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Pu CY, Ospina-Delgado D, Kheir F, Avendano CA, Parikh M, Beattie J, Swenson KE, Wilson J, Gangadharan SP, Majid A. Airway Stents for Excessive Central Airway Collapse: A Randomized Controlled Open-label Trial. J Bronchology Interv Pulmonol 2024; 31:e0980. [PMID: 39119872 DOI: 10.1097/lbr.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 06/26/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Short-term airway stent placement (stent evaluation) has been employed to evaluate whether patients with excessive central airway collapse (ECAC) will benefit from tracheobronchoplasty. Although retrospective studies have explored the impact of stent placement on ECAC, prospective randomized controlled trials are absent. METHODS This was a randomized open-label trial comparing patients receiving airway stent placement and standard medical treatment (intervention group) versus standard medical treatment alone (control group) for ECAC. At baseline, patients' respiratory symptoms, self-reported measures, and functional capabilities were assessed. Follow-up evaluations occurred 7 to 14 days postintervention, with an option for the control group to crossover to stent placement. Follow-up evaluations were repeated in the crossover patients. RESULTS The study enrolled 17 patients in the control group [medical management (MM)] and 14 patients in the intervention group. At follow-up, 15 patients in the MM crossed over to the stent group, resulting in a total of 29 patients in the combined stent group (CSG). Subjectively (shortness of breath and cough), 45% of the CSG exhibited improvement with the intervention compared with just 12% in the MM. The modified St. George Respiratory Questionnaire score in the CSG improved significantly from 61.2 at baseline to 52.5 after stent placement (-8.7, P = 0.04). With intervention, the 6-minute walk test in CSG improved significantly from 364 meters to 398 meters (34 m, P < 0.01). The MM did not show a significant change in the St. George Respiratory Questionnaire score or 6-minute walk test distance. CONCLUSION Short-term airway stent placement in patients with ECAC significantly improves respiratory symptoms, quality of life, and exercise capacity.
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Affiliation(s)
- Chan Yeu Pu
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
- Department of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonary, Massachusetts General Hospital, Harvard Medical School
| | - Daniel Ospina-Delgado
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
- Department of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Boston, MA
| | - Fayez Kheir
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Camilo A Avendano
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
| | - Mihir Parikh
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
| | - Jason Beattie
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
| | - Kai E Swenson
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
| | - Jennifer Wilson
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
| | - Sidharta P Gangadharan
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
| | - Adnan Majid
- Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center
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Basurto D, Watananirun K, Cordier AG, Otaño J, Carriere D, Scuglia M, de Luna Freire Vargas AM, Prat J, Russo FM, Debeer A, Peralta CFA, De Coppi P, Gratacós E, Benachi A, Deprest J. Tracheomalacia and tracheomegaly in infants and children with congenital diaphragmatic hernia managed with and without fetoscopic endoluminal tracheal occlusion (FETO): a multicentre, retrospective cohort study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:580-588. [PMID: 38914091 DOI: 10.1016/s2352-4642(24)00109-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Temporary fetoscopic endoluminal tracheal occlusion (FETO) promotes lung growth and increases survival in selected fetuses with congenital diaphragmatic hernia (CDH). FETO is performed percutaneously by inserting into the trachea a balloon designed for vascular occlusion. However, reports on the potential postnatal side-effects of the balloon are scarce. This study aimed to evaluate the prevalence of tracheomalacia in infants with CDH managed with and without FETO and other consequences related to the use of the balloon. METHODS In this multicentre, retrospective cohort study, we included infants who were live born with CDH, either with FETO or without, who were managed postnatally at four centres (UZ Leuven, Leuven, Belgium; Antoine Béclère, Clamart, France; BCNatal, Barcelona, Spain; and HCor-Heart Hospital, São Paulo, Brazil) between April 5, 2002, and June 2, 2021. We primarily assessed the prevalence of all (symptomatic and asymptomatic) tracheomalacia as reported in medical records among infants with and without FETO. Secondarily we assessed the prevalence of symptomatic tracheomalacia and its resolution as reported in medical records, and compared tracheal diameters as measured on postnatal x-rays. Crude and adjusted risk ratios (aRRs) and 95% CIs were calculated via modified Poisson regression models with robust error variances for potential association between FETO and tracheomalacia. Variables included in the adjusted model were the side of the hernia, observed-to-expected lung-to-head ratio, and gestational age at birth. Crude and adjusted mean differences and 95% CIs were calculated via linear regression models to assess the presence and magnitude of association between FETO and tracheal diameters. In infants who had undergone FETO we also assessed the localisation of balloon remnants on x-rays, and the methods used for reversal of occlusion and potential complications associated with balloon remnants as documented in clinical records. Finally we investigated whether the presence of balloon remnants was influenced by the interval between balloon removal and delivery. FINDINGS 505 neonates were included in the study, of whom 287 had undergone FETO and 218 had not. Tracheomalacia was reported in 18 (6%) infants who had undergone FETO and in three (1%) who had not (aRR 6·17 [95% CI 1·83-20·75]; p=0·0030). Tracheomalacia was first reported in the FETO group at a median of 5·0 months (IQR 0·8-13·0). Symptomatic tracheomalacia was reported in 13 (5%) infants who had undergone FETO, which resolved in ten (77%) children by 55·0 months (IQR 14·0-83·0). On average, infants who had undergone FETO had a 31·3% wider trachea (with FETO tracheal diameter 7·43 mm [SD 1·24], without FETO tracheal diameter 5·10 mm [SD 0·84]; crude mean difference 2·32 [95% CI 2·11-2·54]; p<0·0001; adjusted mean difference 2·62 [95% CI 2·35-2·89]; p<0·0001). At birth, the metallic component was visible within the body in 75 (37%) of 205 infants with available thoraco-abdominal x-rays: it was located in the gastrointestinal tract in 60 (80%) and in the lung in 15 (20%). No side-effects were reported for any of the infants during follow-up. The metallic component was more likely to be in the lung than either outside the body or the gastrointestinal tract when the interval between occlusion reversal and birth was less than 24 h. INTERPRETATION Although FETO was associated with an increased tracheal diameter and an increased probability of tracheomalacia, symptomatic tracheomalacia typically resolved over time. There is a higher risk of retention of metallic balloon components if reversal of the occlusion occurs less than 24 h before delivery. Finally, there were no reported side-effects of the metallic component of the balloon persisting in the body during follow-up. Longer-term follow-up is needed to ensure that no tracheal problems arise later in life. FUNDING None.
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Affiliation(s)
- David Basurto
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Department of Maternal Fetal Medicine, Instituto Nacional de Perinatología, Mexico City, Mexico
| | - Kanokwaroon Watananirun
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anne-Gael Cordier
- Obstetrics and Gynecology Department, Antoine Béclère Hospital-AP-HP, Paris Saclay University, Clamart, France; Centre de Référence Maladie Rare: Hernie de Couple Diaphragmatique, Paris Saclay University, Clamart, France
| | - Juan Otaño
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Universitat de Barcelona, IDIBAPS, IRSJD and CIBER-ER, Barcelona, Spain
| | - Diane Carriere
- Pediatric and Neonatal Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, Paris, France
| | - Marianna Scuglia
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; NIHR BRC Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Anna Moraes de Luna Freire Vargas
- Department of Maternal Fetal Medicine, HCor-Heart Hospital, São Paulo, Brazil Fetal medicine Unit, HCor-Heart Hospital, São Paulo, Brazil
| | - Jordi Prat
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Universitat de Barcelona, IDIBAPS, IRSJD and CIBER-ER, Barcelona, Spain
| | - Francesca Maria Russo
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Cleisson Fábio Andrioli Peralta
- Department of Maternal Fetal Medicine, HCor-Heart Hospital, São Paulo, Brazil Fetal medicine Unit, HCor-Heart Hospital, São Paulo, Brazil
| | - Paolo De Coppi
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; NIHR BRC Great Ormond Street Hospital and Institute for Child Health, University College London, London, UK
| | - Eduard Gratacós
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Universitat de Barcelona, IDIBAPS, IRSJD and CIBER-ER, Barcelona, Spain
| | - Alexandra Benachi
- Obstetrics and Gynecology Department, Antoine Béclère Hospital-AP-HP, Paris Saclay University, Clamart, France; Centre de Référence Maladie Rare: Hernie de Couple Diaphragmatique, Paris Saclay University, Clamart, France
| | - Jan Deprest
- My FetUZ Research Group, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium; Institute for Women's Health, University College London, London, UK; Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.
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Kim S, Lee KY, Siddiquee AT, Kim HJ, Nam HR, Ko CS, Kim NH, Shin C. Gender differences in association between expiratory dynamic airway collapse and severity of obstructive sleep apnea. Eur Radiol 2024; 34:3730-3741. [PMID: 37962598 PMCID: PMC11166772 DOI: 10.1007/s00330-023-10322-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/13/2023] [Accepted: 10/03/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Repetitive unbalances and tensions generated by inspiratory efforts against an obstructive upper airway during sleep predispose the development of expiratory central airway collapse. In addition, structures of the upper airway between men and women have differences and could be the reasons for differences in obstructive sleep apnea (OSA) prevalence between genders. The present study aimed to evaluate the association between parameters of expiratory dynamic tracheal collapse measured using chest multidetector CT and objectively measured OSA severity between men and women. MATERIALS AND METHODS A total of 901 participants who underwent chest CT and overnight in-home polysomnography from the Korean Genome and Epidemiology Study were cross-sectionally analyzed (women: 46.2%). The participants were divided into three groups based on OSA severity by apnea-hypopnea index (AHI). Multivariate linear regression analysis was performed to determine the effects of central airway collapse after adjustment for cardiovascular-related covariates. RESULTS In a multivariate analysis, percentages of expiratory lumen structure reductions involving area, diameter, and perimeter were associated with AHI (all p values < 0.05) and with OSA severity (moderate-to-severe OSA than no OSA: β = 3.30%, p = 0.03; β = 2.05%, p = 0.02; β = 1.97%, p = 0.02, respectively) in women, whereas men had only a greater percentage of expiratory wall thickness reduction in moderate-to-severe OSA than no OSA (β = 0.72%, p = 0.003). In addition, women with both mild OSA and moderate-to-severe OSA had higher expiratory tracheal collapse than men without OSA, and a moderate effect of sex was observed (p for interaction = 0.007). CONCLUSION The expiratory dynamic tracheal collapse was independently associated with severity of OSA in women than in men. CLINICAL RELEVANCE STATEMENT Differences of pharyngeal structures and inherent features of airways by genders may affect the dissimilarities in vulnerability to sleep apnea between men and women. KEY POINTS • The expiratory dynamic tracheal collapse was independently associated with severity of OSA in women than in men. • Women with over mild OSA had higher expiratory tracheal collapse than men without OSA, and moderate effect of sex was observed. • Structural differences of airway may affect differences in susceptibility of sleep apnea between genders.
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Affiliation(s)
- Soriul Kim
- Institute for Human Genomic Study, College of Medicine, Korea University, Seoul, Republic of Korea
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ki Yeol Lee
- Department of Radiology, Korea University Ansan Hospital, #123, Jeokgeum-Ro, Danwon-Gu, Ansan, 15355, Republic of Korea.
- Department of Radiology, Korea University Guro Hospital, Seoul, Republic of Korea.
| | - Ali Tanweer Siddiquee
- Institute for Human Genomic Study, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Hyeon Jin Kim
- Department of Neurology, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Hye Ryeong Nam
- Institute for Human Genomic Study, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Chang Seop Ko
- Department of Radiology, Korea University Ansan Hospital, #123, Jeokgeum-Ro, Danwon-Gu, Ansan, 15355, Republic of Korea
| | - Nan Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Chol Shin
- Institute for Human Genomic Study, College of Medicine, Korea University, Seoul, Republic of Korea.
- Biomedical Research Center, Korea University Ansan Hospital, Ansan, Republic of Korea.
- Division of Respiratory and Critical Care, Department of Internal Medicine, Korea University Ansan Hospital, #123, Jeokgeum-Ro, Danwon-Gu, Ansan, 15355, Republic of Korea.
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Williams ZJ, Orton CM, Garner JL, Chan LT, Tana A, Shah PL, Polkey MI, Semple T, Hull JH. Feasibility of continuous bronchoscopy during exercise in the assessment of large airway movement in healthy subjects. J Appl Physiol (1985) 2024; 136:1429-1439. [PMID: 38660727 DOI: 10.1152/japplphysiol.00746.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/15/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Excessive dynamic airway collapse (EDAC) is a recognized cause of exertional dyspnea arising due to invagination of the trachea and/or main bronchi. EDAC is typically assessed by evaluating large airway movement with forced expiratory maneuvers. This differs from the respiratory response to exercise hyperpnea. We aimed to evaluate large airway movement during physical activity, with continuous bronchoscopy during exercise (CBE), in healthy subjects and compare findings with resting bronchoscopic maneuvers and imaging techniques. Twenty-eight individuals were recruited to complete two visits including treadmill-based CBE, to voluntary exhaustion, and cine magnetic resonance imaging (MRI) with forced expiratory maneuvers at rest. Twenty-five subjects [aged 29 (26-33) yr, 52% female] completed the study (n = 2 withdrew before bronchoscopy, and one was unable to tolerate insertion of bronchoscope). The majority (76%) achieved a peak heart rate of >90% predicted during CBE. The procedure was prematurely terminated in five subjects (n = 3; elevated blood pressure and n = 2; minor oxygen desaturation). The CBE assessment enabled adequate tracheal visualization in all cases. Excessive dynamic airway collapse (tracheal collapse ≥50%) was identified in 16 subjects (64%) on MRI, and in six (24%) individuals during resting bronchoscopy, but in no cases with CBE. No serious adverse events were reported, but minor adverse events were evident. The CBE procedure permits visualization of large airway movement during physical activity. In healthy subjects, there was no evidence of EDAC during strenuous exercise, despite evidence during forced maneuvers on imaging, thus challenging conventional approaches to diagnosis.NEW & NOTEWORTHY This study demonstrates that large airway movement can be visualized with bronchoscopy undertaken during vigorous exercise. This approach does not require sedation and permits characterization of the behavior of the large airways and the tendency toward collapse during upright, ambulatory exercise. In healthy individuals, the response pattern of the large airways during exercise appears to differ markedly from the pattern of airway closure witnessed during forced expiratory maneuvers, assessed via imaging.
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Affiliation(s)
- Zander J Williams
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
| | - Christopher M Orton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Justin L Garner
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ley T Chan
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Anand Tana
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Michael I Polkey
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Thomas Semple
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Department of Radiology, Royal Brompton Hospital, London, United Kingdom
| | - James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- Division of Surgery and Interventional Science, Institute of Sport, Exercise and Health (ISEH), University College London, London, United Kingdom
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Funes‐Ferrada R, Barrios‐Ruiz A, Yu Lee‐Mateus A, Johnson MM, Fernandez‐Bussy S, Abia‐Trujillo D. Long-term pneumatic stenting with positive expiratory pressure therapy for severe expiratory central airway collapse. Respirol Case Rep 2024; 12:e01367. [PMID: 38725709 PMCID: PMC11079437 DOI: 10.1002/rcr2.1367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/28/2024] [Indexed: 05/12/2024] Open
Abstract
Expiratory central airway collapse (ECAC) comprising excessive central airway collapse (EDAC) and tracheobronchomalacia. Treatment is challenging for severe cases that are not candidates for surgical management. We report a case of severe ECAC successfully managed with continuous positive airway pressure (CPAP) therapy. A 75-year-old female patient status post right pneumonectomy, presented with chronic cough. Dynamic bronchoscopy evaluation showed severe EDAC which improved with intraprocedural noninvasive positive pressure (NIPPV) therapy. Due to patients' comorbidities, she was not a candidate to surgical tracheobronchoplasty. Therefore, we attempted pneumatic stenting with long-term CPAP therapy resulting in improvement of symptoms and functional capacity. The long-term efficacy of pneumatic stenting has not been clearly established yet. Literature review of management of ECAC with NIPPV consist primarily of case reports and there is only one clinical trial being conducted to assess the efficacy of CPAP therapy in ECAC. While NIPPV arises as a sufficient alternative for management of severe ECAC, larger scale studies are needed to prove the real efficacy of NIPPV in this setting.
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Affiliation(s)
| | - Alanna Barrios‐Ruiz
- Division of Pulmonary, Allergy, and Sleep MedicineMayo ClinicJacksonvilleFloridaUSA
| | | | - Margaret M. Johnson
- Division of Pulmonary, Allergy, and Sleep MedicineMayo ClinicJacksonvilleFloridaUSA
| | | | - David Abia‐Trujillo
- Division of Pulmonary, Allergy, and Sleep MedicineMayo ClinicJacksonvilleFloridaUSA
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Gesthalter YB, Channick CL. Interventional Pulmonology: Extending the Breadth of Thoracic Care. Annu Rev Med 2024; 75:263-276. [PMID: 37827195 DOI: 10.1146/annurev-med-050922-060929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Interventional pulmonary medicine has developed as a subspecialty focused on the management of patients with complex thoracic disease. Leveraging minimally invasive techniques, interventional pulmonologists diagnose and treat pathologies that previously required more invasive options such as surgery. By mitigating procedural risk, interventional pulmonologists have extended the reach of care to a wider pool of vulnerable patients who require therapy. Endoscopic innovations, including endobronchial ultrasound and robotic and electromagnetic bronchoscopy, have enhanced the ability to perform diagnostic procedures on an ambulatory basis. Therapeutic procedures for patients with symptomatic airway disease, pleural disease, and severe emphysema have provided the ability to palliate symptoms. The combination of medical and procedural expertise has made interventional pulmonologists an integral part of comprehensive care teams for patients with oncologic, airway, and pleural needs. This review surveys key areas in which interventional pulmonologists have impacted the care of thoracic disease through bronchoscopic intervention.
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Affiliation(s)
- Yaron B Gesthalter
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA;
| | - Colleen L Channick
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA;
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Crutu A, Hanna A. [The role of surveillance bronchoscopy after lung transplantation]. Rev Mal Respir 2024; 41:59-68. [PMID: 37827927 DOI: 10.1016/j.rmr.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 08/23/2023] [Indexed: 10/14/2023]
Abstract
The role of surveillance bronchoscopy after lung transplantation. Lung transplantation is currently accepted as a potential treatment for end-stage respiratory diseases. That said, airway complications and the onset of chronic lung allograft dysfunction remain major causes of morbidity and mortality subsequent to lung transplantation and a significant obstacle to long-term survival. In this article, we discuss the advantages and limitations of bronchial endoscopy in post-lung transplant monitoring.
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Affiliation(s)
- A Crutu
- Service de chirurgie thoracique et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France.
| | - A Hanna
- Service de chirurgie thoracique et transplantation cardio-pulmonaire, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
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8
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Kelly D, Juvet F, Lamb V, Holdsworth A. Bronchial collapse and bronchial stenting in 9 dogs. J Vet Intern Med 2023; 37:2460-2467. [PMID: 37695258 PMCID: PMC10658526 DOI: 10.1111/jvim.16859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/24/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Principal and lobar bronchial collapse is increasingly recognized as an isolated entity. OBJECTIVE Retrospectively describe the procedure and outcomes of dogs undergoing bronchial stenting at a single referral hospital. ANIMALS Nine client-owned dogs with variable degrees of collapse of the left principal bronchus (LPB), lobar bronchus 1 (LB1), and lobar bronchus 2 (LB2), and with clinically relevant signs of respiratory dysfunction. METHODS Data were collected from patient records. All dogs underwent stenting of the LPB and LB2. Anatomic and functional impairment grades were assigned to each case before and 4 weeks after stenting. Data regarding response to stenting and complications were evaluated. RESULTS Bronchial stenting was considered successful in all cases, with all dogs experiencing improved quality of life (QOL), and decreased functional impairment grade at 4 weeks post-stenting. Follow-up of >6 months was available for 6 dogs and of these, 5 were alive at 12 months, 3 were alive at 18 months, and 1 was alive at 24 months. Stent-related complications occurred in 4 dogs, and were resolvable in 3. Two dogs developed pneumothorax, 1 developed recurrent pneumonia, and 1 developed new-onset coughing. All dogs had mild and manageable coughing post-stenting. CONCLUSIONS AND CLINICAL IMPORTANCE Stenting of the LBP and LB2 might be an effective option for dogs with advanced collapse of these bronchi and associated signs. Although all included dogs had resolution or improvement of clinical signs considered life-threatening or as affecting QOL, ongoing coughing is expected. Patient selection appears important with regard to achieving successful outcomes.
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Affiliation(s)
- Darren Kelly
- Southern Counties Veterinary SpecialistsRingwoodUnited Kingdom
| | - Florence Juvet
- Southern Counties Veterinary SpecialistsRingwoodUnited Kingdom
| | - Valerie Lamb
- Southern Counties Veterinary SpecialistsRingwoodUnited Kingdom
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9
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Pugh CP, Ali S, Agarwal A, Matlock DN, Sharma M. Dynamic computed tomography for evaluation of tracheobronchomalacia in premature infants with bronchopulmonary dysplasia. Pediatr Pulmonol 2023; 58:3255-3263. [PMID: 37646125 PMCID: PMC10993911 DOI: 10.1002/ppul.26652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/26/2023] [Accepted: 08/19/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Dynamic computed tomography (dCT) gives real-time physiological information and objective descriptions of airway narrowing in tracheobronchomalacia (TBM). There is a paucity of literature in the evaluation of TBM by dCT in premature infants with bronchopulmonary dysplasia (BPD). The aim of this study is to describe the findings of dCT and resultant changes in management in premature infants with TBM. METHODS A retrospective study of 70 infants was performed. Infants included were <32 weeks gestation without major anomalies. TBM was defined as ≥50% expiratory reduction in cross-sectional area with severity defined as mild (50%-75%), moderate (≥75%-90%), or severe (≥90%). RESULTS Dynamic CT diagnosed malacia in 53% of infants. Tracheomalacia was identified in 49% of infants with severity as 76% mild, 18% moderate, and 6% severe. Bronchomalacia was identified in 43% of infants with varying severity (53% mild, 40% moderate, 7% severe). Resultant management changes included PEEP titration (44%), initiation of bethanechol (23%), planned tracheostomy (20%), extubation trial (13%), and inhaled ipratropium bromide (7%). CONCLUSION Dynamic CT is a useful noninvasive diagnostic tool for airway evaluation of premature infants. Presence and severity of TBM can provide actionable information to guide more precise clinical decision making.
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Affiliation(s)
- C. Preston Pugh
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Sumera Ali
- Department of Radiology, Emory University, Children’s Hospital of Atlanta, GA
| | - Amit Agarwal
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - David N. Matlock
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Megha Sharma
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
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Santos Portela AM, Radu DM, Onorati I, Peretti M, Freynet O, Uzunhan Y, Jerbi S, Martinod E. [Interventionnal bronchoscopy for the treatment of tracheobronchomalacia]. Rev Mal Respir 2023; 40:700-715. [PMID: 37714754 DOI: 10.1016/j.rmr.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/18/2023] [Indexed: 09/17/2023]
Abstract
Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.
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Affiliation(s)
- A M Santos Portela
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - D M Radu
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - I Onorati
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - M Peretti
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - O Freynet
- Département de pneumologie, faculté de Médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - Y Uzunhan
- Département de pneumologie, faculté de Médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - S Jerbi
- Département d'anesthésie, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France
| | - E Martinod
- Département de chirurgie thoracique et vasculaire, faculté de médecine SMBH, Assistance publique-Hôpitaux de Paris, hôpitaux universitaires Paris Seine-Saint-Denis, hôpital Avicenne, université Sorbonne Paris Nord, Bobigny, France.
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11
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Mondal A, Visner GA, Kaza AK, Dupont PE. A novel ex vivo tracheobronchomalacia model for airway stent testing and in vivo model refinement. J Thorac Cardiovasc Surg 2023; 166:679-687.e1. [PMID: 37156367 PMCID: PMC10524727 DOI: 10.1016/j.jtcvs.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/14/2023] [Accepted: 04/10/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We sought to develop an ex vivo trachea model capable of producing mild, moderate, and severe tracheobronchomalacia for optimizing airway stent design. We also aimed to determine the amount of cartilage resection required for achieving different tracheobronchomalacia grades that can be used in animal models. METHODS We developed an ex vivo trachea test system that enabled video-based measurement of internal cross-sectional area as intratracheal pressure was cyclically varied for peak negative pressures of 20 to 80 cm H2O. Fresh ovine tracheas were induced with tracheobronchomalacia by single mid-anterior incision (n = 4), mid-anterior circumferential cartilage resection of 25% (n = 4), and 50% per cartilage ring (n = 4) along an approximately 3-cm length. Intact tracheas (n = 4) were used as control. All experimental tracheas were mounted and experimentally evaluated. In addition, helical stents of 2 different pitches (6 mm and 12 mm) and wire diameters (0.52 mm and 0.6 mm) were tested in tracheas with 25% (n = 3) and 50% (n = 3) circumferentially resected cartilage rings. The percentage collapse in tracheal cross-sectional area was calculated from the recorded video contours for each experiment. RESULTS Ex vivo tracheas compromised by single incision and 25% and 50% circumferential cartilage resection produce tracheal collapse corresponding to clinical grades of mild, moderate, and severe tracheobronchomalacia, respectively. A single anterior cartilage incision produces saber-sheath type tracheobronchomalacia, whereas 25% and 50% circumferential cartilage resection produce circumferential tracheobronchomalacia. Stent testing enabled the selection of stent design parameters such that airway collapse associated with moderate and severe tracheobronchomalacia could be reduced to conform to, but not exceed, that of intact tracheas (12-mm pitch, 0.6-mm wire diameter). CONCLUSIONS The ex vivo trachea model is a robust platform that enables systematic study and treatment of different grades and morphologies of airway collapse and tracheobronchomalacia. It is a novel tool for optimization of stent design before advancing to in vivo animal models.
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Affiliation(s)
- Abhijit Mondal
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
| | - Gary A Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Pierre E Dupont
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
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12
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Duignan N, Ridge P, Leonard S, McDonnell M, Cusack R, Harrison M, Rutherford R, O'Malley N, Dolan C. Expanded central role of the respiratory physiotherapists in the community setting. Ir J Med Sci 2023; 192:1581-1588. [PMID: 36380190 PMCID: PMC9666941 DOI: 10.1007/s11845-022-03213-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022]
Abstract
The development of community hubs through the Slaintecare initiative will rely on respiratory physiotherapists and clinical nurse specialists for the management of chronic respiratory diseases. The role of the respiratory physiotherapist has evolved dramatically over the last decade. We review the increasing scope of practice of the physiotherapist and the evidence base for same. We pay particular attention to the role of the physiotherapist in areas such as pulmonary rehabilitation, sputum clearance, neuromuscular disease, chronic respiratory failure, ambulatory oxygen assessments and dysfunctional breathing. We give an in depth review of sputum clearance techniques. We also address areas of potential future expansion for the role of the physiotherapist such as prescription and initiation of non-invasive ventilation.
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Affiliation(s)
- Niamh Duignan
- Department of Respiratory Physiotherapists, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Padraic Ridge
- Department of Respiratory Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland.
| | - Sinead Leonard
- Department of Respiratory Physiotherapists, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Melissa McDonnell
- Department of Respiratory Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Ruth Cusack
- Department of Respiratory Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Michael Harrison
- Department of Respiratory Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Robert Rutherford
- Department of Respiratory Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Niamh O'Malley
- Department of Respiratory Physiotherapists, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Ciara Dolan
- Department of Respiratory Physiotherapists, Galway University Hospitals, Newcastle Road, Galway, Ireland
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13
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Abia-Trujillo D, Yu Lee-Mateus A, Hernandez-Rojas D, Pulipaka SP, Garcia-Saucedo JC, Saifi O, Majid A, Fernandez-Bussy S. Excessive Dynamic Airway Collapse Severity Scoring System: A Call Out for an Overall Severity Determination. J Bronchology Interv Pulmonol 2023; 30:200-206. [PMID: 36999946 DOI: 10.1097/lbr.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 02/20/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Severe excessive dynamic airway collapse (EDAC) is defined as airway narrowing due to posterior wall protrusion into the airway lumen, >90%. We aimed to establish an overall severity score to assess severe EDAC and the need for subsequent intervention. METHODS A retrospective study of patients who underwent dynamic bronchoscopy for evaluation of expiratory central airway collapse between January 2019 and July 2021. A numerical value was given to each tracheobronchial segmental collapse: 0 points (<70%), 1 point (70% to 79%), 2 points (80% to 89%), and 3 points (>90%) to be added for an overall EDAC severity score per patient. We compared the score among patients who underwent stent trials (severe EDAC) and those who did not. Based on the receiver operating characteristics curve, a cutoff total score to predict severe EDAC was calculated. RESULTS One hundred fifty-eight patients were included. Patients were divided into severe (n = 60) and nonsevere (n = 98) EDAC. A cutoff of 9 as the total score had a sensitivity of 94% and a specificity of 74% to predict severe EDAC, based on an area under the curve 0.888 (95% CI: 0.84, 0.93; P < 0.001). CONCLUSION Our EDAC Severity Scoring System was able to discern between severe and nonsevere EDAC by an overall score cutoff of 9, with high sensitivity and specificity for predicting severe disease and the need for further intervention, in our institution.
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Affiliation(s)
| | | | | | | | - Juan C Garcia-Saucedo
- Department of Internal Medicine, Internal Medicine Resident, Morristown Medical Center, Morristown, NJ
| | - Omran Saifi
- Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, FL
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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14
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Lazzaro R, Inra ML. Tracheobronchoplasty: Indications and Best Approaches. Thorac Surg Clin 2023; 33:141-147. [PMID: 37045483 DOI: 10.1016/j.thorsurg.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Tracheobronchomalacia (TBM) is an increasingly recognized abnormality of the central airways in patients with respiratory symptoms. Severe TBM in symptomatic patients warrants screening dynamic CT of the chest and/or awake dynamic bronchoscopy. The goal of surgical repair is to restore the C-shaped configuration of the airway lumen and splint or secure the lax posterior membrane to the mesh to ameliorate symptoms. Robotic tracheobronchoplasty is safe and associated with improvements in pulmonary function and subjective improvement in quality of life.
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Affiliation(s)
- Richard Lazzaro
- Thoracic Surgery, Southern Region Robert Wood Johnson Barnabas Health, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901, USA.
| | - Matthew L Inra
- 130 East 77th Street, 4th Floor, New York, NY 10075, USA
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15
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Kalehoff JP, Bodduluri S, Terry NLJ, Nath H, Bhatt SP. Flow-Volume Curve Patterns in Radiologic Expiratory Central Airway Collapse. Ann Am Thorac Soc 2023; 20:609-612. [PMID: 36880973 PMCID: PMC10112409 DOI: 10.1513/annalsats.202204-303rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
| | | | | | - Hrudaya Nath
- University of Alabama at BirminghamBirmingham, Alabama
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16
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Mondoni M, Rinaldo RF, Solidoro P, Di Marco F, Patrucco F, Pavesi S, Baccelli A, Carlucci P, Radovanovic D, Santus P, Raimondi F, Vedovati S, Morlacchi LC, Blasi F, Sotgiu G, Centanni S. Interventional pulmonology techniques in lung transplantation. Respir Med 2023; 211:107212. [PMID: 36931574 DOI: 10.1016/j.rmed.2023.107212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/04/2023] [Accepted: 03/12/2023] [Indexed: 03/19/2023]
Abstract
Lung transplantation is a key therapeutic option for several end-stage lung diseases. Interventional pulmonology techniques, mostly bronchoscopy, play a key role throughout the whole path of lung transplantation, from donor evaluation to diagnosis and management of post-transplant complications. We carried out a non-systematic, narrative literature review aimed at describing the main indications, contraindications, performance characteristics and safety profile of interventional pulmonology techniques in the context of lung transplantation. We highlighted the role of bronchoscopy during donor evaluation and described the debated role of surveillance bronchoscopy (with bronchoalveolar lavage and transbronchial biopsy) to detect early rejection, infections and airways complications. The conventional (transbronchial forceps biopsy) and the new techniques (i.e. cryobiopsy, biopsy molecular assessment, probe-based confocal laser endomicroscopy) can detect and grade rejection. Several endoscopic techniques (e.g. balloon dilations, stent placement, ablative techniques) are employed in the management of airways complications (ischemia and necrosis, dehiscence, stenosis and malacia). First line pleural interventions (i.e. thoracentesis, chest tube insertion, indwelling pleural catheters) may be useful in the context of early and late pleural complications occurring after lung transplantation. High quality studies are advocated to define endoscopic standard protocols and thus help improving long-term prognostic outcomes of lung transplant recipients.
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Affiliation(s)
- Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.
| | - Rocco Francesco Rinaldo
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Paolo Solidoro
- S.C. Pneumologia, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Fabiano Di Marco
- Pulmonary Medicine Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy; Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità, Novara, Italy
| | - Stefano Pavesi
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Andrea Baccelli
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Paolo Carlucci
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
| | | | - Sergio Vedovati
- Pediatric Intensive Care Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Francesco Blasi
- Respiratory Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy; Department Pathophysiology and Trasplantation, Università degli studi di Milano, Milano, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical, Experimental Sciences, University of Sassari, Sassari, Italy
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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17
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Buitrago DH, Majid A, Wilson JL, Ospina-Delgado D, Kheir F, Bezuidenhout AF, Parikh MS, Chee AC, Litmanovich D, Gangadharan SP. Tracheobronchoplasty yields long-term anatomy, function, and quality of life improvement for patients with severe excessive central airway collapse. J Thorac Cardiovasc Surg 2023; 165:518-525. [PMID: 35764462 DOI: 10.1016/j.jtcvs.2022.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 05/03/2022] [Accepted: 05/30/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES This study examines the long-term anatomic and clinical effects of tracheobronchoplasty in severe excessive central airway collapse. METHODS Included patients underwent tracheobronchoplasty for excessive central airway collapse (2002-2016). The cross-sectional area of main airways on dynamic airway computed tomography was measured before and after tracheobronchoplasty. Expiratory collapse was calculated as the difference between inspiratory and expiratory cross-sectional area divided by inspiratory cross-sectional area ×100. The primary outcome was improvement in the percentage of expiratory collapse in years 1, 2, and 5 post-tracheobronchoplasty. Secondary outcomes included mean response profile for the 6-minute walk test, Cough-Specific Quality of Life Questionnaire, Karnofsky Performance Status score, and St George Respiratory Questionnaire. Repeated-measures analysis of variance was used for statistical analyses. RESULTS The cohort included 61 patients with complete radiological follow-up at years 1, 2, and 5 post-tracheobronchoplasty. A significant linear decrease in the percentage of expiratory collapsibility of the central airways after tracheobronchoplasty was present. Anatomic repair durability was preserved 5 years after tracheobronchoplasty, with decrease in percentage of expiratory airway collapse up to 40% and 30% at years 1 and 2, respectively. The St George Respiratory Questionnaire (74.7 vs 41.8%, P < .001) and Cough-Specific Quality of Life Questionnaire (78 vs 47, P < .001) demonstrated significant improvement at year 5 compared with baseline. Similar results were observed in the 6-minute walk test (1079 vs 1268 ft, P < .001) and Karnofsky score (57 vs 82, P < .001). CONCLUSIONS Tracheobronchoplasty has durable effects on airway anatomy, functional status, and quality of life in carefully selected patients with severe excessive central airway collapse.
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Affiliation(s)
- Daniel H Buitrago
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Daniel Ospina-Delgado
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Abraham F Bezuidenhout
- Department of Radiology, Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Mihir S Parikh
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Alex C Chee
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Diana Litmanovich
- Department of Radiology, Cardiothoracic Imaging, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Mass.
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18
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Majid A, Ospina-Delgado D, Ayala A, Gangadharan SP, Alape D, Buitrago D, Parikh MS, Wilson JL, Chee AC, Fernandez-Bussy S, Herth FJF, Kheir F. Stent Evaluation for Expiratory Central Airway Collapse: Does the Type of Stent Really Matter? J Bronchology Interv Pulmonol 2023; 30:37-46. [PMID: 35318996 DOI: 10.1097/lbr.0000000000000842] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 11/05/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Careful selection of patients with expiratory central airway collapse (ECAC) that may benefit from tracheobronchoplasty (TBP) can be aided by a short-term airway stent evaluation. This can be performed with either silicone Y-stents (SYSs) or uncovered self-expanding metallic airway-stents (USEMAS). No direct comparison has been made between these 2 stent types. METHODS This was a small retrospective review of consecutive patients that underwent a stent evaluation. A propensity score was used to match patients in the USEMAS and SYS groups. Outcomes included complications, changes in the health-related quality-of-life (HR-QoL), and changes in exercise capacity. Baseline measurements were compared with those obtained during stent evaluation and after TBP. RESULTS Forty-two patients with severe ECAC underwent USEMAS placement, while 18 patients had an SYS placed. Propensity score matching resulted in 13 matched SYS and USEMAS pairs. The SYS group had an increased rate of mucus plugging (38.5% vs. 0%, P <0.047). Although not statically significant, a clinical improvement was observed in HR-QoL and exercise capacity in the USEMAS group during stent placement. In patients who underwent TBP, both USEMAS and SYS groups had a statistically significant change in the Modified Medical Research Council Dyspnea Scale during stent evaluation and after TBP. CONCLUSION In patients with severe ECAC, short-term evaluation with airway stents appears to be safe and improves respiratory symptoms, HR-QoL, and exercise capacity. The use of USEMAS led to a lower complication rate, a greater improvement in HR-QoL and exercise capacity, and appeared to better predict how the patients would respond to TBP.
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Affiliation(s)
- Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Daniel Ospina-Delgado
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Alvaro Ayala
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Sidhu P Gangadharan
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Daniel Alape
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
- Department of Internal Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Daniel Buitrago
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Mihir S Parikh
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Alex C Chee
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | | | - Felix J F Herth
- Department of Pulmonary and Critical Care Medicine, Thoraxklinik-University of Heidelberg, Heidelberg, Germany
| | - Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
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19
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Olevano C, Gagliardi G, Antonio M, Eugenio S, Flora L, Lorenzo ED, Fiorani B. The Secret behind Extreme Hypoxia Tolerance: A "Slow-Growth" Thoracoabdominal Aneurysm. AORTA (STAMFORD, CONN.) 2022; 10:304-307. [PMID: 36539149 PMCID: PMC9767754 DOI: 10.1055/s-0042-1757796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A 61-year-old man presented to our institution complaining of back pain. Breathing was comfortable. An arterial blood gas showed extreme hypoxia causing chronic respiratory alkalosis. Further investigations revealed aneurysmal dilatation of the ascending aorta and the Crawford Type II thoracoabdominal aneurysm, with compression of both the left main bronchus and the right pulmonary artery. The patient was managed with a two-stage hybrid surgical approach comprising total arch replacement using the frozen elephant trunk technique followed by endovascular repair.
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Affiliation(s)
- Carlo Olevano
- Division of Cardiac Surgery, Department of Cardiovascular Surgery, S.G. Moscati Hospital, Avellino, Italy,Address for correspondence Carlo Olevano, MD Division of Cardiac Surgery, Department of Cardiovascular Surgery, S.G. Moscati HospitalContrada Amoretta, 83100 Avellino (AV)Italy
| | - Giuliano Gagliardi
- Division of Cardiac Imaging, Department of Radiology, S.G. Moscati Hospital, Avellino, Italy
| | - Mollo Antonio
- Division of Cardiac Surgery, Department of Cardiovascular Surgery, S.G. Moscati Hospital, Avellino, Italy
| | - Santaniello Eugenio
- Division of Cardiac Surgery, Department of Cardiovascular Surgery, S.G. Moscati Hospital, Avellino, Italy
| | - Loris Flora
- Division of Vascular Surgery, Department of Cardiovascular Surgery, S.G. Moscati Hospital, Avellino, Italy
| | - Emilio Di Lorenzo
- Division of Cardiology, Department of Cardiovascular Surgery, S.G. Moscati Hospital, Avellino, Italy
| | - Brenno Fiorani
- Division of Cardiac Surgery, Department of Cardiovascular Surgery, S.G. Moscati Hospital, Avellino, Italy
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Ventilator-Assisted Inspiratory and Expiratory Breath-Hold Thoracic Computed Tomographic Scans Can Detect Dynamic and Static Airway Collapse in Dogs with Limited Agreement with Tracheobronchoscopy. Animals (Basel) 2022; 12:ani12223091. [PMID: 36428319 PMCID: PMC9686793 DOI: 10.3390/ani12223091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/11/2022] Open
Abstract
Airway collapse (AC) in dogs includes a tracheal collapse, mainstem and lobar bronchial collapse, and bronchomalacia (i.e., segmental/subsegmental bronchial collapse). The clinical presentation of AC may overlap with non-collapsible airway disease (NCAD) or another non-lower airway respiratory disease (NLARD). This study determined whether paired inspiratory (I)/expiratory (E)-breath-hold computed tomography (I/E-BH CT) can detect a static and dynamic AC in dogs with spontaneous respiratory disease and it compared the CT-derived metrics of the AC to the tracheobronchoscopy metrics. The CT-acquired I and E diameter and cross-sectional area (CSA) for the trachea, mainstem and lobar bronchi in dogs with an AC (n = 16), NCAD (16), and NLARD (19) served for a dynamic percent of the airway narrowing (%AN) calculation. A scoring system assessed the bronchomalacia. The circularity was calculated for each airway. The results were compared to the tracheobronchoscopy collapse grading. In the dogs with an AC, the %AN was larger for the trachea, right mainstem bronchus and right middle lobar bronchus when they were compared to the dogs with NCAD and NLARD. Flattening was only identified for the trachea of the AC dogs. The agreement between the CT and tracheobronchoscopy scores was 20% from trachea to the lobar bronchi and 47% for the segmental/subsegmental bronchi. Paired I/E-BH CT can detect static and dynamic AC with limited agreement with the tracheobronchoscopy metrics. Independent scoring systems that are tailored to the clinical manifestations of functional impairments are needed.
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Krefft SD, Oh A, Zell-Baran LM, Wolff J, Moore CM, Macedonia TV, Rose CS. Semiquantitative Chest Computed Tomography Assessment Identifies Expiratory Central Airway Collapse in Symptomatic Military Personnel Deployed to Iraq and Afghanistan. J Thorac Imaging 2022; 37:117-124. [PMID: 34121086 PMCID: PMC8876438 DOI: 10.1097/rti.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE We noted incidental findings on chest computed tomography (CT) imaging of expiratory central airway collapse (ECAC) in dyspneic patients after military deployment to southwest Asia (mainly Iraq and Afghanistan). We developed a standardized chest CT protocol with dynamic expiration to enhance diagnostic reliability and investigated demographic, clinical, and deployment characteristics possibly associated with ECAC. MATERIALS AND METHODS We calculated ECAC in 62 consecutive post-9/11 deployers with dyspnea who underwent multi-detector chest CT acquisition. ECAC was defined as ≥70% reduction in the cross-sectional tracheal area at dynamic expiration. We compared demographics (age, smoking, body mass index), comorbid conditions (gastroesophageal reflux, obstructive sleep apnea [OSA]), and clinical findings (air trapping, forced expiratory volume in 1 second percent predicted) in deployers with and without ECAC. We examined associations between ECAC and forced expiratory volume in 1 second percent predicted, air trapping, OSA, deployment duration, and blast exposure. RESULTS Among 62 consecutive deployers with persistent dyspnea, 37% had ECAC. Three had severe (>85%) collapse. Those with ECAC were older (mean age 46 vs. 40 y, P=0.02), but no other demographic or clinical characteristics were statistically different among the groups. Although not statistically significant, ECAC odds were 1.5 times higher (95% confidence interval: 0.9, 2.5) for each additional year of southwest Asia deployment. Deployers with ECAC had 1.6 times greater odds (95% confidence interval: 0.5, 4.8) of OSA. CONCLUSIONS Findings suggest that ECAC is common in symptomatic southwest Asia deployers. Chest high-resolution CT with dynamic expiration may provide an insight into the causes of dyspnea in this population, although risk factors for ECAC remain to be determined. A standardized semiquantitative approach to CT-based assessment of ECAC should improve reliable diagnosis in dyspneic patients.
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Affiliation(s)
- Silpa D. Krefft
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- Veterans Administration Eastern Colorado Health Care System, Division of Pulmonary and Critical Care Medicine
- Division of Pulmonary and Critical Care, School of Medicine
| | - Andrea Oh
- National Jewish Health, Department of Radiology
| | - Lauren M. Zell-Baran
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- Department of Epidemiology, Colorado School of Public Health
| | - Jenna Wolff
- Child Health Associate/Physician Assistant Program, School of Medicine
| | - Camille M. Moore
- National Jewish Health, Center for Genes, Environment and Health, Denver
- Department of Biostatistics and Informatics, University of Colorado Aurora, CO
| | - Tony V. Macedonia
- Division of Pulmonary and Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Cecile S. Rose
- National Jewish Health, Division of Environmental and Occupational Health Sciences
- Division of Pulmonary and Critical Care, School of Medicine
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22
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Gaggini G, Nkamicaniye LM, Meyer S, Dubois PE. Expiratory central airway collapse during positive pressure ventilation: a case report. BMC Anesthesiol 2022; 22:50. [PMID: 35183105 PMCID: PMC8857820 DOI: 10.1186/s12871-022-01591-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Physiologic narrowing of the central airway occurs during expiration. Conditions in which this narrowing becomes excessive are referred to as expiratory central airway collapse. Expiratory central airway collapse is usually managed by applying positive pressure to the airways, which acts as a pneumatic stent. The particularity of the case reported here included the patient’s left main bronchus being permeable during spontaneous breathing but collapsing during general anaesthesia, despite positive pressure ventilation and positive end-expiratory pressure.
Case presentation
We present the case of a 55-year-old man admitted for the placement of a ureteral JJ stent. Rapid desaturation occurred a few minutes after the onset of anaesthesia. After excluding the most common causes of desaturation, fibreoptic bronchoscopy was performed through the tracheal tube and revealed complete collapse of the left main bronchus. The collapse persisted despite the application of positive end-expiratory pressure and several recruitment manoeuvres. After recovery of spontaneous ventilation, the collapse was lifted, and saturation increased back to normal levels. No evidence of extrinsic compression was found on chest X-rays or computed tomography scans.
Conclusion
Cases of unknown expiratory central airway collapse reported in the literature were usually managed with positive pressure ventilation. This approach has been unsuccessful in the case described herein. Our hypothesis is that mechanical bending of the left main bronchus occurred due to loss of the patient’s natural position and thoracic muscle tone under general anaesthesia with neuromuscular blockade. When possible, spontaneous ventilation should be maintained in patients with known or suspected ECAC.
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Ratwani AP, Davis A, Maldonado F. Current practices in the management of central airway obstruction. Curr Opin Pulm Med 2022; 28:45-51. [PMID: 34720097 DOI: 10.1097/mcp.0000000000000838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Airway obstruction continues to cause substantial pulmonary morbidity and mortality. We present a review of classic, current, and evolving management techniques, highlighting recently published studies on the topic. Recommendations have historically been primarily based on anecdotal experience, case reports, and retrospective studies, but more solid evidence has emerged in the last decade. RECENT FINDINGS Novel endobronchial stents are being developed to mitigate the issues of stent migration, mucus plugging, fracture, and granulation tissue formation. Endobronchial drug delivery has become an active area of translational and clinical research, especially with regards to antineoplastic agents used for malignant airway stenosis. Even classic or updated techniques such as spray cryotherapy, injections of mitomycin-c, and balloon dilation have recently been examined in methodologically sound studies. Finally, recently published data have confirmed that patient breathlessness and quality of life improve significantly with therapeutic airway interventions. A multimodal and multidisciplinary approach to patient care is key to achieving the best outcomes. SUMMARY The treatment of central airway stenosis is often multimodal and should focus on patient-centric factors, taking into account risks and benefits of the procedure, operator, and center expertise, and always occur in the context of a multidisciplinary approach. Evidence-based clinical research is increasingly driving patient management.
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Affiliation(s)
| | - Andrea Davis
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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24
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Hernandez‐Rojas D, Abia‐Trujillo D, Rojas C, Yu Lee‐Mateus A, Castillo‐Larios R, Pulipaka SP, Fernandez‐Bussy S. Cinematic CT as a valuable protocol for severe ECAC. Respirol Case Rep 2022; 10:e0884. [PMID: 34934505 PMCID: PMC8652403 DOI: 10.1002/rcr2.884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 11/06/2022] Open
Abstract
Expiratory central airway collapse (ECAC) is a pathology gaining recognition in the medical community due to its unspecific symptoms and diagnostic challenges. Its current gold standard for diagnosis, dynamic bronchoscopy, is invasive. Current non-invasive techniques such as computed tomography (CT) protocols have shown limited reproducibility. We present a case of a 77-year-old man with suspected ECAC who underwent evaluation with two different expiratory CT protocols. The initial standard end-expiratory CT could not detect airway collapsibility. However, dynamic bronchoscopy detected severe ECAC. Afterwards, we implemented a novel CT protocol, called dynamic forced expiratory CT (cinematic), comprising detailed, consecutive helical imaging of the central airway throughout the entire respiratory cycle, detecting severe ECAC, as proven by the earlier dynamic bronchoscopy. We hypothesize this may reduce the risks and need for performing multiple invasive procedures such as dynamic bronchoscopy. Extensive studies are required to evaluate the feasibility of its implementation for diagnosing ECAC.
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Affiliation(s)
- Daniel Hernandez‐Rojas
- Division of Pulmonary, Allergy and Sleep MedicineMayo Clinic FloridaJacksonvilleFloridaUSA
| | - David Abia‐Trujillo
- Division of Pulmonary, Allergy and Sleep MedicineMayo Clinic FloridaJacksonvilleFloridaUSA
| | - Carlos Rojas
- Department of RadiologyMayo Clinic ArizonaPhoenixArizonaUSA
| | | | - Rocio Castillo‐Larios
- Division of Pulmonary, Allergy and Sleep MedicineMayo Clinic FloridaJacksonvilleFloridaUSA
| | - Sai Priyanka Pulipaka
- Division of Pulmonary, Allergy and Sleep MedicineMayo Clinic FloridaJacksonvilleFloridaUSA
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25
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Grillo LJ, Housley GM, Gangadharan S, Majid A, Hull JH. Physiotherapy for large airway collapse: an ABC approach. ERJ Open Res 2022; 8:00510-2021. [PMID: 35211621 PMCID: PMC8864626 DOI: 10.1183/23120541.00510-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/17/2021] [Indexed: 11/05/2022] Open
Abstract
Large airway collapse (LAC) describes the phenomenon of excessive, abnormal, inward movement of the large airways (i.e. trachea and/or main bronchi and/or bronchus intermedius) occurring during the expiratory phase of the respiratory cycle. It is an increasingly well-recognised problem and a prevalent comorbidity in other chronic respiratory conditions (e.g. COPD and asthma). LAC is associated with pervasive respiratory features such as a barking cough, exertional dyspnoea and an increased propensity to lower respiratory tract infection. These symptoms are unpleasant, and patients are often limited in their daily life and their function. The pathophysiology of this condition impairs airway clearance and can cause breathlessness and exercise intolerance, due to a loss of airway patency during expiratory flow. Dysfunctional adaptations to breathing and coughing may further amplify symptoms. This article provides, for the first time, clinically focused physiotherapeutic intervention advice based on our understanding of the pathophysiology of LAC, to support conservative management. It uses the available evidence from LAC, transferable evidence from other conditions and knowledge based on clinical experience. It proposes a practical "ABC model" to ensure physiotherapy assessment and treatments are centred around optimising three key clinical areas: Airways, including airway clearance and cough; Breathing, including breathlessness and breathing pattern; and Capacity for exercise, including an assessment of functional exercise ability.
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Affiliation(s)
- Lizzie J.F. Grillo
- Royal Brompton and Harefield Hospitals, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | | | - Sidhu Gangadharan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Adnan Majid
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - James H. Hull
- Royal Brompton and Harefield Hospitals, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
- Institute of Sport, Exercise and Health, UCL, London, UK
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26
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Crespo MM. Airway complications in lung transplantation. J Thorac Dis 2021; 13:6717-6724. [PMID: 34992847 PMCID: PMC8662498 DOI: 10.21037/jtd-20-2696] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/13/2021] [Indexed: 12/03/2022]
Abstract
Airway complications (ACs) after lung transplantation remain an important source of morbidity and mortality despite significant advances in the surgical technics, leading to increased cost, and decrease quality of life. The incidences of ACs after lung transplantation range from 2% to 33%, even though most transplant centers have reported rates in the range of 7% to 8%. However, the reported rate of ACs has been inconsistent as a result of a lack of standardized airway definitions and grading protocols before the recent 2018 International Society for Heart and Lung Transplantation (ISHLT) proposed consensus guidelines on ACs after lung transplantation. The ACs include stenosis, perioperative and postoperative bronchial infections, bronchial necrosis and dehiscence, excess granulation tissue, and tracheobronchomalacia (TBM). Anastomosis infection, necrosis, or dehiscence typically develops within the first month after lung transplantation. The most frequent AC after lung transplantation is bronchial stenosis. Several risk factors have been proposed to the development of ACs after lung transplantation, including surgical anastomosis techniques, hypoperfusion, infections, donor and recipient factors, immunosuppression agents, and organ preservation. ACs might be prevented by early recognition of the airway pathology, using advance medical management, and interventional bronchoscopy procedures. Balloon bronchoplasty, cryotherapy, laser photo resection, electrocautery, high-dose endobronchial brachytherapy, and bronchial stents placement are the most frequent interventional bronchoscopic procedures utilized for the management of ACs.
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Affiliation(s)
- Maria M Crespo
- Pulmonary, Allergy and Critical Care Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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27
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Zafar MA, Sengupta R, Bates A, Woods JC, Radchenko C, McCormack FX, Panos RJ. Oral Positive Expiratory Pressure Device for Excessive Dynamic Airway Collapse Caused by Emphysema. Chest 2021; 160:e333-e337. [PMID: 34625179 DOI: 10.1016/j.chest.2021.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/06/2021] [Accepted: 04/22/2021] [Indexed: 11/28/2022] Open
Abstract
Excessive dynamic airway collapse (EDAC) contributes to breathlessness and reduced quality of life in individuals with emphysema. We tested a novel, portable, oral positive expiratory pressure (o-PEP) device in a patient with emphysema and EDAC. MRI revealed expiratory tracheal narrowing to 80 mm2 that increased to 170 mm2 with the o-PEP device. After 2-weeks use of the o-PEP device for 33% to 66% of activities, breathlessness, quality of life, and exertional dyspnea improved compared with minimal clinically important differences (MCID): University of California-San Diego Shortness of Breath questionnaire score declined 69 to 42 (MCID, ≥5), St. George's Respiratory Questionnaire score decreased 71 to 27 (MCID, ≥4), and before and after the 6-minute walk test Borg score difference improved from Δ3 to Δ2 (MCID, ≥1). During the 6-minute walk test on room air without the use of the o-PEP device, oxyhemoglobin saturation declined 91% to 83%; whereas, with the o-PEP device, the nadir was 90%. Use of the o-PEP device reduced expiratory central airway collapse and improved dyspnea, quality of life, and exertional desaturation in a patient with EDAC and emphysema.
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Affiliation(s)
- Muhammad Ahsan Zafar
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Ruchira Sengupta
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alister Bates
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Pulmonary Medicine & Department of Radiology, Center for Pulmonary Imaging Research, Cincinnati Children's Hospital, Cincinnati, OH
| | - Jason C Woods
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Pulmonary Medicine & Department of Radiology, Center for Pulmonary Imaging Research, Cincinnati Children's Hospital, Cincinnati, OH
| | - Christopher Radchenko
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Francis X McCormack
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ralph J Panos
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, OH; Department of Medicine, Veterans Affairs Medical Center, Cincinnati, OH
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28
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Mitropoulos A, Song WJ, Almaghlouth F, Kemp S, Polkey M, Hull JH. Detection and diagnosis of large airway collapse: a systematic review. ERJ Open Res 2021; 7:00055-2021. [PMID: 34381840 PMCID: PMC8350125 DOI: 10.1183/23120541.00055-2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/03/2021] [Indexed: 12/20/2022] Open
Abstract
Large airway collapse (LAC) is a frequently encountered clinical problem, caused by tracheobronchomalacia +/− excessive dynamic airway collapse, yet there are currently no universally accepted diagnostic criteria. We systematically reviewed studies reporting a diagnostic approach to LAC in healthy adults and patients, to compare diagnostic modalities and criteria used. Electronic databases were searched for relevant studies between 1989 and 2019. Studies that reported a diagnostic approach using computed tomography (CT), magnetic resonance imaging or flexible fibreoptic bronchoscopy were included. Random effects meta-analyses were performed to estimate the prevalence of LAC in healthy subjects and in patients with chronic obstructive airway diseases. We included 41 studies, describing 10 071 subjects (47% female) with a mean±sd age of 59±9 years. Most studies (n=35) reported CT findings, and only three studies reported bronchoscopic findings. The most reported diagnostic criterion was a ≥50% reduction in tracheal or main bronchi calibre at end-expiration on dynamic expiratory CT. Meta-analyses of relevant studies found that 17% (95% CI: 0–61%) of healthy subjects and 27% (95% CI: 11–46%) of patients with chronic airways disease were classified as having LAC, using this threshold. The most reported approach to diagnose LAC utilises CT diagnostics, and at a threshold used by most clinicians (i.e., ≥50%) may classify a considerable proportion of healthy individuals as being abnormal and having LAC in a quarter of patients with chronic airways disease. Future work should focus on establishing more precise diagnostic criteria for LAC, relating this to relevant physiological and disease sequelae. CT is mostly used to diagnose LAC, and at a threshold used by most clinicians (i.e. ≥50%) that would classify a large proportion of healthy individuals as being abnormal and LAC in a quarter of patients with chronic airway diseaseshttps://bit.ly/3izAuSk
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Affiliation(s)
| | - Woo-Jung Song
- Dept of Allergy and Clinical Immunology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea
| | | | - Samuel Kemp
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Michael Polkey
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - James H Hull
- Dept of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
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29
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Simonova MS, Rusakov MA, Parshin VD. [Airway complications after lung transplantation]. Khirurgiia (Mosk) 2021:77-83. [PMID: 34270198 DOI: 10.17116/hirurgia202107177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lung transplantations have been regularly performed in the Russian Federation since 2010. Therefore, the number of lung transplant recipients, as well as the number of patients with airway complications following lung transplantation has been increasing. Treatment of these patients takes place not only in transplantation centers, but also in other hospitals. This review is devoted to risk factors, clinical manifestations, treatment and prevention of airway complications after lung transplantation. We analyzed literature data over the last 15 years. It was confirmed that bronchoscopy is a «gold standard» for diagnosis of airway complications while bronchoscopic interventions are preferred for treatment. Balloon and rigid bronchodilation and endoscopic airway stenting are the most effective interventions. Silicone stents are the most optimal. Antimicrobial prophylaxis and timely use of antiproliferative immunosuppressive drugs are important factors in prevention and treatment of airway complications after lung transplantation.
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Affiliation(s)
- M S Simonova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - M A Rusakov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V D Parshin
- Sechenov First Moscow State Medical University, Moscow, Russia
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30
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Kheir F, Ospina-Delgado D, Beattie J, Singh R, Vidal B, VanderLaan PA, Parikh M, Chee A, Gangadharan SP, Wilson J, Majid A. Argon Plasma Coagulation (APC) for the Treatment of Excessive Dynamic Airway Collapse (EDAC): An Animal Pilot Study. J Bronchology Interv Pulmonol 2021; 28:221-227. [PMID: 34151900 DOI: 10.1097/lbr.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 11/23/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical stabilization of the airway through tracheobronchoplasty (TBP) is the current treatment modality for patients with severe symptomatic excessive dynamic airway collapse. However, TBP is associated with increased morbidity and mortality. Bronchoscopic treatment of the posterior membrane using argon plasma coagulation (APC) may be a safer alternative to TBP in highly selected patients. This study aimed to evaluate the effect of APC in the tracheobronchial tree of a sheep animal model. PATIENTS AND METHODS Two adult sheep were used for this study. Under flexible bronchoscopy, the posterior tracheal membrane was treated with precise APC using different power settings. Chest computed tomography was done at 2 days and bronchoscopy was performed at 30 days following initial procedure, before euthanasia. The airways were assessed for the presence of treatment-related histopathologic changes along with expression of genes associated with fibrosis. RESULTS There was no perioperative or postoperative morbidity or mortality. Chest computed tomography showed no signs of pneumomediastinum or pneumothorax. Flexible bronchoscopy showed adequate tracheobronchial tissue healing process, independent of the power settings used. Histologic changes demonstrated an increased extent of fibroblastic collagen deposition in the treated posterior membrane when higher power settings were used. In a similar manner, APC treatment managed to activate fibrosis-associated gene transcription factors, with higher settings achieving a higher level of expression. CONCLUSION APC at high-power settings achieved higher levels of fibroblast collagen deposition at the posterior membrane and higher expression of fibrosis-associated gene transcription factors, when compared with lower settings.
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Affiliation(s)
- Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology
| | | | - Jason Beattie
- Division of Interventional Pulmonary, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rani Singh
- Division of Thoracic Surgery and Interventional Pulmonology
| | - Barbara Vidal
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mihir Parikh
- Division of Thoracic Surgery and Interventional Pulmonology
| | - Alex Chee
- Division of Thoracic Surgery and Interventional Pulmonology
| | | | | | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology
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31
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Takimoto T, Kitaoka H, Kijima T. What Is Tracheobronchomalacia in Obstructive Lung Disease? Chest 2021; 159:442-443. [PMID: 33422214 DOI: 10.1016/j.chest.2020.07.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Takayuki Takimoto
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan.
| | - Hiroko Kitaoka
- Department of Biotechnology and Life Science, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Takashi Kijima
- Department of Respiratory Medicine and Hematology, Hyogo College of Medicine, Nishinomiya, Japan
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32
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Shah V, Husta B, Raoof S, Mehta A. Response. Chest 2021; 159:443-444. [PMID: 33422215 DOI: 10.1016/j.chest.2020.08.2050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Varun Shah
- Department of Pulmonary and Critiacal Care, Lenox Hill Hospital NYC, New York, NY
| | - Bryan Husta
- Department of Pulmonary Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Suhail Raoof
- Department of Pulmonary and Critiacal Care, Lenox Hill Hospital NYC, New York, NY.
| | - Atul Mehta
- Respiratory Institute, Cleveland Clinic Foundation Cleveland, OH
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33
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Chaddha U, Agrawal A, Maldonado F, Smaldone G, Murgu S. Excessive Dynamic Airway Collapse in Asthma and COPD: Physiologic Epiphenomenon or Steroid-Induced Myopathy? Chest 2021; 158:2695-2696. [PMID: 33280749 DOI: 10.1016/j.chest.2020.07.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 06/27/2020] [Accepted: 07/04/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Udit Chaddha
- Icahn School of Medicine at Mount Sinai, New York, NY.
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34
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Response. Chest 2021; 158:2696-2697. [PMID: 33280750 DOI: 10.1016/j.chest.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/23/2022] Open
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35
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Reinero CR, Masseau I. Lower airway collapse: Revisiting the definition and clinicopathologic features of canine bronchomalacia. Vet J 2021; 273:105682. [PMID: 34148610 DOI: 10.1016/j.tvjl.2021.105682] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 04/07/2021] [Accepted: 04/15/2021] [Indexed: 12/24/2022]
Abstract
Bronchomalacia (BM) is an inconsistently defined term in dogs, impairing understanding of clinical presentation, therapeutic response and prognosis. Herein the authors propose to clarify the definition of canine bronchomalacia (CBM) as regional to diffuse dynamic airway collapse of segmental and/or subsegmental bronchi with associated clinical signs due to airflow limitation. In contrast to tracheal collapse, mainstem bronchial collapse, and in some cases lobar collapse, CBM requires advanced imaging. Common co-morbid conditions (e.g., chronic bronchitis, mitral valve degenerative disease, etc.) should be identified during a comprehensive diagnostic evaluation. Current empiric treatments advocated in absence of clinical trials documenting efficacy in the dog warrant evaluation, as some (e.g., bronchodilators) may have detrimental effects in certain types of airway collapse in humans. There is no direct treatment for CBM, as defined above, but non-specific therapies and targeted treatment of co-morbid disease may improve clinical signs and quality of life. In this manuscript, the authors provide a review of the different types of airway collapse focusing on CBM, reviewing their definition and etiology, proposing a classification scheme, and discussing clinical signs, diagnostic testing, and treatment. Future studies should focus on both improving understanding of the etiology and natural disease progression of CBM and treatment trials.
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Affiliation(s)
- Carol R Reinero
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, 900 East Campus Drive, University of Missouri, Columbia, MO 65211, USA.
| | - Isabelle Masseau
- Department of Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, St-Hyacinthe, Canada
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Expiratory central airway collapse and symptoms in smokers. Respir Investig 2021; 59:522-529. [PMID: 33883089 DOI: 10.1016/j.resinv.2021.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The prevalence and clinical impacts of expiratory central airway collapse (ECAC) in smokers remain controversial. Although studies have shown associations of ECAC with airflow limitation and symptoms, others have shown that higher tracheal collapsibility is associated with lower expiratory-to-inspiratory ratio of lung volume (E/I-LV), but not airflow limitation. This study tested whether ECAC of the trachea and main bronchi could occur exclusively in smokers with lower E/I-LV and affect their symptoms independent of emphysema and intrapulmonary airway disease. METHODS ECAC was defined as the expiratory-to-inspiratory ratio of cross-sectional lumen area <0.5 for at least one of the three locations, including the trachea, right and left main bronchi on static full-inspiratory, and end-tidal expiratory CT. Symptoms were assessed using the chronic obstructive pulmonary disease (COPD) assessment test (CAT) and modified MRC scale (mMRC). RESULTS Out of 241 smokers with and without COPD (n = 189 and 52, respectively), ECAC was found in 21 (9%) smokers. No ECAC was found in smokers with E/I-LV ≥0.75. CAT and mMRC in smokers with ECAC were higher than in non-ECAC smokers with E/I-LV <0.75, but comparable to those in non-ECAC smokers with E/I-LV ≥0.75. In the multivariable analysis of smokers with E/I-LV <0.75, ECAC was associated with increased mMRC and CAT independent of CT-emphysema severity, wall area percent of segmental airways, and forced expiratory volume in 1 s CONCLUSIONS: ECAC is associated with worsening of symptoms independent of emphysema and segmental airway disease in smokers with a lower expiratory-to-inspiratory lung volume ratio.
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Thermoablative Techniques for Excessive Central Airway Collapse: An Ex Vivo Pilot Study on Sheep Tracheal Tissue. J Bronchology Interv Pulmonol 2021; 27:195-199. [PMID: 32101912 DOI: 10.1097/lbr.0000000000000647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tracheobronchoplasty is the definitive treatment for patients with symptomatic excessive central airway collapse. This procedure is associated with high morbidity and mortality rates. Bronchoscopic techniques are an appealing alternative with less morbidity and the ability to apply it in nonsurgical patients. Although thermoablative methods have been proposed as treatment options to induce fibrosis of the posterior tracheobronchial wall, no studies have compared direct histologic effects of such methods. This study compared the effects of electrocautery, radiofrequency ablation, potassium titanyl phosphate laser, and argon plasma coagulation (APC) in the tracheobronchial tree in an ex vivo animal model. METHODS Four adult sheep cadavers were used for this study. Under flexible bronchoscopy, the posterior tracheal membrane was treated using different power settings on 4 devices. The airways were assessed for the presence of treatment-related histopathologic changes. RESULTS Histologic changes observed were that of acute thermal injury including: surface epithelium ablation, collagen fiber condensation, smooth muscle cytoplasm condensation, and chondrocyte pyknosis. No distinct histologic differences in the treated areas among different modalities and treatment effects were observed. APC at higher power settings was the only modality that produced consistent and homogenous thermal injury effects across all tissue layers with no evidence of complete erosion. CONCLUSION Although electrocautery, radiofrequency ablation, potassium titanyl phosphate laser, and APC all induce thermal injury of the airway wall, only APC at high power settings achieves this effect without complete tissue erosion, favoring potential regeneration and fibrosis. Live animal studies are now plausible.
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Chen YC, Gad SF, Chobisa D, Li Y, Yeo Y. Local drug delivery systems for inflammatory diseases: Status quo, challenges, and opportunities. J Control Release 2021; 330:438-460. [PMID: 33352244 DOI: 10.1016/j.jconrel.2020.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022]
Abstract
Inflammation that is not resolved in due course becomes a chronic disease. The treatment of chronic inflammatory diseases involves a long-term use of anti-inflammatory drugs such as corticosteroids and nonsteroidal anti-inflammatory drugs, often accompanied by dose-dependent side effects. Local drug delivery systems have been widely explored to reduce their off-target side effects and the medication frequency, with several products making to the market or in development over the years. However, numerous challenges remain, and drug delivery technology is underutilized in some applications. This review showcases local drug delivery systems in different inflammatory diseases, including the targets well-known to drug delivery scientists (e.g., joints, eyes, and teeth) and other applications with untapped opportunities (e.g., sinus, bladder, and colon). In each section, we start with a brief description of the disease and commonly used therapy, introduce local drug delivery systems currently on the market or in the development stage, focusing on polymeric systems, and discuss the remaining challenges and opportunities in future product development.
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Affiliation(s)
- Yun-Chu Chen
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
| | - Sheryhan F Gad
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut 71526, Egypt
| | - Dhawal Chobisa
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; Integrated product development organization, Innovation plaza, Dr. Reddy's Laboratories, Hyderabad 500090, India
| | - Yongzhe Li
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; School of Pharmacy, Shenyang Pharmaceutical University, 103 Wenhua Road, Shenyang, Liaoning 110016, PR China
| | - Yoon Yeo
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA; Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA.
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Lima E, Genta PR, Athanazio RA, Rodrigues AJ, Nakamura MAM, Rached SZ, Costa ELV, Stelmach R. What is the optimal large airway size reduction value to determine malacia: exploratory bronchoscopic analysis in patients in Mounier-Kuhn syndrome. J Thorac Dis 2021; 13:425-429. [PMID: 33569226 PMCID: PMC7867837 DOI: 10.21037/jtd-20-2395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Evelise Lima
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Pedro Rodrigues Genta
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rodrigo Abensur Athanazio
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ascedio José Rodrigues
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Aparecida Miyuki Nakamura
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Samia Zahi Rached
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Leite Vieira Costa
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rafael Stelmach
- Pulmonary Division, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Abia-Trujillo D, Majid A, Johnson MM, Mira-Avendano I, Patel NM, Makey IA, Thomas M, Kornafeld A, Hazelett BN, Fernandez-Bussy S. Central Airway Collapse, an Underappreciated Cause of Respiratory Morbidity. Mayo Clin Proc 2020; 95:2747-2754. [PMID: 32829904 DOI: 10.1016/j.mayocp.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 10/23/2022]
Abstract
Dyspnea, cough, sputum production, and recurrent respiratory infections are frequently encountered clinical concerns leading patients to seek medical care. It is not unusual for a well-defined etiology to remain elusive or for the therapeutics of a presumed etiology to be incompletely effective. Either scenario should prompt consideration of central airway pathology as a contributor to clinical manifestations. Over the past decade, recognition of dynamic central airway collapse during respiration associated with multiple respiratory symptoms has become more commonly appreciated. Expiratory central airway collapse may represent the answer to this diagnostic void. Expiratory central airway collapse is an underdiagnosed disorder that can coexist with and mimic asthma, chronic obstructive pulmonary disease, and bronchiectasis. Awareness of expiratory central airway collapse and its spectrum of symptoms is paramount to its recognition. This review includes clear definitions, diagnostics, and therapeutics for this challenging condition. We performed a narrative review through the PubMed (MEDLINE) database using the following MeSH terms: airway collapse, tracheobronchomalacia, tracheomalacia, and bronchomalacia. We include reports from systematic reviews, narrative reviews, clinical trials, and observational studies from 2005 to 2020. Two reviewers evaluated potential references. No systematic reviews were found. A total of 28 references were included into our review. Included studies report experience in the diagnosis and/or treatment of dynamic central airway collapse; case reports and non-English or non-Spanish studies were excluded. We describe the current diagnostic dilemma, highlighting the role of dynamic bronchoscopy and tracheobronchial stent trial; outline the complex therapeutic options (eg, tracheobronchoplasty); and present future directions and challenges.
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Affiliation(s)
- David Abia-Trujillo
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Margaret M Johnson
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Isabel Mira-Avendano
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Neal M Patel
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Ian A Makey
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Mathew Thomas
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Anna Kornafeld
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Britney N Hazelett
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL
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Dunlap DG, Ma KC, DiBardino D. Airway Complications and Endoscopic Management After Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00260-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Excessive Dynamic Airway Collapse: A COPD/Asthma Mimic or a Treatment-emergent Consequence of Inhaled Corticosteroid Therapy: Case Series and Brief Literature Review. ACTA ACUST UNITED AC 2020. [DOI: 10.1097/cpm.0000000000000382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Varney VA, Parnell H, Jagadish CM, Abubacker Z. Longstanding tracheobronchomalacia: A forgotten cause of severe cough and its response to roflumilast. Respir Med Case Rep 2020; 31:101247. [PMID: 33117647 PMCID: PMC7581388 DOI: 10.1016/j.rmcr.2020.101247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 09/17/2020] [Accepted: 10/07/2020] [Indexed: 11/19/2022] Open
Abstract
This case report describes a patient with moderately severe tracheobronchomalacia following mycoplasma pneumonia. The patient was considered to have obstructive lung disease despite no prior smoking or lung disease and failure to respond to standard treatment. The possibility of tracheal pathology causing cough and sputum was not considered in 23yrs confirming this to be a “forgotten zone”. The patient was treated with Roflumilast to reduce airway secretions with great success and the Immunology of Roflumilast is discussed.
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Janowiak P, Rogoza K, Siemińska A, Jassem E. Expiratory central airway collapse - an overlooked entity?: Two case reports. Medicine (Baltimore) 2020; 99:e22449. [PMID: 33080680 PMCID: PMC7572028 DOI: 10.1097/md.0000000000022449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Expiratory central airway collapse is defined by excessive inward bulging of either tracheobronchial posterior membrane or cartilage. The former is called excessive dynamic airway collapse (EDAC), and the latter, depending on the site of collapse, tracheomalacia, bronchomalacia or tracheobronchomalacia. Due to their non-specific symptoms and lack of awareness amongst clinicians they tend to be mislabeled as common obstructive lung disorders, or complicate their course undetected. Particular controversies refer to EDAC sometimes considered just as a symptom of obstructive lung disease and not a separate entity. Nonetheless, a growing body of evidence indicates that EDAC might be present in patients without apparent obstructive lung disease or it might be an independent risk factor in chronic obstructive pulmonary disease or asthma patients. PATIENT CONCERNS Patient #1 was admitted because of idiopathic chronic cough whereas patient #2 was admitted for differential diagnosis of dyspnea of uncertain etiology. In both patients symptoms were unresponsive to bronchodilators and inhaled corticosteroids. FINDINGS AND DIAGNOSIS In both patients an excess collapse of tracheobronchial posterior membrane was detected during bronchoscopy; in patient #1, of right main bronchus and right upper lobe bronchus and in patient #2 of right upper lobe bronchus and both main bronchi. Excess central airway collapse in patient #2 was also visualized on expiratory chest CT. In patient #1 spirometry did not reveal obturation, whereas in patient #2 only mild, irreversible, obstruction was revealed, disproportionate to patients significant breathlessness. INTERVENTIONS Both patients were treated with N-acetylcysteine and adjustable positive expiratory pressure valves. OUTCOMES Due to aforementioned treatment chronic cough in patient #1 subsided almost completely whereas patient's #2 dyspnea improved significantly. CONCLUSIONS In presented cases EDAC was an unexpected finding, even though, it firmly corresponded with reported symptoms. Treatment modification led to improvement of patients quality of life.
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Affiliation(s)
- Piotr Janowiak
- Department of Pneumonology and Allergology, Medical University of Gdańsk, Mariana Smoluchowskiego 17 street, 80-214, Gdańsk
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Murakami S, Tsuruta S, Ishida K, Yamashita A, Matsumoto M. Excessive dynamic airway collapse during general anesthesia: a case report. JA Clin Rep 2020; 6:73. [PMID: 32989528 PMCID: PMC7522133 DOI: 10.1186/s40981-020-00380-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022] Open
Abstract
Background Excessive dynamic airway collapse (EDAC) is an uncommon cause of high airway pressure during mechanical ventilation. However, EDAC is not widely recognized by anesthesiologists, and therefore, it is often misdiagnosed as asthma. Case presentation A 70-year-old woman with a history of asthma received anesthesia with sevoflurane for a laparotomic cholecystectomy. Under general anesthesia, she developed wheezing, high inspiratory pressure, and a shark-fin waveform on capnography, which was interpreted as an asthma attack. However, treatment with a bronchodilator was ineffective. Bronchoscopy revealed the collapse of the trachea and main bronchi upon expiration. We reviewed the preoperative computed tomography scan and saw bulging of the posterior membrane into the airway lumen, leading to a diagnosis of EDAC. Conclusions Although both EDAC and bronchospasm present as similar symptoms, the treatments are different. Bronchoscopy proved useful for distinguishing between these two entities. Positive end-expiratory pressure should be applied and bronchodilators avoided in EDAC.
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Affiliation(s)
- Shunichi Murakami
- Department of Anesthesiology, Shuto General Hospital, Kogaisaku 1000-1, Yanai, Yamaguchi, 742-0032, Japan.
| | - Shunsuke Tsuruta
- Department of Anesthesiology, Shuto General Hospital, Kogaisaku 1000-1, Yanai, Yamaguchi, 742-0032, Japan
| | - Kazuyoshi Ishida
- Department of Anesthesiology, Japan Community Healthcare Organization Tokuyama Central Hospital, Kodacho 1-1, Shunan, Yamaguchi, 745-8522, Japan
| | - Atsuo Yamashita
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Minami-Kogushi 1-1-1, Ube, Yamaguchi, 755-8505, Japan
| | - Mishiya Matsumoto
- Department of Anesthesiology, Yamaguchi University Graduate School of Medicine, Minami-Kogushi 1-1-1, Ube, Yamaguchi, 755-8505, Japan
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Lima E, Nakamura MAM, Genta PR, Rodrigues AJ, Athanazio RA, Rached S, Costa ELV, Stelmach R. Improving Airways Patency and Ventilation Through Optimal Positive Pressure Identified by Noninvasive Mechanical Ventilation Titration in Mounier-Kuhn Syndrome: Protocol for an Interventional, Open-Label, Single-Arm Clinical Trial. JMIR Res Protoc 2020; 9:e14786. [PMID: 32795996 PMCID: PMC7455860 DOI: 10.2196/14786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 04/28/2020] [Accepted: 06/02/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mounier-Kuhn syndrome or congenital tracheobronchomegaly is a rare disease characterized by dilation of the trachea and the main bronchi within the thoracic cavity. The predominant signs and symptoms of the disease include coughing, purulent and abundant expectoration, dyspnea, snoring, wheezing, and recurrent respiratory infection. Symptoms of the disease in some patients are believed to be pathological manifestations arising due to resident tracheobronchomalacia. Although treatment options used for the management of this disease include inhaled bronchodilators, corticosteroids, and hypertonic solution, there is no consensus on the treatment. The use of continuous positive airway pressure (CPAP) has been reported as a potential therapeutic option for tracheobronchomalacia, but no prospective studies have demonstrated its efficacy in this condition. OBJECTIVE The purpose of this is to identify the presence of tracheobronchomalacia and an optimal CPAP pressure that reduces the tracheobronchial collapse in patients with Mounier-Kuhn syndrome and to analyze the repercussion in pulmonary ventilation. In parallel, we aim to evaluate the prevalence of obstructive sleep apnea/hypopnea syndrome. METHODS This interventional, open-label, single-arm clinical trial will enroll patients who are diagnosed Mounier-Kuhn syndrome. Patient evaluation will be conducted in an outpatient clinic and involve 3 visits. Visit 1 will involve the collection and registration of social demographic, clinical, and functional data. Visit 2 will entail polysomnography, bronchoscopy for the evaluation of tracheobronchomalacia, titration of the optimal pressure that reduces the degree of collapse of the airway, and electrical impedance tomography. In visit 3, patients exhibiting a reduction in collapse areas will be requested to undergo chest computed tomography during inspiration and forced expiration with and without positive pressure (titrated to determine optimal CPAP pressure). RESULTS This protocol is a doctorate project. The project was submitted to the institutional review board on January 24, 2017, and approval was granted on February 2, 2017 (Brazilian Research database number CAAE 64001317.4.000.0068). Patient evaluations started in April 2018. Planned recruitment is based on volunteers' availability and clinical stability, and interventions will be conducted at least once a month to finish the project at the end of 2020. A preliminary analysis of each case will be performed after each intervention, but detailed results are expected to be reported in the first quarter of 2021. CONCLUSIONS There is no consensus on the best treatment options for managing Mounier-Kuhn syndrome. The use of positive pressure could maintain patency of the collapsed airways, functioning as a "pneumatic stent" to reduce the degree of airflow obstruction. This, in turn, could promote mobilization of thoracic secretion and improve pulmonary ventilation. TRIAL REGISTRATION ClinicalTrails.gov NCT03101059; https://clinicaltrials.gov/ct2/show/NCT03101059. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14786.
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Affiliation(s)
- Evelise Lima
- Pulmonary Division-Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | | | - Pedro Rodrigues Genta
- Pulmonary Division-Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Ascedio José Rodrigues
- Pulmonary Division-Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Rodrigo Abensur Athanazio
- Pulmonary Division-Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Samia Rached
- Pulmonary Division-Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Eduardo Leite Vieira Costa
- Pulmonary Division-Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
| | - Rafael Stelmach
- Pulmonary Division-Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina de São Paulo, São Paulo, Brazil
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Watase S, Sonoda A, Matsutani N, Muraoka S, Hanaoka J, Nitta N, Watanabe Y. Evaluation of intrathoracic tracheal narrowing in patients with obstructive ventilatory impairment using dynamic chest radiography: A preliminary study. Eur J Radiol 2020; 129:109141. [PMID: 32593078 DOI: 10.1016/j.ejrad.2020.109141] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/03/2020] [Accepted: 06/13/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Dynamic chest radiography (DCR) can observe the dynamic structure of the chest using continuous pulse fluoroscopy irradiation. However, its usefulness remains largely undetermined. The purpose of this study was to examine the relationship between changes in tracheal diameter during deep breathing and obstructive ventilation disorders using DCR. METHOD Twelve participants with obstructive ventilatory impairment and 28 with normal pulmonary function underwent DCR during one cycle of deep inspiration and expiration. Three evaluators blinded to pulmonary function test results independently measured lateral diameters of the trachea in DCR images to determine whether there was a difference in the amount of change in tracheal diameter depending on the presence or absence of pulmonary dysfunction. Tracheal narrowing was defined as a decrease in the lateral tracheal diameter of more than 30 %. Participants were divided into a narrowing group and a non-narrowing group, and it was examined whether each group correlated with values of pulmonary function tests. RESULTS Tracheal diameter was significantly narrowed in subjects with obstructive ventilatory impairment compared to normal subjects (P < 0.01). When subjects were divided into narrowing (tracheal narrowing rate [TNr] = 41.5 ± 7.7 %, n = 9) and non-narrowing groups (TNr = 9.1 ± 7.0 %, n = 31, p < 0.01), FEV1%-G, and %V25 were significantly smaller in the narrowing group than in the non-narrowing group (p < 0.01). CONCLUSIONS Changes in tracheal diameter during deep breathing were easily evaluated using DCR. DCR may, therefore, be useful for evaluating obstructive ventilation disorders.
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Affiliation(s)
- Sayaka Watase
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Akinaga Sonoda
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Noritsugu Matsutani
- Healthcare Business Headquarters, Konica Minolta, Inc, 2970 Ishikawa-machi, Hachioji-shi, Tokyo, 192-8505, Japan.
| | - Shintarou Muraoka
- Healthcare Business Headquarters, Konica Minolta, Inc, 2970 Ishikawa-machi, Hachioji-shi, Tokyo, 192-8505, Japan.
| | - Jun Hanaoka
- Department of Thoracic Surgery, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Norihisa Nitta
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga, 520-2192, Japan.
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Longitudinal Follow-up of Patients With Tracheobronchomalacia After Undergoing Tracheobronchoplasty: Computed Tomography Findings and Clinical Correlation. J Thorac Imaging 2020; 34:278-283. [PMID: 29957676 DOI: 10.1097/rti.0000000000000339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to evaluate intermediate and long-term changes in expiratory tracheal collapsibility by computed tomography (CT) in patients with tracheobronchomalacia following surgical treatment with tracheobronchoplasty and to correlate CT findings with clinical findings. MATERIALS AND METHODS Between 2003 and 2016, 18 patients with tracheobronchomalacia underwent tracheobronchoplasty and were imaged preoperatively and postoperatively at both intermediate and long-term intervals. Imaging included end-inspiratory and dynamic expiratory phase scans. The cross-sectional area of the airway lumen was measured at 2 standard levels (1 cm above the aortic arch and carina). These measurements were used to calculate % collapsibility. Clinical findings recorded included a questionnaire on symptomatology and a 6-minute walk test. RESULTS Before surgery, expiratory collapsibility of the upper trachea was 72%±25% (mean±SD) and that of the lower trachea was 68%±22%. On intermediate follow-up (mean, 1.5 y), collapsibility significantly decreased to 37%±21% at the upper trachea and 35%±19% at the lower trachea (P<0.001). On long-term follow-up (mean, 6 y), collapsibility increased to 51%±20% at the upper trachea and 47%±17% at the lower trachea and was significantly worse than on intermediate follow-up (P=0.002). However, collapsibility on long-term follow-up remained significantly lower than preoperative collapsibility (P=0.015). Clinical findings showed a similar trend as quantitative CT measurements. CONCLUSION Expiratory tracheal collapsibility substantially decreases after tracheobronchoplasty on intermediate follow-up. At long-term follow-up, tracheal collapsibility shows a modest increase, but remains significantly lower than the preoperative baseline. Quantitative measurements from dynamic CT have the potential to play an important role as imaging biomarkers for assessing response to tracheobronchoplasty.
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Crowhurst TD, Tcherveniakov P, Lorraine B, Polasek JF, Nguyen PT, Yeo A. Obstructive sleep apnoea is associated with dynamic intra-thoracic central airway collapse: results of a 10-year multi-centre retrospective analysis. SLEEP SCIENCE AND PRACTICE 2020. [DOI: 10.1186/s41606-020-00045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Gothi D, Patro M, Agarwal M, Vaidya S. A mysterious case of an elevated dome of the right diaphragm. Breathe (Sheff) 2020; 16:190334. [PMID: 33304396 PMCID: PMC7714547 DOI: 10.1183/20734735.0334-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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