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BACKGROUND: Bronchoscopic lung volume reduction (BLVR) with one-way endobronchial valves (EBV) has better outcomes when the target lobe has poor collateral ventilation, resulting in complete lobe atelectasis. High-inspired oxygen fraction (FIO2) promotes atelectasis through faster gas absorption after airway occlusion, but its application during BLVR with EBV has been poorly understood. We aimed to investigate the real-time effects of FIO2 on regional lung volumes and regional ventilation/perfusion by electrical impedance tomography (EIT) during BLVR with EBV. METHODS: Six piglets were submitted to left lower lobe occlusion by a balloon-catheter and EBV valves with FIO2 0.5 and 1.0. Regional end-expiratory lung impedances (EELI) and regional ventilation/perfusion were monitored. Local pocket pressure measurements were obtained (balloon occlusion method). One animal underwent simultaneous acquisitions of computed tomography (CT) and EIT. Regions-of-interest (ROIs) were right and left hemithoraces. RESULTS: Following balloon occlusion, a steep decrease in left ROI-EELI with FIO2 1.0 occurred, 3-fold greater than with 0.5 (p < 0.001). Higher FIO2 also enhanced the final volume reduction (ROI-EELI) achieved by each valve (p < 0.01). CT analysis confirmed the denser atelectasis and greater volume reduction achieved by higher FIO2 (1.0) during balloon occlusion or during valve placement. CT and pocket pressure data agreed well with EIT findings, indicating greater strain redistribution with higher FIO2. CONCLUSIONS: EIT demonstrated in real-time a faster and more complete volume reduction in the occluded lung regions under high FIO2 (1.0), as compared to 0.5. Immediate changes in the ventilation and perfusion of ipsilateral non-target lung regions were also detected, providing better estimates of the full impact of each valve in place. TRIAL REGISTRATION: Not applicable.

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Background: Bronchoscopic lung volume reduction (BLVR) has supplanted surgery in the treatment of patients with advanced emphysema, but not all patients qualify for it. Our study aimed to investigate the outcomes of lung volume reduction surgery (LVRS) among patients who either failed BLVR or were not candidates for it. Methods: We conducted a retrospective analysis of patients who underwent LVRS for upper lobe-predominant emphysema at a single tertiary center between March 2018 and December 2022. The main outcomes measures were preoperative and postoperative respiratory parameters, perioperative morbidity, and mortality. Results: A total of 67 LVRS recipients were evaluated, including 10 who had failed prior valve placement. The median patient age was 69 years, and 35 (52%) were male. All procedures were performed thoracoscopically, with 36 patients (53.7%) undergoing bilateral LVRS. The median hospital length of stay was 7 days (interquartile range, 6-11 days). Prolonged air leak (>7 days) occurred in 20 patients. There was one 90-day mortality from a nosocomial pneumonia (non-COVID-related) and no further deaths at 12 months. There were mean improvements of 10.07% in forced expiratory volume in 1 second and 4.74% in diffusing capacity of the lung for carbon monoxide, along with a mean decrease 49.2% in residual volume (P < .001 for all). The modified Medical Research Council dyspnea scale was improved by 1.84 points (P < .001). Conclusions: LVRS can be performed safely in patients who are not candidates for BLVR and those who fail BLVR and leads to significant functional improvement. Long-term follow-up is necessary to ensure the sustainability of LVRS benefits in this patient population.

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Abstract Introduction: Halting ventilation during cardiopulmonary bypass (CPB) is implemented to operate in a less bleeding setting. It sustains a better visualization of the operation area and helps to perform the operation much more comfortably. On the other hand, it may lead to a series of postoperative lung complications such as atelectasis and pleural effusion. In this study, we investigated the effects of low tidal volume ventilation on inflammatory cytokines during CPB. Methods: Twenty-eight patients undergoing cardiovascular surgery were included in the study. Operation standards and ventilation protocols were determined and patients were divided into two groups: patients ventilated with low tidal volume and non-ventilated patients. Plasma samples were taken from patients preoperatively, perioperatively from the coronary sinus and postoperatively after CPB. IL-6, IL-8, TNF-α and C5a levels in serum samples were studied with enzyme-linked immunosorbent assay (ELISA) kits. Results: C5a, IL-6, IL-8 and TNF-α were similar when compared to the low tidal volume ventilated and non-ventilated groups (P>0.05) Comparing the groups by variables, IL-6 levels were increased during CPB in both groups (P=0.021 and P=0.001), and IL-8 levels decreased in the ventilation group during CPB (P=0.018). Conclusion: Our findings suggest that low tidal volume ventilation may reduce the inflammatory response during CPB. Although the benefit of low tidal volume ventilation in CPB has been shown to decrease postoperative lung complications such as pleural effusion, atelectasis and pneumonia, we still lack more definitive and clear proofs of inflammatory cytokines encountered during CPB.

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INTRODUCTION: Halting ventilation during cardiopulmonary bypass (CPB) is implemented to operate in a less bleeding setting. It sustains a better visualization of the operation area and helps to perform the operation much more comfortably. On the other hand, it may lead to a series of postoperative lung complications such as atelectasis and pleural effusion. In this study, we investigated the effects of low tidal volume ventilation on inflammatory cytokines during CPB. METHODS: Twenty-eight patients undergoing cardiovascular surgery were included in the study. Operation standards and ventilation protocols were determined and patients were divided into two groups: patients ventilated with low tidal volume and non-ventilated patients. Plasma samples were taken from patients preoperatively, perioperatively from the coronary sinus and postoperatively after CPB. IL-6, IL-8, TNF-α and C5a levels in serum samples were studied with enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: C5a, IL-6, IL-8 and TNF-α levels were similar when compared to the low tidal in volume ventilated and non-ventilated groups (P>0.05). Comparing the groups by variables, IL-6 levels were increased during CPB in both groups (P=0.021 and P=0.001), and IL-8 levels decreased in the ventilation group during CPB (P=0.018). CONCLUSION: Our findings suggest that low tidal volume ventilation may reduce the inflammatory response during CPB. Although the benefit of low tidal volume ventilation in CPB has been shown to decrease postoperative lung complications such as pleural effusion, atelectasis and pneumonia, we still lack more definitive and clear proofs of inflammatory cytokines encountered during CPB.

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Endoscopic lung volume reduction is a minimally invasive procedure performed to reduce the space occupied by the emphysemas' lobes. This procedure has been demonstrated to be beneficial for patients with advanced chronic obstructive pulmonary disease and severe hyperinflation. The use of endobronchial valves is increasing, as well as the number of reports of adverse events. The most common complications after the procedure are a pneumothorax, bleeding, infections, the need for valve removal, and valve expulsion. We have recently treated a patient who achieved immediate left upper lobe atelectasis but developed a pneumothorax on the 6th day and near-fatal kinking of the left lower lobe bronchus. This patient had asphyctic episodes probably due to a functional left pneumonectomy. We should consider this unusual complication in patients undergoing endoscopic lung volume reduction whose condition worsens after achieving complete lobar atelectasis.

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A cirurgia de redução de volume pulmonar (CRVP) é um tratamento paliativo utilizado em doentes com enfisema grave que visa melhorar a função pulmonar e a qualidade de vida, através da remoção do tecido fibrosado resultante do enfisema. Esta intervenção promove uma expansão adequada dos pulmões na caixa torácica, melhorando o recoil elástico e a relação ventilação/perfusão devido à diminuição da hiperinsuflação pulmonar. Foi objetivo do presente artigo de revisão caracterizar os efeitos da CRVP no enfisema no respeitante à melhoria da função pulmonar. Foram considerados artigos publicados em periódicos indexados nas bases de dados MEDLINE, SciELO, Latindex e DOAJ. Foram incluídos 25 documentos que abrangem artigos originais e artigos de revisão de literatura. A CRVP promove uma melhoria dos parâmetros avaliados por espirometria e pletismografia corporal total, devido ao aumento do recoil elástico promovido pela redução dos volumes pulmonares não mobilizáveis (redução da hiperinsuflação pulmonar), pelo reposicionamento dos músculos respiratórios e pela diminuição da resistência das vias aéreas. Contudo, diversas investigações demonstraram que os efeitos na função pulmonar são temporários e reversíveis. Fatores como a elevada taxa de morbilidade e mortalidade e o custo elevado relativamente à durabilidade dos benefícios que este procedimento acarreta estão na base das opiniões controversas relativas à CRVP. A CRVP não modifica o curso natural da doença, sendo por isso necessário avaliar a vertente económica deste procedimento bem como a sua relação custo-benefício, isto porque este tratamento se tem demonstrado dispendioso face à durabilidade dos benefícios.

Lung volume reduction surgery (LVRS) is a palliative treatment used in patients with severe emphysema that aims to improve lung function and quality of life by removing the fibrous tissue resulting from emphysema. This intervention promotes an adequate expansion of the lungs in the chest cavity, thus improving the elastic recoil and ventilation/perfusion ratio due to decrease of lung hyperinflation. The aim of this review article is to characterize, the effects of LVRS in emphysema in relation to the improvement in lung function. We considered articles published in journals indexed in MEDLINE , SciELO , Latindex and DOAJ. We included 25 documents covering original articles and literature review articles. LVRS promotes the improvement of the spirometry and whole body plethymography parameters, caused by the increase of elastic recoil through the reduction of not mobilized lung volumes (lung hyperinflation reduction), the repositioning of the respiratory muscles and the decrease of airways resistance. However, several investigations have shown that the effects on lung function are temporary and reversible. Factors such as the high morbidity and mortality rates and the high cost in relation to the durability of the benefits of the procedure lead to controversial opinions about LVRS. LVRS does not modify the natural course of the disease, so it is necessary to evaluate the economic aspect of this procedure and its cost-effectiveness, because this treatment is considered expensive comparatively to the durability of benefits.

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One-way endobronchial valves (EBV) insertion to reduce pulmonary air trapping has been used as therapy for chronic obstructive pulmonary disease (COPD) patients. However, local inflammation may result and can contribute to worsening of clinical status in these patients. We hypothesized that combined EBV insertion and intrabronchial administration of mesenchymal stromal cells (MSCs) would decrease the inflammatory process, thus mitigating EBV complications in severe COPD patients. This initial study sought to investigate the safety of this approach. For this purpose, a phase I, prospective, patient-blinded, randomized, placebo-controlled design was used. Heterogeneous advanced emphysema (Global Initiative for Chronic Lung Disease [GOLD] III or IV) patients randomly received either allogeneic bone marrow-derived MSCs (108 cells, EBV+MSC) or 0.9% saline solution (EBV) (n = 5 per group), bronchoscopically, just before insertion of one-way EBVs. Patients were evaluated 1, 7, 30, and 90 days after therapy. All patients completed the study protocol and 90-day follow-up. MSC delivery did not result in acute administration-related toxicity, serious adverse events, or death. No significant between-group differences were observed in overall number of adverse events, frequency of COPD exacerbations, or worsening of disease. Additionally, there were no significant differences in blood tests, lung function, or radiological outcomes. However, quality-of-life indicators were higher in EBV + MSC compared with EBV. EBV + MSC patients presented decreased levels of circulating C-reactive protein at 30 and 90 days, as well as BODE (Body mass index, airway Obstruction, Dyspnea, and Exercise index) and MMRC (Modified Medical Research Council) scores. Thus, combined use of EBV and MSCs appears to be safe in patients with severe COPD, providing a basis for subsequent investigations using MSCs as concomitant therapy. Stem Cells Translational Medicine 2017;6:962-969.

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The objective of the study was to evaluate the application efficiency with reduced volume from the prototype of a pneumatic spray nozzles aimed to control the coffee leaf miner (Leucoptera coffeella). We evaluated different types of pneumatic nozzles (flat fan, cone jet, AT-1000 model and effervescent), on application of insecticide spray liquids with concentrations of 5, 10, 15 and 20% (v/v) of mineral oil applied in reduced volume and 0.5% applied by conventional airblast sprayer. The application technology parameters studied in laboratory and field conditions were as follows: droplet size (µm), tracer deposit (µg/cm²) and leaf spray coverage (%). The reduced volume application, provided by the prototype of a pneumatic spray nozzles with the effervescent type compared to traditional airblast sprayer, presents proper conditions of use, especially in relation to deposit and coverage of spraying liquid over coffee leaves.

O objetivo do trabalho foi avaliar a eficiência da aplicação em volume reduzido a partir do protótipo de um pulverizador com bocais pneumáticos voltado ao controle do bicho-mineiro do cafeeiro (Leucoptera coffeella). Avaliaram-se diferentes tipos de bocais pneumáticos (jato plano, jato cônico, modelo AT-1000 e efervescente), na aplicação de caldas inseticidas com concentrações de 5, 10, 15 e 20% (v/v) de óleo mineral aplicadas em volume reduzido e 0,5% aplicado via pulverizador convencional de jato transportado. Os parâmetros da tecnologia de aplicação estudados em condições de laboratório e campo foram: tamanho de gotas (µm); depósito de marcador (µg/cm²) e cobertura foliar (%). A aplicação em volume reduzido, proporcionada pelo protótipo de um pulverizador com bocais pneumáticos do tipo efervescente comparada ao turbo-pulverizador tradicional, apresenta adequadas condições de uso, principalmente em relação ao depósito e cobertura de calda sobre folhas de cafeeiro.

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La Enfermedad Pulmonar Obstructiva Crónica (EPOC) es una enfermedad caracterizada por limitación del flujo aéreo espiratorio donde el atrapamiento aéreo y la hiperinsuflación dinámica conducen a la producción de disnea que muchas veces incapacita al paciente a pesar de un correcto tratamiento farmacológico y de rehabilitación. Los tratamientos quirúrgicos destinados a paliar esta situación como la cirugía de reducción de volumen pulmonar (CRVP) presentan una morbimortalidad que limita su uso. La búsqueda de formas menos invasivas para conseguir el mismo propósito dieron origen a una serie de procedimientos broncoscópicos para la reducción de volumen pulmonar dentro de los cuales, las válvulas endobronquiales (VEB), son las que acumulan mayor desarrollo y experiencia. Si bien los estudios con VEB son heterogéneos y en su conjunto, muestran modestos beneficios en los test de función pulmonar, ejercicio y calidad de vida relacionada con la salud, existe un grupo de pacientes con enfisema pulmonar heterogéneo, cisura interlobar intacta, atrapamiento aéreo severo y baja tolerancia al ejercicio que muestra beneficios estadística y clínicamente significativos. Nuevos estudios se encuentran en desarrollo para dar más peso de evidencia a la acumulada en la actualidad.

Chronic Obstructive Pulmonary Disease (COPD) is characterized by airflow limitation, air trapping and dynamic hyperinflation that lead to disabling dyspnea despite appropriate pharmacologic treatment and pulmonary rehabilitation. Though surgical treatments such as lung transplant surgery and lung volume reduction (LVRS) are available, their high morbidity and mortality limit their use. To avoid these complications multiple procedures for bronchoscopic lung volume reduction have been developed, among which endobronchial valves (EBV) have accumulated the largest amount of evidence. While studies with EBV are heterogeneous and show modest benefits in pulmonary function tests, exercise capacity and quality of life, there is a group of patients with heterogeneous emphysema, intact interlobar fissure, severe air trapping and low exercise tolerance that show a statistically and clinically significant benefits. New studies are under way to further support the growing evidence.

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CONTEXT: Ultrasound (US)-guided percutaneous ethanol injection (PEI) has been proposed for treatment of benign thyroid nodules (TNs). However, there is no consensus for the optimal amount of ethanol injection, number of applications, and time to re-evaluation in order to achieve maximum volume reduction with minimum adverse effects. OBJECTIVE: The purpose of the present study was to analyze the effectiveness of an US-guided PEI protocol to treat solid and mixed TNs based on a new target outcome. PATIENTS AND METHODS: We performed a prospective study evaluating the results of PEI in 52 patients with benign solid and mixed TNs. The ethanol dose was fixed in 30% of the nodular volume per session. Patients returned 1 month after each session for US re-evaluation. Therapeutic success was defined as volume reduction of at least 30% associated with disappearance of clinical symptoms and a complete esthetic satisfaction reported by the patient. RESULTS: We performed a mean of 2.8 ± 1.9 PEI sessions, with an average total volume of ethanol injected of 9.1 ± 10.3 ml, and a follow-up time of 10.0 ± 8.7 months. There was a reduction of at least 50% of the initial nodular volume in 33 patients (63.5%). In 11 patients (21.2%), the reduction did not reach 50% (mean reduction of 31 ± 11%), but 6 of them reported esthetically satisfactory results and treatment was stopped. Our therapeutic success rate considering the patients with esthetic improvement was 75%. There were no severe complications. CONCLUSION: Our protocol is effective and safe to treat solid and mixed benign TNs based on our established outcome.

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En cirugía torácica la evaluación de un paciente con enfermedad pulmonar obstructiva crónica muy grave constituye un reto para el equipo quirúrgico, dado que los resultados espirométricos pueden contraindicar la intervención. Este reporte de caso describe los criterios seguidos para definir las intervenciones quirúrgicas; la estrategia asumida por el grupo de tórax; el manejo anestésico y la evolución posterior del paciente, al cual se le realizó cirugía reductora del volumen pulmonar, con abordaje unilateral inicial en lóbulo superior derecho y cirugía definitiva al mes, con toracotomía posterolateral izquierda ulterior para resecar un tumor de Pancoast. Se evidenció disminución de la disnea e incremento gradual en la capacidad física después de cada proceder quirúrgico. El volumen espiratorio forzado en el primer segundo con relación a los valores predichos mejoró, de 25 por ciento a 38 por ciento, después de la cirugía y 41 por ciento a los seis meses. El índice de Tiffeneau varió de 0,43 a 0,57 y 0,60 después de dos cirugías torácicas. Como única complicación el paciente presentó dolor torácico crónico para el cual mantiene tratamiento médico. Se concluye que la realización de cirugía reductora del volumen pulmonar es una alternativa a evaluar en pacientes que presenten neoplasia de pulmón y enfisema pulmonar bulloso. El enfoque multidisciplinario perioperatorio es un pilar fundamental para lograr resultados satisfactorios(AU)

In thoracic surgery, assessing a patient with very severe chronic obstructive pulmonary disease is a challenge for the surgical team, since spirometric results may contraindicate the intervention. This case report describes the criteria used to define surgical interventions, the strategy assumed by the thorax group, the anesthetic management and subsequent evolution of the patient, who underwent lung volume reduction surgery, with an initial unilateral approach in the right upper lobe and final surgery a month later, with posterior left posterolateral thoracotomy to resect a Pancoast tumor. There was a decrease in dyspnea and a gradual increase in physical capacity after each surgical procedure. The forced expiratory volume in the first second in relation to the predicted values improved from 25 percent to 38 percent after surgery, and 41 percent six months later. Tiffeneau index varied from 0.43 to 0.57 and 0.60 after two thoracic surgeries. As a single complication, the patient presented chronic chest pain for which he maintains medical treatment. It is concluded that the performance of pulmonary volume reduction surgery is an alternative to gauge in patients with lung cancer and bullous pulmonary emphysema. The multidisciplinary perioperative approach is a fundamental pillar to achieve satisfactory results(AU)

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Sensory neuronopathies (SN) are peripheral nervous system disorders associated with degeneration of dorsal root ganglion neurons. Despite the evidence of a defective proprioceptive sensory input in SN,the prominent gait and truncal ataxia raises the question of a concomitant involvement of the cerebellum. OBJECTIVE: To evaluate cerebellar atrophy in SN. METHOD: We analyzed MRI-based volumetry of anterior lobe (paleocerebellum) and total cerebellum in patients with non-paraneoplastic chronic SN and compared to age- and gender-matched controls. RESULTS: Cerebellum and anterior lobe MRI volumetry were performed in 20 patients and nine controls. Mean anterior lobe and cerebellar volume were not statistically different. Three patients (15 percent), however, had an abnormal anterior lobe and cerebellar volume index (values outside 2.5 standard deviations). One of them also had a specific atrophy of the anterior lobe. All these patients had infectious or dysimmune associated SN. CONCLUSION: Cerebellar atrophy is infrequently associated with SN, but can be found in some patients with SN related to infectious or immune mediated conditions. It can be more prominent in the anterior lobe and may contribute to the ataxia seen in these patients.

Neuronopatias sensitivas (NS) são distúrbios do sistema nervoso periférico associados com a degeneração dos neurônios do gânglio da raiz dorsal. Apesar da evidência de um defeito das aferências proprioceptivas, a ataxia proeminente da marcha e do tronco levanta a questão de uma participação concomitante do cerebelo. OBJETIVO: Avaliar a atrofia cerebelar nas NS. MÉTODO: Foi analisada volumetria pela ressonância magnética do cerebelo total e do lobo anterior (paleocerebelo) em pacientes com NS crônica não-paraneoplásica e comparada a controles com idades e sexos correspondentes. RESULTADOS: A volumetria do cerebelo e lobo anterior foi realizada em 20 pacientes e nove controles. As médias do volume cerebelar e do lobo anterior não foram estatisticamente diferentes. Três pacientes, entretanto, tiveram um valor anormal do índice de volume cerebelar e do lobo anterior (valores fora de 2,5 desvios-padrão). Um deles tinha inclusive uma atrofia específica do lobo anterior. Todos esses pacientes tinham NS associada a doenças infecciosas ou disimunes. CONCLUSÃO: Atrofia cerebelar é raramente associada com SN, mas pode ser encontrada em alguns pacientes com NS relacionada com doenças infecciosas ou imunológicas. Esta atrofia pode ser mais proeminente no lobo anterior e pode contribuir para a ataxia observada nestes pacientes.

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Se realizó un estudio observacional, analítico, prospectivo, en el período 2006-2008, en el Hospital Neumológico Benéfico Jurídico, con el objetivo de comparar los valores predictivos espirométricos de los enfermos candidatos a resección pulmonar con los obtenidos después de la intervención quirúrgica. La muestra quedó formada por 28 pacientes, residentes en Ciudad de La Habana. Para comparar el valor predictivo del volumen espiratorio forzado en el primer segundo con el valor real, seis meses después de la resección pulmonar se calculó el cociente delta relativo que expresó en porcentaje el grado de coincidencia entre estas dos variables. Una vez recogida la información se sometió a un análisis exploratorio de datos, con pruebas de significación asociadas. Los resultados mostraron que la espirometría clínica tiene un espacio indiscutible en la evaluación de la función pulmonar preoperatoria de los candidatos a resección pulmonar. Los valores predictivos y reales después de la resección pulmonar del volumen espiratorio forzado en el primer segundo fueron semejantes. La lobectomía superior izquierda fue el tipo de intervención quirúrgica con mayor similitud entre estos valores, por el contrario la neumectomía izquierda resultó ser la técnica con mayores diferencias entre los mismos(AU)

We carried out an observacional, analytical, prospective study in the period 2006-2008, at Neumologico Hospital Benéfico Jurídico, with the objective to compare the spirometry predicted values of the patients candidates to pulmonary surgery with the obtained ones after the operation. The sample was formed by 28 patients, residents in Havana City. In order to compare the predictive value of the forced expiratory volume in the first second with the real value six months after the pulmonary surgery, we calculated the quotient relative delta that expressed in percentage the degree of coincidence between these two variables. The information was put under an exploratory analysis of data, with associate tests of meaning. The results showed that the spirometry has an unquestionable space in the evaluation of the preoperating pulmonary function of the candidates to pulmonary surgery. The predictive and real values after the pulmonary surgery of the forced expiratory volume in the first second were similar. The left upper lobectomy was the type of operation with greater similarity between these values, on the contrary the left neumectomy turned out to be the technique with greater differences between such(AU)

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