Predictors of change in postoperative pulmonary function in adolescent idiopathic scoliosis: a prospective study of 254 patients

STUDY DESIGN

A multicenter study of prospectively collected pulmonary function testing and radiographic measures in patients surgically treated for adolescent idiopathic scoliosis (AIS).

OBJECTIVE

The objectives of this study were 1) to identify the factors that determine pulmonary function more than 2 years after surgery for AIS; and 2) to determine what factors, if any, can predict an increase or decrease in the percent predicted 2-year pulmonary function.

SUMMARY OF BACKGROUND DATA

Thoracic spinal deformity can lead to significant pulmonary impairment. Studies have shown that patients with AIS experienced a significantly greater improvement in pulmonary function at 2 years after surgery when treated with a posterior approach compared to an anterior approach.

METHODS

Pulmonary function testing (PFT) and radiographic examination of 254 patients with AIS were completed prospectively. Demographic data, associations between radiographic measurements of spinal deformity, and the results of spirometry underwent correlation analysis and subsequent step-wise multiple regression analysis.

RESULTS

The variables found to be significant predictors of 2-year pulmonary function (FVC, FEV1, TLC) include: preop PFT (R = 0.20-0.39), having an open thoracotomy (as opposed to thoracoscopic or posterior) (R = 0.07-0.09), surgical time (R = 0.03-0.07), and thoracoplasty (R = 0.02-0.04). These models explain 40 to 51% of the variance in 2-year PFT. For patients undergoing open thoracotomy with a thoracoplasty, approximately 54% had a 15% decrease, or more, in percent predicted PFT. This compared with 11% and 15%, respectively of patients who either had posterior or thoracoscopic procedures with no thoracoplasty that had a 15% decrease or more in percent predicted PFT.

CONCLUSION

Aside from preoperative PFT values, open anterior approaches predict the largest percent of variance in 2-year PFT. Additionally, a clinically significant reduction in the predicted 2-year pulmonary function is more likely when performing a thoracoplasty. The magnitude of the effects for both these variables, however, is modest. This may facilitate the decision-making process as regards to operative intervention.

The Wider Scope of Video-Assisted Thoracoscopic Surgery

In the past, rudimentary devices were used to look closely into the chest; currently, advanced video technology, computers, and high-tech electronics are being used to perform many surgical procedures that formerly required a large, open incision. The goal of video-assisted thoracoscopic surgery (VATS) is the same as for comparable open procedures, but it is accomplished with less pain, less patient morbidity, and a shorter hospital stay. In addition to evaluating and treating thoracic injuries, VATS has demonstrated effectiveness in detecting and managing many other conditions, such as pleural disease, interstitial lung disease, and thoracic malignancies.

Use of successive dynamic videoendoscopic evaluations to identify progression of recurrent laryngeal neuropathy in three horses

CASE DESCRIPTION

3 racehorses were evaluated because of poor performance or abnormal noise originating from the upper portion of the respiratory tract.

CLINICAL FINDINGS

During maximal exercise, initial dynamic videoendoscopy of the upper respiratory tract revealed complete arytenoid cartilage abduction in 2 horses and incomplete but adequate abduction of the left arytenoid cartilage in 1 horse. Subsequent exercising endoscopic evaluation revealed severe dynamic collapse of the left arytenoid cartilage and vocal fold in all 3 horses.

TREATMENT AND OUTCOME

2 horses were treated with prosthetic left laryngoplasty and raced successfully. One horse was retired from racing.

CLINICAL RELEVANCE

Idiopathic laryngeal hemiplegia can be a progressive disease. Successive dynamic videoendoscopic upper airway evaluations were used to confirm progression of left laryngeal hemiplegia in these 3 horses. Videoendoscopy of the upper respiratory tract during exercise should be considered as part of the clinical evaluation of horses with signs of upper respiratory tract dysfunction.

Bronchoscopy in children in South America

Bronchoscopy is an important tool in the study of the airway. Diagnostic and therapeutic uses are well described in the literature and standardisation of the technique is well defined. Most relevant publications on bronchoscopy come from Europe and the United States, and in some countries they are used as guidelines for local hospitals. In spite of the limited experience published from South America, and the scarcity of financial resources, important information and research pathways have been developed in paediatric bronchoscopy. The information in this review was compiled from local publications, case reports, review articles, brief reports and congress presentations to provide an overview and share the experience about bronchoscopy in South American children.

Morphine administration in horses anaesthetized for upper respiratory tract surgery

OBJECTIVE

To determine the effect of morphine administration on commonly monitored cardio-respiratory variables and recovery quality in horses undergoing anaesthesia and surgery.

STUDY DESIGN

Prospective, randomized clinical study.

ANIMALS

Thirty-eight thoroughbred horses, 32 geldings and six mares, 3-13 years old, weighing 411-600 kg.

MATERIALS AND METHODS

A standard anaesthetic technique was used. Twenty minutes after induction of anaesthesia horses received 0.1 mg kg(-1) (0.1 m) or 0.2 mg kg(-1) (0.2 m) morphine by intravenous injection. A control group did not receive morphine. Heart rate, respiratory rate (fr), mean arterial pressure (MAP) and blood gases were measured before morphine administration and every 10 minutes thereafter. Horses were positioned for 35 minutes in right lateral recumbency for tension palatoplasty by cautery and were then moved into dorsal recumbency for additional intraluminal surgery comprising one or more of aryepiglottic fold resection, sub-epiglottal mucosal resection, ventriculectomy and cordectomy. A subjective recovery score from 0 (worst) to 5 (best) was assigned by a single observer who was unaware of treatment group. Two-way repeated measures anova, one-way anova, Kruskal-Wallis test, Mann-Whitney test, Pearson and Spearman correlation coefficients, and chi-squared tests were used to analyse the data where appropriate.

RESULTS

Arterial partial pressure of oxygen (PaO(2)) decreased significantly over time and was significantly lower in horses that received morphine. One horse in the control group and two horses in each of the morphine groups had a PaO(2) <13 kPa. No other significant cardiopulmonary effects were detected. Recovery scores [median (range)] were higher in morphine recipients: 4 (2-5) in 0.1 m, 4 (3-5) in 0.2 m compared with 3 (2-4) in the control group.

CONCLUSIONS AND CLINICAL RELEVANCE

The lower PaO(2) in morphine recipients did not appear to be of clinical significance in healthy horses because the number of horses with a low PaO(2) was similar between groups. The quality of recovery was significantly better in morphine recipients. These results indicate that morphine may be considered for use in clinical cases although further work is required to assess the analgesic properties of the drug in this species.

The Cardiac Surgery Advanced Life Support Course (CALS): Delivering Significant Improvements in Emergency Cardiothoracic Care

BACKGROUND

A 3-day cardiac surgery advanced life support course was designed with a series of protocols to manage critically ill cardiac surgical patients and patients who suffer a cardiac arrest. We sought to determine the effect of this course on the management of simulated critically ill and cardiac arrest patients.

METHODS

Twenty-four candidates participated in the course. Critically ill patients were simulated using intubated mannikins, with lines and drains in situ, and a laptop with an intensive care unit monitor simulation program. Candidates were tested before and after the course with rigidly predesigned clinical situations. Candidates were split into groups of 6, and cardiac arrests were simulated in the same fashion, with all required surgical equipment immediately available. All scenarios were videotaped, and after blinding, an independent surgeon assessed the times to achieve predetermined clinical endpoints.

RESULTS

The time to successful definitive treatment was significantly faster postcourse for the critically ill patient scenarios: (565 secs [SD 27 secs] precourse, compared with 303 secs [SD 24 secs] postcourse; p < 0.0005). In addition, the times taken to achieve a wide range of predetermined objectives, including airway check, assessing breathing, circulation assessment, treating with oxygen, appropriate treatment of the circulation, and requesting blood gases, chest radiographs, and electrocardiograms, were also significantly faster in the postcourse scenarios. Times to successful chest reopening and internal cardiac massage were also significantly improved in cardiac arrest patients: (451 secs [SD 39 secs] precourse and 228 secs [SD 17 secs] postcourse; p = 0.011).

CONCLUSIONS

Structured training and practice in the management of critically ill cardiac surgical patients and patients suffering a cardiac arrest leads to significant improvements in the speed and quality of care for these patients.

Review of pediatric airway malacia and its management, with emphasis on stenting

Malacia of the pediatric airway presents itself in a variety of clinical circumstances. Pediatric airway stenting is a more recent treatment modality. Complications may necessitate stent removal. This is usually performed bronchoscopically. We were forced to surgically remove a complicated airway stent. The Palmaz stent had been inserted for bronchomalacia presenting after interrupted aortic arch surgery in a 4-month old child with DiGeorge syndrome. This prompted us to review pediatric airway malacia, its management options and long-term outcomes, in an attempt to crystallize the current status of this relatively uncommon and difficult issue. The role of stents is analysed.

Triangle target principle for the placement of trocars during video-assisted thoracic surgery

OBJECTIVE

The baseball-diamond principle is generally used for trocar placement during video-assisted thoracic surgery; however, we are unable to treat all peripheral lung lesions using this principle. Therefore, we have developed another method for determining trocar placement based on a modification of the conventional principle. We have termed this method the triangle target principle. This report describes the instrument positioning that we now use for many video-assisted thoracic surgical procedures.

METHODS

We position 3 trocars in an equilateral triangle, with the target lesion at the apex. One vertex of the base becomes the site of the first trocar placement for introduction of the thoracoscopic camera. Another vertex of the base becomes the site for the second trocar for forceps or the endoscopic stapler. The third trocar is for forceps and is inserted to create the vicinity of target lesion. Four types of the triangle target principle were developed according to sites of the target lesion.

RESULTS

Between January 2000 and December 2002, we used this principle for 161 patients who underwent video-assisted thoracic surgery and all intrathoracic lesions were accessible except in 3 patients requiring intraoperative modifications.

CONCLUSIONS

We conclude that video-assisted thoracic surgery by this principle is more effective and easier than the conventional principle to treat intrathoracic disease.

Congenital lung malformations?antenatal and postnatal evaluation and management

We reviewed our institutional experience with pulmonary resection for congenital bronchopulmonary malformations and analysed the management and outcome of pregnancies with a prenatal diagnosis of congenital lung malformations. Between January 1993 and December 2003, 31 patients underwent evaluation and pulmonary resection for bronchopulmonary malformations. Common clinical presentations were respiratory distress (9), respiratory infections/pneumonias (22), and dyspnoea (9). Diagnostic modalities included chest radiography, CT scan (22), MRI scan (7), arteriography (1), and bronchoscopy (5). There were 13 congenital cystic adenomatoid malformations (CCAM), six pulmonary sequestrations, three bronchogenic cysts, and nine congenital lobar emphysemas (CLE). Fifteen patients who underwent resection were diagnosed by antenatal ultrasound. No foetus had hydrops or associated malformations. No pregnancy was terminated. There was no foetal demise. Regression of the sonographic appearance was observed in six cases. Amniotic puncture was required for hydramnios in three cases. Eight emergency resections were performed (CCAM 4; CLE 3; Bronchogenic cyst 1). Surgical procedures included 24 lobectomies, one right middle lobectomy with a wedge resection of the right lower lobe, one completion right lower lobectomy, four sequestrectomies, one mediastinal mass excision and one wedge resection for a bronchogenic cyst. There were no deaths. Postoperative complications included: persistent air leak (n=2; one requiring completion lobectomy) and pneumothorax (1). Persistent mild symptoms were present in five patients, at long-term follow-up. Congenital cystic adenomatoid malformation and congenital lobar emphysema were the commonest congenital anomalies. Congenital lung malformations are increasingly diagnosed antenatally, sometimes necessitating emergent surgical resection. The natural history is variable. All infants with a prenatal diagnosis require postnatal evaluation. Patients should be evaluated for associated disorders. The presence of mass effects is an indication for therapeutic decompression. The risk of pulmonary compression, infection and malignant degeneration makes resection imperative, even in asymptomatic patients. Lobectomy is the procedure of choice, is well tolerated, and leads to excellent outcomes.

Laryngeal dystonia in a case of severe motor and intellectual disabilities due to Japanese encephalitis sequelae

Laryngeal dystonia is characterized by stridor due to vocal cord dystonia and is observed in extrapyramidal disorders. Recently, botulinum toxin injection has been used as a primary therapy. Generally, severe motor and intellectual disabilities (SMID) are frequently complicated by various types of respiratory disorders. We report a SMID case with Japanese encephalitis sequelae showing repeated vocal cord abductor disturbance due to laryngeal dystonia, in addition to generalized dystonia, in whom MRI revealed basal ganglia lesions. Tracheostomy was effective for the case, and we believe that botulinum toxin injection may be inappropriate in SMID, both ethically and technically. Also, laryngeal dystonia should be considered as a cause of respiratory disorders in SMID.

[The volume of surgery on the abdominal cavity organs in patients with associated cardiovascular and respiratory system diseases]

The cardiovascular and respiratory disturbances are the main risk factor in acute and chronic surgical deseases of the abdominal cavity organs, including oncological. It is limits the possibility and volume of the diagnostics and surgical tactics choice. The complicated current of main disease is a risk factor of operation perform and the reason of the undertaking inadequate and palliative intervention, which significant reduce of the quality of life. Real by risk level reductions in surgery is a determination of tissues viability, estimation of compensatory reserve sick evidences for determination for operation performance including simultaneous and staged.

Can we develop a protocol for the safe decannulation of tracheostomies in children less than 18 months old?

Expanding indications for airway and head and neck surgery have led to a number of children under 18 months of age being deemed suitable for decannulation of their tracheostomies. We present four cases to illustrate the particular problems encountered in this age group and suggest modifications to our previously-published decannulation protocol.

[Mortality rate in reconstructive plastic surgery in patients with cardiorespiratory diseases]

The results of the reconstruct-plastic operations of 25 patients are presented in the article. The treatment of patients has some specific pecularities. They are the following: difficulties in diagnosing stomach and large intestine cancer recurrence after surgical treatment as well as surgical reoperation restriction resulted from cardio-vascular system, especially heart coronary arteries being affected through the disease development. To improve surgical treatment results of such patients it is recommended to examine vital organs in order to prevent fatal complications and mortality of the surgical operations.

Prevention and management of complications of airway surgery in children

Preventing and managing complications of airway surgery in children requires proactive attention to both surgical and anaesthetic aspects of the planned procedure. Preoperative evaluation should include a thorough physical examination and, especially in children with multiple congenital anomalies, flexible fibreoptic nasopharyngolaryngoscopy, direct laryngoscopy and rigid or flexible bronchoscopy. The goal is to identify dynamic abnormalities such as laryngomalacia or vocal cord paralysis, tracheal or bronchial lesions, gastro-oesophageal reflux disease (GORD), aspiration, laryngotracheal stenosis, totally obstructing tracheostomy-associated granulation tissue and Noonan syndrome preoperatively, and then to plan surgical management to achieve the best possible outcome for each patient.

[The application of argon plasma coagulation in thoracic surgery: principles, surgical technique and clinical results]

BACKGROUND

In recent years, together with the well-known high-frequency electro-coagulation, the application of plasma coagulation has been also introduced in the clinical practice. The argon plasma coagulator (APC) is one of the representatives of this surgical technique. By its nature, the APC represents a non-contact electrothermal tissue coagulation, combining the principle of the augmented surface and enhanced autogenous haemostatic mechanisms.

AIM

The main objective of this study was to evaluate whether APC is an effective and safe modality in the open pulmonary surgery.

MATERIALS AND METHODS

For the period from 01.01.2003 to 30.01.2004 year, in the Clinic of Thoracic Surgery, we have applied the technique of APC to 15 patients. The distribution by sex was: 10 males and 5 females. According to the nosological units, the distribution was as follows: pulmonary carcinoma in 3, pulmonary echinococcosis in 4, pleural empyema in 6, pulmonary abscessus in 1 and esophageal ahalasia in 1 patient. In our practice, we have used an argon plasma coagulator of BERCHTOLD GmbH. A power setting of 20W with exposition time 15 s and an argon gas flow setting of 1,5-2 1/h have been used in our series. Energy dose applied in our patients didn't exceed 300 J/cm2.

RESULTS

The results we have obtained demonstrate the following fundamental advantages of APC: a possibility to work with long electrode--tissue distance; a possibility for large surface coagulation as well as coagulation under variable angle, limited and well controlled depth of penetration, substantial reduction of carbonization; regular distribution of the energy over the whole coagulating surface, a possibility to treat effectively larger bleeding surfaces.

CONCLUSIONS

Although initial, our experience gives us the confidence to recommend the use of APC as an effective and safe procedure in the pulmonary surgery.

Surgical treatment of respiratory complications associated with gastroesophageal reflux disease

Although the association between gastroesophageal reflux (GER) and typical esophageal symptoms, such as heartburn and regurgitation, is straightforward, this is not the case for the relation between GER and respiratory symptoms. The strongest link is the finding of abnormal reflux in the proximal esophagus or pharynx. This finding, in conjunction with evidence of airway injury such as seen on laryngoscopy, strongly supports the relation between GER and airway disease. Medical therapy provides relief to some patients, but with less consistency than for those with typical symptoms of GER disease. This is likely due to persistent aspiration or injury from supraesophageal reflux. Laparoscopic antireflux surgery is extremely safe and effective for reducing reflux as well as aspiration, and appears to be more effective than medical treatment for treating GER-related respiratory symptoms.

Local experience in paediatric flexible bronchoscopy

All children who underwent flexible bronchoscopy in the respiratory unit at Paediatric Institute, Hospital Kuala Lumpur from June 1997 to June 2002 were reviewed. A hundred and ten children underwent the procedure under sedation or general anaesthesia. The median age of these children was eight months. (Q1 3, Q3 30) The commonest indication for performing flexible bronchoscopy was for chronic stridor (50 cases) followed by persistent or recurrent changes such as lung infiltrates, atelectasis and consolidation on the chest radiographs (22). Laryngomalacia was found to be the commonest cause of stridor in 29 children. Two patients were diagnosed with pulmonary tuberculosis. With regard to safety, three procedures were abandoned due to recurrent desaturation below 85%. One of these patients had severe laryngospasm that required ventilation for 48 hours but recovered fully. Two neonates developed pneumonia requiring antibiotics following bronchoscopy. No patients developed pneumothorax or bleeding following the procedure. Bronchoscopy is a safe procedure when performed by well-trained personnel. Since it is an invasive procedure the benefits must outweigh the risks before it is performed.

The use of lasers for treatment of upper respiratory tract disorders

Lasers have become important tools for the equine surgeon in the treatment of upper respiratory tract disease in the horse. Multiple wavelengths and delivery systems are available. Indications for the use of lasers in the upper respiratory tract primarily include minimally invasive procedures not possible with conventional surgical instrumentation. New applications for the use of lasers to treat upper respiratory disease are likely to evolve with the development and introduction of new wavelengths and delivery systems.