Heterogeneity of lung volume reduction surgery outcomes in patients selected by use of evidence-based criteria

Relevance of pleural adhesions for short- and long-term outcomes after lung volume reduction surgery

Objective

Pleural adhesions (PLAs) have been shown to be a possible risk factor for air leak after lung volume reduction surgery (LVRS), but the relevance of PLA for lung function outcome remains unclear. We analyzed our LVRS cohort for the influence of PLA on short-term (ie, prolonged air leak) and long-term outcomes.

Methods

Retrospective observational cohort study with 187 consecutive patients who underwent LVRS from January 2016 to December 2019. PLA were defined as relevant if they were distributed extensively at the dorsal pleura; were present in at least at 2 areas, including the dorsal pleura; or present extensively at the mediastinal pleura. In patients with bilateral emphysema, bilateral LVRS was performed preferentially. The objectives were to quantify the association of PLA and rate of prolonged air leak (chest tube >7 days), and the association of PLA with postoperative exacerbations and with forced expiratory volume in 1 second 3 months postoperatively. The associations were quantified with odds ratios for binary outcomes, and with between-group differences for continuous outcomes. To account for missing observations, 100-fold multiple imputation was used.

Results

PLAs were found in 46 of 187 patients (24.6%). There was a 32.6% rate of prolonged air leak (n = 61), mean chest tube time was 7.84 days. A total of 94 (50.3%) LVRSs were unilateral and 93 were bilateral. There was evidence for an association between PLA and the rate of prolonged air leak (odds ratio, 2.83; 95% CI, 1.36 to 5.89; P = .006). There was no evidence for an association between PLA and postoperative exacerbations (odds ratio, 1.11; 95% CI, 0.5 to 2.45; P = .79). There was no evidence for an association between PLA and forced expiratory volume in 1 second (estimate -1.52; 95% CI -5.67 to 2.63; P = .47). Both unilateral and bilateral LVRS showed significant postoperative improvements in forced expiratory volume in 1 second by 27% (8.43 units; 95% CI, 3.66-13.12; P = .0006) and by 28% (7.87 units; 95% CI, 4.68-11.06; P < .0001) and a reduction in residual volume of 15% (-33.9 units; 95% CI, -56.37 to -11.42; P = .003) and 15% (-34.9 units; 95% CI, -52.57 to -17.22; P = .0001), respectively.

Conclusions

Patients should be aware of potential prolongation of hospitalization due to PLA. However, there might be no relevant influence of PLA on lung function outcomes.

Chronic Obstructive Pulmonary Disease: A Palliative Medicine Review of the Disease, Its Therapies, and Drug Interactions

Despite significant advances in treatment, chronic obstructive pulmonary disease (COPD) remains a chronic and progressive disease that frequently leads to premature mortality. COPD is associated with a constellation of significant symptoms, including dyspnea, cough, wheezing, pain, fatigue, anxiety, depression, and insomnia, and is associated with increased morbidity. Palliative care is appropriate to support these patients. However, historically, palliative care has focused on supporting patients with malignant disease, rather than progressive chronic diseases such as COPD. Therapies for COPD often result in functional and symptomatic improvements, including health-related quality of life (HRQL), and palliative care may further improve symptoms and HRQL. Provision of usual palliative care therapies for this patient population requires understanding the pathogenesis of COPD and common disease-targeted pharmacotherapies, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes COPD and current targeted therapies and their effects on symptoms, exercise tolerance, HRQL, and survival. It is important to note that medications commonly used for symptom management in palliative care can interact with COPD medications resulting in increased risk of adverse effects, enhanced toxicity, or changes in clearance of medications. To address this, we review pharmacologic interactions with and precautions related to use of COPD therapies in conjunction with commonly used palliative care medications.

Coils for the Treatment of Advanced Emphysema: A Growing Body of Evidence and Routine Experience

Endoscopic lung volume reduction (ELVR) mainly comprises endobronchial valves (EBV) and endobronchial coil (EBC) implants. EBV aims to occlude the most diseased and/or hyperinflated lobe thus inducing complete atelectasis. EBC therapy was developed a few years ago and is applicable independently of collateral flow and in patients presenting with disease dispersed throughout the upper and lower lobes. Bronchoscopic lung volume reduction with EBC is feasible in a wider range of patients (irrespective of collateral flow or disease homo/heterogeneity) than for EBV, and provides clinical benefits in the short-term, associated to an acceptable safety profile. The growing clinical and commercial experience of ELVR with nitinol coils will be reviewed in this article.