Airway deformation in patients demonstrating pectus excavatum with an improvement after the Nuss procedure

Clinical Evaluation of Exertional Dyspnea in Adult Pectus Excavatum Patients

Abstract:

Evaluation of patients with pectus excavatum has primarily been focused on the pediatric population who undergo surgical correction of sternal defects mainly for cosmetic reasons combined with exercise-limiting symptoms. The extent of cardiopulmonary improvement in this population based on cardiac imaging, pulmonary function testing, and cardiopulmonary exercise testing may be highly variable. There is no current consensus on the limitations of cardiopulmonary impairment or potential improvement from surgical repair in pediatric patients. Limited data has published in the medical literature on the evaluation of adults with pectus excavatum who may also present with a variety of clinical symptoms. Adult patients with exercise limitation and pectus excavatum may present with exertional dyspnea, chest discomfort, palpitations/tachycardia, exercise-induced wheezing, and use of bronchodilators for asthma-like symptoms. While numerous published review articles outline clinical evaluation and surgical treatment for younger patients, comprehensive evaluation for these adult patients has not been fully elucidated. There is no current consensus on the underlying cause of cardiopulmonary impairment in adult patients or their potential improvement from surgical repair. This review focuses on the recommended evaluation of adult patients to discern the potential cardiopulmonary limitations to exercise due to pectus excavatum, especially in physically fit adults such as active duty military personnel. Two illustrative cases are presented to describe the complexity of the evaluation of adult patients and potential need for surgical correction.

Can plain chest X-ray replace computed tomography for the follow-up of children who have undergone the Nuss procedure?

PURPOSE

To establish whether new indices on plain chest X-ray (CXR) can replace those on computed tomography (CT) for the follow-up of children who have undergone the Nuss procedure.

METHODS

The subjects of this retrospective study were 45 children who underwent the Nuss procedure between 2000 and 2016. The Haller index (HI) was measured by preoperative CT. Preoperative and postoperative chest deformities were evaluated by two CXR measurements: the concave rate on the lateral view (CR; the depth of the concavity divided by the anterior-posterior diameter of the rib cage) and the tracheal bifurcation angle (TBA) on the anterior view. Data are expressed as the median with range.

RESULTS

The median age and HI of the children, when they underwent the Nuss procedure, was 9.3 (3.8-17.3) years and 4.5 (3.2-10.1), respectively. The preoperative CR was correlated significantly with the HI. The postoperative CR was significantly lower than the preoperative CR [pre: 0.17 (0.08-0.37), post: 0.09 (0.01-0.18), p < 0.05], and the low value was sustained after bar removal. The TBA decreased significantly after the Nuss procedure from 74.2° (55-104) preoperatively to 65.0° (45-92) postoperatively (p < 0.05).

CONCLUSIONS

These results suggest that CXR can replace CT for the follow-up of patients after the Nuss procedure, with lower radiation exposure.

Disorders of the Chest Wall: Clinical Manifestations

Chest wall disorders represent deformities and/or injuries that alter the rib cage geometry and result in pulmonary restriction, increased work of breathing, exercise limitations, and cosmotic concerns. These disorders are congenital or acquired and affect all ages. Disorders affecting the spine (kyphoscoliosis, ankylosing spondylitis), ribs (flail chest), and sternum (pectus excavatum) are discussed in this article, with emphasis on clinical presentations, pulmonary function abnormalities, diagnosis, and treatment.

The quality of life after bar removal in patients after the nuss procedure for pectus excavatum

BACKGROUND

The goal of this study was to evaluate the outcome of patients who had the Nuss procedure for repair of pectus excavatum.

METHODS

Thirty-nine patients (26 male, 13 female) of 61 (63.9%) who had bar removal after the Nuss procedure agreed to participate in an interview. All patients and their parents were asked to complete a questionnaire.

RESULTS

The mean age of the patients was 6.8±3.23 years at the time of the Nuss procedure, 9.1±3.54 at bar removal, and 12.0±3.28 when the questionnaire was completed. The scores for satisfaction with the procedure, sense of social belonging, and well-being increased after the Nuss procedure according to the responses of the patients and their parents. However, the scores did not significantly differ after bar removal compared to after the Nuss procedure. Patients (4.1±1.08) and parents (4.1±1.02) reported that they were satisfied with the final result and their responses did not significantly differ (P=0.498). However, the surgical team's score for overall satisfaction was 4.5, which was higher than the patients' and/or parents' scores (P=0.019).

CONCLUSION

The Nuss procedure had a positive impact on the patients' and parents' quality of life. However, the scores before and after bar removal did not differ.