RESUMEN
BACKGROUND: We showed excellent adherence and satisfaction with our telehealth care (TC) approach for COPD. Here, the results of a consecutive randomized controlled trial are presented. METHODS: Patients were randomly assigned to TC or standard care (SC). During TC, patients answered six daily questions online, and focused on the early recognition of exacerbations, in addition to SC. RESULTS: The mean increase in COPD assessment test (CAT) was 1.8 vs. 3.6 points/year in the TC and SC groups, respectively (P = 0.0015). Satisfaction with care (VAS) at baseline was 8.2; at the end of SC, 8.5 (P = 0.062); and after TC, 8.8 (P < 0.001). We detected significantly more moderate exacerbations during TC. CONCLUSION: Whilst receiving TC, the slope of the CAT increase - an indicator of the naturally progressive course of COPD - was reduced by 50%. Satisfaction with care increased with TC. The higher number of detected moderate exacerbations probably indicates a higher diagnostic sensitivity than without TC.
Asunto(s)
Enfermedad Pulmonar Obstructiva Crónica/terapia , Telemedicina , Adulto , Anciano , Estudios Cruzados , Progresión de la Enfermedad , Femenino , Alemania , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Nivel de Atención , Encuestas y Cuestionarios , Suiza , Brote de los SíntomasRESUMEN
PURPOSE: Acute exacerbations (AE) in patients with COPD are associated with a decline in lung function, increased risk of hospitalization, and mortality. In this cross-sectional study we tested whether the level of objectively measured daily physical activity and exercise capacity are associated with the number of COPD exacerbations. METHODS: In 210 patients with COPD (67 % men; mean (SD) age: 63 (8) years) enrolled in The Obstructive Pulmonary Disease Outcomes Cohort of Switzerland (TOPDOCS) physical activity (PA) (steps per day, physical activity level, (PAL)), exercise capacity (6-min walking distance, (6MWD)), comorbidities, lung function, and medication were assessed. Differences between COPD patients with frequent (≥2 year) and infrequent (0-1 year) exacerbations were assessed. Univariate and multivariate analyses were performed to investigate whether the level of objectively measured daily physical activity and exercise capacity are associated with the number of COPD exacerbations. RESULTS: Patients with frequent AE had a significantly lower FEV1 and 6MWD compared to patients with infrequent AE. In univariate analysis, the number of exacerbations was inversely associated with FEV1, 6MWD, BMI, and smoking status while there was a positive association with RV/TLC and combined inhaled medication. However, there was no significant association with PAL and steps per day. In multivariate analysis, FEV1 and the use of combined inhaled medication were independently associated with the number of AE, after correction for covariates. CONCLUSIONS: The findings of this study imply that FEV1, independent of inhaled medication, is significantly associated with COPD exacerbations. Neither physical activity nor exercise capacity was independently associated with COPD exacerbations.
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Tolerancia al Ejercicio , Pulmón/fisiopatología , Actividad Motora , Enfermedad Pulmonar Obstructiva Crónica/fisiopatología , Anciano , Distribución de Chi-Cuadrado , Comorbilidad , Estudios Transversales , Progresión de la Enfermedad , Prueba de Esfuerzo , Femenino , Volumen Espiratorio Forzado , Humanos , Pulmón/efectos de los fármacos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Factores de Riesgo , Índice de Severidad de la Enfermedad , Suiza/epidemiología , Factores de Tiempo , Capacidad Pulmonar TotalRESUMEN
Cough is one of the most prevalent symptoms for which patients seek the attention of their physicians. Cough may serve as a protective reflex but can also impair social well-being and can profoundly and adversely affect patient's quality of life. Short and self-limited cough often does not require therapy, whereas prolonged cough is bothersome and should prompt further workup. If possible, the underlying cause should be identified and treated accordingly. Often, the patient history helps to establish a working hypothesis, such as possible post-nasal drip syndrome or gastroesophageal reflux as a cause. Asthma, another frequent cause of prolonged cough, is readily diagnosed in most cases. The response to empirical therapy often "confirms" a suspected etiology, if not, extensive workup involving function testing such as bronchoprovocation, radiology, endoscopy, and extended search for exceptional causes is warranted. Productive cough is often related to a bronchopulmonary disease, whereas an irritant cough is often of an extrapulmonary origin.
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Tos/etiología , Empirismo , Enfermedad Crónica , Tos/terapia , Diagnóstico Diferencial , HumanosRESUMEN
QUESTIONS UNDER STUDY: Swiss guidelines for the management of chronic obstructive pulmonary disease (COPD) were published in 2002. We aimed at assessing adherence to the proposed guidelines by the physicians in charge for all patients referred to our hospital for acute exacerbations of COPD over a one year period. METHODS: In a prospective observational study, data from a questionnaire and from records of all patients referred to our hospital with acute exacerbation of COPD were collected. Diagnostic steps as well as therapeutic and prophylactic interventions were reviewed. Where applicable, interventions were stratified according to proposed levels of evidence A-D. RESULTS: 45 patients in whom the diagnosis of COPD had been made before were included. Diagnosis was established by spirometry in 71%, in the remaining diagnosis was based on clinical grounds only. Non-smoking advice was given to 69%, and 16% were offered a nicotine-replacement trial (level A). Information about a disease management plan was given in 40% of the patients (level B), 22% had done a six minute walking distance test. 27% of the patients had participated in a pulmonary rehabilitation program (level A). 93% were on regular bronchodilator therapy (level B), and 56% had regular inhaled corticosteroids (level B). CONCLUSION: Confirmation of the diagnosis of COPD by spirometry is lacking in a significant number of patients. Most patients were treated with regular bronchodilators, however, relevant over-treatment with beta-adrenergic substances and overuse of inhaled corticosteroids in mild disease stages are common. Efforts for disease prevention and education as well as awareness of the potential benefits of pulmonary rehabilitation programs are still insufficient. Efforts to improve the adherence to the Swiss guidelines for the management of COPD should be intensified.
Asunto(s)
Adhesión a Directriz , Guías de Práctica Clínica como Asunto , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/terapia , Corticoesteroides/uso terapéutico , Anciano , Broncodilatadores/uso terapéutico , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Hospitales de Enseñanza , Humanos , Masculino , Nicotina/uso terapéutico , Agonistas Nicotínicos/uso terapéutico , Terapia por Inhalación de Oxígeno/estadística & datos numéricos , Educación del Paciente como Asunto , Neumonectomía/estadística & datos numéricos , Estudios Prospectivos , Pruebas de Función Respiratoria , Fumar/epidemiología , Cese del Hábito de Fumar , Encuestas y Cuestionarios , Suiza/epidemiologíaRESUMEN
A 61-year-old man presented with left-sided pneumothorax. On the chest computed tomograghy (CT), severe bilateral emphysema and left-sided pleural thickening were seen. His pneumothorax was drained with a chest tube. Because of a persistent air leakage, video-thoracoscopic wedge-resection of the suspected fistula and muscle-sparing minithoracotomy with extensive wedge resections of the left upper lobe were performed. Biopsy specimens showed micronodular mycetomas with septate hyphae highly suggestive of Aspergillus. The fungus destructed the lung tissue without vessel invasion. The patient had not been taking immunosuppressant drugs and had no prior opportunistic infections. Itraconazole was begun, the lung was expanded and the patient recovered. We propose that extensive resection of affected lung tissue in combination with long-term antifungal therapy with itraconazole is a valuable therapeutic option in patients with a complicated course of chronic necrotizing pulmonary aspergillosis (CNPA).
Asunto(s)
Antifúngicos/uso terapéutico , Aspergilosis Broncopulmonar Alérgica/tratamiento farmacológico , Aspergilosis Broncopulmonar Alérgica/patología , Itraconazol/uso terapéutico , Pulmón/patología , Enfermedad Crónica , Humanos , Masculino , Persona de Mediana Edad , Necrosis , Neumotórax/terapia , Cirugía Torácica Asistida por Video , Resultado del TratamientoRESUMEN
A patient with simultaneous bilateral spontaneous pneumothorax (SBSP) due to pulmonary and pleural manifestations of recurrent multiple myeloma is presented. The patient died in shock of unknown cause. The diagnosis was suspected from pleural fluid examination showing an exudate with numerous plasmocytes. Macroscopically and histologically, the visceral organs and the bone marrow were infiltrated with multiple monoclonal proliferations of plasma cells staining positively for IgG and lambda chains. SBSP is a rare condition and may be caused by trauma, parenchymal lung disease, infections, or neoplasms. This is the first report of SBSP caused by pleuropulmonary infiltration of multiple myeloma.
Asunto(s)
Mieloma Múltiple/complicaciones , Neoplasias Pleurales/complicaciones , Neumotórax/etiología , Anciano , Resultado Fatal , Femenino , Humanos , Mieloma Múltiple/patología , Neoplasias Pleurales/patología , Neumotórax/diagnóstico por imagen , Radiografía , RecurrenciaRESUMEN
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.
Asunto(s)
Neumonectomía , Enfisema Pulmonar/cirugía , Calidad de Vida , Disnea/fisiopatología , Femenino , Estudios de Seguimiento , Volumen Espiratorio Forzado , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Enfisema Pulmonar/fisiopatología , Encuestas y CuestionariosRESUMEN
Nasal prong pressure monitoring (PNOSE) is utilized to assess ventilation during sleep. However, it has not been rigorously validated against the gold standard of face-mask pneumotachography (VFM). Therefore, we compared PNOSE with VFM in 20 patients with suspected sleep apnea during nocturnal polysomnography, and analyzed factors affecting accuracy of PNOSE-derived variables. Patients rated their nasal obstruction on a visual analog scale. Mean +/- SE apnea/hypopnea index (AHI) by VFM was 24.0 +/- 5.1 h(-1). The bias (mean difference) and limits of agreement (+/- 2 SD) of AHI derived from PNOSE, and square root-transformed PNOSE, a measure proposed as a surrogate of airflow, were +3.9 (+/- 4.6), and -0.9 (+/- 9.0) h(-1). Subjective scores of nasal obstruction before polysomnographies did not herald inaccuracy of AHI from PNOSE. Square root-transformed PNOSE closely tracked pneumotachographic airflow over 10 breaths (r(2) among signals 0.88 to 0.96) but the relationship among these signals was highly variable if comparisons were extended over an entire night. Compared with face-mask pneumotachography, nasal pressure monitoring provides accurate AHI for clinical purposes even in patients perceiving nasal obstruction. Square-root transformation provides near linear nasal pressure/airflow relationships over a short time but is not essential for estimation of AHI.
Asunto(s)
Obstrucción Nasal/diagnóstico , Polisomnografía/instrumentación , Polisomnografía/normas , Rinomanometría/instrumentación , Rinomanometría/normas , Síndromes de la Apnea del Sueño/diagnóstico , Adulto , Anciano , Resistencia de las Vías Respiratorias , Sesgo , Femenino , Humanos , Modelos Lineales , Masculino , Máscaras , Persona de Mediana Edad , Obstrucción Nasal/clasificación , Obstrucción Nasal/complicaciones , Obstrucción Nasal/fisiopatología , Oximetría/normas , Pletismografía/normas , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Síndromes de la Apnea del Sueño/clasificación , Síndromes de la Apnea del Sueño/complicaciones , Síndromes de la Apnea del Sueño/fisiopatología , Factores de TiempoRESUMEN
The prevalence of irregular breathing during sleep is age and gender dependent, but the reason for this is unknown. This study tested the hypothesis that older men have a greater sleep-related increase in respiratory resistance. In 48 healthy subjects, 12 in each of four groups of younger and older men and women, airway resistance was measured during wakefulness and sleep using a mask, pneumotachograph, and catheter-mounted pressure sensors. Total respiratory resistance and total "low-flow," and "high-flow" oropharyngeal resistance were analyzed from 170,000 breaths, high flow being at rates above 50% maximal inspiratory flow. High-flow oropharyngeal and total respiratory resistance increased during non-rapid eye movement (NREM) sleep in all groups but not low-flow resistance. Total respiratory resistance increased from 12 +/- 1.2 cmH(2)O. l(-1). s(-1) awake to 16.2 +/- 2.4 in NREM sleep in young men, from 22.8 +/- 3.6 to 33.6 +/- 5.4 in young women, from 18 +/- 3 to 34.8 +/- 4.8 in older men, and from 26.6. +/- 4.2 to 34.2 +/- 6 in older women. The percentage of change in total respiratory resistance from awake to NREM sleep was not different between age groups or genders. We conclude that there are no major age or gender differences in the changes in airway resistance with sleep in normal subjects.
Asunto(s)
Resistencia de las Vías Respiratorias/fisiología , Fases del Sueño/fisiología , Sueño REM/fisiología , Adolescente , Adulto , Factores de Edad , Anciano , Índice de Masa Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Mecánica Respiratoria , Caracteres Sexuales , Síndromes de la Apnea del Sueño , Vigilia/fisiologíaRESUMEN
The obstructive sleep apnea syndrome is a highly prevalent and underdiagnosed disease. Repetitive arousals due to upper airway obstruction lead to hypersomnia. Due to the insidious onset, patients often underestimate the severity of their symptoms. Relatives can give helpful additional informations and should be involved in history taking and motivation for treatment. In general, GP's are confronted with the problem of fatigue and hypersomnia in the first line. They play the most important role in selecting patients for further investigations. The patient history helps to separate hypersomnia from fatigue. Hypersomnia indicates falling asleep at daytime in unappropriate situations, especially when the subject is passive. Often, a multidisciplinary approach including respiratory physicians, ENT specialists, orthopedic dentists and neurologists is warranted. Anatomic narrowing of the upper airway must be ruled out by clinical investigation. Overnight sleep studies detect apneas/hypopneas and repetitive arousals. Continuous positive airway pressure, applied by a nose mask and a flow generator remains the mainstay of therapy. Motivation, counseling and troubleshooting especially in the beginning of this therapy are of outmost importance. Ongoing research aims to improve comfort of nose masks and optimize function of flow generators.
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Trastornos de Somnolencia Excesiva/etiología , Medicina Familiar y Comunitaria , Apnea Obstructiva del Sueño/diagnóstico , Adulto , Monitoreo de Gas Sanguíneo Transcutáneo , Diagnóstico Diferencial , Fatiga/etiología , Humanos , Persona de Mediana Edad , Grupo de Atención al Paciente , Rol del Médico , Polisomnografía , Respiración con Presión Positiva , Derivación y Consulta , Factores de Riesgo , Apnea Obstructiva del Sueño/complicaciones , Apnea Obstructiva del Sueño/terapia , SuizaRESUMEN
Lung volume reduction surgery is a palliative procedure that improves dyspnea and pulmonary function in selected patients with advanced emphysema. Postoperative benefit is sustained for an individual period and depends on the emphysema morphology, the surgical technique, and other not yet well-defined factors. The question whether lung volume reduction surgery can be performed a second time on the same thoracic cavity is often raised but experience in this regard is lacking. We describe a patient who has undergone a successful redo operation 2 years after the initial lung volume reduction surgery.
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Neumonectomía , Enfisema Pulmonar/complicaciones , Enfisema Pulmonar/cirugía , Deficiencia de alfa 1-Antitripsina/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Fenotipo , ReoperaciónRESUMEN
We tested the practicability of dipyridamole myocardial nitrogen-13 ammonia positron emission tomography (dipyridamole (13)NH(3 )PET) for the perioperative risk assessment of coronary artery disease (CAD) in a cohort of patients with severe chronic obstructive pulmonary disease (COPD) undergoing lung volume reduction surgery (LVRS). Twenty consecutive LVRS candidates, 13 men and 7 women (mean age 57+/-2 years), without symptoms of CAD were prospectively studied by dipyridamole (13)NH(3 )PET. Side-effects and overall tolerance were assessed by a questionnaire and visual analogue scale. Repeated pulmonary function tests were performed before and 4, 12, 16 and 30 minutes after dipyridamole injection. All dipyridamole (13)NH(3 )PET studies were negative for CAD. Seventeen patients underwent LVRS without cardiac complications; three patients did not undergo LVRS for other reasons. Nine patients suffered intolerable dyspnoea requiring i.v. aminophylline. Mean FEV(1) decreased significantly after dipyridamole infusion: in nine patients the reduction in FEV(1)exceeded 15% from baseline. We found that dipyridamole is not well tolerated and causes significant bronchoconstriction in patients with severe COPD. Although all dipyridamole-induced side effects can be promptly reversed by aminophylline, dipyridamole cannot be recommended as a pharmacological stress in this setting.
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Enfermedad Coronaria/diagnóstico por imagen , Dipiridamol/efectos adversos , Corazón/diagnóstico por imagen , Enfermedades Pulmonares Obstructivas/fisiopatología , Vasodilatadores/efectos adversos , Amoníaco , Broncoconstricción/efectos de los fármacos , Disnea/inducido químicamente , Femenino , Humanos , Masculino , Persona de Mediana Edad , Radioisótopos de Nitrógeno , Selección de Paciente , Estudios Prospectivos , Radiofármacos , Pruebas de Función Respiratoria , Seguridad , Tomografía Computarizada de EmisiónAsunto(s)
Antibacterianos/metabolismo , Clindamicina/metabolismo , Ciclosporina/metabolismo , Inmunosupresores/metabolismo , Adulto , Antibacterianos/administración & dosificación , Clindamicina/administración & dosificación , Ciclosporina/administración & dosificación , Interacciones Farmacológicas , Femenino , Humanos , Inmunosupresores/administración & dosificación , Persona de Mediana EdadAsunto(s)
Hematoma/diagnóstico , Enfermedades Pulmonares/diagnóstico , Adulto , Biopsia/efectos adversos , Humanos , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/cirugía , Pulmón/patología , Trasplante de Pulmón , Masculino , Complicaciones Posoperatorias , Deficiencia de Proteína S/complicaciones , Embolia Pulmonar/complicaciones , Embolia Pulmonar/cirugíaRESUMEN
BACKGROUND: Cytomegalovirus is the single most frequent pulmonary pathogen in lung transplant recipients who survive at least 2 weeks. Patients at increased risk are either seropositive or have received an allograft from a donor with latent infection. Morbidity and mortality caused by cytomegalovirus disease is still considerably high. METHODS: In an open, comparative study, we evaluated the efficacy, tolerance, and cost effectiveness of postoperative ganciclovir prophylaxis: intravenous dose of 2x5 mg/kg/day for 14 days, followed by either intravenous doses of 5 mg/kg]day (five patients), or oral doses of 3x 1000 mg (nine patients) up to 90 days. Oral ganciclovir was continued until prednisone was tapered below 15 mg/day. Prophylaxed groups were compared with a historical control (eight patients) in respect to cytomegalovirus disease, in-hospital stay, overall costs, and survival. Follow-up times and the net state of immunosuppressive therapy between groups were comparable. RESULTS: Six (75%) of the non-prophylaxed patients developed cytomegalovirus disease compared to none in the intravenous and one in the oral ganciclovir group (P=0.013). The non-prophylaxed patients had a longer cytomegalovirus-related in-hospital stay (P=0.018) and nonsignificantly higher cytomegalovirus-related costs. Bronchiolitis obliterans syndrome was less frequent with prophylaxis (P=0.039), and survival tended to be better (P=0.072). The only adverse effect was a subclavian vein thrombosis in the intravenous ganciclovir group. CONCLUSIONS: In lung transplant recipients, ganciclovir prophylaxis, either intravenous or oral, is safe, well tolerated, and effective in preventing cytomegalovirus disease. Moreover, ganciclovir prophylaxis seems likely to reduce the incidence of bronchiolitis obliterans syndrome. The oral formulation might be preferable because its convenience and possibly lower costs.
Asunto(s)
Antivirales/uso terapéutico , Infecciones por Citomegalovirus/economía , Infecciones por Citomegalovirus/prevención & control , Ganciclovir/uso terapéutico , Trasplante de Pulmón/economía , Administración Oral , Adolescente , Adulto , Antivirales/administración & dosificación , Antivirales/economía , Bronquiolitis Obliterante/epidemiología , Bronquiolitis Obliterante/prevención & control , Análisis Costo-Beneficio , Infecciones por Citomegalovirus/epidemiología , Femenino , Ganciclovir/administración & dosificación , Ganciclovir/economía , Humanos , Inyecciones Intravenosas , Tiempo de Internación , Trasplante de Pulmón/mortalidad , Trasplante de Pulmón/fisiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Tasa de Supervivencia , SuizaRESUMEN
Lung perfusion scintigraphy is employed to evaluate patients with severe emphysema who are candidates for lung volume reduction surgery (LVRS). Our purpose was to investigate the role of scintigraphy in relation to chest computed tomography (CT) and lung function in this setting. Six observers blinded to clinical data retrospectively scored preoperative scintigrams of 70 patients undergoing bilateral video-assisted LVRS according to the distribution of lung perfusion as homogeneous, intermediately heterogeneous, or markedly heterogeneous. Heterogeneity of emphysema distribution was also assessed by chest CT. Dyspnea and pulmonary function were measured preoperatively and 3 mo postoperatively. In 42 patients with markedly heterogeneous, in 18 with intermediately heterogeneous, and in 10 with homogeneous perfusion, mean (+/- SE) FEV1 increased by 57 +/- 8% (p < 0.0001), 38 +/- 9% (p < 0.001), and 23 +/- 9% (p = NS) (p = NS for intergroup comparisons). In a multiple regression analysis, functional improvement after LVRS was more closely correlated with preoperative hyperinflation and the degree of emphysema heterogeneity estimated by chest CT than with the degree of perfusion heterogeneity assessed by scintigraphy. In 16 of 22 patients with homogeneous emphysema distribution in the chest CT scintigraphy revealed intermediately or markedly heterogeneous perfusion. We conclude that lung perfusion scintigraphy has a limited role in prediction of outcome, but it may help to identify target areas for resection in LVRS candidates with homogeneous CT morphology.
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Pulmón/diagnóstico por imagen , Neumonectomía , Enfisema Pulmonar/diagnóstico , Enfisema Pulmonar/cirugía , Pruebas de Función Respiratoria , Adulto , Anciano , Femenino , Humanos , Pulmón/fisiopatología , Masculino , Persona de Mediana Edad , Selección de Paciente , Perfusión , Periodo Posoperatorio , Radiografía Torácica , Cintigrafía , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Lung volume reduction surgery (LVRS) improves dyspnoea and pulmonary function in selected patients with severe emphysema. The purpose of this study was to assess the effects of LVRS on exercise performance and gas exchange in relation to changes in pulmonary function. In 40 patients (63.2+/-1.4 yrs, mean+/-SE) with severe emphysema (forced expiratory volume in one second (FEV1) 29+/-1% predicted, residual volume/total lung capacity (RV/TLC) ratio: 0.63+/-0.01) we assessed dyspnoea, pulmonary function and exercise performance before and 3 months after bilateral video-assisted thoracoscopic LVRS. The Medical Research Council dyspnoea score fell from 3.5+/-0.1 to 1.4+/-0.1 (p<0.0005); FEV1 increased by 55+/-9% to 44+/-2% pred (p<0.0005), RV/TLC decreased from 0.63+/-0.01 to 0.51+/-0.02 (p<0.0005). The diffusing capacity remained unchanged. Maximal work load during bicycle ergometry increased from 34.3+/-2.0 to 48.9+/-2.4 W (p< 0.0005), maximal oxygen uptake (V'O2max) from 10.0+/-0.4 to 12.8+/-0.3 mL x kg(-1) x min(-1) (p<0.0005). The increase in maximal ventilation during exercise (V'Emax) from 29.5+/-1.5 to 38.6+/-1.8 L x min(-1) (p<0.0005) was associated with increases in tidal volumes at isowatt and maximal exercise while corresponding breathing frequencies remained unaltered. The increases in V'O2max and V'Emax correlated with the increases in FEV1 and the decreases in RV/TLC. We conclude that the improvement in pulmonary hyperinflation and airflow obstruction after bilateral thoracoscopic lung volume reduction surgery may reduce ventilatory limitation, thereby increasing exercise capacity.
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Enfisema/fisiopatología , Enfisema/cirugía , Tolerancia al Ejercicio/fisiología , Neumonectomía/métodos , Intercambio Gaseoso Pulmonar/fisiología , Adulto , Anciano , Enfisema/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Neumonectomía/instrumentación , Periodo Posoperatorio , Pronóstico , Pruebas de Función Respiratoria , Índice de Severidad de la Enfermedad , Toracoscopios , Toracoscopía/métodos , Grabación en VideoRESUMEN
OBJECTIVE: The presence of pulmonary hypertension in severe pulmonary emphysema has been considered a relative contraindication to lung volume reduction surgery (LVRS). There was concern that resection of lung tissue might further increase pulmonary artery pressure. To address this point, the prevalence of pulmonary hypertension in candidates for LVRS was investigated. The changes in pulmonary artery pressures after bilateral videoassisted thoracoscopic resection was studied in patients with homo- and heterogeneously destroyed emphysematous lungs. DESIGN: The pulmonary arterial pressures by right heart catheterization were prospectively assessed, before and 6 months after LVRS in 21 consecutive patients (15 males, six females, mean (+/- S.E.) age: 62 +/- 1.9, range 42-74 years). All were former smokers and three had ZZ-AT1 deficiency. The inclusion criteria were: (a) severe bronchial obstruction (FEV1 < 35% predicted); (b) pulmonary hyperinflation (RV/TLC > 0.60); and (c) absence of hypercapnia (PaCO2 < 50 mmHg). RESULTS: The FEV1 had increased from 28 +/- 2% to 35 +/- 3% of the predicted value (P < 0.05) 6 months after surgery. The RV/TLC had declined from 0.65 +/- 0.02 to 0.55 +/- 0.02; PaO2 increased (66 +/- 1 versus 71 +/- 2 mmHg, P = 0.04), PaCO2 (38 +/- 2 versus 36 +/- 1 mmHg, P = 0.26) did not change. The pulmonary artery mean pressure (PAPmean) remained unchanged (18 +/- 1 versus 19 +/- 1 mmHg, P = 0.26). In six patients PAPmean was > or = 20 mmHg (up to 24 mmHg) preoperatively. After 6 months, six patients had a PAPmean > or = 20 mmHg (up to 31 mmHg). CONCLUSIONS: In patients with severe emphysema who are candidates for LVRS (but have only mild to moderate hypoxemia and a PaCO2 < 50 mmHg) we found no relevant pulmonary hypertension and pulmonary artery pressure did not change significantly after surgery. Therefore, routine right heart catheterization is not mandatory for preoperative evaluation.