-deficient individuals with
moderate lung disease or accelerated FEV1 decline. Improved ways of monitoring
disease progression, including computed tomography scanning and exacerbations,
are being proposed as primary endpoints. Apart from one small randomized,
placebo-controlled trial using computed tomography scanning, which showed a
trend toward preservation of lung density on scanning with treatment, the
literature lacks proof of effectiveness from large randomized trials. SUMMARY:
There might be a possible, but so far unproven, role of alpha-1-antitrypsin
augmentation therapy in reducing the progression of emphysema in subsets of
patients with alpha-1-antitrypsin deficiency. Placebo-controlled, randomized
clinical trials are required to draw firm conclusions. Recent advances in the
understanding of the molecular pathology provide opportunities for development
of new therapeutic targets for this genetic disorder.
-----
Respir Care. 2006 Feb;51(2):173-82.
Surgical Options for Patients With COPD: Sorting Out the Choices.
Benditt JO.
Division of Pulmonary and Critical Care Medicine, Department of Medicine,
University of Washington, Seattle, Washington, benditt@u.washington.edu.
Surgical procedures designed to improve pulmonary function and quality of life
of patients with advanced emphysema have been attempted for more than a century.
Of the many attempted procedures, only giant bullectomy, lung transplantation,
and lung-volume-reduction surgery have withstood the test of time and are
currently being practiced. This article reviews each of these procedures and
also develops a rational approach to selecting appropriate candidates for these
3 interventions.
-----
Eur J Cardiothorac Surg. 2006 Jan 23; [Epub ahead of print]
Bronchoscopic procedures for emphysema treatment.
Venuta F, Rendina EA, De Giacomo T, Anile M, Diso D, Andreetti C, Pugliese F,
Coloni GF.
Universita di Roma "La Sapienza", Cattedra di Chirurgia Toracica, Policlinico
Umberto I, V.le del Policlinico, 00100 Rome, Italy.
Emphysema is a debilitating lung disease continuing to be a major source of
morbidity and mortality in the developed countries. Medical treatment is the
mainstay of therapy and consists of smoking cessation, pulmonary rehabilitation,
administration of bronchodilators and, when indicated, steroids and supplemental
oxygen. Various surgical procedures have been promoted in the past to relieve
dyspnoea and improve quality of life in patients with advanced emphysema; whilst
early results were often encouraging, a sustained objective functional
improvement was rarely achieved and most of those procedures were progressively
abandoned. Despite controversies, LVRS has been shown to be beneficial to
selected patients with end-stage emphysema when medical therapy has failed.
There is no doubt that LVRS allows a significative functional improvement in a
selected group of patients; however, it still carries a substantial morbidity,
even if mortality is low at the centres with the larger experience. Patients
with a most advanced functional deterioration show a higher surgical mortality
and less impressive functional results, suggesting that LVRS should be
considered more carefully in these situations. Bronchoscopic alternatives to the
surgical approach have been recently proposed and some of them may play an
important role in the future; in particular, the airway bypass and bronchoscopic
lung volume reduction with one-way valves are certainly one step beyond on their
way to clinical application. We hereby report the initial experimental and
clinical experience with these new treatment options.
-----
Intern Med J. 2006 Jan;36(1):5-11.
Lung transplantation for chronic obstructive pulmonary disease at
St Vincent's Hospital.
Gunes A, Aboyoun CL, Morton JM, Plit M, Malouf MA, Glanville AR.
Thoracic Medicine, Cairns Base Hospital, Cairns, Queensland, Australia.
Abstract Background: Lung transplantation (LTx) offers selected patients with
end-stage chronic obstructive pulmonary disease (COPD) an improved quality of
life and possibly enhanced survival. Aim: To determine local outcomes of LTx for
COPD we analysed 173 consecutive heart-LTx (n = 8), single LTx (SLTx; n = 99)
and bilateral LTx (BLTx; n = 66) carried out at a single institution during
1989-2003 for smoking-related emphysema (E) (n = 112) and emphysema related to
alpha-1 antitrypsin deficiency (AATD) (n = 61). Methods: There were 98 men and
75 women with a mean age of 50 +/- 6 years (standard deviation) (range 32-63
years). Median waiting time was 113 days (interquartile range (IQR) 50-230
days), and median inpatient stay was 13 days (IQR 9-21 days). Results:
Perioperative survival (30 days) was 95% with deaths from sepsis (n = 5),
cerebrovascular accident (n = 3) and multiorgan failure (n = 1). Mean follow-up
period was 1693 +/- 1302 days (2-4805 days). The 1-, 5- and 10-year survivals
(%) were similar for patients with E and AATD (P = 0.480 log rank) at 86 +/- 5,
57 +/- 7 and 31 +/- 11, respectively, but 1- and 5-year survivals for E were
higher after BLTx than after SLTx (97 +/- 2 and 81 +/- 8 vs 85 +/- 4 and 47 +/-
6) (P = 0.015). Pretransplant body mass index, forced expiratory volume in 1
second, forced vital capacity, PaCO(2), PaO(2), six-minute walk distance, home
oxygen use, age, sex, cytomegalovirus donor-recipient mismatch, cardiopulmonary
bypass use, year of transplant and ischaemic time did not influence survival
after LTx. Increasing donor age was a survival risk factor for patients with E
but not for those with AATD (hazard ratio 1.043; 95%confidence interval
1.014-1.025). Conclusion: Survival after LTx for COPD is similar to survival for
other forms of solid organ transplantation, in part reflecting risk factor
management.
-----
J Heart Lung Transplant. 2006 Jan;25(1):67-74. Epub 2005 Nov 10.
Effect of pre-transplantation prednisone on survival after lung
transplantation.
McAnally KJ, Valentine VG, LaPlace SG, McFadden PM, Seoane L, Taylor DE.
Lung Transplantation, Ochsner Clinic Foundation, New Orleans, Louisiana, USA.
BACKGROUND: It is routine practice to discontinue corticosteroids or at least
reduce the dose to <or=20 mg/day in patients being considered for lung
transplantation. No studies have either evaluated the risks of
pre-transplantation steroid use or determined safe or optimal doses in the pre-
or post-lung transplantation time frame. We sought to determine whether there
are deleterious effects of prednisone administration before lung transplantation
and if corticosteroids affect survival after lung transplantation. METHODS:
Between November 1990 and January 2005, 201 patients underwent lung
transplantation. Of these, 126 patients had been prescribed prednisone before
lung transplantation. Sixty-four had taken low-dose (LD) prednisone (<0.42
mg/kg/m(2) per day), and 62 had taken high-dose (HD) prednisone (>or=0.42
mg/kg/m(2) per day). The LD Group also included 75 patients never prescribed
steroids before lung transplantation (n = 139). RESULTS: A comparison of
survival rates between LD and HD Cohorts showed better survival in the LD group,
p value by log rank for LD vs HD <0.01. Other than having more emphysema
patients (53/139, 40%) and fewer idiopathic pulmonary fibrosis patients (21/139,
16%) in the LD group (p < 0.01), pre-transplantation characteristics between the
2 cohorts were similar. In addition, the LD Group had more bilateral lung
recipients (p < 0.01). During the first 100 days after transplantation, 20 HD
(20/62) patients and 16 LD (16/139) died (p < 0.01). CONCLUSIONS: Survival in
the LD Cohort was strikingly better than for patients receiving >or=0.42
mg/kg/m(2) per day. Deaths in the early post-operative period for the HD Group
may be related to steroid-induced complications such as poor wound healing and
serious infections. A pre-lung transplantation steroid dose adjusted for body
mass index of >or=0.42 mg/kg/m(2) per day may be associated with increased
complications and worse survival after lung transplantation. Further studies are
warranted to confirm these results.
-----
Chest. 2005 Dec;128(6):3799-809.
The effects of pulmonary rehabilitation in the national emphysema
treatment trial.
Ries AL, Make BJ, Lee SM, Krasna MJ, Bartels M, Crouch R, Fishman AP; National
Emphysema Treatment Trial Research Group.
UCSD Medical Center, 200 W Arbor Dr, No. 8377, San Diego, CA 92103-8377, USA.
aries@ucsd.edu
STUDY OBJECTIVES: Pulmonary rehabilitation is an established treatment in
patients with chronic lung disease but is not widely utilized. Most trials have
been conducted in single centers. The National Emphysema Treatment Trial (NETT)
provided an opportunity to evaluate pulmonary rehabilitation in a large cohort
of patients who were treated in centers throughout the United States. DESIGN:
Prospective observational study of cohort prior to randomization in a
multicenter clinical trial. SETTING: University-based clinical centers and
community-based satellite pulmonary rehabilitation programs.Patients and
intervention: A total of 1,218 patients with severe emphysema underwent
pulmonary rehabilitation before and after randomization to lung volume reduction
surgery (LVRS) or continued medical management. Rehabilitation was conducted at
17 NETT centers supplemented by 539 satellite centers. MEASUREMENTS AND RESULTS:
Lung function, exercise tolerance, dyspnea, and quality of life were evaluated
at regular intervals. Significant (p < 0.001) improvements were observed
consistently in exercise (cycle ergometry, 3.1 W; 6-min walk test distance, 76
feet), dyspnea (University of California, San Diego Shortness of Breath
Questionnaire score, -3.2; Borg breathlessness score: breathing cycle, -0.8;
6-min walk, -0.5) and quality of life (St. George Respiratory Questionnaire
score, -3.5; Quality of Well-Being Scale score, +0.035; Medical Outcomes Study
36-item short form score: physical health summary, +1.3; mental health summary,
+ 2.0). Patients who had not undergone prior rehabilitation improved more than
those who had. In multivariate models, only prior rehabilitation status
predicted changes after rehabilitation. In 20% of patients, exercise level
changed sufficiently after rehabilitation to alter the NETT subgroup predictive
of outcome. Overall, changes after rehabilitation did not predict differential
mortality or improvement in exercise (primary outcomes) by treatment group.
CONCLUSIONS: The NETT experience demonstrates the effectiveness of pulmonary
rehabilitation in patients with severe emphysema who were treated in a national
cross-section of programs. Pulmonary rehabilitation plays an important role in
preparing and selecting patients for surgical interventions such as LVRS.
-----
Chest. 2005 Nov;128(5):3489-99.
Comparison of lung volume reduction surgery and physical training
on health status and physiologic outcomes: a randomized controlled clinical
trial.
Hillerdal G, Lofdahl CG, Strom K, Skoogh BE, Jorfeldt L, Nilsson F,
Forslund-Stiby D, Ranstam J, Gyllstedt E.
Department of Pulmonary Medicine, Karolinska Hospital, Stockholm, Sweden.
gunnar.hillerdal@karolinska.se
STUDY OBJECTIVES: In 1996, researchers in Sweden initiated a collaborative
randomized study comparing lung volume reduction surgery (LVRS) and physical
training with physical training alone. The primary end point was health status;
secondary end points included survival and physiologic measurements. DESIGN:
After an initial 6-week physical training program, researchers' patients were
randomized to either LVRS (surgical group [SG]) with continued training for 3
months, or to continued training alone (training group [TG]) for 1 year.
SETTING: All seven thoracic surgery centers in Sweden. PATIENTS: All patients in
Sweden with severe emphysema fulfilling inclusion criteria for LVRS.
INTERVENTIONS: Patients randomized to surgery underwent a median sternotomy,
except for a few patients in whom thoracotomy or video-assisted thoracoscopy
were performed. In the TG, supervised physical training continued for 1 year; in
the SG, supervised physical training continued for 3 months postoperatively.
MEASUREMENTS AND RESULTS: Fifty-three patients were included in each group. Six
in-hospital deaths occurred after surgery (12%), and one more death occurred
during follow-up. Two deaths occurred in the TG. The difference in death rates
between the groups was not statistically significant. Health status, as measured
by St. George Respiratory Questionnaire (SGRQ) [total scale score mean
difference at 1 year, 14.7; 95% confidence interval (CI), 9.8 to 19.7] as well
as by the Medical Outcomes Study Short-Form General Health Survey (physical
function scale score mean difference at 1 year, 19.7; 95% CI, 12.1 to 27.3) was
improved from baseline in the SG compared with the TG. FEV(1), residual volume,
and shuttle walking test values also improved in the SG but not in the TG after
6 months and 12 months. CONCLUSIONS: In severe emphysema, LVRS can improve
health status in survivors but is associated with mortality risk. The effects
are stable for at least 1 year. Physical training alone failed to achieve a
similar improvement.
-----
Respir Med. 2005 Nov 19; [Epub ahead of print]
Short- and long-term outcome of lung volume reduction surgery.
The predictive value of the preoperative clinical status and lung scintigraphy.
Hardoff R, Shitrit D, Tamir A, Steinmetz AP, Krausz Y, Kramer MR.
Departments of Nuclear Medicine, Rabin Medical Center, Beilinson Campus, Petach
Tikva 49100, Israel.
The NETT study assessed the benefits of lung volume reduction surgery (LVRS)
versus medical treatment. However, data is available only on the early outcome
of LVRS (24 months). We evaluate the factors affecting the outcome at one-year
and up to 6 years after LVRS. Thirty-seven patients underwent LVRS. Thirty-five
patients, who survived the operation for at least one-year, were followed up to
6 years. Patients' laboratory, clinical and scintigraphic data before surgery
were reviewed retrospectively, and follow-up at one-year and at the end of data
collection. Successful LVRS with improvement of FEV(1)30% at one-year was
observed in 13 of 35 patients. Five of these patients had initial FEV(1) values
of <20% of the predicted. The group of patients with improvement was younger as
compared to the 22 patients without improvement (P<0.005). The younger age group
used less supplemental oxygen and had a PDiff of >23%. Combinations of age under
60 years and PDiff >23% were a favorable factor (P<0.002) for successful LVRS.
Thirty-four patients were followed up to 6 years. Fifteen of the 34 patients
(44.1%) remained well. Use of supplemental oxygen before surgery, and FEV(1)
improvement of 30% at one-year after surgery were good prognostic factors. We
concluded that the long-term success of LVRS is affected by non-dependence on
oxygen supplementation before surgery, and the one-year post-surgical
improvement of FEV(1) (30%). Based on our findings, the subgroup of patients
below 60 years old with severe disease (FEV(1)<20%) and heterogeneous upper lobe
emphysema (Pdiff>23%) has improved outcome.
-----
Ann Pharmacother. 2005 Nov;39(11):1861-9. Epub 2005 Oct 11.
Aralast: A New {alpha}1-Protease Inhibitor for Treatment of
{alpha}-Antitrypsin Deficiency.
Louie SG, Sclar DA, Gill MA.
Department of Pharmacy, University of Southern California, Los Angeles, CA.
OBJECTIVE: To review the epidemiology, pathogenesis, and management of patients
with alpha-antitrypsin (AAT) deficiency syndrome and compare Aralast with
Prolastin, 2 of the 3 available human plasma-derived AAT agents. DATA SOURCES:
Articles were identified using a MEDLINE (1966-September 2005) search with MESH
headings that included alpha-antitrypsin and emphysema. STUDY SELECTION AND DATA
EXTRACTION: All papers from peer-reviewed journals on the laboratory or clinical
efficacy of plasma-derived AAT (eg, Prolastin, Aralast) for patients with this
autosomal recessive disorder were reviewed. DATA SYNTHESIS: Clinical trials
found that AAT augmentation prevents progression of AAT-deficient emphysema and
thus its associated morbidity and mortality. Treatment with Aralast has been
shown to be safe and well tolerated, with a low incidence of mild to moderate
adverse events. Pharmacoeconomics studies of AAT augmentation demonstrated that
the use of Aralast was cost-effective as lifelong augmentation therapy for AAT-deficient
emphysema. CONCLUSIONS: Because of its effectiveness and extra safety measure
compared with Prolastin, Aralast should be recommended for formulary inclusion.
-----
Chest. 2005 Oct;128(4):2653-63.
Improved neurobehavioral functioning in emphysema patients
following lung volume reduction surgery compared with medical therapy.
Kozora E, Emery CF, Ellison MC, Wamboldt FS, Diaz PT, Make B.
ABPP/CN, National Jewish Medical and Research Center, 1400 Jackson St, A111,
Denver, CO 80206. kozorae@njc.org.
STUDY OBJECTIVES: The goal of this study was to evaluate the neuropsychological
and psychological functioning of emphysema patients following lung volume
reduction surgery (LVRS) compared with patients receiving only medical therapy
(MT). DESIGN: Patients with moderate-to-severe emphysema who were enrolled in
the National Emphysema Treatment Trial at two sites (National Jewish Medical and
Research Center and Ohio State University) were given a neuropsychological
battery at baseline, 6 to 10 weeks later (following participation in pulmonary
rehabilitation), and at 6 months following randomization to either LVRS or MT
treatment.Subjects and measurements: Twenty patients randomized to MT, 19
patients randomized to LVRS, and 39 matched, healthy control subjects completed
a battery of tests that measured cognitive functioning, depression, anxiety, and
quality of life (QoL). RESULTS: Controlling for practice, patients in the LVRS
treatment arm at the 6-month follow-up demonstrated significant improvement
compared with MT patients in cognitive tasks involving sequential skills and
verbal memory. The LVRS patients also showed significant reductions in
depression compared with the MT patients, as well as improved physical and
psychosocial QoL. Correlational analysis indicated that improved immediate
verbal memory in the LVRS group was related to improved QoL. No associations
were found between changes in cognitive function and changes in depression,
exercise performance, or pulmonary functioning. CONCLUSION: Patients who
received LVRS demonstrated improvement in specific neuropsychological functions,
depression, anxiety, and QoL scores compared with patients with continued MT
treatment 6 months following randomization. However, mechanisms for these
neurobehavioral changes are unclear. Improved verbal memory and sequential
skills following LVRS were not directly associated with depression or exercise
capacity. Nonetheless, LVRS led to a strong and likely clinically significant
improvement in neuropsychological functioning over and above that explained by
practice effects or MT. This finding adds to the growing list of clinical
benefits of LVRS over MT, and supports additional research into the underlying
mechanisms of this therapeutic effect.
-----
Chest. 2005 Oct;128(4):2043-50.
Elective Surgery for Giant Bullous Emphysema: A 5-Year Clinical
and Functional Follow-up.
Palla A, Desideri M, Rossi G, Bardi G, Mazzantini D, Mussi A, Giuntini C.
U.O. Fisiopatologia Respiratoria, Dipartimento Cardio-Toracico, Via Paradisa 2,
Pisa 56100, Italy. A.A.Palla@med.unipi.it.
BACKGROUND: So far, very few studies in the literature have reported data on the
long-term follow-up of patients who have undergone surgery for giant bullous
emphysema (GBE), and much still needs to be known on the late fate of these
patients.Aims: To evaluate patients who have undergone elective surgery due to
GBE, early and late mortality following surgery, the early and late reappearance
of bullae, and the early and late modifications of clinical and functional data.
SUBJECTS AND METHODS: Forty-one consecutive patients (36 men; mean [+/- SD] age,
48.4 +/- 14.8 years) who underwent elective surgery for GBE were enrolled in a
prospective study, and were studied both before and after undergoing bullectomy
for a 5-year-follow-up period. Analyses were performed on the whole population
and on two subgroups of patients who were divided on the basis of the absence of
underlying diffuse emphysema (group A; n = 23) or the presence of underlying
diffuse emphysema (group B; n = 18). RESULTS: The early mortality rate was 7.3%
(within the first year), and the late mortality rate was 4.9% (overall mortality
rate at 5 years, 12.2%; mortality rate in group B, 27.8%). Bullae did not
reappear and residual bullae did not become enlarged in any patients at the site
of the bullectomy. During the follow-up, the dyspnea score was reduced
significantly soon after bullectomy and up to the fourth year of follow-up;
intrathoracic gas volume also was reduced significantly (average, 0.7 L). The
same was true for the FEV(1) percent predicted and the FEV(1)/vital capacity
ratio, which kept increasing until the second year; then, from the third year of
follow-up these values were reduced, yet remained above the prebullectomy values
until the fifth year of follow-up. When considered separately, the patients in
group B appeared to be the most impaired, clinically and functionally (eg,
FEV(1) showed a similar significant increase up to the second year in both
groups after surgery, while a different mean annual decrease was appreciable
from the second to the fifth year of follow-up: group A, 25 mL/year; group B, 83
mL/year. Furthermore, patients in group B were the only ones who contributed to
the mortality rate, on the whole showing a behavior similar to that of patients
who had undergone lung volume reduction surgery. CONCLUSIONS: In patients with
GBE who were enrolled in the study prospectively and were investigated yearly
during a 5-year-follow-up period, elective surgery appears to have been fairly
safe, and allowed clinical and functional improvement for at least 5 years.
Better results may be expected in patients without underlying diffuse emphysema.
-----
Respir Med. 2005 Oct 24; [Epub ahead of print]
Pulmonary rehabilitation for COPD.
Reardon J, Casaburi R, Morgan M, Nici L, Rochester C.
Department of Medicine, Hartford Hospital, 80 Seymour Street, Hartford, CT
06102, USA.
Pulmonary rehabilitation is a therapeutic process, which entails taking a
holistic approach to the welfare of the patient with chronic respiratory
illness-most commonly chronic obstructive pulmonary disease (COPD). Pulmonary
rehabilitation is considered essential throughout the lifetime management of
patients with symptomatic chronic respiratory disease. It requires the
coordinated action of a multidisciplinary healthcare team in order to deliver an
individualised rehabilitation programme to best effect-incorporating multiple
modalities, such as advice on smoking cessation, exercise training and patient
self-management education, among others. As core components of pulmonary
rehabilitation, exercise training and self-management education have been shown
to be beneficial in improving health-related quality of life (HRQoL) in patients
with chronic respiratory disease. Physical training can help to reduce the
muscle de-conditioning that occurs when the activity of patients is restricted
by their breathlessness and fatigue, and is often associated with an increase in
patient HRQoL. HRQoL can also be improved by the use of self-management
education, which is designed to provide the patient with the skills to manage
the health consequences of their disease. In doing so, patients are better able
to cope with disease symptoms, potentially leading to reduced healthcare costs.
A great deal of research has been conducted to try and fully define which
patients will benefit most from pulmonary rehabilitation. Although progress has
been made, many questions remain as to the best means of delivering
rehabilitation, particularly with respect to the optimum programme of physical
training and patient self-management education.
-----
Arch Intern Med. 2005 Oct 24;165(19):2286-92.
Efficacy of bupropion and nortriptyline for smoking cessation
among people at risk for or with chronic obstructive pulmonary disease.
Wagena EJ, Knipschild PG, Huibers MJ, Wouters EF, van Schayck CP.
Departments of General Practice.
BACKGROUND: The observations that smokers with chronic obstructive pulmonary
disease (COPD) are at increased risk of depression and that nicotine may have
antidepressant effects and regulate mood provide a rationale for the use of
antidepressant drugs for smoking cessation in patients with COPD. No clinical
trial has studied the efficacy of bupropion hydrochloride and nortriptyline
hydrochloride for smoking cessation in this patient population, to our
knowledge. METHODS: In a placebo-controlled double-dummy randomized trial, 255
adults at risk for COPD or with COPD were prescribed sustained-release bupropion
(bupropion SR) (150 mg twice daily) or nortriptyline (75 mg once daily) for 12
weeks. All patients received smoking cessation counseling. The main outcome
measure was prolonged abstinence from smoking from week 4 to week 26 after the
target quit date. RESULTS: The use of bupropion SR and nortriptyline resulted in
higher prolonged abstinence rates compared with placebo, although only the
difference between bupropion SR and placebo was statistically significant
(differences with placebo, 13.1% [95% confidence interval, 1.2%-25.1%] for
bupropion SR and 10.2% [95% confidence interval, -1.7% to 22.2%] for
nortriptyline). In patients with COPD, bupropion SR and nortriptyline seem
efficacious in achieving prolonged abstinence (differences with placebo, 18.9%
[95% confidence interval, 3.6%-34.2%] for bupropion SR and 12.9% [95% confidence
interval, -0.8% to 26.4%] for nortriptyline). In participants at risk for COPD,
no statistically significant differences with placebo in prolonged abstinence
rates were found. CONCLUSIONS: Bupropion SR treatment is an efficacious aid to
smoking cessation in patients with COPD. Nortriptyline treatment seems to be a
useful alternative.
-----
Respir Med. 2005 Oct 17; [Epub ahead of print]
Treatments for COPD.
Hanania NA, Ambrosino N, Calverley P, Cazzola M, Donner CF, Make B.
Pulmonary and Critical Care Medicine, Baylor College of Medicine, 1504 Taub
Loop, Houston, TX 77030, USA.
The multicomponent nature of chronic obstructive pulmonary disease (COPD) has
provided a challenging environment in which to develop successful treatments. A
combination of pharmacological and non-pharmacological approaches is used to
combat this problem, and an overview of these approaches and their possible
future direction is given. Bronchodilators are the mainstay of COPD treatment
and can be combined with inhaled corticosteroids for greater efficacy and fewer
side effects. A new generation of pharmacotherapeutic agents, most notably
phosphodiesterase-4 inhibitors, which are already in the advanced stages of
clinical development, and leukotriene B(4) inhibitors (in early clinical
development), may shape future treatment as further insight is gained into the
pathological mechanisms underlying COPD. Non-pharmacologic treatments for COPD
include long-term oxygen therapy (LTOT), nasal positive pressure ventilation (nPPV),
pulmonary rehabilitation and lung-volume-reduction surgery (LVRS). Apart from
smoking cessation, LTOT is the only treatment to date which has been shown to
modify survival rates in severe cases; thus its role in COPD is well defined.
The roles of nPPV and LVRS are less clear, though recent progress is reported
here. In the future, it will be important to establish the precise value of the
different treatments available for COPD-evaluating both clinical and
physiological endpoints and using the data to more accurately define candidate
patients accordingly. The challenge will be to develop this base of knowledge in
order to shape future research and allow clinicians to deliver tailored COPD
management programmes for the growing number of patients afflicted with this
disease.
-----
Chest. 2005 Sep;128(3):1371-8.
Health-related quality of life following single or bilateral lung
transplantation: a 7-year comparison to functional outcome.
Gerbase MW, Spiliopoulos A, Rochat T, Archinard M, Nicod LP.
Division of Pulmonary Medicine, Clinic of Thoracic Surgery and Unit of Liaison
Pyschiatry, University Hospitals of Geneva, 24 rue Micheli-du-Crest, 1211 Geneva
14, Switzerland. margaret.gerbase@hcuge.ch
OBJECTIVES: To compare long-term health-related quality of life (HRQL) in single
and bilateral lung transplant recipients independent of the underlying disease,
and in a subset of patients with native pulmonary emphysema. METHODS: Forty-four
lung transplant recipients (mean [+/- SD] age, 44.8 +/- 11.6 years) were
followed up for > 2 years after single lung transplantation (LTx) [14
recipients] or bilateral LTx (30 recipients). Data were prospectively collected,
before undergoing LTx and annually after undergoing LTx, measuring FEV1, 6-min
walk test (6MWT) results, and quality of life using the St. George respiratory
questionnaire (SGRQ) and a visual analog scale (VAS). The SGRQ addresses three
domains, namely, respiratory symptoms, accomplishment of routine activities, and
disease impact on daily life. RESULTS: Statistically significant correlation
coefficients were found comparing the SGRQ and the VAS (r = 0.812; p < 0.0001),
the SGRQ and the 6MWT (r = 0.610; p < 0.0001), and the SGRQ and the FEV1 (r =
0.523; p < 0.0001) in all patients. Significant improvements on the FEV1, 6MWT,
and SGRQ were observed after LTx in both single and bilateral LTx recipients.
Increased risk for the development of bronchiolitis obliterans syndrome (BOS)
[relative risk, 2.86; 95% confidence interval, 1.22 to 6.67; p = 0.03] and
significantly lower FEV1 values were observed in patients following a single
graft, compared to that in patients following a bilateral graft (p < 0.01). In
contrast, the 6MWT and the SGRQ scores were not significantly different between
recipients of single and double LTx. The same patterns of results were observed
in comparisons between single and bilateral lung recipients with prior pulmonary
emphysema. CONCLUSIONS: Despite poorer FEV1 recovery and increased risk of BOS
after LTx, single lung transplant recipients had comparable long-term exercise
tolerance and quality-of-life scores as patients who received bilateral
transplants. These results suggest the limited influence of functional
performance on objective and subjective markers of HRQL recovery after LTx.
-----
Eur Respir J. 2005 Aug;26(2):214-22.
Comparison of tiotropium once daily, formoterol twice daily and
both combined once daily in patients with COPD.
van Noord JA, Aumann JL, Janssens E, Smeets JJ, Verhaert J, Disse B, Mueller A,
Cornelissen PJ.
Dept of Respiratory Diseases, Atrium medisch centrum, Henri Dunantstraat 5, 6419
PC Heerlen, The Netherlands. j.a.vannoord@atriummc.nl
This study compared the bronchodilator effects of tiotropium, formoterol and
both combined in chronic obstructive pulmonary disease (COPD). A total of 71
COPD patients (mean forced expiratory volume in one second (FEV1) 37% predicted)
participated in a randomised, double-blind, three-way, crossover study and
received tiotropium 18 microg q.d., formoterol 12 microg b.i.d. or both combined
q.d. for three 6-week periods. The end-points were 24-h spirometry (FEV1, forced
vital capacity (FVC)) at the end of each treatment, rescue salbutamol and
safety. Compared with baseline (FEV1 prior to the first dose in the first
period), tiotropium produced a significantly greater improvement in average
daytime FEV1 (0-12 h) than formoterol (127 versus 86 mL), while average
night-time FEV1 (12-24 h) was not different (tiotropium 43 mL, formoterol 38 mL).
The most pronounced effects were provided by combination therapy (daytime 234 mL,
night-time 86 mL); both differed significantly from single-agent therapies.
Changes in FVC mirrored the FEV1 results. Compared with both single agents,
daytime salbutamol use was significantly lower during combination therapy (tiotropium
plus formoterol 1.81 puffs.day(-1), tiotropium 2.41 puffs x day(-1), formoterol
2.37 puffs x day(-1)). All treatments were well tolerated. In conclusion, in
chronic obstructive pulmonary disease patients, tiotropium q.d. achieved a
greater improvement in daytime and comparable improvement in night-time lung
function compared with formoterol b.i.d. A combination of both drugs q.d. was
most effective and provided an additive effect throughout the 24-h dosing
interval.
-----
Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005374.
Oral corticosteroids for stable chronic obstructive pulmonary
disease.
Walters J, Walters E, Wood-Baker R.
Discipline of Medicine, University of Tasmania Medical School, Discipline of
Medicine, University of Tasmania, 43 Collins Street, Hobart, Tasmania,
AUSTRALIA, 7001.
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common chronic
lung disorder, usually related to cigarette smoking, representing a major and
increasing cause of morbidity and mortality. It is defined "as a disease state
characterized by airflow limitation that is not fully reversible. The airflow
limitation is usually both progressive and associated with an abnormal
inflammatory response of the lungs to noxious particles or gases". The use of
corticosteroids for their anti-inflammatory effects has been suggested.
OBJECTIVES: To assess the effects of oral corticosteroids on the health status
of patients with stable COPD. SEARCH STRATEGY: Searches of the Cochrane Airways
Group Specialised Register and MEDLINE were carried out in December 2003 and
2004. Review articles and bibliographies were searched. SELECTION CRITERIA:
Randomised controlled prospective studies in adults with stable COPD (
post-bronchodilator FEV1 <80% of predicted, FEV1/FVC <70%) and a history of
smoking, excluding known asthmatics, in which oral steroid use was compared with
placebo and use of co-interventions was matched in both groups. DATA COLLECTION
AND ANALYSIS: Data was extracted independently by two reviewers. All trials were
combined using Review Manager (version 4.2.7). MAIN RESULTS: From 459 titles 24
studies met the inclusion criteria. Treatment lasted three weeks or less in 19
studies, high dose oral steroid was used in 21 studies and subjects had moderate
or severe COPD in 15 studies. There was a significant difference in FEV1 after
two weeks treatment, WMD 53.30 ml; 95% confidence interval 22.21 to 84.39
favouring oral steroid use compared to placebo when 14 studies with available
data (n=396) were combined, with no significant heterogeneity. There was a
significant increase in odds for individual patient FEV1 response greater than
20% from baseline with high dose oral steroid treatment compared to placebo, OR
2.71; 95% CI 1.84 to 4.01 (9 studies) . It would be necessary to treat 7
patients (95% CI 5 to 12) with oral corticosteroids to achieve one extra case of
increasing FEV1 by more than 20%, with a placebo group risk of 0.13. All
differences in health-related quality of life were less than the minimum
clinically important difference.There were small statistically significant
advantages for functional capacity and respiratory symptom of wheeze with oral
steroid treatment but no significant difference in risk of withdrawal from study
due to an exacerbation or rate of serious exacerbations over 2 years with low
dose oral steroid treatment. There was an increased risk of adverse effects,
including increased blood glucose, adrenal suppression and reduced serum
osteocalcin. AUTHORS' CONCLUSIONS: There is no evidence to support the long-term
use of oral steroids at doses less than 10-15 mg prednisolone though some
evidence that higher doses (>/= 30 mg prednisolone) improve lung function over a
short period. Potentially harmful adverse effects e.g.. diabetes, hypertension,
osteoporosis would prevent recommending long-term use at these high doses in
most patients.
-----
Ann Thorac Cardiovasc Surg. 2005 Apr;11(2):73-9.
Physiologic aspects in human lung transplantation.
Miyoshi S, Mochizuki Y, Nagai S, Kobayashi S, Seki N.
Department of Cardiothoracic Surgery, Dokkyo University School of Medicine,
Tochigi, Japan.
Heart-lung transplantation (HLT), followed by single lung transplantation (SLT)
and subsequently bilateral lung transplantation (BLT) have been developed as
treatments for patients with end-stage pulmonary diseases. Initially, SLT was
limited to idiopathic pulmonary fibrosis (IPF) cases and thought to be
contraindicated not only for infectious diseases, but also for non-infectious
diseases, including pulmonary emphysema (PE) and primary pulmonary hypertension
(PPH), based on physiologic points of view. However, SLT is now widely performed
for those non-infectious diseases and most of the recipients return to a normal
active life. It is quite possible that BLT is superior to SLT in terms of
pulmonary function, and it has been reported that BLT is better for PE and PPH
patients in regards to perioperative course, postoperative exercise capacity,
and long-term survival. For those situations and because of the present scarcity
of donor organs, SLT must be utilized for selected non-infectious diseases for
which it is safe and effective. When a single lung is replaced for IPF, PE, and
PPH recipients, different physiologic situations are produced postoperatively,
the understanding of which is extremely important to achieve good results, not
only in the perioperative but also in the long term.
-----
J Music Ther. 2005 Spring;42(1):20-48.
The singer's breath: implications for treatment of persons with
emphysema.
Engen RL.
Queens University of Charlotte.
This study investigated the effects of group singing instruction on the physical
health and general wellness of senior citizens with emphysema. Subjects (n = 7)
participated in 6 weeks of group vocal instruction, which emphasized breath
management techniques. Dependent measures reflected physical health, functional
outcomes, and quality of life. No significant differences were found on measures
of physical health (FEV1, inspiratory threshold, distance walked, and The DUKE
physical health subscale). Measures of functional outcomes each showed a
significant change across time. Results of the ANOVAs for breath management
(extent of counting) and breath support (intensity of speech) were significant
(p < .038 & p < .000 respectively). Descriptive analyses showed a clear and
dramatic shift in breathing mode from clavicular to diaphragmatic breathing that
was maintained 2 weeks after the treatment period. Quality of life measures
(subjective scales and The Duke Health Profile) yielded mixed results. Findings
of this study suggest that vocal instruction, inclusive of breathing exercises,
may help to improve the quality of life for senior citizens with emphysema.
Subjects in this study responded positively to the instruction and further
investigation of the treatment method is warranted.
-----
Semin Respir Crit Care Med. 2005 Apr;26(2):235-45.
The role of corticosteroids in chronic obstructive pulmonary
disease.
Calverley PM.
Department of Medicine, Clinical Sciences Centre, University Hospital Aintree,
Liverpool, United Kingdom. pmacal@liverpool.ac.uk.
Oral corticosteroids are powerful relatively nonspecific antiinflammatory agents
with a range of well-characterized side effects. There is good evidence to show
that they accelerate the rate of resolution of exacerbations of COPD and relapse
is less likely if patients receive these drugs. Maintenance therapy with oral
preparations is associated with worse mortality and skeletal muscle myopathy is
a particular problem. Corticosteroids have little effect on biopsy proven
inflammation or its surrogates in COPD and did not change the rate of decline of
FEV (1) over a range of spirometric disease severity in a number of trials each
lasting 3 years. However, meta-analysis of the data suggests that a small effect
(up to 10ml /year) might be present. There is more consistent evidence for an
effect on postbronchodilator FEV (1) with both fluticasone propionate and
budesonide. In patients with a postbronchodilator FEV (1) < 50% predicted where
self-reported exacerbations become more common, inhaled corticosteroids can
reduce the number of attacks. This effect is the major factor accounting for the
reduction in deterioration in health status seen in patients who receive inhaled
corticosteroids. Inhaled corticosteroids are much safer than oral therapy,
although they do have a predictably higher incidence of candidiasis and
hoarseness of the voice. Skin bruising is seen in patients with better lung
function who use these drugs. Triamcinolone use is associated with reduction in
bone density but this was not seen with budesonide. Combining an inhaled
corticosteroid and a long-acting beta-agonist in the same inhaler increases the
efficacy of the latte drug in COPD patients, with a significantly larger
improvement in FEV (1), a larger reduction in reported breathlessness, and a
reduction in exacerbation numbers in those with severe disease where
beta-agonists appear to be less effective. Inhaled corticosteroids are not
suitable for monotherapy in COPD but can be helpfully combined with an inhaled
bronchodilator in patients with symptomatic disease.
-----
Semin Respir Crit Care Med. 2005 Apr;26(2):221-34.
Role of bronchodilators in chronic obstructive pulmonary disease.
Weder MM, Donohue JF.
Division of Pulmonary and Critical Care Medicine, University of North Carolina
at Chapel Hill, Chapel Hill, North Carolina.
The prevalence of chronic obstructive pulmonary disease (COPD) continues to be
on the rise. Bronchodilators are first line agents for the symptomatic
management of this disease and have proven to be effective in both stable
disease status and exacerbations. The stepwise escalation of therapy for COPD
according to severity has been outlined in international guidelines. Different
classes of bronchodilators exist. The most experience is available for
short-acting beta-agonists and anticholinergics. These agents are mainly
recommended for the treatment of mild COPD and for symptomatic patients on an as
needed basis. Long-acting beta-agonists and anticholinergics have been developed
more recently. They are more convenient to use for patients with advanced
disease who require maintenance therapy with bronchodilators, and have been
shown in this group of patients to provide superior efficacy compared with
short-acting agents. Tiotropium, a long-acting anticholinergic, appears to be
particularly powerful and may eventually replace ipratropium as the primary
agent for COPD treatment. In contrast, the usage of theophylline, which used to
be part of the mainstay of treatment for COPD, has declined, mainly secondary to
a narrow therapeutic margin and side effects, but it is inexpensive and still
has its role. New agents like phosphodiesterase-4-inhibitors are interesting
substances that may become important adjuncts in COPD management, but there is
limited experience so far. None of the bronchodilators have been shown to change
outcome in COPD, but this issue is under active investigation.
-----
Semin Respir Crit Care Med. 2005 Apr;26(2):192-203.
Pathogenesis and treatment of acute exacerbations of chronic
obstructive pulmonary disease.
Sethi S.
Division of Pulmonary and Critical Care Medicine, Department of Medicine,
University at Buffalo SUNY, Buffalo, New York. ssethi@buffalo.edu.
Once thought to be a mere nuisance, exacerbations are now recognized as a major
contributor to the morbidity and mortality associated with chronic obstructive
pulmonary disease. This recognition has led to research using new investigative
tools that has substantially enhanced our understanding of the pathogenesis of
exacerbations. Several overlapping etiologies can precipitate the symptom
complex of an exacerbation. Treatment of exacerbations requires the use of
several therapeutic modalities with the goal of restoring the patient to
baseline. Results of recent clinical trials and observational studies have
allowed a refinement of the approach to treatment of exacerbations. These
include a rational, stratified approach to the use of antibiotics and several
trials substantiating the use of systemic corticosteroids. Relapse or failure
rates of 20 to 33% have been described in the treatment of acute exacerbation,
with these treatment failures contributing substantially to the costs associated
with exacerbations. Improved treatment based on enhanced understanding and good
clinical evidence should lead to better outcomes in this common clinical entity.
-----
Semin Respir Crit Care Med. 2005 Apr;26(2):167-91.
Surgical therapy for chronic obstructive pulmonary disease.
Martinez FJ, Chang A.
Departments of Internal Medicine, Division of Pulmonary and Critical Care
Medicine. fmartine@umich.edu.
Many patients with severe chronic obstructive pulmonary disease (COPD)
experience incapacitating breathlessness and exercise limitation. Multiple
surgical techniques have been utilized to achieve resection of giant, localized
bullae with documented short-term benefit in pulmonary function and dyspnea in
highly selected patients. The poorest long-term outcome has been noted in those
with greater degrees of emphysema in the remaining lung, greater underlying
chronic bronchitis, and a bulla occupying less than one third of the hemithorax,
particularly if compressed normal lung is not evident. Lung volume reduction
surgery (LVRS) in the absence of giant bullae has become more widely accepted in
selected patients. Bilateral LVRS procedures appear to result in greater
short-term improvement than unilateral LVRS, whereas physiological benefits
appear similar with video-assisted thoracoscopy (VATS) or median sternotomy (MS)
techniques. Improvement in dyspnea and health status after LVRS has been
documented and appears to be better preserved over longer-term follow-up than
physiological improvement. Clear direction has been provided in identifying
optimal candidates for bilateral LVRS; patients with a postbronchodilator forced
expiratory volume in 1 second (FEV (1)) </= 20% predicted and a diffusing
capacity for carbon monoxide (DL (CO)) </= 20% predicted or homogeneous
emphysema exhibit a much higher mortality with LVRS than with medical
management. Patients with upper-lobe predominant emphysema and a low
postrehabilitation exercise tolerance exhibited a decreased risk of mortality
after LVRS. Patients with non-upper lobe predominant emphysema on
high-resolution computed tomography (HRCT) and a high postrehabilitation
exercise capacity exhibit an increased risk of death after LVRS. Patients with
upper lobe predominant emphysema and a high postrehabilitation exercise capacity
or patients with non-upper lobe predominant emphysema and a low
postrehabilitation exercise capacity do not have a survival advantage or
disadvantage, whereas those with upper lobe predominant emphysema treated
surgically are more likely to improve their exercise capacity after surgery.
Lung transplantation is an option for a more limited number of patients.
Consistent short-term spirometric improvement after both single- and double-lung
transplant has been documented. Long-term results of lung transplantation are
limited by significant complications that impair survival; an approximately 80%
1-year, 50% 5-year, and 35% 10-year survival has been reported. Bronchiolitis
obliterans is the most important long-term complication of lung transplantation
resulting in decreased pulmonary function. In general, a COPD patient can be
considered an appropriate candidate for transplantation when the FEV (1) is
below 25% predicted and/or the paCO (2) is >/= 55 mm Hg.
-----
Semin Respir Crit Care Med. 2005 Apr;26(2):133-41.
Pulmonary Rehabilitation and COPD.
Ries AL.
Department of Medicine and Family and Preventive Medicine, University of
California, San Diego, San Diego, California. aries@ucsd.edu.
Pulmonary rehabilitation has been well established and increasingly recommended
in disease management plans for patients with chronic obstructive pulmonary
disease. Key elements include a multidisciplinary approach to care, focus on the
individual patient, and attention to emotional and social as well as physical
aspects of health. Appropriate candidates are symptomatic patients with chronic
lung disease who are aware of their disability and motivated to participate
actively in their own health care. Pulmonary rehabilitation has also been useful
for patients with other types of chronic lung diseases. Program components
include a careful patient evaluation, education, instruction in respiratory and
chest physiotherapy techniques, exercise training, and psychosocial support.
Benefits demonstrated in a growing body of evidence include improvement in
symptoms, exercise tolerance, and quality of life and reduction in utilization
of health care resources. Pulmonary rehabilitation has also been included as an
adjunct to surgical programs such as lung transplantation and lung volume
reduction surgery.
-----
Treat Respir Med. 2005;4(4):275-81.
The Role of Tiotropium Bromide, a Long-Acting Anticholinergic
Bronchodilator, in the Management of COPD.
Saberi F, O'donnell DE.
Division of Respiratory and Critical Care Medicine, Queen's University,
Kingston, Ontario, Canada.
Bronchodilator therapy forms the mainstay of treatment for symptomatic patients
with COPD. Long-acting bronchodilators, which maintain sustained airway patency
over a 24-hour period, represent an advance in therapy. Tiotropium bromide is a
new long-acting inhaled anticholinergic agent with superior pharmacodynamic
properties compared with the short-acting anticholinergic, ipratropium bromide.
Tiotropium bromide has been consistently shown to have a greater impact than
ipratropium bromide on clinically important outcome measures such as health
status. The mechanisms of clinical benefit with tiotropium bromide are
multifactorial, but improved airway function, which enhances lung emptying and
allows sustained deflation of over-inflated lungs, appears to explain
improvements in dyspnea and exercise endurance in COPD. Inhaled tiotropium
bromide therapy has also been associated with reduction in acute exacerbations
of COPD as well as reduced hospitalizations. The safety profile of tiotropium
bromide is impressive: dry mouth is the most common adverse event and rarely
necessitates termination of the drug. No tachyphylaxis to tiotropium bromide has
been demonstrated in clinical trials lasting up to 1 year. There is preliminary
information that the combination of long-acting anticholinergics and long-acting
beta(2)-adrenoceptor agonists provides additive physiological and clinical
benefits. According to recent international guidelines, long-acting
bronchodilators should be considered early in the management of symptomatic
patients with COPD in order to achieve effective symptom alleviation and
reduction in activity limitation. Tiotropium bromide, because of its once-daily
administration and its established efficacy and tolerability profile, has
emerged as an attractive therapeutic option for this condition.
-----
Respir Med. 2005 May;99(5):596-601. Epub 2004 Nov 19.
Successful steroid withdrawal in lung transplant recipients: result of a pilot
study.
Shitrit D, Bendayan D, Sulkes J, Bar-Gil Shitrit A, Huerta M, Kramer MR.
Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqwa 49100,
Israel.
Objective: Corticosteroids play a key role in immunosuppression after
transplantation. However, because chronic steroid treatment may cause
significant morbidity and mortality, steroid-free immunosuppression remains a
desirable goal. To the best of our knowledge, there are no reports on successful
steroid withdrawal (SW) in lung transplant recipients. Methods: The study group
included 35 patients who underwent heart-lung, double-lung or single-lung
transplantation. Criteria for initiation of SW were stable pulmonary function
tests and absence of clinical or bronchoscopic evidence of acute or chronic
rejection in the last 6 months. Pulmonary function, blood pressure and metabolic
parameters were compared between the patients who underwent SW and those who did
not. Results: Eight patients (23%) underwent SW. Median follow-up was 19 months
(range 11-23 months). Compared to the non-withdrawal group, the withdrawal group
was older (60+/-6+/-vs. 52+/-13 years, P=0.01, r=0.49), had higher rates of
emphysema (88% vs. 18%, P=0.01) and use of a cyclosporine-based regimen (62% vs.
26%, P=0.0001), and had longer time from transplantation to the withdrawal
attempt (70+/-13 vs. 29+/-26 months, P=0.0002). The SW group showed no adverse
effects in graft function and no deterioration on pulmonary function tests. SW
had a beneficial metabolic effect, with a decrease in mean cholesterol level
from 229+/-45 to 194+/-25mg/dl (P=0.02) and no significant change in weight,
systolic blood pressure or glucose level. In the non-withdrawal group, mean
cholesterol levels increased from 175+/-34 to 209+/-57mg/dl (P=0.0005), weight
increased from 72+/-15 to 80+/-14kg (P=0.0001), and systolic blood pressure
increased from 125+/-15 to 139+/-16mmHg (P=0.001); glucose levels did not
change. There was a significant correlation between total cholesterol level and
weight in both groups (P=0.0006, r=-0.56 and P=0.01, r=-0.46, respectively).
Conclusions: Late SW is safe in stable patients after lung transplantation.
There was no evidence of rejection or a deterioration in pulmonary function.
Lipid profile improvement and blood pressure stabilization accompanied the
termination of steroid therapy.
-----
Eur J Cardiothorac Surg. 2005 May;27(5):762-7.
Extended donor lungs: eleven years experience in a consecutive series.
Lardinois D, Banysch M, Korom S, Hillinger S, Rousson V, Boehler A, Speich R,
Weder W.
Division of Thoracic Surgery, University Hospital Zurich, Raemistrasse 100, 8091
Zurich, Switzerland.
Objective: The aim of this study was to delineate the profile of extended donor
lungs in comparison to ideal donor lungs and to analyse their outcome.
Particular attention was given to donor lungs with a low PaO(2) (<250mmHg)
before harvesting or with multiple extended criteria. Methods: Between 1993 and
2003, 148 patients (79 women, 69 men, mean age 39.9 years) underwent lung
transplantation. Indications were cystic fibrosis in 35.8%, emphysema in 26.4%,
pulmonary fibrosis in 12.2%, pulmonary hypertension in 9.5%, and others in
16.1%. Donor data and recipients medical files were reviewed. Criteria for donor
lungs were considered extended if one or more of the following criteria were
met: age >55 years, smoking >20 pack-years, PaO(2) before harvesting <300mmHg,
pathologic chest X-ray, and purulent secretion at bronchoscopy. A comparison
between recipients from ideal and from extended donor lungs was performed with
respect to the median duration of mechanical ventilation, the median length of
stay at the intensive care unit, postoperative complications, the 30-day and the
1-year survival, and the 6-month follow-up spirometry. Results: Sixty-three
(42.6%) donor lungs were considered extended and 20 (31.7%) met more than one
criteria. Outcome comparison between recipients from ideal (I) and extended (II)
donor lungs did not statistically differ in postoperative complications (18.8%
(I) vs. 26.9% (II), P=0.32), mean duration of mechanical ventilation (d)
(4.4+/-2.7 (I) vs. 2.6+/-2.1 (II), P=0.2), mean length of stay at the ICU (d)
(11.5+/-8.8 (I) vs. 9.2+/-6.9 (II), P=0.4), 6-month pulmonary function
(FEV1=83+/-23% of the predicted value (I) vs. 82+/-18% (II), P=0.81), 30-day
survival (90.6% (I) vs. 93.7% (II), P=0.56), 1-year survival (83.5% (I) vs. 81%
(II), P=0.83). Thirty-day survival was also comparable even in recipients from
donor lungs with PaO(2)<250mmHg (n=8) (90.6% (I) vs. 87.5%, P=0.57). The number
of extended criteria had no impact on the outcome. The combination of
PaO(2)<300mmHg with purulent secretion at bronchoscopy seemed to influence the
early outcome of recipients from extended donor lungs negatively. Conclusions:
Our results suggest that the use of selected extended donor lungs does not
compromise the outcome after transplantation. PaO(2) <250mmHg before harvesting
of the lungs is not an absolute contra-indication for transplantation.
-----
Chest. 2005 Apr;127(4):1166-77.
Lung volume reduction surgery vs medical treatment: for patients with advanced
emphysema.
Miller JD, Berger RL, Malthaner RA, Celli BR, Goldsmith CH, Ingenito EP,
Higgins D, Bagley P, Cox G, Wright CD.
McMaster University, Hamilton Ontarion, Canada.
OBJECTIVE: To contribute to the knowledge on the therapeutic value of lung
volume reduction surgery (LVRS). DESIGN: Two similar, independently conceived
and conducted, multicenter, randomized clinical trials. SETTING: The Canadian
Lung Volume Reduction (CLVR) study and the Overholt-Blue Cross Emphysema Surgery
Trial (OBEST). METHODS: Using a fixed-effects meta-analysis, the 6-month results
produced by the addition of LVRS to optimal medical therapy were compared to
those obtained from optimal medical therapy alone. Patients were required to
have severe emphysema, marked airflow limitation (ie, FEV(1), 15 to 40%
predicted), hyperinflation (total lung capacity [TLC], > 120% predicted), CO(2),
< 55 mm Hg, and measurable dyspnea (chronic respiratory disease questionnaire [CRDQ]
scores </= 4 for the CLVR study, or Medical Research Council dyspnea scale >/= 1
for the OBEST). Optimal medical therapy included pulmonary rehabilitation in
both arms of both studies. RESULTS: The CLVR study randomized 58 patients and
the OBEST randomized 35 patients for a total of 93 patients. Of these, 54
patients were randomized to undergo surgery, and 39 patients were randomized to
receive medical treatment. The 6-month mortality rate (including operative
mortality) in the surgical and medical cohorts was similar (5.6% vs 5.1%,
respectively). A comparison of the medical and surgical arms of the combined
CLVR study/OBEST population showed that LVRS was associated with a higher FEV(1)
(167 mL or 24% predicted; 95% confidence interval [CI], 29 to 304; p = 0.017),
lower residual volume (-1,342 mL or 24.5% predicted; 95% CI, -1,844 to -840; p <
0.001), lower TLC (-1,044 mL or 13% predicted; 95% CI, -1483 to -605; p <
0.001), and higher 6-min walk distance (148.8 feet; 95% CI, 24.3 to 273.2; p =
0.019). Each domain of the CRDQ showed statistically significant improvement in
the surgical arm of the study, but not in the medical arm. The summary physical
component scale of the Medical Outcomes Study 36-item short form (SF-36) was
also more favorable in the LVRS cohort (6.9; 95% CI, 2.86 to 10.90; p < 0.001).
The summary mental component scale of the SF-36 did not show a statistically
significant difference between the two groups. CONCLUSION: Six months after
randomization, LVRS produced better palliation than optimal medical therapy in
patients with advanced emphysema.
-----
Postgrad Med. 2005 Mar;117(3):27-34.
New treatment strategies for COPD. Pairing the new with the tried and true.
Cote CG, Celli BR.
University of South Florida College of Medicine, Tampa, USA.
Knowledge about COPD has increased substantially in recent years. Smoking
cessation campaigns have significantly decreased smoking prevalence in the
United States, and similar efforts in the rest of the world will likely have the
same impact. The consequence should be a drop in incidence of COPD in the years
to come. The use of LTOT for hypoxemic patients has resulted in increased
survival, and expanded drug therapy options have effectively improved dyspnea
and quality of life. Recent studies have documented the benefits of pulmonary
rehabilitation. In addition, noninvasive mechanical ventilation offers new
alternatives for patients with acute or chronic failure. Furthermore, the
revival of surgery for emphysema may serve as an alternative to lung
transplantation for patients with severe COPD who remain symptomatic despite
maximal medical therapy. With all of these options, a nihilistic attitude toward
management of COPD is not justified.
-----
Treat Respir Med. 2005;4(1):1-8.
Emphysema in alpha1-antitrypsin deficiency: does replacement therapy affect
outcome?
Abboud RT, Ford GT, Chapman KR.
Respiratory Division, University of British Columbia, 2775 Heather Street,
Vancouver, V5Z 3J5, British Columbia, Canada. rtabboud@interchange.ubc.ca
Severe alpha(1)-antitrypsin (AAT) deficiency is an inherited disorder that leads
to the development of emphysema in smokers at a relatively young age; most are
disabled in their forties. Emphysema is caused by the protease-antiprotease
imbalance when smoking-induced release of neutrophil elastase in the lung is
inadequately inhibited by the deficient levels of AAT, the major inhibitor of
neutrophil elastase. This protease-antiprotease imbalance leads to proteolytic
damage to lung connective tissue (primarily elastic fibers), and the development
of panacinar emphysema. AAT replacement therapy, most often applied by weekly
intravenous infusions of AAT purified from human plasma, has been used to
partially correct the biochemical defect and raise the serum AAT level above a
theoretically protective threshold level of 0.8 g/L. A randomized controlled
clinical trial was not considered feasible when purified antitrypsin was
released for clinical use. However, AAT replacement therapy has not yet been
proven to be clinically effective in reducing the progression of disease in AAT-deficient
patients. There was a suggestion of a slower progression of emphysema by
computed tomography (CT) scan in a small randomized trial. Two nonrandomized
studies comparing AAT-deficient patients already receiving replacement therapy
with those not receiving it, and a retrospective study evaluating a decline in
FEV(1) before and after replacement therapy, suggested a possible benefit for
selected patients.Because of the lack of definitive proof of the clinical
effectiveness of AAT replacement therapy and its cost, we recommend reserving
AAT replacement therapy for deficient patients with impaired FEV(1) (35-65% of
predicted value), who have quit smoking and are on optimal medical therapy but
continue to show a rapid decline in FEV(1) after a period of observation of at
least 18 months. A randomized placebo-controlled trial using CT scan as the
primary outcome measure is required. Screening for AAT deficiency is recommended
in patients with chronic irreversible airflow obstruction with atypical features
such as early onset of disease or disability in their forties or fifties, or
positive family history, and in immediate family members of patients with AAT
deficiency.
-----
Transpl Int. 2005 Feb 15; [Epub ahead of print]
Lung transplantation for emphysema. Lung hyperinflation: incidence and outcome.
Angles R, Tenorio L, Roman A, Soler J, Rochera M, de Latorre FJ.
Hospital Vall d'Hebron, P. Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
Lung transplantation, single or bilateral sequential, is the final option for
patients with emphysema. This study analyzed the outcome of lung transplants for
emphysema (single or double), and evaluates the incidence, predictive factors
and prognosis of lung hyperinflation (LHI) in unilateral transplants. We
prospectively studied patients undergoing lung transplantation for emphysema. On
admission to the Intensive Care Unit (ICU) and at 12, 24, 48 and 72 h we tested
the patients' respiratory function, oxygen arterial pressure (P(a)O(2)) and mean
pulmonary arterial pressure (MPAP) before transplantation. LHI incidence,
duration of mechanical ventilation and hypoxemia, ICU stay and mortality was
also analyzed. We studied 34 consecutive patients undergoing lung
transplantation for emphysema, 14 single and 20 bilateral. Single-lung
transplantation had a higher mortality (50%) than double-lung transplantation
(11%), with an odds ratio of 9.0 (1.3--48.7). Of the 14 patients who received a
single graft, 9 patients (64%) developed LHI. No predictive factors for LHI
could be established. Duration of mechanical ventilation (22 vs 3 days) and ICU
stay (36 vs 6 days) was much longer in patients with LHI; however, only ICU stay
reached statistical significance (P=0.011). Mortality in patients with LHI was
higher, 67% vs 20% (NS). We conclude that single-lung transplant in emphysema
patients has a worse prognosis than bilateral transplant, with a 9-fold higher
mortality rate. LHI is a common event in single-lung transplant for emphysema
and is associated in our patients with a longer stay at the ICU.
-----
Cochrane Database Syst Rev. 2005
Jan 25;(1):CD001288.
Systemic corticosteroids for acute
exacerbations of chronic obstructive pulmonary disease.
Wood-Baker R, Gibson P, Hannay M, Walters E, Walters J.
Medicine, University of Tasmania, GPO Box 252-34, 43Collins Street, Hobart,
Tasmania, AUSTRALIA, 7001.
BACKGROUND: COPD is a common condition, mainly related to smoking. The burden of
the disease is increasing and it is projected to rank fifth in 2020 for the
world-wide burden of disease. Acute exacerbations of COPD, usually related to
superimposed infection occur commonly and systemic corticosteroids are widely
used in their management in combination with other treatments including
antibiotics, oxygen supplementation and bronchodilators. OBJECTIVES: To
determine the efficacy of corticosteroids, administered either parenterally or
orally, on the outcome in patients with acute exacerbations of COPD. SEARCH
STRATEGY: Searches were carried out using the Cochrane Airways Group COPD RCT
register with additional studies sought in the bibliographies of randomised
controlled trials and review articles. Authors of identified randomised
controlled trials were contacted for other published and unpublished studies.
The last search was carried out in August 2004. SELECTION CRITERIA: Randomised
controlled trials comparing corticosteroids, administered either parenterally or
orally, with appropriate placebo. Other interventions e.g. bronchodilators and
antibiotics were standardised. Clinical studies of acute asthma were excluded.
DATA COLLECTION AND ANALYSIS: Data was extracted independently by two reviewers.
Outcome data was sent to authors for verification. All trials were combined
using Review Manager (version 4.2.4) for analyses. MAIN RESULTS: Ten studies
were identified that fulfilled the inclusion criteria. There were significantly
fewer treatment failures within thirty days in patients given corticosteroid
treatment, odds ratio 0.48; 95% confidence interval 0.34 to 0.68 and Hazard
Ratio 0.78; 95% confidence interval 0.63 to 0.97. It would have been necessary
to treat 9 patients (95%CI 6 to 14) with systemic corticosteroids to avoid one
treatment failure in this time period. There was no significant difference in
mortality. The early FEV1, up to 72 hours, showed a significant treatment
benefit, weighted mean difference140 mls (95% confidence interval 80-200 mls),
although this benefit was not found for later time points. There was a
significant improvement in breathlessness and blood gases between 6 - 72 hours
after treatment. There was an increased likelihood of an adverse drug reaction
with corticosteroid treatment, odds ratio 2.29; 95% confidence interval 1.55 to
3.38. Overall one extra adverse effect occured for every 6 people treated (95%
CI 4 to 10). The risk of hyperglycaemia was significantly increased, odds ratio
5.48; 95% confidence interval 1.58 to 18.96. AUTHORS' CONCLUSIONS: Treatment of
an exacerbation of COPD with oral or parenteral corticosteroids significantly
reduces treatment failure and the need for additional medical treatment . It
increases the rate of improvement in lung function and dyspnoea over the first
72 hours, but at a significantly increased risk of an adverse drug reaction.
-----
Internist (Berl). 2005 Jan 18; [Epub ahead of print]
[Chronic bronchitis, COPD.]
[Article in German]
Wirtz HR.
Abteilung Pneumologie, Medizinische Klinik I, Universitatsklinikum Leipzig, .
Chronic bronchitis is part and precursor of COPD, a complex disease triggered
mostly by exposure to cigarette smoke. However COPD develops only in patients
with specific susceptibility probably determined by genetic factors or
additional risk factors. A specific type of inflammation resides in the
bronchial and bronchiolar walls, that infers damage not only to airway structure
but also to surrounding alveolar attachments and thus to the lung parenchyma.
Chronic bronchitis, fibrosing bronchiolitis and emphysema constitute the three
main stems of pathology of the disease but may coexist with varying extent. The
clinical picture is therefore quite variable. Treatment exists largely in
bronchodilation combining different mechanisms and using long acting drugs
usually applied by inhalation. Acute exacerbations promote progression of the
disease, which must be counteracted by adaptation and intensification of
therapy, in some cases including non invasive or invasive ventilation. Several
non-pharmacologic measures such as smoking cessation, rehabilitation,
nutritional support, long term oxygen therapy, lung volume reduction and
possibly lung transplantation may be available for appropriate patients and have
to be considered.
-----
J Thorac Cardiovasc Surg. 2005 Jan;129(1):73-9.
Results of unilateral lung volume
reduction surgery in patients with distinct heterogeneity of emphysema between
lungs.
Mineo TC, Pompeo E, Mineo D, Rogliani P, Leonardis C, Nofroni I.
Objective This study was undertaken to analyze the comprehensive outcome of
unilateral lung volume reduction in patients with distinct heterogeneity of
emphysema between lungs assessed by a visual radiologic scoring system. Methods
Ninety-seven patients who underwent intentional unilateral lung volume reduction
because of distinct heterogeneity of emphysema between lungs (asymmetric ratio
of emphysema >/=1.1) between 1995 and 2003 were evaluated. Baseline median
measures were 0.83 L for forced expiratory volume in 1 second, 5.0 L for
residual volume, 380 m for 6-minute walking test distance, 0.50 for maximal
incremental treadmill test score, and 25 for physical functioning domain score
assessed by the Short Form-36 Quality of Life questionnaire. Results Median
follow-up was 34 months. Significant improvements occurred for as long as 36
months in forced expiratory volume in 1 second (+24%), residual volume (-12%),
Short Form-36 Quality of Life questionnaire physical functioning domain score
(+100%), 6-minute walking test distance (+18%), and maximal incremental
treadmill test score (+200%). A direct correlation was found between asymmetric
ratio of emphysema and change in forced expiratory volume in 1 second ( r =
0.65, P < .00001). At 60 months, residual volume (-6.2%), maximal incremental
treadmill test score (+100%), and Short Form-36 Quality of Life questionnaire
physical functioning domain score (+70%) were still significantly improved.
Five-year survival was 82%; 5-year freedom from contralateral lung volume
reduction was 70%. Conclusions In this series, significant, long-lasting
improvements and satisfactory survival were seen after intentional unilateral
lung volume reduction. Heterogeneity of emphysema between lungs was directly
correlated with improvement at 36 months in forced expiratory volume in 1
second. Our results suggest that unilateral lung volume reduction is a suitable
option for patients with distinct heterogeneity of emphysema between lungs.
-----
Yonsei Med J. 2004 Dec 31;45(6):1181-90.
Lung transplantation in patients
with pulmonary emphysema.
Paik HC, Hwang JJ, Lee DY.
Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital,
Yonsei University College of Medicine, 146-92 Dogok- dong, Kangnam-gu, Seoul
135-720, Korea. hcpaik@yumc.yonsei.ac.kr
Lung transplantation is a viable option for patients with chronic obstructive
pulmonary disease (COPD), and emphysema is the most common indication to undergo
lung transplantation. A total of seven lung and one heart-lung transplantations
were performed between July 1996 and June 2004 at the Yongdong Severance
Hospital, and herein, three emphysema patients who underwent single lung
transplantations are reviewed. There were 2 males and 1 female, with a mean age
of 50 years (35, 57 and 58 years). They all underwent an operation, without
cardiopulmonary bypass, and there was no operative mortality. The mean survival
was 12 months (4 months, 15 months and 17 months) and all succumbed to death due
to activation of pulmonary tuberculosis, post-transplantation
lymphoproliferative disease and cytomegalovirus (CMV) gastritis associated with
asphyxia. Infection was the most common postoperative complication, resulting in
longer hospital stays, higher medical expenses and shorter survival rates,
necessitating aggressive prophylactic management. The accumulation of
experience, modifications to operative procedures and perioperative care may
lead to improved early and long-term survival in patients with emphysema
undergoing single or bilateral lung transplantations.
-----
Am J Respir Crit Care Med. 2004 Dec 3; [Epub ahead of print]
Effect of Bronchoscopic Lung Volume
Reduction on Dynamic Hyperinflation and Exercise in Emphysema.
Hopkinson NS, Toma TP, Hansell DM, Goldstraw P, Moxham J, Geddes DM, Polkey MI.
Respiratory Muscle Laboratory, Royal Brompton Hospital, London, United Kingdom.
Endobronchial valve placement improves pulmonary function in some patients with
chronic obstructive pulmonary disease, but its effects on exercise physiology
have not been investigated. In 19 patients, mean(SD) FEV1 28.4(11.9) percent
predicted studied before and four weeks after unilateral valve insertion,
functional residual capacity decreased from 7.1(1.5) to 6.6(1.7) liters (p=0.03)
and diffusing capacity rose from 3.3(1.1) to 3.7(1.2) mmol.min-1kpa-1 (p=0.03).
Cycle endurance time at 80% of peak workload increased from 227(129) seconds to
315(195) seconds (p=0.03). This was associated with a reduction in end
expiratory lung volume at peak exercise from 7.6(1.6) to 7.2(1.7) liters
(p=0.03). Using stepwise logistic regression analysis, a model containing
changes in transfer factor and resting inspiratory capacity explained 81% of the
variation in Deltaexercise time (p<0.0001). The same variables were retained if
the five patients with radiological atelectasis were excluded from analysis. In
a sub-group of patients in whom invasive measurements were performed improvement
in exercise capacity was associated with a reduction in lung compliance (r2 0.43
p=0.03) and isotime esophageal pressure time product (r2 0.47 p=0.03).
Endobronchial valve placement can improve lung volumes and gas transfer in
patients with COPD and prolong exercise time by reducing dynamic hyperinflation.
-----
Internist (Berl). 2004 Nov;45(11):1246-59.
[Lung transplantation: potentials
and limitations]
[Article in German]
Gottlieb J, Welte T, Hoper MM, Struber M, Niedermeyer J.
Abteilung Pneumologie, Medizinische Hochschule Hannover. gottlieb.jens@mh-hannover.de
Lung transplantation is an option for patients with endstage pulmonary diseases
without contraindications. Recent European studies showed a survival benefit for
patients with cystic fibrosis, fibrosis and emphysema after lung
transplantation. Early mortality has been reduced recently by surgical
improvements. Life expectancy after lung transplantation has improved in recent
years but is still lower than in patients with other solid organ
transplantations. Quality of life is consistently improved but exercise
tolerance keeps reduced in comparison to the normal population. Specific
problems described in detail are frequent organ rejections and infections,
airway problems and a high incidence of malignant diseases. 5-year survival
after lung transplantation is in average 60%.
-----
Arch Bronconeumol. 2004
Oct;40(10):443-448.
Four-Year Results After Lung Volume
Reduction Surgery for Emphysema.
[Article in English, Spanish]
Juan Samper G, Ramon Capilla M, Canto Armengol A, Martinez Perez ML, Lloret
Perez T, Rubio Gomis E, Marin Pardo J.
Unidad de Neumologia. Departamento de Medicina. Facultad de Medicina.
Universidad de Valencia. Valencia. Spain.
Objectives: While the short-term results of lung volume reduction surgery are
known, follow-up over several years has not often been described. The purpose of
the present study was to describe results in terms of functional improvement,
dyspnea, quality of life, and mortality over a 4-year period in patients with
advanced emphysema. Patients and Methods: Fourteen successive patients were
enrolled between 1996 and 2000 and studied prospectively for 4 years. All
patients served as their own controls and initially received pulmonary
rehabilitation and medication. Preoperative data were used as baseline and were
compared to postoperative data over 4 years. The data analyzed were: functional
improvement (forced expiratory volume in 1 second [FEV1]), quality of life,
dyspnea, and patient loss due to death or referral to a lung transplantation
program. Results: Patients with advanced emphysema (mean FEV1 [SD]: 22.8% [11%]
of predicted) were studied. Postoperative mortality was 14%. Overall mortality
(postoperative plus deaths due to respiratory insufficiency) was 28% at 1 year
and 35% at 4 years. Two patients died of cancer and 5 were referred for
transplantation. At 3 months, FEV1 had improved more than 15% in 9 patients
(64%); the improvement was maintained in 43% of patients at 1 year and 7% at 4
years. Improvement in dyspnea paralleled improvement in FEV1. Overall, at 3
months mean FEV1 had improved 41.9% (68%), transitional dyspnea index 2.7 (3),
and quality of life questionnaire score 1 (0.9). Thus, improvements were
considerable, but there was great variation. Preoperative mean decrease in FEV1
was 50 (32) mL/y, and postoperative decrease 194 (70) mL/y. Conclusions: With
the inclusion criteria used, there was considerable variation in the results.
Significant overall functional improvement was maintained in 50% of the patients
1 year following surgery and in 7% 4 years after surgery. Given such results,
together with a surgical mortality rate of 14% and overall mortality of 28% in
the first year, we believe that the criteria for using lung reduction surgery
should be revised.
-----
Internist (Berl). 2004 Oct 7 [Epub ahead of print]
[Lung transplantation: potentials
and limitations.]
[Article in German]
Gottlieb J, Welte T, Hoper MM, Struber M, Niedermeyer J.
Abteilung Pneumologie, Medizinische Hochschule Hannover.
Lung transplantation is an option for patients with endstage pulmonary diseases
without contraindications. Recent European studies showed a survival benefit for
patients with cystic fibrosis, fibrosis and emphysema after lung
transplantation. Early mortality has been reduced recently by surgical
improvements. Life expectancy after lung transplantation has improved in recent
years but is still lower than in patients with other solid organ
transplantations. Quality of life is consistently improved but exercise
tolerance keeps reduced in comparison to the normal population. Specific
problems described in detail are frequent organ rejections and infections,
airway problems and a high incidence of malignant diseases. 5-year survival
after lung transplantation is in average 60%.
-----
Thorax. 2004 Oct;59(10):904-9.
alpha1-Antitrypsin deficiency
.6: new and emerging treatments for alpha1-antitrypsin deficiency.
Sandhaus RA.
Alpha-1 Program, National Jewish Medical and Research Center, Southside Building
G106, 1400 Jackson Street, Denver, CO 80206, USA. rasandhaus@alphaone.org
Alpha-1-antitrypsin (AAT) deficiency is a genetic condition that increases the
risk of developing lung and liver disease, as well as other associated
conditions. Most treatment of affected individuals is not specifically directed
at AAT deficiency but focuses on the resultant disease state. The only currently
available specific therapeutic agent-namely, intravenous augmentation with
plasma derived AAT protein-is marketed in a limited number of countries.
Treatments aimed at correcting the underlying genetic abnormality, supplementing
or modifying the gene product, and halting or reversing organ injury are now
beginning to emerge. These innovative approaches may prove effective at
modifying or eliminating diseases association with AAT deficiency.
-----
J Thorac Cardiovasc Surg. 2004 Sep;128(3):408-13.
Long-term results after lung
volume reduction surgery in patients with alpha1-antitrypsin deficiency.
Tutic M, Bloch KE, Lardinois D, Brack T, Russi EW, Weder W.
Division of Thoracic Surgery, University Hospital, Zurich, Switzerland.
BACKGROUND: The favorable effects of lung volume reduction surgery for selected
patients with smoker's emphysema has been demonstrated. However, outcome data
for patients with alpha(1)-antitrypsin deficiency emphysema are scarce. METHODS:
We prospectively studied pulmonary function, dyspnea, and 6-minute walking
distance in 21 patients with severe alpha(1)-antitrypsin deficiency emphysema (PiZZ
18, PiZO 1, PiSZ 2, 10 female patients, median age 56 years, range 38-74 years)
for as long as 5 years after thoracoscopic lung volume reduction surgery.
RESULTS: Lung volume reduction surgery improved the mean dyspnea score, from 3.7
+/- 0.1 preoperatively to 1.4 +/- 0.2 at 3 months; the score remained improved
for as long as 3.5 years. Mean vital capacity (% predicted) improved from 79%
+/- 4.4% to 98% +/- 4.8% at 3 months, and the ratio of residual volume to total
lung capacity decreased from 0.67 to 0.51. These improvements lasted for as long
as 2 years. The mean airflow obstruction (forced expiratory volume in 1 second %
predicted) improved from 27% +/- 1.9% to 38% +/- 3.3% at 3 months and remained
statistically improved for 1 year. Four patients showed long-term improvement in
lung function for as long as 3.5 years. These patients had markedly
heterogeneous emphysema and showed no radiologic signs of airway inflammation.
CONCLUSIONS: Lung volume reduction surgery in patients with advanced emphysema
from alpha(1)-antitrypsin deficiency results in a significant improvement in
dyspnea and lung function for as long as 3.5 years in some cases. It appears
that magnitude and duration of these effects are inferior and shorter than those
in patients with pure smoker's emphysema. Patients with heterogeneous disease
and no or minor inflammatory airway disease may benefit most.
-----
Rev Prat. 2004 Sep 15;54(13):1425-31.
[Management of stable COPD]
[Article in French]
Ouksel H, Le Guen Y, Racineux JL.
Departement de pneumologie, CHU d'Angers, 49033 Angers 01. HaOuksel@chu-angers.fr
The term chronic obstructive pulmonary disease (COPD) is mainly characterised by
an irreversible obstructive airway obstruction, that in most cases, is secondary
to tobacco exposure. Management of the disease includes an assessment of
severity, and measures to decrease FEV decline, to treat bronchial obstruction,
to improve exercise tolerance and to correct abnormal gas exchange. Treatment
not only requires drug therapy, but also respiratory rehabilitation, surgery of
emphysema, and psychosocial support. In this way, a global strategy, adapted to
the severity of COPD, can be proposed.
-----
Rev Prat. 2004 Sep 15;54(13):1419-23.
[Emphysema]
[Article in French]
Fournier M.
Service de pneumologie et reanimation respiratoire, hopital Beaujon, 92110
Clichy. michel.fournier@bjn.ap-hop-paris.fr
The term emphysema refers both to abnormal enlargement and destruction of distal
spaces of the lung. Diagnosis of emphysema is achieved by high resolution
CT-scan of the thorax. Advanced forms of emphysema are associated with severe
respiratory insufficiency. Isolated forms of emphysema may present as giant
bullae with normal surrounding parenchyma. Diffuse panlobular emphysema is
frequently associated with a genetic disease characterized by a severe deficit
in alpha1-antitrypsin (AAT). Common forms of emphysema are observed in the
distal lung of patients with COPD, or around fibrous and retractile lesions of
the lung. Apart from the possible beneficial effect of augmentation therapy in
case of severe deficit in AAT, there is no medical therapy currently active on
the emphysematous process. Surgical approaches include bullaectomy which may be
indicated in some cases of giant bullae, and lung transplantation and lung
volume reduction surgery whose indications are both restricted to selected cases
of advanced emphysema.
-----
Thorac Surg Clin. 2004 Aug;14(3):375-83.
Quality of life after lung
volume reduction surgery.
Wood DE.
Section of General Thoracic Surgery, Lung Cancer Research, University of
Washington, Box 356310, 1959 NE Pacific, AA-115, Seattle, WA 98195-6310, USA.
dewood@u.washington.edu
The common physiologic and functional variables that quantify limitation in
emphysema patients have been the most common outcomes measured after LVRS.
Spirometric values and exercise capacity are merely surrogates, however, for
their impact on symptoms and QOL in patients with severe emphysema. Because LVRS
has been developed as a surgery to palliate disabling symptoms of emphysema,
many studies now have included HRQOL outcomes along with the commonly measured
physiologic and functional outcomes. Some studies have centered on the QOL as
the primary outcome instead of physiologic variables. Many symptom scales and
disease-specific and general instruments of HRQOL have been used for evaluating
emphysema patients before and after LVRS. Case-control studies and randomized
studies have shown a consistent improvement in symptoms related to emphysema and
general QOL. These studies validate the use of LVRS as a palliative therapy for
selected patients with emphysema. The NETT suggests that this benefit is
applicable primarily to patients with an upper lobe-predominant pattern of
emphysema or patients with low exercise capacity. Validation or refinement of
these criteria depends on the continued contributions of the many investigators
performing LVRS.
------
Pneumologie. 2004
Aug;58(8):566-9.
[Multicenter Study on "Non-Invasive
Ventilation in Patients with Severe Chronic Obstructive Pulmonary Disease and
Emphysema(COPD)"]
[Article in German]
Kohnlein T, Criee CP, Kohler D, Welte T, Laier-Groeneveld G.
Medizinische Hochschule Hannover, Abteilung Pneumologie, Hannover (Leiter: Prof.
Dr. T. Welte).
Non-invasive ventilation is applied with increasing frequency in patients with
chronic hypercapnic COPD and insufficiency of the ventilatory pump. In the few
existing clinical trials on long-term use of NIV, no significant improvement on
survival could be proven, mainly due to methodical reasons. The "National Task
Force for Non-invasive ventilation and weaning" plans to study patients with
severe COPD and hypercapnic ventilatory pump insufficiency in a prospective,
randomised, multicentre clinical trial over one year. In the intervention group,
NIV will be applied for at least six hours per day in addition to standard COPD-treatment.
The target of mechanical ventilation is a reduction of PCO (2) during
spontaneous breathing by at least 20 %, or into the normal range. The main
outcome parameter is all-cause mortality, secondary outcome parameters are
course of the disease, exercise capacity, quality of life and consumption of
medical resources. The sample size is estimated on 300 patients (150 control
group, 150 intervention group). The whole study will take approximately three
years.
-----
Rev Mal Respir. 2004 Jun;21(3 Pt
1):567-72.
[Lung Volume reduction surgery for
emphysema: a unilateral or bilateral approach?]
[Article in French]
Pezzetta E, Vallet C, El-Lamaa Z, Haller C, Ris HB.
Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne, Suisse.
INTRODUCTION: Lung Volume reduction surgery (LVRS) is a recognized therapeutic
option for patients presenting with severe and disabling pulmonary emphysema.
Case selection is based upon clinical, morphological and functional
criteria.STATE OF THE ART: LVRS has shown promising results, with improvements
in exercise capacity, pulmonary function and quality of life, in selected
patients with severe and disabling emphysema. A variety of surgical techniques
have been described. The procedure may be unilateral or bilateral, through a
sternotomy or by a video-assisted thoracoscopic (VATS) technique. The
controversial aspects of the surgical technique will be analysed and discussed
in the following review.PERSPECTIVES: A bilateral approach clearly offers a
better functional improvement when compared to a unilateral procedure, however,
the postoperative functional decline appears greater and more rapid after a
bilateral procedure. A unilateral approach, with often less postoperative
morbidity, allows the option to perform a future contra-lateral procedure in the
event of further clinical or functional deterioration.CONCLUSIONS: In selected
cases LVRS is an effective treatment for severe pulmonary emphysema. Different
surgical techniques have been described. Nowadays VATS is considered to be the
technique of choice, with the option to carry out a future unilateral or
bilateral procedure.
-----
J Manag Care Pharm. 2004 Jul;10(4 Suppl):S3-10.
Chronic obstructive pulmonary
disease overview: prevalence, pathogenesis, and treatment.
Briggs DD Jr.
Department of Medicine, University of Alabama at Birmingham, UAB Medical Center,
35294-0012, USA. dbriggs@chairdom.dom.uab.edu
OBJECTIVE: To discuss the current clinical data on the prevalence, pathogenesis,
staging, and treatment of chronic obstructive pulmonary disease (COPD). DATA
SOURCES: This article reviews the results of published studies and presents data
from current guidelines and expert opinion. CONCLUSIONS: An insidious disorder
that is asymptomatic early, COPD (the preferred term for patients with chronic
bronchitis and emphysema) prevalence has increased in recent decades, adding a
significant burden to patients and the health care system. COPD, an inflammatory
disorder secondary to the chronic inhalation of principally tobacco smoke,
induces a progressive deterioration in pulmonary function with a marked increase
in morbidity and mortality over time. The signs and symptoms of COPD, which
appear in many patients only after forced expiratory volume in 1 second (FEV1)
is <50% predicted, should not be confused with asthma, because these two
diseases display grossly different inflammatory processes, etiologies, clinical
courses, responses to treatment, and outcomes. The effective management of COPD
relies primarily on early identification, changing smoking habits, and the use
of bronchodilators to improve pulmonary function, symptoms, acute exacerbation
rate, quality of life, mortality, and comorbidities. With early detection and
aggressive treatment, the natural history of this disease can be improved.
Office spirometry for all smokers and ex-smokers as well
-----
J Thorac Cardiovasc Surg. 2004 Jun;127(6):1564-73.
Early results of endoscopic lung
volume reduction for emphysema.
Yim AP, Hwong TM, Lee TW, Li WW, Lam S, Yeung TK, Hui DS, Ko FW, Sihoe AD, Thung
KH, Arifi AA.
Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales
Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China. yimap@cuhk.edu.hk
BACKGROUND: We determined the feasibility, safety, and short-term efficacy of
bronchoscopic placement of a one-way endobronchial valve in selected
bronchopulmonary segments as an alternative to surgical lung volume reduction.
METHODS: A total of 21 patients with incapacitating emphysema who underwent this
procedure were studied. All patients had placement of the endobronchial valves
into the most emphysematous lung segments. We recorded any major complications
or deaths attributed to the procedure and analyzed (1) improvements in the
spirometric and functional parameters and quality of life and (2) the radiologic
changes compared with the baseline data at 30 and 90 days. RESULTS: A total of
20 patients had complete follow-up data. There was no mortality in the group
studied. The forced expiratory volume at 1 second, forced expiratory volume at 1
second (percentage of predicted), forced vital capacity, and forced vital
capacity (percentage of predicted) all improved significantly at 90 days (0.73
+/- 0.26 L vs 0.92 +/- 0.34 L [P =.009]; 33.3% +/- 11.9% vs 42.2% +/- 15.0% [P
=.006]; 1.94 +/- 0.62 L vs 2.25 +/- 0.61 L [P =.015]; and 63.3% +/- 17.6% vs
73.9% +/- 17.1% [P =.012], respectively). The 6-minute walking distance improved
at 30 and 90 days (251.6 +/- 100.2 m vs 306.3 +/- 112.3 m and 322.3 +/- 129.7 m;
P =.012 and P =.003). The results of the 36-Item Short-Form Health Survey and
the St George Respiratory Questionnaire showed significant improvements at 90
days. The Medical Research Council dyspnea grade also improved significantly at
30 and at 90 days (P =.006 and P =.003, respectively). CONCLUSIONS:
Endobronchial valve placement is a safe procedure, with significant short-term
improvements in functional status, quality of life, and relief of dyspnea in
selected patients with emphysema. A larger study with long-term follow-up is
therefore warranted.
-----
Minerva Anestesiol. 2004 May;70(5):307-12.
Surgical treatment of end stage
emphysema.
Cohen E.
Thoracic Anesthesia, The Mount Sinai School of Medicine, New York New York, USA.
Emphysematous changes are common in the general population. A significant number
of these patients requires surgical interventions. Lung volume reduction surgery
(LVRS) rapidly gained popularity without a sufficient evidence of beneficial
outcome; the presumed mechanism of improvement in lung function is secondary to
re-expansion of more normal, underlying compressed lung. The NETT study proposed
to evaluate effectiveness of medical treatment vs LVRS in patients with severe
bilateral emphysema. Complete results of the NETT study are unknown yet, but
there are evidences of beneficial effects of LVRS, at least in a short term. The
anesthetic management of these patients includes the continuation of the
bronchodilator therapy till surgery, the use of steroids and antisialologue.
Pain relief must be optimal and mobilization must be early. One lung ventilation
is an absolute necessity, achieved with double lumen tube insertion.
-----
Rev Mal Respir. 2004 Apr;21(2 Pt 1):287-98.
[Surgery for emphysema: recent
advances]
[Article in French]
Estenne M.
Service de Pneumologie, Hopital Erasme, Bruxelles, Belgique. mestenne@ulb.ac.be
INTRODUCTION: The treatment of chronic obstructive pulmonary disease has
progressed considerably over the past 40 Years but, for most patients with
advanced disease, medical management does not often produce more than limited
benefits, particularly in terms of quality of life. STATE OF ART: Over the last
decade the surgical treatment of emphysema, which was previously limited to
bullectomy, has seen important developments: for carefully selected patients
lung Volume reduction surgery and lung transplantation now offer the possibility
of real symptomatic improvement and even prolonged survival. Thanks to the
thousands of patients who have received these treatments our understanding of
the pathophysiological mechanisms, surgical techniques, risks and benefits,
medium and long-term results, and selection criteria has improved considerably.
PERSPECTIVES AND CONCLUSIONS: This review summarises the most important aspects
of these developments and discusses the role of Volume reduction and lung
transplantation in the treatment of advanced emphysema.
-----
Rev Pneumol Clin. 2004 Apr;60(2):79-88.
[Lung transplantation]
[Article in French]
Bonnette P.
Groupe de Transplantation Pulmonaire et Service de Chirurgie Thoracique, Hopital
Foch, 40, rue Worth, 92151 Suresnes. p.bonnette@hopital-foch.org
Lung transplantation is indicated for patients with cystic fibrosis, emphysema,
pulmonary fibrosis or pulmonary hypertension whose life expectancy is less than
two years. Criteria of severity are detailed. Three types of transplantation can
be proposed: single lung transplant for fibrosis and dry emphysema; bilateral
lung transplant for cystic fibrosis, and certain types of emphysema and
pulmonary hypertension; heart-lung transplant for pulmonary hypertension and
Eisenmenger syndrome. Due to insufficient supply of donor organs, one quarter of
the candidates die on the waiting list and the limit for inscription is often 60
years. Postoperative mortality at two months is about 15% and is related to
graft dysfunction, infection, bronchial complications,... Acute rejection
usually occurs during the first year. Chronic rejection is expressed by
obliterating bronchiolitis, the leading cause of death after one year. There is
a risk of cancer (EBV-induced lymphoproliferative syndromes and skin cancer).
Five-year survival is still only about 50%. Immunosuppressor treatments still
cause numerous adverse effects (hypertension, renal toxicity...); function and
quality-of-life have however greatly improved.
-----
Respir Med. 2004
Apr;98(4):285-93.
Long-term
oxygen therapy improves health-related quality of life.
Eaton T, Lewis
C, Young P, Kennedy Y, Garrett JE, Kolbe J.
Respiratory Services, Green Lane Hospital, Green Lane West, Auckland,
New Zealand. teaton@adhb.govt.nz
Guidelines for
the prescription of long-term oxygen therapy (LTOT) in hypoxemic
COPD patients are based on two landmark studies in which survival
was the primary outcome. Such patients are importantly symptomatic
with poor health-related quality of life (HRQL) but the effect
of LTOT on HRQL remains uncertain. We undertook a prospective
longitudinal interventional study of consecutive COPD patients
referred to our regional oxygen service; n = 43 fulfilling criteria
and commenced on LTOT, n = 25 not fulfilling criteria and continued
on standard care. HRQL was measured at baseline, 2 and 6 months.
Both patient groups had severe COPD as defined by mean FEV1 <
35% predicted. At baseline the LTOT group demonstrated significantly
worse HRQL as defined by the Chronic Respiratory Questionnaire
(CRQ) (fatigue, emotional function, mastery and total scores),
total generic Dartmouth COOP Charts and anxiety domain of the
Hospital Anxiety and Depression scale. Significant improvements
in HRQL were noted at 2 and 6 months in the LTOT group. Conversely
the non-LTOT group demonstrated a progressive decline in HRQL.
Using validated criteria for a minimal clinically significant
improvement in CRQ, there were 28 (67%) and 26 (68%) 'responders'
at 2 and 6 months respectively in the LTOT group. The introduction
of LTOT to patients with severe COPD fulfilling standard criteria
was associated with early significant improvements in HRQL with
sustained or further response at 6 months.
-----
Internist (Berl).
2004 Mar 31 [Epub ahead of print]
[Acute exacerbation
of COPD]
[Article in
German]
Lange CG, Scheuerer B, Zabel P.
Medizinische Klinik, Forschungszentrum Borstel.
Acute exacerbations
of chronic obstructive pulmonary disease (AECOPD) often develop
into emergency situations that are associated with high morbidity
and mortality. There is still a lack of a generally accepted definition
for the risk stratification in AECOPD to guide an optimal diagnosis
and treatment. In this article we propose a classification based
on 4 degrees of severity, depending on whether outpatient treatment
can be done by the patient himself or is provided by a physician
and whether inpatient treatment is carried out on a general ward
or on an intensive care unit. The pharmacological therapy of AECOPD
relies on short acting bronchodilators, systemic corticosteroids
and in case of purulent sputum on antibiotics. Longacting beta(2)-agonists
or anticholinergics, theophyllin, mucolytic drugs or mechanical
percussion to the chest by a physiotherapist have no proven value
in the emergency treatment of AECOPD. In respiratory failure the
use of oxygen therapy and non-invasive positive pressure ventilation
(NIPPV) can often prevent the need for endotracheal intubation
and controlled mechanical ventilation, thus preventing associated
risks like the development of nosocomial pneumonia.
-----
Recenti Prog Med.
2004 Jan;95(1):40-6.
[Non invasive
mechanical ventilation in the domiciliary treatment of chronic
obstructive pulmonary disease]
[Article in
Italian]
Scala R.
Unita Operativa di Pneumologia, Ospedale S. Donato, ASL 8, Arezzo.
raffaele_scala@hotmail.com
Since hypercapnia
is a negative prognostic index in stable chronic obstructive pulmonary
disease (COPD), the chance of applying non invasive ventilation
(NIV) to COPD with CO2 retention has been investigated for the
two last decades. Patho-physiologic basis of its employ are resting
of respiratory muscles and/or resetting of respiratory centres.
Due to its poor tolerability, negative pressure NIV has been taken
over by positive pressure technique. As the results of the few
available controlled studies aren't enthusiastic and univocal,
it's not possible to draw guidelines about the domiciliary use
of NIV in COPD. In conclusion, the author suggests that, in order
to avoid useless waste of resources, the application of NIV to
stable COPD should be reserved to very selected cases (significant
hypercapnia, frequent nocturnal desaturations and/or sleep disordered
breathing and/or hospital admissions) if its compliance and effectiveness
are demonstrated.
-----
Chest. 2004 Feb;125(2):777-83.
New and emerging
minimally invasive techniques for lung volume reduction.
Maxfield
RA.
Department of Medicine, Division of Pulmonary, Allergy, and Critical
Care Medicine, Columbia University College of Physicians &
Surgeons, New York, NY.
Lung volume reduction
surgery (LVRS) has been shown to improve pulmonary function, exercise
capacity, quality of life, and survival in selected patients with
heterogeneous emphysema. However, LVRS is a major surgical procedure
with potential morbidity and mortality. Minimally invasive techniques
are emerging to achieve lung volume reduction without open thoracotomy.
Devices and techniques under study include one-way bronchial valves
inserted via fiberoptic bronchoscopy to promote atelectasis in
emphysematous lung, promotion of focal atelectasis and fibrosis
by bronchoscopic injection of polymers into emphysematous regions
of lung, bronchopulmonary fenestrations to enhance expiratory
flow, and thoracoscopic plication or compression of emphysematous
lung. The goal of all of these procedures is to replicate the
benefit of LVRS without the trauma, risks, and extended recovery
of open LVRS. Refinement and application of these techniques will
allow patients with emphysema and their physicians and surgeons
to choose from a number of viable options for lung volume reduction.
-----
Respir Care. 2004
Jan;49(1):53-63.
Surgical therapies
for chronic obstructive pulmonary disease.
Benditt
JO.
Division of Pulmonary and Critical Care Medicine, University of
Washington School of Medicine, Box 356522, Seattle WA 98195-6522,
USA. benditt@u.washington.edu
Surgical procedures
for treating emphysema were first developed nearly 100 years ago.
Despite a wide range of surgical procedures performed over the
years, only three appear to have true clinical benefit: bullectomy,
lung volume reduction surgery (LVRS), and lung transplantation.
Lung volume reduction surgery has been reintroduced in the past
decade and is currently under active research. A recent large,
multicenter trial showed LVRS to improve quality of life, exercise
capacity, and even survival in certain highly selected patients.
Some individuals with emphysema may be candidates for either LVRS
or lung transplantation. Patient-selection criteria for these
procedures are being developed.
-----
Harefuah. 2004
Jan;143(1):2-3, 88.
[Lung and heart-lung
transplantation in Rabin medical center: early experience with
70 cases]
[Article
in Hebrew]
Kramer MR, Saute M, Eidelman L, Aravot D, Fink G, Shitrit D, Izvicky
G, Dayan DB, Bakal I, Kogan A, Gendel B, Vidne B, Sahar G.
Pulmonary Institute, Cardiothoracic Surgery and Anesthesiology
Departments, Rabin Medical Center.
Lung transplantation
is a relatively new field in solid organ transplantation. We present
our early experience with the first 70 cases at the Rabin Medical
Center during the years 1997-2003. Forty seven patients underwent
single lung, eight double lung and eight heart-lung transplantations.
The patients treated included 49 men and 21 women aged 5-66 years.
There were 26 cases with emphysema COPD. 30 patients with pulmonary
fibrosis. 5 patients with pulmonary hypertension/Eisenmenger and
9 patients with cystic fibrosis and bronchiectasis. Although early
results (1997-1999) showed 1 and 3 year survival of only 50%,
in the last 3 years (2000-2003), survival reached 84% and 82%
at 1 and 3 years respectively. Improvement in the success rate
is due to better patient selection, new immunosuppressive regimen
and, most importantly, excellent teamwork. We conclude that lung
transplantation is a viable option for selected patients with
end-stage lung disease.
-----
Swiss Med Wkly.
2004 Jan 10;134(1-2):18-23.
Ten years of lung
transplantation in Switzerland: results of the Swiss Lung Transplant
Registry.
Speich
R, Nicod LP, Aubert JD, Spiliopoulos A, Wellinger J, Robert JH,
Stocker R, Zalunardo M, Gasche-Soccal P, Boehler A, Weder W.
Department of Internal Medicine, University Hospital, Raemistrasse
100, CH-8091 Zurich, Switzerland. klinspr@usz.unizh.ch
OBJECTIVE: Lung
transplantation has evolved from an experimental procedure to
a viable therapeutic option in many countries. In Switzerland,
the first lung transplant was performed in November 1992, more
than ten years after the first successful procedure world-wide.
Thenceforward, a prospective national lung transplant registry
was established, principally to enable quality control. PATIENTS:
The data of all patients transplanted in the two Swiss Lung Transplant
centres Zurich University Hospital and Centre de Romandie (Geneva-Lausanne)
were analysed. RESULTS: In 10 years 242 lung transplants have
been performed. Underlying lung diseases were cystic fibrosis
including bronchiectasis (32%), emphysema (32%), parenchymal disorders
(19%), pulmonary hypertension (11%) and lymphangioleiomyomatosis
(3%). There were only 3% redo procedures. The 1, 5 and 9 year
survival rates were 77% (95% CI 72-82), 64% (95% CI 57-71) and
56% (95% CI 45-67), respectively. The 5 year survival rate of
patients transplanted since 1998 was 72% (95% CI 64-80). Multivariate
Cox regression analysis revealed that survival was significantly
better in this group compared to those transplanted before 1998
(HR 0.44, 0.26-0.75). Patients aged 60 years and older (HR 5.67,
95% CI 2.50-12.89) and those with pulmonary hypertension (HR 2.01,
95% CI 1.10-3.65) had a significantly worse prognosis The most
frequent causes of death were infections (29%), bronchiolitis
obliterans syndrome (25%) and multiple organ failure (14%). CONCLUSION:
The 10-year Swiss experience of lung transplantation compares
favourably with the international data. The best results are obtained
in cystic fibrosis, pulmonary emphysema and parenchymal disorders.
-----
Chest Surg Clin
N Am. 2003 Nov;13(4):709-26.
Results of lung volume
reduction surgery for emphysema.
Wood DE.
General Thoracic Surgery, University of Washington, 1959 NE Pacific,
AA-115, Box 356310, Seattle, WA 98195-6310, USA. dewood@u.washington.edu
LVRS provides
an exciting opportunity for palliation of symptoms and improvement
in quality of life for patients who have severe end-stage emphysema.
Because no medical therapy has been able to improve pulmonary
function or reverse the inexorable decline of breathless patients
who have emphysema, this opportunity to improve lung function
and quality of life is one of the most innovative additions to
thoracic surgery since the first successful lung transplant procedure
20 years ago. Although initial short-term, case-controlled surgeries
were criticized because of incomplete and short follow-up care,
substantial long-term data now exist to support the use of LVRS
for select patients who have severe emphysema. Patients who have
upper lobe predominant disease or low exercise capacity are more
likely to have a benefit in exercise capacity and quality of life
after LVRS. Selected patients who have upper lobe emphysema and
poor exercise capacity are also more likely to have improved survival
after LVRS. The individual contributions by the large number of
investigators pioneering LVRS development, along with the collective
contributions of the NETT investigators, have propelled the knowledge
surrounding LVRS far beyond that of any similar new technology
or procedure in its adolescence.
-----
Chest Surg Clin
N Am. 2003 Nov;13(4):651-67, vi.
Lung transplantation
for emphysema.
Force
SD, Choong C, Meyers BF.
Division of Cardiothoracic Surgery, Department of Surgery, Emory
University School of Medicine, Atlanta, GA 30322, USA.
Great strides
have been made in lung transplantation in the past two decades.
Changes in technique, immunosuppression regimens, and treatment
of infectious complications have led to improvements in survival
and functional results. Current areas of discussion concern the
use of single lung transplantation versus bilateral sequential
lung transplantation and the criteria for allocating donor lungs.
This article reviews the current state of lung transplantation
for emphysema and provides insight from more than one decade of
experience with Washington University's lung transplant program.
-----
Chest Surg Clin
N Am. 2003 Nov;13(4):589-613.
Pathophysiology and
classification of emphysema.
Keller
CA.
Mayo Clinic, 4205 Belfort Road, Suite 1100, Jacksonville, FL 32216,
USA. keller.cesar@mayo.edu
Current research
is providing new understanding in the pathophysiology of emphysema,
and this knowledge will be translated in finding better modalities
of therapy for patients currently affected by COPD. The single
best effort that can alter the course of COPD is promoting policies
to remove smoking as an available option to young people, before
they become addicted and thus prey of tobacco-producing companies.
Landmark studies like NETT and the GOLD initiative are providing
tool classify emphysema in the context of physiological criteria
and possible therapeutic alternatives.
-----
Am J Respir Med.
2003;2(6):451-8.
Is there a role for
systemic corticosteroids in the management of stable chronic obstructive
pulmonary disease?
Wood-Baker
R.
Royal Hobart Hospital & University of Tasmania, Hobart, Tasmania,
Australia. Richard.WoodBaker@utas.edu.au
COPD, encompassing
both chronic bronchitis and emphysema, usually results from exposure
to tobacco smoke. Smoking causes infiltration of the airways with
leukocytes, an imbalance between proteases and their naturally
occurring inhibitors and local cytokine secretion in the lung,
which leads to airway inflammation and alveolar destruction. Corticosteroids
have a range of anti-inflammatory actions, particularly inhibition
of cytokine secretion, which suggests that they may be effective
in COPD. However, data from the highest quality studies available
do not show any evidence of significant improvement in symptoms
of patients with COPD treated with systemic corticosteroids.A
meta-analysis found that about 10% of patients with stable COPD
showed an improvement in lung function following treatment with
short-term systemic corticosteroids compared with placebo. Exercise
capacity in patients with COPD was evaluated in four studies,
only one of which found a significant improvement with oral corticosteroids
compared with placebo. Long-term systemic corticosteroid treatment
in patients with stable COPD has not been found to alter the rate
of decline in FEV(1). Although systemic corticosteroids are associated
with a range of adverse effects, the data do not allow precise
quantification of their contribution to morbidity. However, studies
show an increased risk of osteoporosis in COPD. Recent studies
have also found an association between oral corticosteroid administration
and mortality in patients with stable COPD, but it is not clear
if this is a cause and effect relationship.Current data do not
support long-term administration of systemic corticosteroids to
all patients with stable COPD. Results of studies suggest that
short-term oral corticosteroid administration may identify a sub-population
of patients with COPD who may benefit through a reduction in the
decline in FEV(1) and better control of symptoms by long-term
administration of inhaled corticosteroids; these findings need
to be tested by further research.
-----
Thorac Cardiovasc
Surg. 2003 Oct;51(5):277-82.
Evaluation of lung
volume reduction surgery (LVRS) based on long-term survival rate
analysis.
Iwasaki
A, Yosinaga Y, Kawahara K, Shirakusa T.
Second Department of Surgery, School of Medicine, Fukuoka University,
Japan. akinori@fukuoka-u.ac.jp
OBJECTIVE: Lung
volume reduction surgery (LVRS) is an effective therapy for some
patients with end-stage emphysema. In most cases, functional improvement
is maximized during the first 6 months after surgery and decreases
steadily afterwards. This study was aimed at gaining further understanding
of the optimal candidates for LVRS and survival rates. METHODS:
62 patients with LVRS were selected according to the inclusion
criteria. Changes in lung function were evaluated by FEV1, VC,
RV, TLC, DLCO, PaO2, and PaCO2, and survival rates were analyzed
at 12, 24, 36, and 48 months. Patients with LVRS were divided
into two groups--those surviving after 48 months and those not
surviving after 48 months--and analyzed according to group. RESULTS:
The overall survival rate at 2 years and 4 years was 81.0 % and
67 %, respectively, with LVRS. VC, FEV1, TLC, DLCO, PaO2, and
PaCO2 were potential factors leading to mortality according to
univariate analysis. Multivariate analysis demonstrated that DLCO
was the only independent factor that could predict the post-LVRS
prognosis; the other factors failed as independent factors. Preoperatively,
the FEV1 percentage predicted gave a good index for post-LVRS
survival. CONCLUSIONS: Patients with higher preoperative FEV1
values had higher survival rates. These favorable long-term survival
rates might justify LVRS for treating selected patients with severe
emphysema. Additionally, DLCO turned out to be the only predictive
factor for high mortality risk 4 years after LVRS. DLCO may thus
be a very important marker in surgical planning.
-----
Chest. 2003 Sep;124(3):1073-80.
The potential for
bronchoscopic lung volume reduction using bronchial prostheses:
a pilot study.
Snell
GI, Holsworth L, Borrill ZL, Thomson KR, Kalff V, Smith JA, Williams
TJ.
Department of Respiratory Medicine, Alfred Hospital, Melbourne,
Victoria 3004, Australia. g.snell@alfred.org.au
STUDY OBJECTIVES:
Significant morbidity and mortality offset the benefits of lung
volume reduction surgery (LVRS) for emphysema. By contributing
to distal lung collapse, bronchoscopic placement of valved prostheses
has the potential to noninvasively replicate the beneficial effects
of LVRS. The purpose of this study was to investigate the safety
and feasibility of placing valves in segmental airways of patients
with emphysema. DESIGN: Case series. SETTING: Tertiary hospital,
severe airways disease clinic. PATIENTS: Ten patients aged 51
to 69 years with apical emphysema and hyperinflation, otherwise
suitable for standard LVRS. Mean preoperative FEV(1) was 0.72
L (19 to 46% predicted), and 6-min walk distance was 340 m (range,
245 to 425 m). INTERVENTION: Apical, bronchoscopic, segmental
airway placement of one-way valves (silicone-based Nitinol bronchial
stent; Emphasys Medical; Redwood City, CA) under general anesthesia.
Placement was over a guidewire under bronchoscopic and fluoroscopic
control. RESULTS: Four to 11 prostheses per patient took 52 to
137 min to obstruct upper-lobe segments bilaterally. Inpatient
stay was 1 to 8 days. No major complications were seen in the
30-day study period. Minor complications included exacerbation
of COPD (n = 3), asymptomatic localized pneumothorax (n = 1),
and lower-lobe pneumonia (day 37; n = 1). Symptomatic improvement
was noted in four patients. No major change in radiologic findings,
lung function, or 6-min walk distance was evident at 1 month,
although gas transfer improved from 7.47 +/- 2.0 to 8.26 +/- 2.6
mL/min/mm Hg (p = 0.04) and nuclear upper-lobe perfusion fell
from 32 +/- 10 to 27 +/- 9% (mean +/- SD) [p = 0.02]. CONCLUSION:
Bronchoscopic prostheses can be safely and reliably placed into
the human lung. Further study is needed to explore patient characteristics
that determine symptomatic efficacy in a larger patient cohort.
-----
Pediatr Pulmonol.
2003 Oct;36(4):357-8.
An alternative to
lung transplantation.
Cohen
G, Saglani S, Dinwiddie R, Webb M, Jaffe A.
Department of Cardiothoracic Surgery, Great Ormond Street Hospital
for Children NHS Trust, London, UK.
Lung volume reduction
surgery (LVRS) has been used increasingly in adults for treatment
of breathlessness caused by severe emphysema.1 It is of particular
benefit to patients with a heterogenous anatomic distribution
of emphysema, with obvious target areas for resection,2 as it
allows an improved chance of reclaiming function from surrounding
compressed lung.3 We report on an 8-year-old male with obliterative
bronchiolitis in whom LVRS has been used as a measure to significantly
improve quality of life and avoid the immediate need for lung
transplantation. Pediatr Pulmonol. 2003; 36:357-358. Copyright
2003 Wiley-Liss, Inc.
-----
Chest. 2003 Aug;124(2):468-73.
Specific expiratory
muscle training in COPD.
Weiner
P, Magadle R, Beckerman M, Weiner M, Berar-Yanay N.
Department of Medicine A, Hillel Yaffe Medical Center, Hadera,
Israel. weiner@hillel-yaffe.health.gov.ac.il
BACKGROUND: There
are several reports showing that expiratory muscle strength and
endurance can be impaired in patients with COPD. This muscle weakness
may have clinically relevant implications. Expiratory muscle training
tended to improve cough and to reduce the sensation of respiratory
effort during exercise in patients other than those with COPD.
METHODS: Twenty-six patients with COPD (FEV(1) 38% predicted)
were recruited for the study. The patients were randomized into
two groups: group 1, 13 patients were assigned to receive specific
expiratory muscle training (SEMT) daily, six times a week, each
session consisting of 1/2 h of training, for 3 months; and group
2, 13 patients were assigned to be a control group and received
training with very low load. Spirometry, respiratory muscle strength
and endurance, 6-min walk test, Mahler baseline dyspnea index
(before), and the transitional dyspnea index (after) were measured
before and after training. RESULTS: The training-induced changes
were significantly greater in the SEMT group than in the control
group for the following variables: expiratory muscle strength
(from 86 +/- 4.1 to 104 +/- 4.9 cm H(2)O, p < 0.005; mean difference
from the control group, 24%; 95% confidence interval, 18 to 32%),
expiratory muscle endurance (from 57 +/- 2.9% to 76 +/- 4.0%,
p < 0.001; mean difference from the control group, 29%; 95%
confidence interval, 21 to 39%), and in the distance walked in
6 min (from 262 +/- 38 to 312 +/- 47 m, p < 0.05; mean difference
from the control group, 14%; 95% confidence interval, 9 to 20%).
There was also a small but not significant increase (from 5.1
+/- 0.9 to 5.6 +/- 0.7, p = 0.14) in the dyspnea index. CONCLUSIONS:
The expiratory muscles can be specifically trained with improvement
of both strength and endurance in patients with COPD. This improvement
is associated with increase in exercise performance and no significant
change in the sensation of dyspnea in daily activities.
-----
Chest. 2003 Aug;124(2):699-713.
Acute applications
of noninvasive positive pressure ventilation.
Liesching
T, Kwok H, Hill NS.
Division of Pulmonary, Critical Care and Sleep Medicine, Brown
Medical School, Providence, RI, USA.
Noninvasive positive-pressure
ventilation (NPPV) has been used increasingly to treat acute respiratory
failure (ARF). The best indications for its use are ARF in patients
with COPD exacerbations, acute pulmonary edema, and immunocompromised
states. For these indications, multiple controlled trials have
demonstrated that therapy with NPPV avoids intubation and, in
the case of COPD and immunocompromised patients, reduces mortality
as well. NPPV is used to treat patients with numerous other forms
of ARF, but the evidence is not as strong for its use in those
cases, and patients must be selected carefully. The best candidates
for NPPV are able to protect their airway, are cooperative, and
are otherwise medically stable. Success is optimized when a skilled
team applies a well-fitted, comfortable interface. Ventilator
settings should be adjusted to reduce respiratory distress while
avoiding excessive discomfort, patient-ventilator synchrony should
be optimized, and adequate oxygenation should be assured. The
appropriate application of NPPV in the acute care setting should
lead to improved patient outcomes and more efficient resource
utilization.
-----
Chest. 2003 Aug;124(2):449-58.
The effect of smoking
intervention and an inhaled bronchodilator on airways reactivity
in COPD:
the Lung Health Study.
Wise RA,
Kanner RE, Lindgren P, Connett JE, Altose MD, Enright PL, Tashkin
DP; Lung Health Study Research Group.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.
BACKGROUND: The
Lung Health Study (LHS), a 5-year, randomized, prospective clinical
trial, studied the effects of smoking intervention and therapy
with inhaled anticholinergic bronchodilators on FEV(1) in participants
who were 35 to 60 years of age and had mild COPD. Participants
were randomized into the following three groups: usual care; smoking
cessation plus inhaled ipratropium bromide; and smoking cessation
plus placebo inhaler. This report evaluates the effects of these
interventions, demographic characteristics, smoking status, and
FEV(1) changes on airway responsiveness (AR). METHODS AND RESULTS:
Of 5,887 participants, 4,201 underwent methacholine challenge
testing both at study entry and study completion. All groups increased
AR during the 5-year period. The increase in AR was greatest in
continuing smokers and was associated with a greater FEV(1) decline.
An intent-to-treat analysis indicated no significant differences
in AR changes among the three groups. CONCLUSIONS: Changes in
AR over a 5-year period in the LHS were primarily related to changes
in the FEV(1). The greater the decline in FEV(1), the greater
the increase in AR. Smoking cessation had a small additional benefit
in AR beyond its favorable effects on FEV(1) changes.
-----
Chest. 2003 Jul;124(1):94-7.
A simple pulmonary
rehabilitation program improves health outcomes and reduces hospital
utilization in patients with COPD.
Hui KP,
Hewitt AB.
Department of Medicine, Changi General Hospital, Singapore.
STUDY OBJECTIVES:
A prospective longitudinal study to investigate if a simple outpatient-based
pulmonary rehabilitation program (PRP) can improve health outcome
and hospital utilization in patients with COPD. PATIENTS: Patients
with COPD and FEV(1) < 60% predicted. SETTING: Outpatient physiotherapy
department at a district general hospital (Fairfield Hospital,
Sydney, Australia). INTERVENTION: Completion of a simple PRP.
RESULTS: Thirty-six patients with COPD completed the PRP. Improved
exercise endurance (mean +/- SD 6-min walking distance increased
from 333 +/- 76 to 423 +/- 107 m [p < 0.001]), reduced dyspnea
scale, and improved quality-of-life measurements were found. There
was no improvement in lung functions (FEV(1) preprogram mean,
0.97 +/- 0.43 L; postprogram mean, 0.96 +/- 0.42 L). In the 12
months following completion of program, hospitalization and length
of stay were reduced compared to prior to starting the program
(preprogram, 7.4 days; postprogram, 3.3 days; p < 0.005). CONCLUSIONS:
A simple, low-cost, outpatient PRP was able to improve health
outcome for patients with COPD. Hospital utilization and health
cost were reduced as well.
-----
J Am Geriatr Soc.
2003 Jul;51(7):908-16.
Emergency department
management of acute exacerbations of chronic obstructive pulmonary
disease in the elderly: the Multicenter Airway Research Collaboration.
Cydulka
RK, Rowe BH, Clark S, Emerman CL, Camargo CA Jr; MARC Investigators.
MetroHealth Medical Center, Case Western Reserve University, Cleveland,
Ohio, USA. rcydulka@metrohealth.org
OBJECTIVES: To
determine adherence of emergency department (ED) management of
acute exacerbation of chronic obstructive pulmonary disease (COPD)
to current treatment guidelines. DESIGN: A prospective cohort
study, as part of the Multicenter Airway Research Collaboration.
SETTING: The study was performed at 29 EDs in 15 U.S. states and
three Canadian provinces. PARTICIPANTS: ED patients, aged 55 and
older, who presented with COPD exacerbation and underwent a structured
interview in the ED and another by telephone 2 weeks later. MEASUREMENTS:
Adherence of ED management of COPD exacerbation to that recommended
in current treatment guidelines. RESULTS: The cohort consisted
of 397 subjects, of whom 224 (56%) reported only COPD and 173
(44%) reported asthma and COPD. The average age was 70. Most (80%)
patients had used rescue medications in the 6 hours before seeking
emergency care. Only 31% were evaluated using spirometry and 48%
using arterial blood gas measurement. ED treatment included inhaled
short-acting beta-agonists for 91% of patients, inhaled anticholinergics
for 77%, methylxanthines for 0.3%, systemic corticosteroids for
62%, and antibiotics for 28%. More than half the patients required
hospitalization. At 2-week follow-up, 43% of patients reported
a relapse event or ongoing exacerbation. Overall, adherence to
national and international guidelines was low. CONCLUSION: Important
differences exist between guideline recommendations and actual
ED management of COPD exacerbations in older adults. Outcomes
after ED treatment are poor and may be related to these shortcomings
in quality of care. Better adherence to guideline recommendations
when caring for elderly patients with COPD exacerbations may lead
to improved clinical outcomes and better resource usage.
-----
Expert Opin Pharmacother.
2003 Jul;4(7):1063-82.
Advances in the management
of chronic obstructive pulmonary disease.
Ziedalski
TM, Sankaranarayanan V, Chitkara RK.
Medical Service, Pulmonary Section, Veterans Affairs Palo Alto
Healthcare System, USA. ziedalski@stanford.edu
Chronic obstructive
pulmonary disease (COPD) is a progressive and irreversible airflow
limitation with extreme economic and social burden. It is estimated
that over the next two decades, it will become the 5(th) most
prevalent disease and the 3(rd) most common cause of death in
the world. A better understanding of the pathogenesis of airway
inflammation and alveolar destruction allows for the development
of new therapeutic targets. Tobacco smoking is the most important
risk factor in the development of COPD, thus making smoking cessation
of the outermost importance. This article provides a critical
review of present therapy for COPD. In addition to conventional
treatment (bronchodilators, corticosteroids and antibiotics) and
smoking cessation therapies, novel approaches with potential benefit
are discussed.
-----
J Thorac Cardiovasc
Surg. 2003 Jun;125(6):1294-9.
Feasibility and safety
of the airway bypass procedure for patients with emphysema.
Rendina
EA, De Giacomo T, Venuta F, Coloni GF, Meyers BF, Patterson GA,
Cooper JD.
Division of Thoracic Surgery, Dipartimento P. Stefanini University
La Sapienza, Rome, Italy. erinoangelo.redina@tin.it
OBJECTIVE: We
have proposed that direct passages created between pulmonary parenchyma
and large airways (airway bypass) could take advantage of the
extensive collateral ventilation present in emphysematous lungs
to provide improvement in expiratory flow and respiratory mechanics.
A critical step in the safe performance of these procedures is
to create passages through the airway wall into lung parenchyma
while avoiding injury to adjacent blood vessels. METHODS: The
procedure consists of selection of a target site bronchoscopically,
use of a Doppler catheter to detect and avoid peribronchial blood
vessels, and creation of a passage through the airway wall with
a cautery probe. To evaluate the safety of airway bypass, 10 patients
were treated during prescheduled lobectomies for neoplasm. The
procedure was done after thoracotomy and immediately before resection
and was confined to airways in the lung identified for removal.
Airway bypass was subsequently performed in 5 patients undergoing
lung transplantation for emphysema just before lung excision to
evaluate the procedure in emphysematous patients. RESULTS: Twenty-nine
passages (1-5 per subject) were created in the patients undergoing
lobectomy. Eighteen passages were created (3-4 per subject) in
the patients undergoing transplantation. There were 2 instances
of mild bleeding in the patients undergoing lobectomy and no bleeding
in the patients undergoing transplantation. Both instances were
treated with suction and topical application of epinephrine and
resolved without incident. CONCLUSION: The results of this study
confirm that passages can be made safely through the airways of
human subjects. These clinical results support further investigation
of the efficacy of the airway bypass procedure in patients with
emphysema.
-----
N Engl J Med.
2003 Jun 26;348(26):2618-25.
Outpatient oral prednisone
after emergency treatment of chronic obstructive pulmonary disease.
Aaron
SD, Vandemheen KL, Hebert P, Dales R, Stiell IG, Ahuja J, Dickinson
G, Brison R, Rowe BH, Dreyer J, Yetisir E, Cass D, Wells G.
Department of Medicine, University of Ottawa, Ottawa, Ont, Canada.
saaron@ottawahospital.on.ca
BACKGROUND: In
this randomized, double-blind, placebo-controlled trial, we studied
the effectiveness of prednisone in reducing the risk of relapse
after outpatient exacerbations of chronic obstructive pulmonary
disease (COPD). METHODS: We enrolled 147 patients who were being
discharged from the emergency department after an exacerbation
of COPD and randomly assigned them to 10 days of treatment with
40 mg of oral prednisone once daily or identical-appearing placebo.
All patients received oral antibiotics for 10 days, plus inhaled
bronchodilators. The primary end point was relapse, defined as
an unscheduled visit to a physician's office or a return to the
emergency department because of worsening dyspnea, within 30 days
after randomization. RESULTS: The overall rate of relapse at 30
days was lower in the prednisone group than in the placebo group
(27 percent vs. 43 percent, P=0.05), and the time to relapse was
prolonged in those taking prednisone (P=0.04). After 10 days of
therapy, patients in the prednisone group had greater improvements
in forced expiratory volume in one second than did patients in
the placebo group (mean [+/-SD] increase from base line, 34+/-42
percent vs. 15+/-31 percent; P=0.007). Patients in the prednisone
group also had significant improvements in dyspnea, as measured
by the transitional dyspnea index (P=0.04) and by the dyspnea
domain of the Chronic Respiratory Disease Index Questionnaire
(P=0.02), but not in health-related quality of life (P=0.14).
CONCLUSIONS: Outpatient treatment with oral prednisone offers
a small advantage over placebo in treating patients who are discharged
from the emergency department with an exacerbation of COPD. Copyright
2003 Massachusetts Medical Society
-----
Cochrane Database
Syst Rev. 2003;(2):CD002999.
Smoking cessation
for chronic obstructive pulmonary disease.
van der
Meer RM, Wagena EJ, Ostelo RW, Jacobs JE, van Schayck CP.
Defacto - for a smokefree future, Parkstraat 83, P.O. Box 16070,
Den Haag, Netherlands. rvdmeer@defacto-rookvrij.nl
BACKGROUND: Smoking
cessation is the most important treatment for smokers with chronic
obstructive pulmonary disease (COPD), but little is known about
the effectiveness of different smoking cessation interventions
for this particular group of patients. OBJECTIVES: To determine
the effectiveness of smoking cessation interventions in people
with COPD. SEARCH STRATEGY: Electronic searches were undertaken
on MEDLINE (from 1966 to March 2002), EMBASE (from 1989 to March
2002) and Psyclit (from 1971 to March 2002), and CENTRAL (Issue
1, 2002). SELECTION CRITERIA: Randomised controlled trials in
which smoking cessation was assessed in participants with confirmed
COPD. DATA COLLECTION AND ANALYSIS: Two authors extracted the
data and performed the methodological quality assessment independently
for each study, with disagreements resolved by consensus. High-quality
was defined, based on pre-set criteria according to the DelphiList.
MAIN RESULTS: Five studies were included in this systematic review,
two of which were of high-quality. The high-quality studies show
the effectiveness of psychosocial interventions combined with
pharmacological intervention compared to no treatment: psychosocial
interventions combined with nicotine replacement therapy (NRT)
and a bronchodilator versus no treatment at a 5 year follow-up
(RD = 0.16, 95% CI 0.14 to 0.18), (RR = 4.0, 95% CI 3.25 to 4.93),
psychosocial interventions combined with NRT and placebo versus
no treatment at a 5 year follow-up (RD = 0.17, 95% CI 0.14 to
0.19), (RR = 4.19, 95% CI 3.41 to 5.15). Furthermore the results
show the effectiveness of various combinations of psychosocial
and pharmacological interventions at a 6 months follow-up (RD
= 0.07, 95% CI 0.0 to 0.13), (RR = 1.74, 95% CI 1.01 to 3.0).
Unfortunately, none of the included studies compared psychosocial
interventions with no treatment. Therefore we found no evidence
with regard to the effectiveness of these interventions. REVIEWER'S
CONCLUSIONS: Based on this systematic review, the authors found
evidence that a combination of psychosocial interventions and
pharmacological interventions is superior to no treatment or to
psychosocial interventions alone. Furthermore we conclude that
there is no clear or convincing evidence for the effectiveness
of any psychosocial intervention for patients with COPD due to
lack of a sufficient number of high-quality studies.
-----
Cochrane Database
Syst Rev. 2003;(2):CD002168.
Methylxanthines for
exacerbations of chronic obstructive pulmonary disease.
Barr RG,
Rowe BH, Camargo CA.
Division of General Medicine, PH-9 East Room 105, Columbia-Presbyterian
Medical Center, 622 West 168th Street, New York, NY 10032, USA.
rgb9@columbia.edu
BACKGROUND: Most
international guidelines currently recommend methylxanthines (e.g.,
theophylline, aminophylline) for severe exacerbations of chronic
obstructive pulmonary disease (COPD), yet clinical trials underlying
this recommendation have been small and underpowered. OBJECTIVES:
To determine the benefit of methylxanthines compared to placebo
for COPD exacerbations. SEARCH STRATEGY: Randomised controlled
trials (RCTs) were identified from the Cochrane Airways Review
Group COPD Register, a compilation of systematic searches of CINAHL,
EMBASE, MEDLINE and CENTRAL and hand searching of 20 respiratory
journals. Primary authors and content experts were contacted to
identify eligible studies. Bibliographies from included studies
and reviews were searched. SELECTION CRITERIA: Included studies
were limited to RCTs of patients presenting with acute COPD exacerbations,
treated with methylxanthines (oral or intravenous) or placebo
plus standard care. Two reviewers independently selected articles
for inclusion and assessed methodological quality. DATA COLLECTION
AND ANALYSIS: Two reviewers independently extracted data. Missing
data were obtained from authors or calculated from other data
presented in the paper. The data were analysed using the Cochrane
Review Manager 4.1. Studies were pooled to yield weighted mean
differences (WMD), standardised mean difference (SMD) or odds
ratios (OR) and reported using 95% confidence intervals (95%CI).
MAIN RESULTS: From 29 identified references, 4 RCTs met inclusion
criteria (169 patients). Mean change in forced expiratory volume
in one second (FEV1) at 2 hours was similar in methylxanthine
and placebo groups. Data on clinical outcomes were sparse. Trends
toward improvements in hospitalisation and length-of-stay were
offset by a trend toward more relapses at one week. Changes in
symptom scores were not significant. Methylxanthines caused more
nausea and vomiting than placebo (OR: 4.6; 95% CI: 1.7 to 12.6)
and trended toward more frequent tremor, palpitations, and arrhythmias.
REVIEWER'S CONCLUSIONS: Given current evidence, methylxanthines
should not be used for COPD exacerbations. Possible beneficial
effects in lung function and clinical endpoints were modest and
inconsistent, whereas adverse effects were significantly increased.
More selective agents, tested in larger randomised trials, are
necessary if methylxanthines are to have any role in the treatment
of COPD exacerbations.
-----
Thorax. 2003 Jul;58(7):580-4.
Regular inhaled short
acting beta2 agonists for the management of stable chronic obstructive
pulmonary disease: Cochrane systematic review and meta-analysis.
Ram FS,
Sestini P.
St George's Hospital Medical School, Department of Physiological
Medicine, University of London, UK. fram@sghms.ac.uk
BACKGROUND: Despite
the lack of reversibility, patients with chronic obstructive pulmonary
disease (COPD) often report symptomatic improvement with inhaled
short acting beta(2) agonist bronchodilators (ISABAs) in the management
of both stable and acute exacerbations of COPD. A review of the
literature was undertaken to determine the effectiveness of regular
treatment with ISABAs compared with placebo in stable COPD. METHODS:
A search for randomised controlled trials was carried out using
the Cochrane Collaboration database of trials up to and including
May 2002. RESULTS: Thirteen studies of 7 days to 8 weeks in duration
on 237 patients aged 56-70 years with forced expiratory volume
in 1 second (FEV(1)) 60-70% predicted were included in the review.
All studies used a crossover design with adequate washout periods
and were of high methodological quality. ISABA was delivered either
through a nebuliser or a pressurised metered dose inhaler. Spirometric
tests performed at the end of the study and after the treatment
(post-bronchodilator) showed a slight but significant increase
in FEV(1) and forced vital capacity (FVC) compared with placebo.
In addition, both morning and evening peak expiratory flow rate
(PEFR) were significantly better during active treatment than
during placebo. An improvement in the daily breathlessness score
was observed with ISABA treatment. The risk of treatment failure
was reduced by more than 50% with ISABA. Preference for ISABA
was nine times higher than for placebo. CONCLUSIONS: Use of ISABA
on a regular basis for at least 7 days in patients with stable
COPD is associated with improvements in post-bronchodilator lung
function and decreases in both breathlessness and treatment failure.
This review has shown that regular administration of ISABAs is
an effective and inexpensive treatment for the management of patients
with stable COPD.
-----
Thorax. 2003 Jul;58(7):634-8.
Chronic obstructive
pulmonary disease. 10: Bullectomy, lung volume reduction surgery,
and transplantation for patients with chronic obstructive pulmonary
disease.
Meyers
BF, Patterson GA.
Division of Cardiothoracic Surgery, Washington University, St
Louis, Missouri, USA. meyersb@msnotes.wustl.edu
There are currently
three surgical treatments for emphysema: bullectomy, lung transplantation,
and lung volume reduction surgery (LVRS). Unfortunately, most
emphysema patients are poor candidates for any surgical intervention.
A meticulous selection process is favored in which indications
and contraindications are considered and the best solution is
devised for each patient. Patients with giant bullae filling half
the thoracic volume and compressing relatively normal adjacent
parenchyma are offered bullectomy; those with hyperinflation,
heterogeneous distribution of destruction, forced expiratory volume
in 1 second (FEV(1)) >20%, and a normal carbon dioxide tension
(PCO(2)) are offered LVRS; and patients with diffuse disease,
lower FEV(1), hypercapnia, and associated pulmonary hypertension
are directed towards transplantation. Using these criteria, few
patients are serious candidates for surgical procedures. Combinations
of LVRS and lung transplantation, either simultaneously or sequentially,
are possible but rarely necessary.
-----
Chest. 2003 Jun;123(6):1810-6.
A comparison of the
effects of salbutamol and ipratropium bromide on exercise endurance
in patients with COPD.
Oga T,
Nishimura K, Tsukino M, Sato S, Hajiro T, Mishima M.
Respiratory Division (Drs. Oga and Nishimura), Kyoto-Katsura Hospital,
Kyoto, Japan. ogat@df7.so-net.ne.jp
STUDY OBJECTIVE:
Inhaled bronchodilators are the first-line pharmacotherapy against
COPD. The purpose of the present study was to investigate the
effects of beta(2)-agonists and anticholinergic agents on the
exercise capacity of patients with COPD. METHODS: A total of 67
stable patients with COPD were recruited at the Kyoto University
Hospital. After inhaling 400 micro g salbutamol, 80 micro g ipratropium
bromide, or an identical placebo in a randomized, double-blind,
crossover fashion, the patients performed cycle endurance tests
at a constant workload of 80% of the maximum work rate reached
on progressive cycle ergometry, and the endurance time was recorded.
RESULTS: Both salbutamol and ipratropium bromide significantly
improved the endurance time by 29 s (15%; p < 0.001) and 27
s (14%; p < 0.001), respectively, in comparison with the placebo.
However, there was no statistically significant difference between
them (p = 0.71). The dyspnea ratios were also similarly reduced
by both bronchodilators. The difference in the endurance time
between therapy with salbutamol and placebo was significantly,
but moderately, related to the difference between therapy with
ipratropium bromide and placebo. In addition, there were no relationships,
or only weakly significant relationships, between the change in
FEV(1) and the change in the endurance time, the highest oxygen
uptake, and the highest minute ventilation for both salbutamol
and ipratropium bromide. CONCLUSIONS: Therapy with both salbutamol
and ipratropium bromide improved exercise capacity, as evaluated
by the endurance time, and reduced dyspnea similarly in patients
with COPD. In addition, the effects of the different bronchodilators
on exercise capacity varied within individuals, and a complex
mechanism may be responsible for the different effects of these
two bronchodilators on exercise capacity vs airflow limitation.
These results support the conclusion that both types of inhaled
bronchodilators can be used as first-line drugs for the treatment
of stable patients with COPD.
-----
Nurs Times. 2003
May 20-26;99(20):49.
Noninvasive ventilation
and COPD.
Riches
A.
Countess of Chester Hospital.
The British Thoracic
Society (BTS) guidelines for noninvasive ventilation (NIV) provide
overwhelming evidence that NIV is effective in supporting patients
with acute hypercapnic respiratory failure (AHRF) (BTS, 2002).
AHRF, which causes a rise in carbon dioxide levels and a fall
in pH, is common in patients presenting with acute exacerbations
of chronic obstructive pulmonary disease (COPD). NIV is also beneficial
to patients with chest wall deformity and neuromuscular diseases.
-----
Eur J Pediatr
Surg. 2003 Apr;13(2):108-11.
Congenital lobar
emphysema: a clinicopathologic evaluation of 14 cases.
Tander
B, Yalcin M, Yilmaz B, Ali Karadag C, Bulut M.
Department of Paediatric Surgery, Sisli Children's Hospital, Istanbul,
Turkey. buraktander@hotmail.com
Controversy still
exists concerning the diagnosis and treatment of congenital lobar
emphysema (CLE). Although surgical removal of the affected lobe
is the most commonly accepted form of treatment, detection of
milder or even asymptomatic cases is usually followed by a more
conservative management of patients, i. e. non-surgical treatment
and follow-up. We therefore decided to evaluate our patients with
CLE, placing special emphasis on treatment and diagnostic techniques.
We also evaluated quantitative analyses of alveolar diameters.
Fourteen children with CLE were analysed retrospectively, including
age, sex, clinical picture, localisation, diagnostic and surgical
modalities and histopathologic diagnosis. The alveolar diameters
of affected lobes were compared with those of the lobectomised
patients with other non-obstructive respiratory diseases. All
children but one had severe respiratory distress as an initial
symptom. All patients, except newborns, had a history of pulmonary
infection. All cases underwent thoracic CT examination as the
main radiologic method. In all of the patients, only one lobe
was affected. We found an obvious mediastinal shift and atelectasis
of adjacent lobes due to compression of the affected lobe. The
affected lobe was therefore surgically removed in all of the children.
In one case, we had to carry out a partial lobectomy to reduce
the duration of the operation, due to an intraoperative fall of
oxygen saturation. All of the children had an uneventful clinical
course postoperatively. The alveolar diameters of the cases with
CLE were significantly greater than those of the control patients.
We think that the majority of cases with CLE have too severe respiratory
distress to avoid surgical removal of affected lobe. Conservative
management should be reserved only for patients with milder symptoms
or no distress at all.
-----
An Med Interna.
2003 Mar;20(3):148-55.
[Treatment of chronic
obstructive pulmonary disease]
[Article
in Spanish]
Fernandez-Fernandez FJ, Ameneiros-Lago E, Gonzalez Moraleja J,
Pia Iglesias G, Martinez-Deben FS, Sesma P.
Servicio de Medicina Interna, Hospital Arquitecto Marcide, Ferrol.
fjf-fernandez@terra.es
Chronic obstructive
pulmonary disease (COPD) is a highly prevalent condition and most
epidemiological studies have found that COPD prevalence, morbidity
and mortality have increased over the last few years. Recent trials
suggest that treatments are improving. Several studies have demonstrated
the usefulness of the long-acting inhaled beta-2-agonists. Inhaled
glucocorticoids, although unable to alter the progression of COPD,
may reduce the frequency of acute exacerbations and health status
deterioration in a limited group of patients with COPD. Likewise,
these drugs may offer benefits in combination with long-acting
inhaled beta-agonists. Finally, a better understanding of the
molecular and cellular mechanisms involved in COPD pathogenesis
should lead to effective treatments that slow or halt the course
of the disease. New classes of agents such as the phosphodiesterase
inhibitors are now in development.
-----
N Engl J Med.
2003 May 22;348(21):2059-73. Epub 2003 May 20.
A randomized trial
comparing lung-volume-reduction surgery with medical therapy for
severe emphysema.
Fishman
A, Martinez F, Naunheim K, Piantadosi S, Wise R, Ries A, Weinmann
G, Wood DE; National Emphysema Treatment Trial Research Group.
University of Pennsylvania, Philadelphia, USA.
BACKGROUND: Lung-volume-reduction
surgery has been proposed as a palliative treatment for severe
emphysema. Effects on mortality, the magnitude and durability
of benefits, and criteria for the selection of patients have not
been established. METHODS: A total of 1218 patients with severe
emphysema underwent pulmonary rehabilitation and were randomly
assigned to undergo lung-volume-reduction surgery or to receive
continued medical treatment. RESULTS: Overall mortality was 0.11
death per person-year in both treatment groups (risk ratio for
death in the surgery group, 1.01; P=0.90). After 24 months, exercise
capacity had improved by more than 10 W in 15 percent of the patients
in the surgery group, as compared with 3 percent of patients in
the medical-therapy group (P<0.001). With the exclusion of
a subgroup of 140 patients at high risk for death from surgery
according to an interim analysis, overall mortality in the surgery
group was 0.09 death per person-year, as compared with 0.10 death
per person-year in the medical-therapy group (risk ratio, 0.89;
P=0.31); exercise capacity after 24 months had improved by more
than 10 W in 16 percent of patients in the surgery group, as compared
with 3 percent of patients in the medical-therapy group (P<0.001).
Among patients with predominantly upper-lobe emphysema and low
exercise capacity, mortality was lower in the surgery group than
in the medical-therapy group (risk ratio for death, 0.47; P=0.005).
Among patients with non-upper-lobe emphysema and high exercise
capacity, mortality was higher in the surgery group than in the
medical-therapy group (risk ratio, 2.06; P=0.02). CONCLUSIONS:
Overall, lung-volume-reduction surgery increases the chance of
improved exercise capacity but does not confer a survival advantage
over medical therapy. It does yield a survival advantage for patients
with both predominantly upper-lobe emphysema and low base-line
exercise capacity. Patients previously reported to be at high
risk and those with non-upper-lobe emphysema and high base-line
exercise capacity are poor candidates for lung-volume-reduction
surgery, because of increased mortality and negligible functional
gain. Copyright 2003 Massachusetts Medical Society
-----
Chest. 2003 Apr;123(4):1026-37.
A prospective evaluation
of lung volume reduction surgery in 200 consecutive patients.
Yusen
RD, Lefrak SS, Gierada DS, Davis GE, Meyers BF, Patterson GA,
Cooper JD.
Division of Pulmonary, Washington University School of Medicine,
St. Louis, MO 63110, USA. yusenr@msnotes.wustl.edu
OBJECTIVES: Though
numerous studies have demonstrated the short-term efficacy of
lung volume reduction surgery (LVRS) in select patients with emphysema,
the longer-term follow-up studies are just being reported. The
primary objectives of this study were to assess long-term health-related
quality of life, satisfaction, physiologic status, and survival
of patients following LVRS. DESIGN: We used a prospective cohort
study design to assess the first 200 patients undergoing bilateral
LVRS (from 1993 to 1998), with follow-up through the year 2000.
Each patient served as his own control, initially receiving optimal
medical management including exercise rehabilitation before undergoing
surgery. Preoperative postrehabilitation data were used as the
baseline for comparisons with postoperative data. The primary
end points were the effects of LVRS on dyspnea (modified Medical
Research Council dyspnea sale), general health-related quality
of life (Medical Outcomes Study 36-Item Short-Form Health Survey
[SF-36]), patient satisfaction, and survival. The secondary end
points were the effects of LVRS on pulmonary function, exercise
capacity, and supplemental oxygen requirements. SETTING: A tertiary
care urban university-based referral center. PATIENTS: Eligibility
requirements for LVRS included disabling dyspnea due to marked
airflow obstruction, thoracic hyperinflation, and heterogeneously
distributed emphysema that provided target areas for resection.
Patients were assessed at 6 months, 3 years, and 5 years after
surgery. INTERVENTIONS: Preoperative pulmonary rehabilitation
and bilateral stapling LVRS. Measurements and results: The 200
patients accrued 735 person-years (mean +/- SD, 3.7 +/- 1.6 years;
median, 4.0 years) of follow-up. Over the three follow-up periods,
an average of > 90% of evaluable patients completed testing.
Six months, 3 years, and 5 years after surgery, dyspnea scores
were improved in 81%, 52%, and 40% of patients, respectively.
Dyspnea scores were the same or improved in 96% (6 months), 82%
(3 years), and 74% (5 years) of patients. Improvements in SF-36
physical functioning were demonstrated in 93% (6 months), 78%
(3 years), and 69% (5 years) of patients. Good-to-excellent satisfaction
with the outcomes was reported by 96% (6 months), 89% (3 years),
and 77% (5 years) of patients. The FEV(1) was improved in 92%
(6 months), 72% (3 years), and 58% (5 years) of patients. Changes
in dyspnea and general health-related quality-of-life scores,
and patient satisfaction scores were all significantly correlated
with changes in FEV(1). Following surgery, the median length of
hospital stay in survivors was 9 days. The 90-day postoperative
mortality was 4.5%. Annual Kaplan-Meier survival through 5 years
after surgery was 93%, 88%, 83%, 74%, and 63%, respectively. During
follow-up, 15 patients underwent subsequent lung transplantation.
CONCLUSIONS: In stringently selected patients, LVRS resulted in
substantial beneficial effects over and above those achieved with
optimized medical therapy. The duration of improvement was at
least 5 years in the majority of survivors.
-----
J Thorac Cardiovasc
Surg. 2003 Mar;125(3):513-25.
Long-term outcome
of bilateral lung volume reduction in 250 consecutive patients
with emphysema.
Ciccone
AM, Meyers BF, Guthrie TJ, Davis GE, Yusen RD, Lefrak SS, Patterson
GA, Cooper JD.
Washington University School of Medicine, Division of Cardiothoracic
Surgery, Department of Surgery, St Louis, Mo, USA.
OBJECTIVE: Numerous
reports have confirmed the early benefits of lung volume reduction
surgery for selected patients with emphysema. This report documents
the long-term survival and functional results after lung volume
reduction surgery. METHODS: Between January 1993 and June 2000,
a total of 250 consecutive patients underwent bilateral lung volume
reduction surgery through median sternotomy at our institution.
All patients had disabling dyspnea, thoracic hyperinflation, and
a heterogeneous pattern of emphysema with suitable target areas
for resection. Preoperative pulmonary rehabilitation was required
and post-rehabilitation data were used as the baseline for data
analysis. Follow-up ranged from 1.8 to 9.1 years (median 4.4 years).
RESULTS: Prolonged air leaks (>7 days) were the most common
complication (45.2%, n = 113). Reexploration rates for air leak
and bleeding were 3.2% (n = 8) and 1.2% (n = 3), respectively.
Eighteen patients (7.2%) required reintubation and mechanical
ventilation. The in-hospital mortality in this series was 4.8%
(n = 12). The median length of hospitalization was 9 days (range
4-168 days). Kaplan-Meier survivals after lung volume reduction
surgery were 93.6%, 84.4%, and 67.7% at 1, 3, and 5 years, respectively.
Eighteen patients (7.2%) have subsequently undergone lung transplantation
after a median interval of 4.3 years (range 2.1-6.4 years). Spirometric
values, lung volumes, and gas exchange parameters improved after
surgery. The forced expiratory volume in 1 second and the residual
volume showed statistically significant improvements between preoperative
values and each time point of follow-up. Health-related quality
of life showed significant postoperative improvement and with
time correlated well with the improvement in forced expiratory
volume in 1 second. CONCLUSIONS: Lung volume reduction surgery
produces significant functional improvement for selected patients
with emphysema. For most of these patients, benefits appear to
last at least 5 years.
-----
J Cardiovasc Surg
(Torino). 2003 Feb;44(1):101-8.
Bronchoscopic lung
volume reduction.
Sabanathan
S, Richardson J, Pieri-Davies S.
Department of Thoracic Surgery, Bradford Royal Infirmary, Bradford,
England, UK.
AIM: Because traditional
lung volume reduction involves major surgery in unfit patients,
resource implications are formidable. Many patients are too ill
for consideration and overall survival rates have lead to questions
about its continuation. We report on a new method of lung volume
reduction, through a bronchoscopic approach. Patients with severe
dyspnoea with end stage emphysema were recruited. Target areas
for collapse therapy were upper lobes or segments with severe
destruction, occupying a large volume, with surrounding lung compression
and little perfusion. These were delineated radiologically and
with ventilation-perfusion scanning. Endobronchial blockade was
initially with detachable, silicone balloons and later with especially
designed and hospital manufactured stainless steel wire stents
containing bio-compatible sponge. METHODS: Five males and 3 females
with preoperative breathlessness at rest and muscle wasting were
treated. Operative time was a mean of 67.5 min. Rehabilitation
began immediately and 7 patients left hospital the following day.
RESULTS: Five patients had improvements in well-being, dyspnoea,
exercise tolerance, lifestyles and medication requirements. One
patient survived at least 2 years and 2 are still alive 4(1/2)
years later. Endoscopic balloon replacement with wire and sponge
devices was required in 5 patients. Complications were related
to intraoperative oxygenation problems in 2 patients and late
infections in 4. CONCLUSIONS: Bronchoscopic lung volume reduction
for the treatment of end-stage emphysema subjectively improved
the majority of patients. The use of stents was promising: balloons
were disappointing.
-----
Ann Thorac Surg.
2003 Feb;75(2):393-7; discussion 398.
Bronchial fenestration
improves expiratory flow in emphysematous human lungs.
Lausberg
HF, Chino K, Patterson GA, Meyers BF, Toeniskoetter PD, Cooper
JD.
Division of Cardiothoracic Surgery, Department of Surgery, Washington
University School of Medicine and Barnes-Jewish Hospital, St.
Louis, Missouri, USA.
BACKGROUND: The
crippling effects of emphysema are due in part to dynamic hyperinflation,
resulting in altered respiratory mechanics, an increased work
of breathing, and a pervasive sense of dyspnea. Because of the
extensive collateral ventilation present in emphysematous lungs,
we hypothesize that placement of stents between pulmonary parenchyma
and large airways could effectively improve expiratory flow, thus
reducing dynamic hyperinflation. METHODS: Twelve human emphysematous
lungs, removed at the time of lung transplantation, were placed
in an airtight ventilation chamber with the bronchus attached
to a tube traversing the chamber wall, and attached to a pneumotachometer.
The chamber was evacuated to -10 cm H2O pressure for lung inflation.
A forced expiratory maneuver was simulated by rapidly pressurizing
the chamber to 20 cm H2O, while the expiratory volume was continuously
recorded. A flexible bronchoscope was then inserted into the airway
and a radiofrequency catheter (Broncus Technologies) was used
to create a passage through the wall of three separate segmental
bronchi into the adjacent lung parenchyma. An expandable stent,
1.5 cm in length and 3 mm in diameter, was then inserted through
each passage. Expiratory volumes were then remeasured as above.
In six experiments, two additional stents were then inserted and
forced expiratory volumes again determined. RESULTS: The forced
expiratory volume in 1 second (FEV1) increased from 245 +/- 107
mL at baseline to 447 +/- 199 mL after placement of three bronchopulmonary
stents (p < 0.001). With two additional stents, the FEV1 increased
to 666 +/- 284 mL (p < 0.001). CONCLUSIONS: Creation of extra-anatomic
bronchopulmonary passages is a potential therapeutic option for
emphysematous patients with marked hyperinflation and severe homogeneous
pulmonary destruction.
-----
Bratisl Lek Listy.
2003;104(1):44-8.
Initial experience
with lung transplantation in Slovakia--an example for successful
bilateral cooperation between countries.
Pereszlenyi
A Jr, Harustiak S, Jaksch P, Wisser W, Klepetko W.
Clinic of Thoracic Surgery, National Tuberculosis and Respiratory
Diseases Institute, Bratislava, Slovakia. Arpad_pp@hotmail.com
OBJECTIVE: To
review initial experiences, results of single lung transplantation
(SLT) and double lung transplantation (DLT) on the basis of bilateral
cooperation between Slovakia and Austria. PATIENTS AND METHODS:
During the period between July 1998 and January 2003 ten patients
from Slovakia underwent lung transplantation in Vienna, Austria.
There were 7 males and 3 females with an age range from 21 to
48 years. Eight patients underwent double lung transplantation,
two patients had single lung transplantation. Indications were:
pulmonary fibrosis in 2, cystic fibrosis in 2, emphysema in 2,
primary pulmonary hypertension (PPH) in 4 cases. In the PPH patients
(n = 4) and in the patients with cystic fibrosis (n = 2), bilateral
lung transplantation under ECMO support was performed. One patient
(n = 1) with postradiative pulmonary fibrosis and intracardial
myxoma underwent bilateral lung transplantation under cardiopulmonary
bypass. Only three patients (e.i. the two with emphysema and one
with pulmonary fibrosis) underwent lung transplantation without
any intraoperative circulatory support. RESULTS: No perioperative
mortality was recorded. Two patients died in late postoperative
period: one due to multiorgan failure on 93rd day after DLT, the
other one--on a liver failure caused by cirrhosis after 2.5 years
after LTX. All the remaining eight patients, but the two ones
who underwent LTX several days ago, are with improved functional
status in full work activity. The follow up period for all patients
ranges between 10 days and 54 months. CONCLUSION: Both unilateral
and bilateral lung transplantations are accepted treatment modalities
in patients with end-stage pulmonary disease. Bilateral cooperation
for such countries as Slovakia (with limited possibilities) offers
a unique example of possible and successful way how to deal with
such demanding procedures. (Tab. 3, Fig. 2, Ref. 19.).
-----
Swiss Med Wkly.
2002 Nov 2;132(39-40):557-61.
News on lung volume
reduction surgery.
Russi
EW, Weder W.
Pulmonary Division, University Hospital of Zurich, CH-8091 Zurich,
Switzerland. erich.russi@dim.usz.ch
Lung volume reduction
surgery (LVRS) is an established therapeutic option for patients
with advanced pulmonary emphysema after all conservative measures,
including comprehensive pulmonary rehabilitation, have been exhausted.
LVRS improves pulmonary function, shortness of breath, exercise
capacity and hence quality of life in some 80% of cases for up
to four years. Even patients with homogeneous types of pulmonary
emphysema improve if those with extremely low FEV1 and/or very
low diffusion capacity are excluded. At experienced centres perioperative
mortality is less than 2% in appropriately selected patients,
and current results suggest that the five-year survival in COPD
patients may even be improved by this palliative surgical intervention.
In patients under 60 LVRS may serve as a bridging procedure to
lung transplantation. Bronchoscopic creation of extraanatomic
bronchopulmonary passages--endoscopic LVRS--is a novel approach
now under investigation.
-----
Thorac Cardiovasc
Surg. 2002 Oct;50(5):315-22.
Evidence-based medicine:
lung volume reduction surgery (LVRS).
Koebe
HG, Kugler C, Dienemann H.
Schwerpunkt Thoraxchirurgie, Klinikum Kassel, Germany.
Lung volume reduction
surgery (LVRS) was developed as a means of surgical treatment
for severe pulmonary emphysema. To date, various studies have
been designed to explain the mechanisms involved in pathophysiological
changes after treatment, to define criteria for patient selection,
to identify the surgical technique of choice and to propose appropriate
follow-up care. Preliminary results of follow-up studies (up to
five years) have already been published, indicating improved pulmonary
function and quality of life after surgical treatment. However,
the alarming results from the National Emphysema Treatment Trial
(NETT) Research Group indicated a considerable risk for death
in patients with homogenous emphysema and low forced expiratory
volume in one second (FEV1) undergoing LVRS. This brief review
summarizes the results of currently published studies to supply
evidence for selection criteria in order to better define the
subset of patients for which LVRS offers an effective and safe
means of palliation from the symptoms of advanced COPD. Due to
acceptable morbidity and mortality rates, stapler device wedge
excision and closure has become the standard procedure for removing
non-functioning, hyperinflated lung areas in heterogeneously affected
organs. LVRS is carried out in two ways - using video-assisted
thoracoscopic surgery (VATS) as well as thoracotomy/sternotomy-and
performed in unilateral and bilateral procedures. In contrast,
most clinics have found laser resection of emphysematous parenchyma
to be unsuccessful. In some patients, LVRS was carried out as
an alternative to lung transplantation, whereas in others, it
served as a bridge-to-transplant procedure. LVRS has proven effective
in the reduction of dyspnea, especially in patients with recovery
options in both the circulatory and pulmonary system. In responders,
recovery from labored breathing and O(2) dependency and increased
physical capacity are usually accompanied by improved spirometric
data. These results are mainly explained by a more regular breathing
pattern and an increase in the maximum volume of ventilation in
the affected lung. In most cases, functional improvement is maximized
during the first six months postoperatively and decreases steadily
thereafter indicating the need for a systematic postoperative
patient care after surgical treatment. After indicating at-risk
patients who should not be considered for LVRS, long-term results
from the multicenter NETT research group will hopefully help clarify
the impact of this treatment on survival of patients further.
-----
Minerva Chir.
2002 Oct;57(5):625-33.
Reduction pneumoplasty
for severe emphysema. Does the debate await a neat sentence?
Mineo
TC, Pompeo E.
Division of Thoracic Surgery, Policlinico Tor Vergata, Tor Vergata
University, Rome, Italy. mineo@med.uniroma2.it
The aim of this
study is to review the literature regarding reduction pneumoplasty
(RP) or lung volume reduction surgery in order to assess the state
of the art of this topic. Reduction pneumoplasty is a palliative
surgical therapy that is offered to selected patients with severe
non-bullous emphysema not responding to maximized medical therapy.
The use of staple excision or plication of the most destroyed
target areas of the lung appeared to be more effective than laser
ablation. Currently, a one-stage bilateral procedure is the standard
of care although a unilateral reduction can be preferable in patients
with asymmetric emphysema and/or if a staged bilateral treatment
strategy is planned. Randomized studies have suggested that RP
is superior to medical therapy including respiratory rehabilitation
for improving subjective dyspnea, exercise capacity, respiratory
function and quality of life for up to 1 year. In addition, few
long-term studies have suggested that the improvements obtained
with RP can be maintained for several years in properly selected
patients. Although several issues still await a definitive answer,
the available literature data and our current experience have
clearly indicated that RP works well and is a safe and effective
procedure for palliating symptoms and improving respiratory function
in severely disabled emphysematous patients.
-----
Ann Thorac Surg
2002 Nov;74(5):1663-9; discussion 1669-70
Thirteen-year experience
in lung transplantation for emphysema.
Cassivi SD, Meyers
BF, Battafarano RJ, Guthrie TJ, Trulock EP, Lynch JP, Cooper JD,
Patterson GA.
Division of Cardiothoracic
Surgery, Washington University Medical Center, St. Louis, Missouri
63110-1013, USA.
BACKGROUND: Emphysema
is the most common indication for lung transplantation. Recipients
include younger patients with genetically determined alpha-1 antitrypsin
deficiency (AAD) and, more commonly, patients with chronic obstructive
pulmonary disease (COPD). We analyzed the results of our single-institution
series of lung transplants for emphysema to identify outcome differences
and factors predicting mortality and morbidity in these two groups.
METHODS: A retrospective analysis was undertaken of the 306 consecutive
lung transplants for emphysema performed at our institution between
1988 and 2000 (220 COPD, 86 AAD). Follow-up was complete and averaged
3.7 years. RESULTS: The mean age of AAD recipients (49 +/- 6 years)
was less than those with COPD (55 +/- 6 years; p < 0.001).
Hospital mortality was 6.2%, with no difference between COPD and
AAD, or between single-lung transplants and bilateral-lung transplants.
Hospital mortality during the most recent 6 years was significantly
lower (3.9% vs 9.5%, p = 0.044). Five-year survival was 58.6%
+/- 3.5%, with no difference between COPD (56.8% +/- 4.4%) and
AAD (60.5% +/- 5.8%). Five-year survival was better with bilateral-lung
transplants (66.7% +/- 4.0%) than with single-lung transplants
(44.9% +/- 6.0%, p < 0.005). Independent predictors of mortality
by Cox analysis were single lung transplantation (relative hazard
= 1.98, p < 0.001), and need for cardiopulmonary bypass during
the transplant (relative hazard = 1.84, p = 0.038). CONCLUSIONS:
AAD recipients, despite a younger age, do not achieve significantly
superior survival results than those with COPD. Bilateral lung
transplantation for emphysema results in better long-term survival.
Accumulated experience and modifications in perioperative care
over our 13-year series may explain recently improved early and
long-term survival.
--
Eur J Cardiothorac
Surg 2002 Sep;22(3):363-7
Successful
lung volume reduction surgery brings patients into better condition
for later lung transplantation.
Senbaklavaci O,
Wisser W, Ozpeker C, Marta G, Jaksch P, Wolner E, Klepetko W.
Department of
Cardiothoracic Surgery, University of Vienna, Wahringer Gurtel
18-20, A-1090 Vienna, Austria.
OBJECTIVES: Lung
volume reduction surgery (LVRS) is accepted as a potential alternative
therapy to lung transplantation (LTX) for selected patients. However,
the possible impact of LVRS on a subsequent LTX has not been clearly
elucidated so far. We therefore analyzed the course of 27 patients
who underwent LVRS followed by LTX in our institution. METHODS:
Twenty-seven patients (11 male, 16 female, mean age 51.9+/-2.2
years) out of 119 patients who underwent LVRS between 1994 and
1999 underwent LTX 29.7+/-3.2 months (range 2-57 months) after
LVRS. Based on the postoperative course of FeV1 after LVRS (best
value within the first 6 months postoperatively compared with
the preoperative value) patients were divided into two groups:
Group A (n=11) without any improvement (FeV1 <20% increase),
and Group B (n=16) with FeV1 increase > or = 20% after successful
LVRS which declined to preoperative values after 8-42 months.
Subsequent LTX was performed 22.9+/-5.6 months after LVRS in Group
A and 34.3+/-4.9 months after LVRS in Group B (P<0.05). Patients
were analyzed according to the course of their functional improvement
and of their body mass index (BMI) after LVRS and to survival
after LTX, respectively. Values are given as the mean+/-SEM and
significance was calculated by the chi(2)-test whereas continuous
values were estimated by Student's t-test. RESULTS: Patients in
Group A without improvement in FeV1 after LVRS had no increase
in BMI as well and this resulted in a high perioperative mortality
of 27.3% after LTX. On the contrary, patients in Group B, who
had a clear increase of FeV1 after LVRS, experienced a significant
increase of BMI of 23.2+/-4.5% as well (P<0.05). This improvement
in BMI remained stable despite a later deterioration of FeV1 prior
to LTX. After LTX, these patients had a significantly lower perioperative
mortality of 6.3% as compared to Group A (P=0.03). CONCLUSIONS:
Successful LVRS delays the need for transplantation, improves
nutritional status and brings patients into a better pretransplant
condition, which results in decreased perioperative mortality
at LTX. Patients after failed LVRS, however, should be considered
as poor candidates for later transplantation.
--
Eur J Cardiothorac
Surg 2002 Sep;22(3):357-62
Bullectomy
is comparable to lung volume reduction in patients with end-stage
emphysema.
De Giacomo T,
Rendina EA, Venuta F, Moretti M, Mercadante E, Mohsen I, Filice
MJ, Coloni GF.
Department of
Thoracic Surgery, University of Rome La Sapienza, Policlinico
Umberto I, V.le Policlinico, 00161 Rome, Italy. tdegiac@tin.it
OBJECTIVES: Emphysema
is one of the most prevalent disabling diseases, not modified
by current medical treatment and physical rehabilitation. Lung
transplantation is an effective clinical option in end-stage emphysema
but it is available only for a limited number of patients. Bullectomy
and lung volume reduction represent other surgical options to
improve symptoms and exercise tolerance in selected patients.
Both procedures allow the removal of the area of emphysematous
lung resulting in improvement in chest wall mechanics, ventilation/perfusion
ratio and re-expansion and better function of the residual lung.
There is some evidence that in patients with end-stage emphysema
bullectomy and lung volume reduction work in the same manner and
yield similar functional results. METHODS: We compared and analyzed
retrospectively two groups of patients with end-stage emphysema
who underwent bullectomy or lung volume reduction. Over the last
5 years 20 patients with end-stage emphysema presenting with bullae
underwent thoracoscopic bullectomy (Group I). During the same
period of time 18 patients with end-stage non-bullous emphysema
underwent thoracoscopic unilateral lung volume reduction. Pre-operative
baseline respiratory function data, peri-operative data, and functional
results recorded at 6 and 12 months were compared and analyzed.
RESULTS: Both groups were homogeneous in terms of age, degree
of respiratory derangement and severity of emphysema. Complication
rate and peri-operative data were similar in the two groups. Improvement
in symptoms, respiratory function and exercise tolerance was comparable.
CONCLUSIONS: Our experience supports the hypothesis that the physiopathological
basis of respiratory improvement after bullectomy and lung volume
reduction surgery in patients with end-stage emphysema is the
same, although the exact mechanism remains incompletely understood.
--
Chest 2002 Aug;122(2):590-6
Classification
of emphysema in candidates for lung volume reduction surgery:
a new objective and surgically oriented model for describing CT
severity and heterogeneity.
Cederlund K, Tylen
U, Jorfeldt L, Aspelin P.
Department of
Physiology and Thoracic Radiology, Karolinska Hospital, Stockholm,
Sweden. kerstin.cederlund@ks.SE
OBJECTIVE: To
elaborate a surgically oriented and objective model for classification
of emphysema heterogeneity. PATIENTS AND INTERVENTIONS: CT examinations
of 66 candidates for lung volume reduction surgery. DESIGN: Emphysema
severity was calculated by computer as the emphysema index (EI),
a commonly used computer-based quantification that accurately
assesses the extent of emphysema of a CT image. The distribution
of the EI in different parts of each lung was illustrated in a
diagram with the position in the lung (from cranial to caudal)
on the x-axis and the EI on the y-axis. The slope of the fitted
line was calculated. As a measure of the variation of the EI within
each lung, the EI difference was calculated. RESULTS: A diagram
was constructed with the absolute value of slope, k, on the x-axis
and EI difference on the y-axis. This resulted in a diagram differentiating
markedly heterogeneous, intermediately heterogeneous, and homogeneous
emphysema. Nineteen patients fulfilled the criteria of bilateral
markedly heterogeneous emphysema, 3 patients filled the criteria
of bilateral intermediately heterogeneous emphysema, and 18 patients
filled the criteria of bilateral homogeneous emphysema. Twenty-six
patients had different types of emphysema in the right and left
lung. CONCLUSION: We present a method for classification of emphysema
heterogeneity that is (1) objective, (2) surgically oriented,
and (3) classifies both lungs separately.
--
J Assoc Physicians
India 2002 Apr;50:579-82
Alpha-1 antitrypsin
deficiency in emphysema.
Khan H, Salman
KA, Ahmed S.
Department of
Biochemistry, JN Medical College, Aligarh Muslim University, India.
Human plasma contains
a number of proteinase inhibitors which together form 10% of the
total plasma proteins. Serine proteases are a group of closely
related proteolytic enzymes, with serine in their active site.
These play a key role in coagulation, fibrinolysin, kinin and
complement activation. Serine protease inhibitors or "serpins"
are specific inhibitors which control the activities of these
enzymes. Among the serine protease inhibitors. Alpha-1 antitrypsin
(alpha1 ATD) is found in highest concentration in plasma. It is
the major physiologic inhibitor for neutrophil elastase. It has
control over the elastase mediated degradation of elastic tissue
in the lung. Alpha1ATD deficiency is a common genetic disorder
and potentially lethal disease predominantly found in North European
population--where the incidence is one in 2500; worldwide figures
suggest that one in 6000 people have classic alpha1ATD. In cases
of deficiency, antielastase activity is reduced in the lungs which
results in increased elastin breakdown and development of emphysema.
Cigarette smoking contributes to destructive changes in emphysema
by suppressing the proteinase inhibitory activity of human serum
and by inducing certain bronchoalveolar changes. Prevalence and
severity of asthma increases in persons with abnormal alpha1ATD
phenotype.
--
J Cardiothorac
Vasc Anesth 2002 Aug;16(4):459-62
Differential
lung ventilation after single-lung transplantation for emphysema.
Mitchell JB, Shaw
AD, Donald S, Farrimond JG.
Department of
Anaesthesia, Harefield Hospital, Harefield, Middlesex, United
Kingdom.
OBJECTIVE: To
review outcome and cardiovascular and respiratory function after
initiation of differential lung ventilation for acute severe native
lung hyperinflation in patients who have had a single-lung transplant
for end-stage emphysema. DESIGN: Retrospective review. SETTING:
Cardiothoracic tertiary referral center. PARTICIPANTS: Thirteen
patients who had differential lung ventilation for acute severe
native lung hyperinflation, of a total of 132 patients who had
a single-lung transplant for end-stage emphysema between 1988
and the end of 2000. INTERVENTIONS: None. measurements and main
results: Thirteen patients had differential lung ventilation for
acute severe native lung hyperinflation; 7 survived to 1 year
after transplant. There was a highly significant (p = 0.0006)
improvement in mean PaO(2) from 8.23 (95% confidence interval
[CI], 6.15 to 10.3) to 16.6 (95% CI, 12.84 to 20.45) 1 hour after
start of differential lung ventilation. The average ratio of estimated
dynamic compliance in the native lung compared with the transplanted
(donor) lung was 2.69 (95% CI, 1.75 to 3.62). CONCLUSION: In addition
to previous case reports, this series shows that differential
lung ventilation is an appropriate treatment for acute severe
native lung hyperinflation. A difference in estimated effective
dynamic compliance of > or = 2.69 between native and transplanted
lung may require differential lung ventilation. Copyright 2002,
Elsevier Science (USA). All rights reserved.
--
Medicina (B Aires)
2002;62(2):115-23
[Lung volume
reduction surgery for emphysema. Long term results]
[Article in Spanish]
Lopez AM, Casas
JP, Abbona H, Robles AM, Navarro R.
Servicio de Neumonologia,
Hospital Privado Cordoba, Calle Naciones Unidas 346, 5016 Cordoba,
Argentina. alopez@hospitalprivadosa.com.ar
We prospectively
analyzed 19 patients submitted to lung volume reduction surgery
(LVRS). Mean age 54 years. Fourteen patients, with predominant
emphysema of upper lobes, were approached through a median sternotomy.
Five patients with predominant lower lobes lesions, were approached
through a bilateral anterolateral thoracotomy. Surgery consisted
in resection of 20 to 30% of lung volume corresponding to areas
of severe parenchymal destruction by stapling suture additioned
with bovine pericardium. Changes in lung function and physical
performance were evaluated by FEV1, FVC and RV, 6 minutes walk
test and dyspnea index according to Medical Research Council at
3, 12, 24, 36 and 48 months. Variance analysis with correction
of Bonferroni was performed. One patient died of acute myocardial
infarction. There was a significant average improvement in all
parameters measured at 3, 12, 24 and 36 months with regard to
preoperative values. Comparing the preoperative and 3 months values,
there was an increment in FEV1 from 0.94 +/- 0.37 (31% of predicted)
to 1.35 +/- 0.40 L (45%) (p < 0.05), in FVC from 2.24 +/- 0.69
(54%) to 3.05 +/- 0.80 L (75%) (p < 0.05) and in 6 minutes
walk test from 395 +/- 66 to 517 +/- 50 mts (p < 0.001). There
was also a decrease in the RV of 4.78 +/- 1.14 L (284%) to 3 +/-
0.68 L (180%) (p < 0.001) and in dyspnea index of 3.34 +/-
0.82 to 0.53 +/- 0.53 (p < 0.001). The percentage of average
increment in FEV1 was 53% at 3 months (n = 18), 72% at 12 months
(n = 13), 58% at 24 months (n = 10), 53% at 36 months (n = 6)
and 60% at 48 months (n = 3). LVRS can be performed with acceptable
morbidity and mortality in highly selected emphysematous patients.
Decrease of dyspnea and improvement in physical performance reach
a maximum between 3 and 12 months and may remain so after four
years.
--
Ann Thorac Surg
2002 May;73(5):1587-93
Outcomes of
lung volume reduction surgery followed by lung transplantation:
a matched cohort study.
Burns KE, Keenan
RJ, Grgurich WF, Manzetti JD, Zenati MA.
Division of Pulmonary
Transplantation, The University of Pittsburgh Medical Center,
Pennsylvania, USA.
BACKGROUND: Lung
volume reduction surgery (LVRS) has been demonstrated to provide
symptomatic relief and to improve lung function in patients with
end-stage emphysema. The goal of this study was to assess the
additional morbidity associated with lung transplantation after
LVRS for end-stage emphysema with regard to immediate postoperative
outcomes, longitudinal spirometry, and survival rates compared
to an age-, gender-, procedure-matched, and transplant time-matched
cohort that had lung transplantation alone. METHODS: We compared
the postoperative and long-term outcomes of a sequential procedure
cohort to a matched cohort to assess the possible added post-transplant
morbidity. RESULTS: Fifteen patients who underwent sequential
LVRS (including 11 unilateral LVRS, 4 bilateral LVRS) and lung
transplantation (ipsilateral in 7 and contralateral in 8) on average
28.1 +/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7
months) later were assessed. No significant differences were noted
in pretransplant demographics, post-transplant variables, longitudinal
spirometric indices, or survival. A trend toward a lower pretransplant
arterial carbon dioxide tension was apparent in the sequential
procedure cohort. Group analysis revealed a significant increase
in the number of patients requiring transfusion and in the total
number of units transfused in patients undergoing ispsilateral
transplantation after LVRS; a significant increase in the length
of intensive care unit stay; and a trend toward an increase in
the duration of hospital stay in patients undergoing lung transplantation
within 18 months of LVRS. CONCLUSIONS: In appropriate candidates,
LVRS bridged the time to transplantation by an average of 28.1
+/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7 months)
without significantly increasing post-transplant morbidity or
mortality. Furthermore, bilateral LVRS bridged the time to transplantation
to a greater extent than unilateral LVRS (34.9 +/- 29.8 months;
median, 32.1 months versus 25.4 +/- 16.3 months; median, 22.3
months; p = 0.23).
--
J Thorac Cardiovasc
Surg 2002 May;123(5):845-54
Gain and subsequent
loss of lung function after lung volume reduction surgery in cases
of severe emphysema with different morphologic patterns.
Bloch KE, Georgescu
CL, Russi EW, Weder W.
Pulmonary and
Thoracic Surgery Division, University Hospital of Zurich, Switzerland.
OBJECTIVE: Surgical
lung volume reduction improves lung function and dyspnea in advanced
emphysema to a variable degree. Because long-term results with
this procedure are scant, we prospectively investigated lung function
over several years after lung volume reduction surgery with regard
to emphysema morphology. METHODS: Bilateral video-assisted thoracoscopic
lung volume reduction surgery was performed in severely symptomatic
patients with marked hyperinflation caused by advanced nonbullous
emphysema. Emphysema heterogeneity was visually graded on chest
computed tomography. Symptoms and lung function were assessed
before the operation and 3, 6, and then every 6 months after the
operation. RESULTS: A total of 115 patients with a median forced
expiratory volume in 1 second of 0.73 L (27% of predicted value)
underwent lung volume reduction surgery. Follow-up extended over
a median of 37 months. Median forced expiratory volume in 1 second
significantly increased within 6 months after the operation by
37% in homogeneous (n = 27), by 38% in intermediately heterogeneous
(n = 37), and by 63% in markedly heterogeneous emphysema (n =
51, P <.05 vs. other morphologies). Maximal forced expiratory
volume in 1 second was reached within 6 months after lung volume
reduction surgery and decreased in the first postoperative year
by 0.16 L per year in homogeneous, by 0.19 L per year in intermediately
heterogenous, and by 0.32 L per year in markedly heterogeneous
emphysema (P <.01 vs. other morphologies). The decline in forced
expiratory volume in 1 second over subsequent years decelerated
according to an exponential decay and was similar for all morphologic
types (median annual decrease of 0.09 L [9%]). CONCLUSIONS: Lung
volume reduction surgery improves lung function in severe homogeneous
and, to an even greater extent, heterogeneous emphysema. Forced
expiratory volume in 1 second peaks within 6 months postoperatively.
The subsequent decline is most rapid in the first year and slows
down in succeeding years according to an exponential decay. Therefore,
long-term functional results of lung volume reduction surgery
may be more favorable than expected from linear extrapolations
of short-term observations.
--
J Pediatr Surg
2002 May;37(5):799-801
Congenital
lobar emphysema: Like father, like son.
Roberts PA, Holland
AJ, Halliday RJ, Arbuckle SM, Cass DT.
Sydney, New South
Wales, Australia.
Congenital lobar
emphysema (CLE) is an uncommon cause of progressive respiratory
distress that typically presents in the first few days of life.
There has been a previous report of CLE in a mother and daughter.
The authors describe 2 cases involving the right upper and middle
lobes in a father and son secondary to relative deficiency of
the bronchial cartilage. This provides additional evidence for
inherited factors in the etiology of CLE. Copyright 2002, Elsevier
Science (USA). All rights reserved.
--
Acta Radiol 2002
Jan;43(1):48-53
Visual grading
of emphysema severity in candidates for lung volume reduction
surgery. Comparison between HRCT, spiral CT and "density-masked"
images.
Cederlund K, Bergstrand
L, Hogberg S, Rasmussen E, Svane B, Aspelin P.
Department of
Thoracic Radiology, Karolinska Hospital, SE-171 76 Stockholm,
Sweden.
PURPOSE: To investigate
which of three types of CT imaging yielded the best results in
estimating the degree of emphysema in patients undergoing evaluation
for lung volume reduction surgery (LVRS), whether there was any
difference in this regard between the cranial and caudal part
of the lung, and whether the degree of emphysema had an impact
on the estimation. MATERIAL AND METHODS: Four radiologists visually
classified different degrees of emphysema on three different types
of CT images into four groups. The degree of emphysema was calculated
by a computer. The three types of images were as follows: HRCT
images (2-mm slice thickness); spiral CT images (10-mm slice thickness);
and density-masked images (spiral CT images printed with pixels
below -960 HU, depicted in white). RESULTS: The conventionally
presented images from HRCT and spiral CT yielded the same results
(60% respective 62% correct classifications) in assessing the
degree of emphysema irrespective of localisation. Significantly
improved results were obtained when the spiral CT images were
presented as density-masked images (74%). CONCLUSION: There was
no difference between HRCT and spiral CT in assessing the degree
of emphysema in candidates for LVRS. Improvement can be achieved
by the use of density-masked images.
--
Ann Acad Med Singapore
2002 Mar;31(2):223-7
Anaesthetic
considerations for lung volume reduction surgery--a case report.
Chow MY, Tan LH,
Agasthian T.
Department of
Anaesthesia and Surgical Intensive Care, Singapore General Hospital,
Outram Road, Singapore 169608.
INTRODUCTION:
This case describes some of the unique problems faced by the thoracic
anaesthesiologists during anaesthesia for lung volume reduction
surgery. CLINICAL PICTURE: The usual pulmonary function requirements
for lobectomy are normally not met in these patients with severe
emphysema. TREATMENT: Maintenance of the functional residual capacity
of the lung and normocapnia during anaesthesia are not as important.
Instead problems due to barotrauma and dynamic hyperinflation
from positive pressure ventilation are. OUTCOME: Modification
of ventilation strategy and providing an anaesthetic tailored
towards early extubation is the cornerstone of the anaesthetic
plan. CONCLUSION: A good understanding of the respiratory physiology
in patients with severe emphysema is essential.
--
Zhonghua Wai Ke
Za Zhi 2002 Mar;40(3):194-7
[Late-stage
emphysema treated with lung volume reduction: report of 22 cases]
[Article in Chinese]
Zhao F, Liu D,
Shi B, Tian Y, Wang Z, Bao T, Li F, Guo Y, Zhang H, Chen J, Ge
B.
Department of
Thoracic Surgery, China-Japan Friendship Hospital, Beijing 100029,
China.
OBJECTIVE: To
Summarize the clinical experience in the treatment of late-stage
emphysema by lung volume reduction (LVR) in 5 years. METHODS:
We retrospectively studied the indications, contraindications,
operation procedures and complications of LVR in 22 patients.
RESULTS: Before operation, the average FEV(1) was 24.5%, RV 196.8%,
and TLC 130.5%; after operation they were 27.8%, 148.8% and 112.5%,
respectively. 16 patients needed inhaling oxygen before operation,
and 5 after operation. 16 patients finished 6-minute walking test
with an average of 198 m, all patients walked much longer with
an average of 256 m after operation. 3-degree lung function was
observed in 14 patients, and 4-degree before operation in 8 patients;
but 2-degree lung function in 5 patients, 3-degree in 13, and
4-degree in 4 after operation. CONCLUSIONS: Heterogeneous type
emphysema with clear target area, especially bullous emphysema
is the best indication for LVR. Lung function and life quality
could be much improved postoperatively. Homogeneous type could
also be treated with LVR in highly selected cases. TLCO < 20%
is not an absolute contraindication, others standards need further
investigation. Video-assistant thoracoscopic surgery (VATS) with
subaxillary small incision for LVR is safe, reliable and effective.
Application of stapler buttressing with bovine pericardia could
decrease air leakage postoperatively.
--
Eur J Cardiothorac
Surg 2002 Mar;21(3):483-8
Long-term results
of lung volume reduction surgery.
Fujimoto T, Teschler
H, Hillejan L, Zaboura G, Stamatis G.
Department of
Thoracic Surgery and Endoscopy, Ruhrlandklinik, Essen, Germany.
OBJECTIVE: Lung
volume reduction surgery (LVRS) is effective in the short and
intermediate term for the improvement of pulmonary function and
subjective symptoms in selected patients with advanced emphysema.
The purpose of this study was to examine the long-term functional
results of LVRS and to investigate which subgroups would benefit
in terms of long-term survival. METHODS: All records of the patients
who underwent LVRS between 1994 and, 1998 at our hospital were
reviewed. RESULTS: Eighty-eight consecutive patients underwent
LVRS during the period. There were 62 men and 26 women with an
average age of 56.1 years (range 34-72 years). Eleven patients
with alpha1-antitrypsin deficiency were included. The perioperative
mortality rate (<90 days) was 2.3% (n=2). Total lung capacity
(7.5+/-0.3 l) and residual volume (4.8+/-0.3 l) at 3 years remained
lower than baseline (9.2+/-0.2 l, 6.5+/-0.2 l, each) (P<0.001).
The mean forced expiratory volume in 1 s (FEV(1)) at 3 years (0.86+/-0.08
l) was higher than baseline (0.78+/-0.02 l), but the difference
did not reach statistical significance. The FEV(1) of the patients
with alpha1-antitrypsin deficiency and of those with respiratory
bronchiolitis returned to baseline at one year after LVRS and
showed further deterioration. Overall survival rate at 5 years
was 71.0% with the mean length of follow-up of 54.2 months. The
survival difference was statistically significant between patients
with preoperative FEV(1) >or=28.5% and those with FEV(1)<28.5%
(P=0.0152). CONCLUSIONS: The improvement of total lung capacity
and residual volume persisted long after the operation. Patients
with alpha1-antitrypsin deficiency and those with bronchiolitis
showed early deterioration of the lung function. Patients with
higher preoperative FEV(1) had a survival benefit. The favorable
long-term survival might justify LVRS for the treatment of selected
patients with severe emphysema.
--
Am J Respir Crit
Care Med 2002 Feb 15;165(4):489-94
Effect of lung
volume reduction surgery for severe emphysema on right ventricular
function.
Mineo TC, Pompeo
E, Rogliani P, Dauri M, Turani F, Bollero P, Magliocchetti N.
Division of Thoracic
Surgery, University Tor Vergata, Rome, Italy. mineo@med.uniroma2.it
Lung volume reduction
surgery (LVRS) can improve the functional capacity of selected
patients with severe emphysema. Hypothesized physiologic effects
of LVRS include an improvement in right ventricular function,
although this has not been investigated in detail. To help clarify
this issue, we used fast-thermistor thermodilution at rest and
during submaximal upright exercise in 12 patients, before and
6 mo after bilateral LVRS. Preoperatively, all patients had severe
airflow obstruction, with a mean FEV(1) of 0.69 L and an RV-to-TLC
ratio of 0.67. Six months after LVRS, significant improvements
occurred in respiratory function measures (+0.39 L in FEV(1),
p < 0.002; and +/- 0.15 in RV/TLC ratio, p < 0.002) and
in right ventricular function indexes measured at rest (+0.21
L in cardiac index [CI], p < 0.01; and +3.0 ml in stroke volume,
p < 0.01) and during exercise (+0.9 L in CI, p < 0.002;
+10.0 ml in stroke volume index, p < 0.002; and +20% in ejection
fraction [EF], p < 0.002). A significant correlation was found
between pre- to postoperative changes in the EF response to exercise
and changes in the RV/TLC ratio (R = -0.68; p = 0.01). We conclude
that a significant improvement in right ventricular performance,
particularly during exercise, can occur 6 mo after bilateral LVRS.
--
Curr Opin Pulm
Med 2002 Mar;8(2):126-36
Recent advances
in diagnosis and management of chronic bronchitis and emphysema.
Chitkara RK, Sarinas
PS.
Division of Pulmonary,
Critical Care, and Sleep Medicine, Veterans Administration Palo
Alto Health Care System, and Stanford University School of Medicine,
Palo Alto, California 94304, USA. rkc@stanford.edu
Chronic obstructive
pulmonary disease is a progressive inflammatory disease of the
airways and lung parenchyma. Expiratory airflow limitation is
the hallmark of chronic obstructive pulmonary disease. It is a
significant cause of morbidity and mortality in the United States
and worldwide and results in a large consumption of health care
resources. Unfortunately, despite efforts to curb this disease,
its prevalence is increasing. The diagnosis is usually made when
the patient complains of dyspnea on exertion; by this time, irreversible
structural damage to the lung has already occurred. Given the
nonspecific symptoms of the disease and the inability to effectively
treat and reverse the damage, it is essential to diagnose the
disease in its early stages and take the necessary preventive
measures, thus avoiding disability or death. This review summarizes
the latest developments in the diagnosis and management of chronic
obstructive pulmonary disease. The first half of the review discusses
functional, radiographic, biochemical, and cellular/histopathologic
issues in the diagnosis of chronic obstructive pulmonary disease.
The second half focuses on the current pharmacologic and nonpharmacologic
advances in chronic obstructive pulmonary disease, including the
role of respiratory support and surgical treatment. Based on the
research on the cellular mechanisms of chronic obstructive pulmonary
disease, the review also makes a reference to novel and experimental
therapies for chronic obstructive pulmonary disease.
--
Eur Respir J 2002
Jan;19(1):54-60
Improved quality
of life after lung volume reduction surgery.
Hamacher J, Buchi
S, Georgescu CL, Stammberger U, Thurnheer R, Bloch KE, Weder W,
Russi EW.
Dept of Internal
Medicine, University Hospital, Zurich, Switzerland.
Lung volume reduction
surgery (LVRS) improves dyspnoea, pulmonary function, and physical
performance in patients with severe pulmonary emphysema. This
study investigated the impact of LVRS on health-related quality
of life (HRQL) over a 2-yr period following surgery. Thirty-nine
consecutive patients were prospectively assessed before LVRS,
and followed over 24 months postoperatively. The assessments included
pulmonary function, dyspnoea (Medical Research Council (MRC) dyspnoea
score), 6-min walking distance (6MWD) and HRQL using the Short
Form 36-item questionnaire (SF-36). Several domains of SF-36 improved
considerably over 2 yrs after surgery: Physical Functioning: 39
+/- 4 (mean +/- SEM) versus 16 +/- 2 (p<0.01); Vitality: 51
+/- 3 versus 32 +/- 3 (p<0.01); Social Functioning: 72 +/-
4 versus 51 +/- 5 (p<0.01). Also, improvements in pulmonary
function (forced expiratory volume in one second (FEV1): 27 +/-
1% predicted, residual volume (RV)/total lung capacity (TLC):
0.65 +/- 0.01), 6 MWD (274 +/- 16 m) and dyspnoea (MRC: 3.9 +/-
01) were sustained for up to 2 yrs after LVRS (FEV1 36 +/- 2%
pred, RV/TLC: 0.58 +/- 0.02; 6 MWD: 342 +/- 19 m; MRC: 2.0 +/-
0.2; p<0.05). In patients with severe emphysema, lung volume
reduction surgery had positive effects on health-related quality
of life and pulmonary function over 2 yrs.
--
Psychol Rep 2001
Dec;89(3):707-17
Quality of
life before and after lung transplantation in patients with emphysema
versus other indications.
TenVergert EM,
Vermeulen KM, Geertsma A, van Enckevort PJ, de Boer WJ, van der
Bij W, Koeter GH.
University Hospital
Groningen, Office for Medical Technology Assessment, The Netherlands.
e.m.tenvergert@mta.azg.nl
Whether lung transplantation
improves Health-related Quality of Life in patients with emphysema
and other end-stage lung diseases before and after lung transplantation
was examined. Between 1992 and 1999, 23 patients with emphysema
and 19 patients with other indications completed self-administered
questionnaires before lung transplantation, and at 4, 7, 13, and
25 mo. after transplantation. The questionnaire included the Nottingham
Health Profile, the State-Trait Anxiety Inventory, the Self-rating
Depression Scale, the Index of Well-being, the self-report Karnofsky
Index, and four respiratory-specific questions. Neither before
nor after transplantation were significant differences found on
most dimensions of Health-related Quality of Life between patients
with emphysema and other indications. Before transplantation,
both groups report major restrictions on the dimensions Energy
and Mobility of the Nottingham Health Profile, low experienced
well-being, depressive symptoms, and high dyspnea. About 4 mo.
after transplantation, most Health-related Quality of Life measures
improved significantly in both groups. These improvements were
maintained in the following 21 mo.
--
N Engl J Med 2001
Oct 11;345(15):1075-83
Patients at
high risk of death after lung-volume-reduction surgery.
National Emphysema
Treatment Trial Research Group.
BACKGROUND: Lung-volume-reduction
surgery is a proposed treatment for emphysema, but optimal selection
criteria have not been defined. The National Emphysema Treatment
Trial is a randomized, multicenter clinical trial comparing lung-volume-reduction
surgery with medical treatment. METHODS: After evaluation and
pulmonary rehabilitation, we randomly assigned patients to undergo
lung-volume-reduction surgery or receive medical treatment. Outcomes
were monitored by an independent data and safety monitoring board.
RESULTS: A total of 1033 patients had been randomized by June
2001. For 69 patients who had a forced expiratory volume in one
second (FEV1) that was no more than 20 percent of their predicted
value and either a homogeneous distribution of emphysema on computed
tomography or a carbon monoxide diffusing capacity that was no
more than 20 percent of their predicted value, the 30-day mortality
rate after surgery was 16 percent (95 percent confidence interval,
8.2 to 26.7 percent), as compared with a rate of 0 percent among
70 medically treated patients (P<0.001). Among these high-risk
patients, the overall mortality rate was higher in surgical patients
than medical patients (0.43 deaths per person-year vs. 0.11 deaths
per person-year; relative risk, 3.9; 95 percent confidence interval,
1.9 to 9.0). As compared with medically treated patients, survivors
of surgery had small improvements at six months in the maximal
workload (P= 0.06), the distance walked in six minutes (P=0.03),
and FEV1 (P<0.001), but a similar health-related quality of
life. The results of the analysis of functional outcomes for all
patients, which accounted for deaths and missing data, did not
favor either treatment. CONCLUSIONS: Caution is warranted in the
use of lung-volume-reduction surgery in patients with emphysema
who have a low FEV1 and either homogeneous emphysema or a very
low carbon monoxide diffusing capacity. These patients are at
high risk for death after surgery and also are unlikely to benefit
from the surgery.
--
Surg Oncol 2002
Dec;11(4):201-6
Treatment of
patients with lung cancer and severe emphysema: lessons from lung
volume reduction surgery.
Waddell TK.
Division of Thoracic
Surgery, University of Toronto, Toronto General Hospital, 200
Elizabeth Street, Room EN 10-233, Ont., M5G 2C4, Toronto, Canada
Lung volume reduction
surgery (LVRS) is effective therapy for selected patients with
end-stage emphysema. Surgery produces improved pulmonary function,
increased exercise tolerance and enhanced quality of life. It
has been shown to be superior to medical management over the short-term
in randomized controlled trials. The experience gained by dealing
with this select group of patients has had a substantial impact
on management of lung cancer in some patients with advanced lung
disease. Numerous surgical, anaesthetic, and nursing advances
gained in dealing with lung volume reduction surgery (LVRS) procedures
now allow surgery to be considered as the optimal cancer management
technique. For some carefully selected candidates, cancer resection
and LVRS can be performed simultaneously, with dual benefits.
The physiologic principles underlying LVRS and selection guidelines
will be reviewed. The impact on cancer management and the current
strategy at Toronto General Hospital will also be presented.
--
Arzneimittelforschung
2002;52(10):764-8
Study on the
usefulness of seratrodast in the treatment of chronic pulmonary
emphysema.
Horiguchi T, Tachikawa
S, Kondo R, Shiga M, Hirose M, Fukumoto K.
Department of
Internal Medicine, Fujita Health University Second Hospital, Nagoya,
Aichi, Japan. holiguchitakahiko@hotmail.com
It has been reported
that the biosynthesis of thromboxane A2 (TXA2) is enhanced in
platelets in the presence of chronic obstructive pulmonary disease
(COPD), and 11-dehydro-TXB2, a urinary metabolite of thromboxane,
also increases in blood. In the present study, seratrodast (CAS
112665-43-7, Bronica), a TXA2 receptor antagonist, was administered
to 14 patients with chronic pulmonary emphysema in the stable
phase for 8 weeks. Respiratory distress was evaluated in the attending
physicians' judgments using the Hugh-Jones (H-J) classification,
and also by the patients themselves using the Borg scale. Respiratory
function tests, including forced vital capacity (FVC), percent
of one second forced expiratory volume (FEV1.0%), arterial blood
gases during respiration of room air, and peak expiratory flows
(PEF) (morning and evening), and measurement of plasma 11-denhydro-TXB2
and TXB2 levels were performed before and 8 weeks after the start
of administration, as well as at the time of the start of administration.
The results revealed significant improvement of respiratory distress,
evaluated on both the H-J classification and the Borg scale, at
week 8. Although no significant changes were observed in plasma
TXB2 levels, the plasma 11-dehydro-TXB2 level significantly decreased
at week 8. Among the respiratory function parameters examined,
only FVC was significantly improved. These results indicated that
seratrodast is useful for the improvement of respiratory distress
in patients with chronic pulmonary emphysema in the stable phase.
--
Radiol Med (Torino)
2002 Jul-Aug;104(1-2):13-24
[Spiral CT
evaluation of pulmonary emphysema using a low-dose technique]
[Article in Italian]
Zompatori M, Fasano
L, Mazzoli M, Sciascia N, Cavina M, Pacilli AM, Paioli D.
Radiologia Zompatori,
Policlinico S. Orsola-Malpighi, Bologna, Italy.
PURPOSE: To evaluate
the diagnostic accuracy and clinical acceptability of low-dose
spiral CT for determining pulmonary volumes and emphysema extension
in patients with pulmonary emphysema, in comparison with studies
based on spiral CT at conventional dose. MATERIALS AND METHODS:
We prospectively evaluated eighteen patients, current or former
smokers, with a clinical diagnosis of chronic obstructive pulmonary
disease. All the patients underwent: HRCT with three scans at
predetermined levels; quantitative spiral CT, with two inspiratory
scans, one conventional scan at 240 mA, and the second one a low-dose
scan at 80 mA. We used the following parameters: 120 kV, rotation
time 0.8", scan time less than 20" (single inspiratory
breath-hold), layer thickness 7.5 mm, pitch 6 (high speed), interpolation
algorithm at 180 degrees. A 3D reconstruction was performed, with
segmentation of the lungs and automatic quantification of pulmonary
volumes. We compared the volumes of absolute and percent emphysema
and the ratings of the dose delivered to the patient (CTDIw and
DLP) obtained with the two spiral CT scans with each other and
with the respiratory function tests. RESULTS: The average total
lung capacity (TLC) obtained by conventional-dose spiral CT (CTs1)
was 6889.4 cc (SD +/-1813.2), and the capacity with low-dose spiral
CT (CTs2) was 6929.4 cc (SD +/-1811.6). The percentage of emphysema
was 39.7% (range: 2.2-63.5%; SD: +/-19.9) for the CTs1 and 41.1%
(range: 2.1-66.4%; SD: +/-20). The CTDIw corresponding to CTs1
was 12.2 mGy (range: 11.9-16.4; SD: +/-1), the one corresponding
to CTs2, 3.6 mGy (range: 3.6-4.9; SD: +/-0.3). The DLP corresponding
to CTs1 was 391.7 mGy x cm (range: 333.3-518.9; SD: +/-46.7),
the one corresponding to CTs2 was 117.8 mGy x cm (range: 100.3-156;
SD: +/-14). As for the respiratory function tests, the total lung
capacity (TLC) obtained by body plethysmography was 7061 cc (SD:
+/-2029.7); the percent TLC was 115.9 (range: 66-165; SD: +/-27.6),
the forced expiratory volume at one second (FEV1%, percentage
of predicted value) was 46.7% (range: 17-123; SD: +/-27.3), residual
volume (RV%) as a percentage of predicted value was 186.3 (range:
84-359; SD: +/-80.7), the Tiffeneau index (TI) was 46% (range:
25-71; SD: +/-15.7). We observed a very significant correlation
between radiological and functional TLC for both CT methods. The
percentage scores for emphysema obtained with the two methods
correlated significantly with the functional indexes. The pixel
index of CTs1 correlated with TLC% (r=0.87; p<0.0001), FEV1%
(r=-0.53; p<0.02), RV% (r=0.76; p=0.004), TI (r=-0.79; p=0.0001).
The pixel index of CTs2 correlated with TLC% (r=0.87; p<0.0001),
FEV1% (r=-0.56; p=0.01), RV% (r=0.78; p=0.003), TI (r=-0.8; p=0.0001).
The adoption of the method with low tube current entailed a highly
significant reduction in the estimated dose delivered to patients
(CTDIw and DLP) with r=0.9 and p < 0.0001. DISCUSSION AND CONCLUSIONS:
Quantitative low-dose spiral CT is a very good method to quantify
pulmonary volumes and calculate the extension of the anatomic
emphysema. The reduction of mA from 240 to 80 lowers the estimated
dose by 30%, without compromising the accuracy of the results.
Our study achieved a highly significant correlation between the
results obtained with the two spiral CT techniques and between
these results and the respiratory function tests. In clinical
practice, the easiest way to reduce the dose in spiral CT of the
lung is to reduce the tube current. The low-dose method allows
a significant reduction in radiation exposure. Further studies
are required to establish to what extent the dose can be reduced
without increasing in quantum noise and thereby compromising the
quality of the study.
--
Chest 2002 Oct;122(4):1256-63
The relation
of body mass index to asthma, chronic bronchitis, and emphysema.
Guerra S, Sherrill
DL, Bobadilla A, Martinez FD, Barbee RA.
Arizona Respiratory
Center, College of Medicine, University of Arizona, 1501 N. Campbell
Avenue, Tucson, AZ 85724-5030, USA.
BACKGROUND: Recent
studies have suggested a relationship between asthma and obesity.
Despite these reports, the effect of being underweight or overweight
as a risk factor for airway obstructive diseases (AODs) is not
clear. OBJECTIVES: To determine whether a relation of body mass
index (BMI) to asthma, chronic bronchitis (CB), or emphysema exists
(analysis 1), and, if so, whether the association between obesity
and asthma is modified by gender (analysis 2). DESIGN: Nested
case-control study from the longitudinal cohort of the Tucson
Epidemiologic Study of Airways Obstructive Diseases. PATIENTS:
Analysis 1: physician-confirmed incident cases of asthma (n =
102), CB (n = 299), or emphysema (n = 72) who denied any prior
AODs. Analysis 2: all 169 incident cases of asthma, regardless
of any previous AODs, stratified by gender and by other potential
effect modifiers. In both analyses, we selected only subjects
at least 20 years old who had weight and height measured during
the study. MEASUREMENTS: BMI and other risk factors were assessed
prior to the onset of the AOD (cases) or prior to the last completed
survey (control subjects). RESULTS: A diagnosis of emphysema was
significantly associated with a BMI < 18.5 (odds ratio [OR],
2.97; 95% confidence interval [CI], 1.33 to 6.68, when compared
to healthy control subjects). A BMI >/= 28 increased the risk
of receiving a diagnosis of asthma (OR, 2.10; 95% CI, 1.31 to
3.36) and CB (OR, 1.80; 95% CI, 1.32 to 2.46). About 30% of the
patients with asthma and 25% of the patients with CB (vs 16% of
the control subjects, p < 0.001) were preobese or obese, regardless
whether BMI was assessed before the diagnosis or before the onset
of respiratory symptoms. The relation of elevated BMI to asthma
was significant only among women. CONCLUSIONS: Patients with emphysema
are more likely to be underweight, and patients with CB are more
likely to be obese. However, the temporal relationship between
abnormal BMI and the onset of COPD is uncertain. Preobese and
obese women are at increased risk of acquiring asthma. This relation,
particularly if it is causal, has potentially relevant public
health implications.
--
Minerva Chir 2002
Oct;57(5):625-33
Reduction pneumoplasty
for severe emphysema. Does the debate await a neat sentence?
Mineo TC, Pompeo
E.
Division of Thoracic
Surgery, Policlinico Tor Vergata, Tor Vergata University, Rome,
Italy. mineo@med.uniroma2.it
The aim of this
study is to review the literature regarding reduction pneumoplasty
(RP) or lung volume reduction surgery in order to assess the state
of the art of this topic. Reduction pneumoplasty is a palliative
surgical therapy that is offered to selected patients with severe
non-bullous emphysema not responding to maximized medical therapy.
The use of staple excision or plication of the most destroyed
target areas of the lung appeared to be more effective than laser
ablation. Currently, a one-stage bilateral procedure is the standard
of care although a unilateral reduction can be preferable in patients
with asymmetric emphysema and/or if a staged bilateral treatment
strategy is planned. Randomized studies have suggested that RP
is superior to medical therapy including respiratory rehabilitation
for improving subjective dyspnea, exercise capacity, respiratory
function and quality of life for up to 1 year. In addition, few
long-term studies have suggested that the improvements obtained
with RP can be maintained for several years in properly selected
patients. Although several issues still await a definitive answer,
the available literature data and our current experience have
clearly indicated that RP works well and is a safe and effective
procedure for palliating symptoms and improving respiratory function
in severely disabled emphysematous patients.
--
Tohoku J Exp Med
2002 Jun;197(2):67-80
Pathogenesis
and management of virus infection-induced exacerbation of senile
bronchial asthma and
chronic pulmonary emphysema.
Yamaya M.
Department of
Geriatric and Respiratory Medicine, Tohoku University School of
Medicne, Sendai, Japan. dept@geriat.med.tohoku.ac.jp
The number of
senile patients with therapy resistant bronchial asthma, chronic
pulmonary emphysema increases due to the habit of smoking and
increased number of older people, and these inflammatory pulmonary
diseases are the leading causes of death worldwide. Rhinoviruses
cause the majority of common colds, and provoke exacerbations
of bronchial asthma and chronic pulmonary emphysema. Here, I review
the pathogenesis and management of rhinovirus infection-induced
exacerbation of senile bronchial asthma and chronic pulmonary
emphysema.
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