Pulmonary resection for complications of cystic fibrosis

Approaches to the management of haemoptysis in young people with cystic fibrosis

Haemoptysis occurs in up to 25 % of young people with Cystic fibrosis (CF) [1]. We undertook a literature review and described the management approach to haemoptysis in CF between 2010 and 2020 at an Australian tertiary paediatric centre, The Children's Hospital Westmead, Sydney, New South Wales, using a retrospective review of the medical records which identified 67 episodes. Sixty episodes met inclusion criteria, including 31 patients. Using the US CF Foundation guidelines, episodes were classified as scant (53.3 %), moderate (38.3 %) or massive (8.3 %). Fifty-two percent of patients were female, mean age at presentation was 15.4 years (SD+/- 2.4) and 58 % were homozygous for the Fdel508 genotype. Twelve episodes (9 patients) required bronchial artery embolization (BAE). BAE was used in all cases of massive haemoptysis 5/5 (100 %), 6/23 (22 %) episodes of moderate and 1/32 (3 %) episode of scant haemoptysis as an elective procedure for recurrent haemoptysis. Our literature review and institutional experience highlights the need for up-to-date management guidelines in the management of haemoptysis in Cystic Fibrosis. Based on our experience, we provide a proposed algorithm to help guide the management of haemoptysis in CF.

Cystic fibrosis lung transplant recipients 10 years of age or younger: Predisposing factors for end-stage disease

BACKGROUND

The largest age group among children and adolescents referred for lung transplantation for cystic fibrosis (CF) have been those in the pubertal or postpubertal age range. However, over 100 younger patients with CF have undergone lung transplantation over the last three decades in the United States.

METHODS

We performed a retrospective review of our experience with 18 children with CF who underwent lung transplantation in our center before the age of 11 years and compared them to our older CF lung transplant recipients and our larger CF Center population.

RESULTS

The transplant population was demographically distinct from our CF center in terms of ethnicity, country of origin, and insurance status. Other notable findings were a high prevalence of methicillin-resistant Staphylococcus aureus, a high prevalence of CF-related diabetes mellitus, and a high prevalence of consolidated lobar or whole lung disease. Posttransplant outcomes were comparable to those older than 10 years of age in our center until 5 years after transplant after which the younger cohort showed a superior enduring survival.

CONCLUSIONS

In an era of increasingly effective medications modifying the natural history of CF, identification of risk factors for early severe lung disease in CF remains relevant to permit interventions to prevent or postpone the time of future lung transplantation.

Infection prevention and chronic disease management in cystic fibrosis and noncystic fibrosis bronchiectasis

Bronchiectasis is a chronic lung disease (CLD) characterized by irreversible bronchial dilatation noted on computed tomography associated with chronic cough, ongoing viscid sputum production, and recurrent pulmonary infections. Patients with bronchiectasis can be classified into two groups: those with cystic fibrosis and those without cystic fibrosis. Individuals with either cystic fibrosis related bronchiectasis (CFRB) or noncystic fibrosis related bronchiectasis (NCFRB) experience continuous airway inflammation and suffer airway architectural changes that foster the acquisition of a unique polymicrobial community. The presence of microorganisms increases airway inflammation, triggers pulmonary exacerbations (PEx), reduces quality of life (QOL), and, in some cases, is an independent risk factor for increased mortality. As there is no cure for either condition, prevention and control of infection is paramount. Such an undertaking incorporates patient/family and healthcare team education, immunoprophylaxis, microorganism source control, antimicrobial chemoprophylaxis, organism eradication, daily pulmonary disease management, and, in some cases, thoracic surgery. This review is a summary of recommendations aimed to thwart patient acquisition of pathologic organisms, and those therapies known to mitigate the effects of chronic airway infection. A thorough discussion of airway clearance techniques and treatment of or screening for nontuberculous mycobacteria (NTM) is beyond the scope of this discussion.

Staphylococcal lung abscess in a child with cystic fibrosis: Case report & review of literature

With contemporary cystic fibrosis (CF) care, a lung abscess is an uncommon occurrence. We describe a case of a staphylococcal lung abscess in a teenage girl with CF who presented with a two-week history of non-specific malaise followed by two days of left posterior chest pain and fever. A chest radiograph was consistent with a left sided pulmonary abscess, which was confirmed on a CT scan of the chest. The abscess was drained under ultrasound guidance and cultured methicillin-sensitive Staphylococcus aureus. The patient responded well to antibiotic treatment with the abscess cavity showing complete radiological resolution by six weeks post drainage.

Indications for lung resection surgery and lung transplant in South American children with cystic fibrosis

The current available literature evaluating lung resection surgery and lung transplantation in children with cystic fibrosis (CF) was reviewed through a PubMed search and references from selected studies were additionally included. Pulmonary resections, i.e. lobectomy, segmentectomy, and pneumonectomy, are seldom performed in CF. The main indications, in patients with a forced expiratory volume in 1second (FEV₁) that is greater than 30% predicted, are localized bronchiectasis/atelectasis, severe hemoptysis, and bronchopleural fistula refractory to medical management. The potential benefits are decreased symptoms and pulmonary exacerbations, and an improved quality of life. Pre and postoperative intensive care is mandatory for surgical candidates. The risk of death should be taken into account when the procedure is considered. Selection for lung transplantation (LTx) candidates in children with CF in South America follows the International Society for Heart and Lung Transplantation (ISHLT) criteria. When compared to adults with CF, a poorer survival rate after LTx in children with CF has been observed in the literature, as well as in our LTx center in Brazil, reasons for which are still unknown. The main complications after LTx in children are early and late acute rejection, and infections. LTx is a therapeutic option for eligible children with CF, fulfilling the lung transplant candidacy criteria, as post-transplant survival rates are increasingly improving due to better management of the transplanted patient.

Nontuberculous mycobacteria: the changing epidemiology and treatment challenges in cystic fibrosis

PURPOSE OF REVIEW

Although patients with cystic fibrosis (CF) face numerous infectious pathogens over the course of their lifespan, increasing attention has recently been paid to nontuberculous mycobacteria (NTM). As reported prevalence rates rise across many countries such as the United States, the ability to recognize disease caused by NTM and subsequently treat such disease has become increasingly important. This review summarizes new observations on the epidemiology of NTM in CF as well as key elements to consider during the treatment phase.

RECENT FINDINGS

Although overall rates of NTM isolation appear to be increasing, particular concern has focused on the emerging predominance of Mycobacterium abscessus. New data suggest that chronic macrolide therapy now part of routine CF care has contributed to this rise; however, these have yet to be confirmed prospectively. Transmission of M. abscessus between CF patients has also now been described through the use of genome sequencing. Although the greater virulence of M. abscessus makes it a challenging species to treat, identification of the subspecies type can now determine the presence of inducible macrolide resistance, thereby helping to guide treatment.

SUMMARY

Given increasing prevalence rates, clinicians should maintain a high level of suspicion for NTM as disease-causing organisms in CF, particularly for M. abscessus. New knowledge regarding this species, however, can help to tailor appropriate therapy.

Lobectomy in patients with cystic fibrosis

BACKGROUND

Some patients with cystic fibrosis (CF) develop severe but localized lung disease or recurrent hemoptysis⁄pneumothorax refractory to conventional medical therapies.

METHODS

The outcomes of lung resection in patients with CF and worsening localized lung disease or recurrent hemoptysis⁄pneumothorax refractory to conventional therapy (n=15) were evaluated by reviewing the medical records of all patients with CF followed at the CF Center at Nationwide Children's Hospital (Columbus, Ohio, USA), who underwent lobectomy over a 15-year period (1998 to 2012).

RESULTS

The median age of the 15 patients (93% Caucasian) was 20 years (range two to 41 years) and their mean forced expiratory volume in 1 s (FEV1) was 59.5% of predicted one year before surgery. Three patients died within two years after lobectomy; all three deaths occurred in patients with an FEV1 ≤40% of predicted before surgery. There were no significant changes in mean height, weight, body mass index, hospital admissions or antibiotic use over time. The mean FEV1 decreased over time. Compared with at surgery, decline in FEV1 in the year before surgery was -5.4% (P=0.024) and decline in the year after surgery was -1.3% (P=0.513); however, the difference in the rate of decline was not statistically significant.

CONCLUSION

In patients with CF and localized worsening bronchiectasis and⁄or recurrent hemoptysis⁄pneumothorax, lobectomy carried a significant risk of mortality, especially in patients with FEV1 ≤40% of predicted, and should only be considered when all other measures fail.

Cystic fibrosis and the thoracic surgeon

Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.

Pulmonary surgery in cystic fibrosis

Cystic fibrosis (CF) has a variety of pulmonary manifestations that include pneumonia, pulmonary abscess, bronchiectasis, hemoptysis, and pneumothorax. Although newer therapies have greatly improved survival of patients with CF, surgical interventions for definitive treatment of these sequelae are often required. Several reports have illustrated that, with the current advances in the perioperative treatment and care of CF patients, surgical interventions for these pulmonary manifestations may be performed safely, resulting in a greatly improved quality of life. Also, although improvements in lung transplantation offer new hope for definitive treatment of those patients with cystic fibrosis, special considerations regarding other surgical issues, such as the prevalence of gastroesophageal reflux, need to be addressed.

Lung resection in cystic fibrosis: a survival analysis

Lung resection may be considered for cystic fibrosis (CF) patients showing localized severe chronic atelectasis and/or bronchiectasis. Nonetheless, literature on survival after surgery is scarce. This study was carried out to assess survival time after partial lung resection. Twenty-one CF patients were operated from 1988 to 2003 and were followed until November 30th, 2004. Survival analysis was performed through Kaplan-Meier method. Mean age at resection was 8.09 years (SD 4.40 years) and two-thirds were females. Z-scores for height, weight, and body mass index as well as FEV1 values showed no statistical significance when comparing values obtained from 2 years before to 2 years after resection. Eleven years after resection, survival probability was 93.8%. Our results suggest that lobectomy or segmentectomy are safe procedures and should be considered in carefully selected patients with unilateral severe symptomatic localized and chronic persistent atelectasis and/or bronchiectasis refractory to conservative management.

Surgical management of pulmonary and gastrointestinal complications in children with cystic fibrosis

PURPOSE OF REVIEW

Cystic fibrosis is a common disorder, affecting as many as 1:2500 Caucasian live births. Despite improved medical management, disease-specific complications are common and are responsible for substantial morbidity and ultimately mortality. Both pulmonary and gastrointestinal complications of cystic fibrosis are well known; however, the complications requiring surgical intervention in the pediatric population are infrequent. We provide a detailed review of the cystic fibrosis-associated pulmonary and gastrointestinal complications and potential surgical options for management in children with cystic fibrosis.

RECENT FINDINGS

Recent operative approaches are described that include application of minimally invasive surgical techniques primarily for intrathoracic disease. Novel medical therapies are also presented. Finally an attempt is made to put in perspective those surgical care advances that have had a benefit on disease outcomes.

SUMMARY

This report will provide the physician caring for the child with cystic fibrosis an understanding of those disease complications that will require surgical consultation and potential operative intervention.

[Pneumonectomy in cystic fibrosis]

We present the case of a 13-year-old boy with cystic fibrosis (CF) who developed severe right-sided lung infection with formation of abscess and localized bronchiectasis. The boy's lung disease was complicated by nephrotic syndrome and secondary amyloidosis. Unilateral pneumonectomy was performed, producing significant clinical improvement with a remarkable increase in quality of life which has lasted to the present date, 15 years later. Most patients with CF develop lung disease, which is the main cause of adult mortality in this population. Lung transplantation is currently considered the treatment of choice in severe bilateral lung disease in CF. However, in severe unilateral lung disease such as localized bronchiectasis, surgical resection of the affected lobe or lung is still a worthwhile option as a rescue therapy for patients who are at high risk of dying while waiting for lung transplantation.

Bronchial artery embolization for hemoptysis in young patients with cystic fibrosis

PURPOSE

To review the authors' 15-year experience with bronchial artery embolization (BAE) for treatment of hemoptysis in young patients with cystic fibrosis.

MATERIALS AND METHODS

By searching the 1985-1999 radiology database, the authors identified 23 young patients who had been referred to the radiology department for angiography. Twenty of these patients underwent BAE. The 23 medical records were retrospectively reviewed with regard to embolization agents used, embolization success rates, number of repeat embolizations, survival times, and causes of death.

RESULTS

BAE was performed on 38 occasions in 20 patients. The mean age of patients at first BAE was 15 years (age range, 7-19 years). The majority (n = 34 [89%]) of BAEs were performed by using polyvinyl alcohol. The immediate success rate after BAE (ie, no recurrent bleeding within 24 hours) was 95% (36 of 38 BAEs). Eleven (55%) patients required more than one BAE, and the median time between first and second embolizations was 4 months (range, 5 days to 61 months). Three patients died as a consequence of severe hemoptysis during induction of anesthesia with intermittent positive pressure ventilation in preparation for BAE. The median survival duration after the first BAE (Kaplan-Meier estimate) was 84 months (average follow-up, 61 months; range, 5 days to 169 months).

CONCLUSION

BAE had a high success rate for short-term control of bleeding; however, more than half the patients required repeat embolization during the long-term follow-up.

Surgical experience in patients with cystic fibrosis: a 25-year perspective

The spectrum of surgical diseases in patients with cystic fibrosis (CF) has not been comprehensively studied. A retrospective review of 792 consecutive patients with CF presenting over a 25 year period (1970-1994) was made to determine the incidence of operations, procedures performed, complications encountered, and impact on physical development and pulmonary function tests (PFTs). A total of 191 operations were performed on 130 (16%) of the 792 patients; 98 operations (51%) were abdominal, 58 (30%) thoracic, and 31 (16%) hernias; 64 were male, and 66 female; average age was 14 +/- 10 years. Complications occurred in 12 (16%); 9 deaths were from progressive respiratory failure, 2 from superficial wound infections, and 1 from an episode of line sepsis. In the first 15 years, 9 complications occurred in 126 operations vs. 3 in 73 operations during the last 10 years. Operations were classified as emergent, urgent, or elective. Of the 9 deaths, 8 occurred after emergent or urgent operations (4 abdominal and 4 thoracic), while 1 death occurred following elective herniorrhaphy. For each subgroup, (abdominal, thoracic, and hernia), there was no difference in height/weight indicies, peak flow, forced vital capacity (FVC), forced expired volume in 1 sec (FEV(1)), or FEV(1)/FVC ratio when comparing 1 year preoperation and 1 year postoperation. In conclusion, patients in this high-risk population were operated on with few complications, but when a complication occurred it tended to be pulmonary and fatal (4.7% of all operations). Furthermore, operations did not cause significant deteriorations in PFTs and they did not cause these children to fall off their expected age-adjusted growth curves.

Pneumonectomy in cystic fibrosis

A 17-year-old boy and a 12-year-old girl with cystic fibrosis (forced expiratory volume in 1 sec, 36% and 14% of predicted values, respectively) developed severe right-sided lung infections with abscess formations and complete atelectases unresponsive to medical therapy. In both patients, unilateral emergency pneumonectomy resulted in rapid clinical improvement. Despite her severe underlying lung disease, the girl experienced a remarkable increase in quality of life; 2 years after surgery, she died from respiratory failure. The male patient has now survived for 4 years, and lung transplantation still remains a therapeutic option for him. We believe that pneumonectomy is a valuable rescue therapy for patients with cystic fibrosis and intractable unilateral lung infections who are at high risk of dying while waiting for lung transplantation.

Lung resection in cystic fibrosis patients with localised pulmonary disease

The results of lobar resection to treat severe localised bronchiectasis in six children with cystic fibrosis are described. Sustained clinical improvements occurred in children undergoing this surgical approach to treatment. Detailed assessment and intensive preoperative and postoperative medical treatment are essential to a favourable outcome in carefully selected patients.

Anaesthesia and cystic fibrosis

Cystic fibrosis occurs in 1 in 2000 children and the majority now reach adulthood. The disease is a complex multisystem disorder which is likely to challenge anaesthetists with increasing frequency. In this review the presentation and genetics of the disease are briefly described, followed by a detailed account of the pathophysiology relevant to anaesthesia. The pre-operative assessment and conduct of anaesthesia are discussed and some suggestions made regarding management.

Predicting outcome following pulmonary resection in cystic fibrosis patients

A small subset of cystic fibrosis (CF) patients develop pulmonary disease primarily limited to one lobe or lung segment requiring prolonged recurrent hospitalizations with intensive medical therapy. Although surgery has been advocated for patients who do not respond to medical therapy, very little is known about criteria for selection of patients who might benefit from resection of the involved parenchyma. In an attempt to further define criteria for pulmonary resection in these patients, we retrospectively reviewed our experience at Tulane Medical Center over the past 10 years. Fourteen patients with CF, ranging from 3 to 30 years of age, underwent 17 pulmonary resections. Indications for surgery were persistent lobar or pulmonary atelectasis and bronchiectasis requiring multiple hospitalizations and unresponsive to medical therapy (n = 13), bronchopleural fistula (n = 2), or hemoptysis not responding to medical therapy or selective embolization (n = 2). Thirteen lobectomies and four pneumonectomies were performed. Only two resections were on the left side and 11 right upper lobectomies were performed. Postoperative hospitalization ranged from 5 to 21 days (mean, 8.5 days). Preoperative pulmonary function tests showed widely divergent function in these patients. Forced expiratory volume (FEV1) ranged from 11% to 88% whereas forced vital capacity (FVC) ranged from 20% to 100% of predicted values. Oxygen saturation ranged from 86% to 99%. Although there was no significant difference in preoperative and postoperative FVC or O2 saturation, there was a significant (P less than .003) decrease in the postoperative FEV1. In the 12 surviving patients followed for at least 1 year, there was also a significant reduction (P less than .001) in the number of hospitalizations required due to pulmonary exacerbations from an average 2.2 admissions per year (range, 0.44 to 3.5 admissions per year) to 1.1 admissions per year (range, 0 to 8).(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchial artery embolization for severe hemoptysis in cystic fibrosis

We studied the long-term outcome after BAE for life-threatening hemoptysis in patients with CF. Data from pulmonary function tests were available for 18 of the 25 patients followed. A case-control comparison revealed that these 18 patients died sooner than hemoptysis-free patients with CF matched for age, sex, and pulmonary function (p less than 0.02), with the excess mortality occurring within the first three months after BAE. Of all 25 patients followed, six died of cardiorespiratory failure within three months of BAE; in two of them, hemoptysis was a contributing cause of death. The 19 patients who lived more than three months after BAE had a mean survival after embolization of 3.5 years (five were still alive at the end of the study). Most patients experienced long intervals (greater than 1 year) free of major hemoptysis. Extended follow-up (mean, 35 months) revealed a higher incidence of recurrent severe bleeding than previously reported for 13 of these patients followed a mean of 11 months. Repeat BAE for severe recurrence was performed successfully in eight of nine patients, without complication.

Pulmonary resection for localized bronchiectasis in cystic fibrosis. Report of three cases and review of the literature

Three children with cystic fibrosis and localized bronchiectasis were treated by surgical removal of the affected lobe, after attempts to clear the obstructed bronchus by medical therapy and bronchoscopy with suction and lavage had been unsuccessful. Three to six years after surgery, the results are excellent. Pulmonary disease is mild in all patients, shown by chest radiographs and pulmonary function tests. A review of 102 cases reported in the literature demonstrates that pulmonary surgery is effective and can be performed safely in selected patients.

Surgery in patients with cystic fibrosis

A 15-year review of children's hospital patients with cystic fibrosis (CF) who underwent surgery yielded 578 cases in 210 patients (mean 2.7 per patient). The median age was 16 years (range newborn to 43 years). Four hundred procedures were done under general anesthesia and 176 under local. There was one anesthetic complication, respiratory depression in a patient whose MediPort (Cormed, Inc, Medina, NY) was inserted using local anesthesia and sedation. The most frequent procedure was nasal polypectomy, with 165 procedures in 50 patients. The second most common procedures were vascular access procedures: 75 central lines and 29 MediPorts were implanted in 57 patients, complicated by two pneumothoraces. Thoracic procedures included 32 bronchoscopies, 8 lobectomies, 2 pneumonectomies, and 30 pleural strippings. There were three reoperations for bleeding in the pulmonary resection patients. Thirteen newborns underwent a total of 26 procedures for meconium ileus and its complications, with two deaths secondary to respiratory failure and sepsis. These, and one death postlobectomy were the only operative deaths in the entire series of 578 cases (0.5% mortality rate). There were four slings for rectal prolapse; two required removal secondary to infection. Eight patients underwent central splenorenal shunts for portal hypertension, 15 underwent cholecystectomy, 5 underwent Nissen fundoplication, 16 underwent inguinal herniorrhaphy, 2 underwent umbilical herniorrhaphy, 3 underwent orchidopexies, and 4 underwent miscellaneous pediatric surgical procedures. Eleven patients underwent appendectomy for appendicitis; four were ruptured at the time of diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of anaesthesia for patients with cystic fibrosis

The clinical problems of patients with cystic fibrosis who require anaesthesia are reviewed. The management and the complications of anaesthesia in 77 patients over a 3-year period are presented. The long term effects of anaesthesia are analysed by a study of the lung function tests of these patients. The results suggest that even multiple procedures, as for instance nasal polypectomy, are not harmful. A method for safe peroperative management is presented.