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Urban MH, Mayr AK, Schmidt I, Grasmuk-Siegl E, Burghuber OC, Funk GC. Effects of Dynamic Hyperinflation on Left Ventricular Diastolic Function in Healthy Subjects - A Randomized Controlled Crossover Trial. Front Med (Lausanne) 2021; 8:659108. [PMID: 34017848 PMCID: PMC8129530 DOI: 10.3389/fmed.2021.659108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Diastolic dysfunction of the left ventricle is common in patients with chronic obstructive pulmonary disease (COPD). Dynamic hyperinflation has been suggested as a key determinant of reduced diastolic function in COPD. We aimed to investigate the effects of induced dynamic hyperinflation on left ventricular diastolic function in healthy subjects to exclude other confounding mechanisms associated with COPD. Design: In this randomized controlled crossover trial (NCT03500822, https://www.clinicaltrials.gov/), we induced dynamic hyperinflation using the validated method of expiratory resistance breathing (ERB), which combines tachypnea with expiratory resistance, and compared the results to those of tachypnea alone. Healthy male subjects (n = 14) were randomly assigned to the ERB or control group with subsequent crossover. Mild, moderate, and severe hyperinflation (i.e., ERB1, ERB2, ERB3) were confirmed by intrinsic positive end-expiratory pressure (PEEPi) using an esophageal balloon catheter. The effects on diastolic function of the left ventricle were measured by transthoracic echocardiographic assessment of the heart rate-adjusted transmitral E/A-ratio and E/e'-ratio. Results: We randomly assigned seven participants to the ERB group and seven to the control group (age 26 [24-26] vs. 24 [24-34], p = 0.81). Severe hyperinflation decreased the E/A-ratio compared to the control condition (1.63 [1.49-1.77] vs. 1.85 [0.95-2.75], p = 0.039), and moderate and severe ERB significantly increased the septal E/e'-ratio. No changes in diastolic function were found during mild hyperinflation. PEEPi levels during ERB were inversely correlated with the E/A ratio (regression coefficient = -0.007, p = 0.001). Conclusions: Our data indicate dynamic hyperinflation as a determinant of left ventricular diastolic dysfunction in healthy subjects. Therapeutic reduction of hyperinflation might be a treatable trait to improve diastolic function in patients with COPD.
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Affiliation(s)
- Matthias Helmut Urban
- Department of Internal and Respiratory Medicine, Klinik Floridsdorf, Vienna, Austria.,Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria.,Otto Wagner Hospital, Ludwig-Boltzmann Institute for Lung Health, Vienna, Austria
| | - Anna Katharina Mayr
- Department of Internal and Respiratory Medicine, Klinik Floridsdorf, Vienna, Austria.,Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria
| | - Ingrid Schmidt
- Department of Internal and Respiratory Medicine, Klinik Floridsdorf, Vienna, Austria.,Institute for Physical and Rehabilitation Medicine/Cardiorespiratory Therapy, Klinik Floridsdorf, Vienna, Austria
| | - Erwin Grasmuk-Siegl
- Department of Internal and Respiratory Medicine, Klinik Floridsdorf, Vienna, Austria.,Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria
| | - Otto Chris Burghuber
- Otto Wagner Hospital, Ludwig-Boltzmann Institute for Lung Health, Vienna, Austria.,Medical School, Sigmund Freud University, Vienna, Austria
| | - Georg-Christian Funk
- Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria.,Department of Internal and Respiratory Medicine, Klinik Ottakring, Vienna, Austria
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Opitz I, Ulrich S. Pulmonary hypertension in chronic obstructive pulmonary disease and emphysema patients: prevalence, therapeutic options and pulmonary circulatory effects of lung volume reduction surgery. J Thorac Dis 2018; 10:S2763-S2774. [PMID: 30210830 PMCID: PMC6129805 DOI: 10.21037/jtd.2018.07.63] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/12/2018] [Indexed: 11/06/2022]
Abstract
The exact prevalence of pulmonary hypertension (PH) and cor pulmonale (CP) in chronic obstructive pulmonary disease (COPD) is unknown, and varies considerably from 20-91%. Usually, mean pulmonary artery pressure (mPAP) does not exceed 30 mmHg, and PH is not severe. However, PH and CP are important predictors of mortality in COPD and contribute to disability in this disease. Many factors contribute to the development of PH in chronic lung disease, including reduction of the pulmonary vascular cross-sectional area due to parenchymal loss and accompanying hypoxia, effects of abnormal pulmonary mechanics due to hyperinflation, but also vascular remodeling processes. So far, PH associated with chronic lung disease cannot be treated medically. Therefore, it is indicated to treat the underlying pulmonary disease. Patients with severe PH should be referred to centers experienced in the management of PH and enrollment in clinical trials should be considered. Lung volume reduction surgery (LVRS) theoretically further increases pulmonary vascular resistance (PVR) by reducing the vascular bed when resecting lung tissue, however, this might be compensated by better pulmonary mechanics through reduction of hyperinflation, which will be discussed in the present article.
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Affiliation(s)
- Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Respiratory Diseases, University Hospital Zurich, Zurich, Switzerland
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3
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Xu Y, Yamashiro T, Moriya H, Tsubakimoto M, Tsuchiya N, Nagatani Y, Matsuoka S, Murayama S. Hyperinflated lungs compress the heart during expiration in COPD patients: a new finding on dynamic-ventilation computed tomography. Int J Chron Obstruct Pulmon Dis 2017; 12:3123-3131. [PMID: 29123390 PMCID: PMC5661839 DOI: 10.2147/copd.s145599] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose The aims of this study were to evaluate dynamic changes in heart size during the respiratory cycle using four-dimensional computed tomography (CT) and to understand the relationship of these changes to airflow limitation in smokers. Materials and methods A total of 31 smokers, including 13 with COPD, underwent four-dimensional dynamic-ventilation CT during regular breathing. CT data were continuously reconstructed every 0.5 s, including maximum cross-sectional area (CSA) of the heart and mean lung density (MLD). Concordance between the cardiac CSA and MLD time curves was expressed by cross-correlation coefficients. The CT-based cardiothoracic ratio at inspiration and expiration was also calculated. Comparisons of the CT indices between COPD patients and non-COPD smokers were made using the Mann–Whitney test. Spearman rank correlation analysis was used to evaluate associations between CT indices and the forced expiratory volume in 1 s (FEV1.0) relative to the forced vital capacity (FVC). Results Cardiac CSA at both inspiration and expiration was significantly smaller in COPD patients than in non-COPD smokers (P<0.05). The cross-correlation coefficient between cardiac CSA and MLD during expiration significantly correlated with FEV1.0/FVC (ρ=0.63, P<0.001), suggesting that heart size decreases during expiration in COPD patients. The change in the cardiothoracic ratio between inspiration and expiration frames was significantly smaller in COPD patients than in non-COPD smokers (P<0.01). Conclusion Patients with COPD have smaller heart size on dynamic-ventilation CT than non-COPD smokers and have abnormal cardiac compression during expiration.
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Affiliation(s)
- Yanyan Xu
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Japan.,Department of Radiology, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Tsuneo Yamashiro
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Japan
| | - Hiroshi Moriya
- Department of Radiology, Ohara General Hospital, Fukushima, Japan
| | - Maho Tsubakimoto
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Japan
| | - Nanae Tsuchiya
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Japan
| | - Yukihiro Nagatani
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
| | - Shin Matsuoka
- Department of Radiology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Japan
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4
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McKeough ZJ, Alison JA, Bayfield MS, Bye PTP. Supported and unsupported arm exercise capacity following lung volume reduction surgery: a pilot study. Chron Respir Dis 2016; 2:59-65. [PMID: 16279152 DOI: 10.1191/1479972305cd074oa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Study Objectives: Lung volume reduction surgery (LVRS) has been shown to improve lung function, leg exercise capacity and quality of life in subjects with severe COPD. This is the first study to examine the effect of LVRS on supported and unsupported arm exercise capacity. Design: Eight subjects with COPD (% pred FEV1 ±SD = 31.1 ± 9.8%) completed testing. At baseline (TI), after eight weeks pulmonary rehabilitation (T2) and four months after LVRS (T3), each subject had tests of lung function, and performed three symptom-limited exercise tests to peak work capacity:supported arm exercise (SAE), unsupported arm exercise (UAE) and leg exercise (LE).Measurements: The FEV1 (% pred) increased from 27.8 ± 7.4 (mean ± SD) at T2 to 36.3 ± 7.1 at T3 (P <0.05). Peak oxygen consumption (VO2) remained similar from TI to T2 for SAE, UAE and LE (all P=1.0) but increased from T2 to T3 (P <0.05) (SAE: T2 = 0.59 ± 0.2 L/min,T3 = 0.72 ± 0.1 L/min; UAE: T2 = 0.45 ± 0.1 L/min, T3 = 0.54 ± 0.1 L/min; LE:T2-0.68 ± 0.2 L/min, T3 = 0.81 ± 0.2 L/min). The ratio of end-expiratory lung volume to total lung capacity was reduced at peak SAE and LE from T2 to T3 (P < 0.01) (SAE:T2 = 81 ± 4.0%, T3 = 76 ± 2.7%; LE: T2-81 ± 5.1%, T3 = 75 ± 3.6%). Conclusion: There was a significant increase in SAE and UAE capacity following LVRS. Dynamic hyperinflation wras reduced during SAE following LVRS.
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Affiliation(s)
- Z J McKeough
- School of Physiotherapy, Faculty of Health Sciences, Sydney University, Australia.
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5
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Edelman JD, Kotloff RM. Critical Care of the Lung Volume Reduction Surgery Patient. J Intensive Care Med 2016. [DOI: 10.1177/088506660001500402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lung volume reduction surgery (LVRS) offers the potential to improve lung function, exercise tolerance, and quality of life for patients with advanced emphysema. At present, the specific role of this procedure in the treatment of advanced emphysema is a subject of ongoing investigation. LVRS is most commonly performed bilaterally via either median sternotomy or video thoracoscopic approach with resection of the most severely affected lung tissue to reduce the overall lung volume by 20–30%. This results in improvements in lung elastic recoil, airway conductance, chest wall, and diaphragmatic function leading to greater inspiratory and expiratory airflow, decreased hyperinflation, and improved exercise tolerance. The greatest improvement after LVRS occurs within 3–6 months after surgery. In the perioperative period, however, lung function may be compromised by surgical incisions, pain, chest tubes, retained secretions, pneumonia, and parenchymal injury associated with resection. The risks of LVRS are not insignificant, with reported mortality prior to hospital discharge ranging from 2.5 to 14%. Pulmonary complications may include respiratory failure, persistent air leaks, pneumonia, tracheobronchitis, retained secretions, atelectasis, pneumothorax, bleeding, and sternal wound infections or dehiscence. Cardiac and gastrointestinal complications are the most common extrathoracic causes of perioperative morbidity after LVRS. Although many patients have an uneventful postoperative course, patients who experience complications frequently require prolonged mechanical ventilation and intensive care. Critical care practitioners must therefore be familiar with LVRS, its potential complications, and the ICU management of LVRS patients.
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Affiliation(s)
- Jeffrey D. Edelman
- From the Pulmonary and Critical Care Division, Oregon Health Sciences University, Portland, OR
| | - Robert M. Kotloff
- From the Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Medical Center, Philadelphia, PA
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6
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Matsuoka S, Yamashiro T, Kotoku A, Matsushita S, Fujikawa A, Yagihashi K, Kurihara Y, Nakajima Y. Changes in the Superior Vena Cava Area During Inspiration and Expiration in Relation to Emphysema. COPD 2014; 12:168-74. [DOI: 10.3109/15412555.2014.922171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Shin Matsuoka
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Tsuneo Yamashiro
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
- 2Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Nishihara, Japan
| | - Akiyuki Kotoku
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shoichiro Matsushita
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Atsuko Fujikawa
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kunihiro Yagihashi
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
- 3Department of Radiology, National Jewish Health, School of Medicine, University of Colorado-Denver Denver, CO, USA
| | - Yasuyuki Kurihara
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuo Nakajima
- 1Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
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8
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Abstract
The development of pulmonary hypertension in COPD adversely affects survival and exercise capacity and is associated with an increased risk of severe acute exacerbations. Unfortunately not all patients with COPD who meet criteria for long term oxygen therapy benefit from it. Even in those who benefit from long term oxygen therapy, such therapy may reverse the elevated pulmonary artery pressure but cannot normalize it. Moreover, the recent discovery of the key roles of endothelial dysfunction and inflammation in the pathogenesis of PH provides the rationale for considering specific pulmonary vasodilators that also possess antiproliferative properties and statins.
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Criner GJ, Belt P, Sternberg AL, Mosenifar Z, Make BJ, Utz JP, Sciurba F. Effects of lung volume reduction surgery on gas exchange and breathing pattern during maximum exercise. Chest 2009; 135:1268-1279. [PMID: 19420196 PMCID: PMC2818416 DOI: 10.1378/chest.08-1625] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2008] [Accepted: 11/11/2008] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The National Emphysema Treatment Trial studied lung volume reduction surgery (LVRS) for its effects on gas exchange, breathing pattern, and dyspnea during exercise in severe emphysema. METHODS Exercise testing was performed at baseline, and 6, 12, and 24 months. Minute ventilation (Ve), tidal volume (Vt), carbon dioxide output (Vco(2)), dyspnea rating, and workload were recorded at rest, 3 min of unloaded pedaling, and maximum exercise. Pao(2), Paco(2), pH, fraction of expired carbon dioxide, and bicarbonate were also collected in some subjects at these time points and each minute of testing. There were 1,218 patients enrolled in the study (mean [+/- SD] age, 66.6 +/- 6.1 years; mean, 61%; mean FEV(1), 0.77 +/- 0.24 L), with 238 patients participating in this substudy (mean age, 66.1 +/- 6.8 years; mean, 67%; mean FEV(1), 0.78 +/- 0.25 L). RESULTS At 6 months, LVRS patients had higher maximum Ve (32.8 vs 29.6 L/min, respectively; p = 0.001), Vco(2), (0.923 vs 0.820 L/min, respectively; p = 0.0003), Vt (1.18 vs 1.07 L, respectively; p = 0.001), heart rate (124 vs 121 beats/min, respectively; p = 0.02), and workload (49.3 vs 45.1 W, respectively; p = 0.04), but less breathlessness (as measured by Borg dyspnea scale score) [4.4 vs 5.2, respectively; p = 0.0001] and exercise ventilatory limitation (49.5% vs 71.9%, respectively; p = 0.001) than medical patients. LVRS patients with upper-lobe emphysema showed a downward shift in Paco(2) vs Vco(2) (p = 0.001). During exercise, LVRS patients breathed slower and deeper at 6 months (p = 0.01) and 12 months (p = 0.006), with reduced dead space at 6 months (p = 0.007) and 24 months (p = 0.006). Twelve months after patients underwent LVRS, dyspnea was less in patients with upper-lobe emphysema (p = 0.001) and non-upper-lobe emphysema (p = 0.007). CONCLUSION During exercise following LVRS, patients with severe emphysema improve carbon dioxide elimination and dead space, breathe slower and deeper, and report less dyspnea.
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Affiliation(s)
| | - Patricia Belt
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Barry J Make
- National Jewish Medical and Research Center, Denver, CO
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10
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Abstract
Bullectomy for giant bullae, lung volume reduction surgery, and lung transplantation are three surgical therapies that may benefit highly selected patients with advanced chronic obstructive pulmonary disease. In this article, each procedure is reviewed, with an emphasis on guidelines for patient selection and clinical outcomes for the practicing pulmonologist. Recent results from the National Emphysema Treatment Trial, updated International Society for Heart and Lung Transplantation Registry data, and revised guidelines for patient selection for lung transplantation are discussed.
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Affiliation(s)
- David J Lederer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, Lung Transplantation Program, PH-14 East, Room 104, New York, NY 10032, USA
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11
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Jörgensen K, Müller MF, Nel J, Upton RN, Houltz E, Ricksten SE. Reduced intrathoracic blood volume and left and right ventricular dimensions in patients with severe emphysema: an MRI study. Chest 2007; 131:1050-7. [PMID: 17426209 DOI: 10.1378/chest.06-2245] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Left ventricular (LV) filling is impaired in patients with severe emphysema manifesting in small end-diastolic dimensions. We hypothesized that the hyperinflated lungs of these patients with high intrinsic positive end-expiratory pressure will decrease intrathoracic blood volume (ITBV) and ventricular preload. We therefore measured ITBV, and LV and right ventricular (RV) dimensions and function using MRI techniques in patients with severe emphysema. METHODS Patients with severe emphysema (n = 13) and matched healthy volunteers (n = 11) were included. The magnetic resonance (MR) examination consisted of three parts: (1) evaluation of RV and LV dimensions and function and interventricular septum curvature using cine MRI; (2) quantification of aortic flow using MR phase velocity mapping; and (3) calculation of the cardiopulmonary peak transit time (PTT) from the pulmonary artery to the ascending aorta using contrast-enhanced, time-resolved, two-dimensional MR angiography. RESULTS There were no differences between the groups regarding age, height, or weight. In the emphysema patients, ITBV index (- 35%), LV end-diastolic volume index (LVEDVI) [- 21%], RV end-diastolic volume index (- 20%), cardiac index (- 22%), and stroke volume index (SVI) [- 40%] were lower compared to control subjects. LV and RV end-systolic volumes, LV wall mass, septal curvature, and PTT did not differ between the groups. LVEDVI (r = 0.83) as well as SVI (r = 0.82) correlated closely to ITBV index. SVI correlated closely to LVEDVI (r = 0.84). CONCLUSIONS LV and RV performance is impaired in patients with severe emphysema because of small end-diastolic dimensions. One possible explanation for the decreased biventricular preload in these patients is intrathoracic hypovolemia caused by hyperinflated lungs.
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Affiliation(s)
- Kirsten Jörgensen
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden
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12
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Jörgensen K, Houltz E, Westfelt U, Ricksten SE. Left ventricular performance and dimensions in patients with severe emphysema. Anesth Analg 2007; 104:887-92. [PMID: 17377101 DOI: 10.1213/01.ane.0000258020.27849.6b] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Concomitant heart dysfunction during the course of chronic obstructive pulmonary disease is well recognized. The prevailing view is that mainly the right side of the heart is involved. We evaluated left ventricular (LV) function and dimensions in patients with severe emphysema. METHODS Patients with severe emphysema undergoing lung volume reduction surgery were studied after anesthesia induction (n = 10). Non-emphysematous patients scheduled for lobectomy served as controls (n = 10). LV dimensions were measured with patients in the supine position by transesophageal two-dimensional echocardiography and systemic hemodynamics by a pulmonary artery thermodilution catheter, before and during central blood volume expansion by passive leg elevation. RESULTS Baseline cardiac index (-25%), stroke volume index (SVI, -32%) stroke work index (-34%) and LV end-diastolic area index (EDAI, -33%) were significantly (P < 0.001) lower in the emphysema group. Passive leg elevation increased SVI and LV area ejection fraction more in the emphysema group than in controls (P < 0.05). The DeltaSVI/Delta pulmonary capillary wedge pressure and the DeltaSVI/DeltaEDAI relationships were significantly (P < 0.05) higher in the emphysema group compared to controls (2.2 +/- 0.71 vs 0.6 +/- 0.2 mL/mm Hg x m2 and 5.8 +/- 0.89 vs 2.8 +/- 0.8 mL/cm2 x m2, respectively). Preload-recruitable stroke work (Deltastroke work index/DeltaEDAI), a load-independent index of systolic LV function, did not differ between the two groups. CONCLUSION The LV in patients with severe emphysema is hypovolemic, and operates on a steeper portion of the LV function curve, while indices of systolic function are not significantly impaired compared to non-emphysematous controls.
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Affiliation(s)
- Kirsten Jörgensen
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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13
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Krachman SL, Chatila W, Martin UJ, Nugent T, Crocetti J, Gaughan J, Criner GJ. Effects of lung volume reduction surgery on sleep quality and nocturnal gas exchange in patients with severe emphysema. Chest 2005; 128:3221-8. [PMID: 16304265 DOI: 10.1378/chest.128.5.3221] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES We hypothesized that associated with improvements in respiratory mechanics, lung volume reduction surgery (LVRS) would result in an improvement in both sleep quality and nocturnal oxygenation in patients with severe emphysema. DESIGN Prospective randomized controlled trial. SETTING University hospital. PATIENTS Sixteen patients (10 men, 63 +/- 6 years [+/- SD]) with severe airflow limitation (FEV(1), 28 +/- 10% predicted) and hyperinflation (total lung capacity, 123 +/- 14% predicted) who were part of the National Emphysema Treatment Trial. INTERVENTIONS AND MEASUREMENTS Patients completed 6 to 10 weeks of outpatient pulmonary rehabilitation. Spirometry, measurement of lung volumes, arterial blood gas analysis, and polysomnography were performed prior to randomization and again 6 months after therapy. Ten patients underwent LVRS and optimal medical therapy, while 6 patients received optimal medical therapy only. RESULTS Total sleep time and sleep efficiency improved following LVRS (from 184 +/- 111 to 272 +/- 126 min [p = 0.007], and from 45 +/- 26 to 61 +/- 26% [p = 0.01], respectively), while there was no change with medical therapy alone (236 +/- 75 to 211 +/- 125 min [p = 0.8], and from 60 +/- 18 to 52 +/- 17% [p = 0.5], respectively). The mean and lowest oxygen saturation during the night improved with LVRS (from 90 +/- 7 to 93 +/- 4% [p = 0.05], and from 83 +/- 10 to 86 +/- 10% [p = 0.03], respectively), while no change was noted in the medical therapy group (from 91 +/- 5 to 91 +/- 5 [p = 1.0], and from 84 +/- 5 to 82 +/- 6% [p = 0.3], respectively). There was a correlation between the change in FEV(1) and change in the lowest oxygen saturation during the night (r = 0.6, p = 0.02). In addition, there was an inverse correlation between the change in the lowest oxygen saturation during the night and the change in residual volume (- r = 0.5, p = 0.04) and functional residual capacity (- r = 0.6, p = 0.03). CONCLUSION In patients with severe emphysema, LVRS, but not continued optimal medical therapy, results in improved sleep quality and nocturnal oxygenation. Improvements in nocturnal oxygenation correlate with improved airflow and a decrease in hyperinflation and air trapping.
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Affiliation(s)
- Samuel L Krachman
- Division of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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14
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Eves ND, Jones RL, Petersen SR. The Influence of the Self-Contained Breathing Apparatus (SCBA) on Ventilatory Function and Maximal Exercise. ACTA ACUST UNITED AC 2005; 30:507-19. [PMID: 16293900 DOI: 10.1139/h05-137] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Our previous work showed that breathing low density gases during exercise with the self-contained breathing apparatus (SCBA) improves maximal ventilation (VE) and maximal oxygen consumption [Formula: see text] This suggests that the SCBA limits exercise by adding a resistive load to breathing. In this study we compared [Formula: see text] with and without the various components comprising the SCBA to determine their impact on [Formula: see text] Twelve males performed 4 randomly ordered incremental exercise tests to exhaustion on a treadmill: (1) low-resistance breathing valve only (CON); (2) full SCBA (SCBA); (3) SCBA regulator only (REG); and (4) carrying the cylinder and harness assembly but breathing through a low-resistance breathing valve (PACK). Compared to CON, [Formula: see text] was reduced to a similar extent in the SCBA and REG trials (14.9% and 13.1%, respectively). The PACK condition also reduced [Formula: see text] but to a lesser extent (4.8 ± 5.3%). At [Formula: see text][Formula: see text] was decreased and expiratory mouth pressure and external breathing resistance (BR) were increased in both the SCBA and REG trials. There was a significant correlation between the change in maximal [Formula: see text] and [Formula: see text] with the SCBA. The results show that the SCBA reduces [Formula: see text] by limiting [Formula: see text] secondary to the increased BR of the SCBA regulator. Key words: ventilation, breathing resistance, expiratory flow limitation, [Formula: see text]
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Affiliation(s)
- Neil D Eves
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Alberta T6G 2H9, Canada
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15
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Cordova FC, Criner GJ. Lung volume reduction surgery as a bridge to lung transplantation. ACTA ACUST UNITED AC 2005; 1:313-24. [PMID: 14720034 DOI: 10.1007/bf03256625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Lung volume reduction surgery (LVRS) improves lung function, exercise capacity, and quality of life in patients with advanced emphysema. In some patients with emphysema who are candidates for lung transplantation, LVRS is an alternative treatment option to lung transplantation, or may be used as a bridge to lung transplantation. Generally accepted criteria for LVRS include severe non-reversible airflow obstruction due to emphysema associated with significant evidence of lung hyperinflation and air trapping. Both high resolution computed tomography (CT) scan of the chest and quantitative ventilation/perfusion scan are used to identify lung regions with severe emphysema which would be used as targets for lung resection. Bilateral LVRS is the preferred surgical approach compared with the unilateral procedure because of better functional outcome. Lung transplantation is the preferred surgical treatment in patients with emphysema with alpha1 antitrypsin deficiency and in patients with very severe disease who have homogeneous emphysema pattern on CT scan of the chest or very low diffusion capacity.
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Affiliation(s)
- Francis C Cordova
- Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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Leroy S, Marquette CH. [VENT: International study of bronchoscopic lung volume reduction as a palliative treatment for emphysema]. Rev Mal Respir 2005; 21:1144-52. [PMID: 15767960 DOI: 10.1016/s0761-8425(04)71590-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Therapeutic options for patients with severe emphysema remain limited. In selected patients, lung volume reduction surgery has been shown to improve pulmonary function, exercise capacity, quality of life and also survival. The technique of inserting one-way valves endoscopically into the airways supplying the most affected areas of lung provides the possibility of achieving similar results to surgery (i.e. volume reduction) in a less invasive way, which is also reversible, since the valves can be removed at any time. This technique has been shown to be safe. The aim of this study is to evaluate the efficacy of this technique compared to optimal medical therapy in patients with heterogeneous emphysema defined according to radiological criteria. METHODS A prospective, international, multicentre (20 centres) randomised trial is underway to establish the efficacy and safety of endobronchial valve placement in this patient group. This study will enrol 270 patients and be analysed on an intention to treat basis. Patients are randomised either to valve insertion or optimal medical treatment alone in a ratio of 2 to 1. Follow up will be ensured for at least one year. EXPECTED RESULTS The two principal outcome measures will be improvement at six months in FEV1 and in six minute walk distance. The safety of the technique will be evaluated over the same period. Details of the study are available online for patients and their physicians at www.euroemphysema.com.
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Affiliation(s)
- S Leroy
- Clinique des Maladies Respiratoires, Hôpital Calmette, CHRU de Lille, France
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Smith RA, Bratzke EC, Miguel RV. Constant positive airway pressure reduces hypoventilation induced by inhalation anesthesia. J Clin Anesth 2005; 17:44-50. [PMID: 15721729 DOI: 10.1016/j.jclinane.2004.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2003] [Accepted: 03/31/2004] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE To discover if reducing respiratory system impedance would increase tidal volume and improve ventilation during inhalation anesthesia. DESIGN Prospective, randomized cross-over study. SUBJECTS Nine ASA physical status I and II adult female oncology patients undergoing breast operations with or without lymph node dissection and general anesthesia while breathing spontaneously. INTERVENTIONS AND MEASUREMENTS Patients underwent alternating trials of constant positive airway pressure, with or without pressure support. Constant positive airway pressure and pressure support were titrated to maximize respiratory system compliance and equal inspiratory pressure gradient across tracheal tube, respectively. Variables reflecting cardiovascular function, pulmonary mechanics and lung gas exchange, and respired gases and isoflurane concentrations were measured. MAIN RESULTS End-tidal concentration of isoflurane (1.3 +/- 0.2%), Fio(2) (0.43 +/- 0.09 ), and CO(2) elimination (209 +/- 42 mL min(-1)) was unchanged throughout study in patients aged 63 +/- 12 years, weighing 72 +/- 12 kg. Constant positive airway pressure (12 +/- 2 cm H(2)O) increased respiratory system compliance from 52 +/- 8 to 80 +/- 9 mL cm H(2)O(-1) (P < .001), tidal volume from 156 +/- 32 to 325 +/- 52 mL (P < .001), and minute ventilation from 4.37 +/- 0.86 to 6.18 +/- 0.92 L min(-1) (P < .001). Respiratory rate decreased from 29 +/- 7 to 19 +/- 2 min(-1) (P < .001), Paco(2) decreased from 54 +/- 8 to 44 +/- 6 mm Hg (P < .001), and Pao(2) increased from 137 +/- 37 to 160 +/- 64 mm Hg (P < .001). Pressure support (3.1 +/- 0.3 cm H(2)O) did not alter ventilation or gas exchange. CONCLUSION We conclude that constant positive airway pressure titrated to optimal respiratory system compliance will increase efficiency of inspiratory muscles and improve ventilation. Constant positive airway pressure facilitates a pattern of breathing that minimizes some of the adverse pulmonary effects of inhalation anesthesia.
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Affiliation(s)
- Robert A Smith
- Department of Anesthesiology, University of South Florida College of Medicine, Tampa, FL 33612-4799, USA.
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18
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Jörgensen K, Houltz E, Westfelt U, Nilsson F, Scherstén H, Ricksten SE. Effects of lung volume reduction surgery on left ventricular diastolic filling and dimensions in patients with severe emphysema. Chest 2003; 124:1863-70. [PMID: 14605061 DOI: 10.1378/chest.124.5.1863] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Data on the influence of lung volume reduction surgery (LVRS) on cardiac function and hemodynamics are scarce and controversial. Previous studies have focused mainly on right ventricular function and pulmonary hemodynamics. Here, we evaluated the effects of LVRS on left ventricular (LV) end-diastolic filling pattern, dimensions, stiffness, and performance, as well as pulmonary and systemic hemodynamics. DESIGN A prospective, open, controlled study. PATIENTS Patients with severe emphysema undergoing LVRS (10 patients). Patients scheduled for pulmonary lobectomy due to carcinoma (ie, the lobectomy group) served as control subjects (10 patients). MEASUREMENTS LV dimensions and mitral flow velocities were measured by transesophageal, two-dimensional, Doppler echocardiography, and central hemodynamics were measured by a pulmonary artery thermodilution catheter. Measurements were performed during anesthesia in the supine position, before and after surgery, without and with passive leg elevation. RESULTS Baseline cardiac index (CI) [- 21%], stroke volume index (SVI) [- 31%], stroke work index (SWI) [- 26%], and LV end-diastolic area index (EDAI) [- 15%] were significantly (p < 0.001) lower, whereas LV end-diastolic stiffness (LVEDS) did not differ in the LVRS group compared to the lobectomy group. The time from peak early diastolic filling to zero flow (E-dec time) [58%] and the deceleration slope of early diastolic filling (E-dec slope) [45%] were significantly higher (p < 0.01), whereas peak early diastolic filling velocity (E-max) [- 31%; p < 0.01] and the proportion of E-max vs peak late diastolic filling velocity (A-max) [ie, the E/A ratio] (- 27%; p < 0.001) were significantly lower compared to the lobectomy group. LVRS significantly increased CI (40%; p < 0.001), SVI (34%; p < 0.001), SWI (58%; p < 0.001), LV EDAI (18%; p < 0.001), E-max (44%; p < 0.01), A-max (15%; p < 0.05) and E/A ratio (28%; p < 0.01), decreased E-dec time (- 31%; p < 0.05) and E-dec slope (- 98%; p < 0.01), and had no effect on LVEDS. In the lobectomy group, surgery affected none of these variables. CONCLUSIONS LV function is impaired in patients with severe emphysema due to small end-diastolic dimensions. LVRS increases LV end-diastolic dimensions and filling, and improves LV function.
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Affiliation(s)
- Kirsten Jörgensen
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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19
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Abstract
LVRS provides an exciting opportunity for palliation of symptoms and improvement in quality of life for patients who have severe end-stage emphysema. Because no medical therapy has been able to improve pulmonary function or reverse the inexorable decline of breathless patients who have emphysema, this opportunity to improve lung function and quality of life is one of the most innovative additions to thoracic surgery since the first successful lung transplant procedure 20 years ago. Although initial short-term, case-controlled surgeries were criticized because of incomplete and short follow-up care, substantial long-term data now exist to support the use of LVRS for select patients who have severe emphysema. Patients who have upper lobe predominant disease or low exercise capacity are more likely to have a benefit in exercise capacity and quality of life after LVRS. Selected patients who have upper lobe emphysema and poor exercise capacity are also more likely to have improved survival after LVRS. The individual contributions by the large number of investigators pioneering LVRS development, along with the collective contributions of the NETT investigators, have propelled the knowledge surrounding LVRS far beyond that of any similar new technology or procedure in its adolescence.
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Affiliation(s)
- Douglas E Wood
- General Thoracic Surgery, University of Washington, 1959 NE Pacific, AA-115, Box 356310, Seattle, WA 98195-6310, USA.
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20
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Affiliation(s)
- Katherine P Grichnik
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Duke Heart Center, Duke University Health Care Systems, Durham, NC 27710, USA.
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21
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Mineo TC, Pompeo E, Rogliani P, Dauri M, Turani F, Bollero P, Magliocchetti N. Effect of lung volume reduction surgery for severe emphysema on right ventricular function. Am J Respir Crit Care Med 2002; 165:489-94. [PMID: 11850341 DOI: 10.1164/ajrccm.165.4.2108129] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lung volume reduction surgery (LVRS) can improve the functional capacity of selected patients with severe emphysema. Hypothesized physiologic effects of LVRS include an improvement in right ventricular function, although this has not been investigated in detail. To help clarify this issue, we used fast-thermistor thermodilution at rest and during submaximal upright exercise in 12 patients, before and 6 mo after bilateral LVRS. Preoperatively, all patients had severe airflow obstruction, with a mean FEV(1) of 0.69 L and an RV-to-TLC ratio of 0.67. Six months after LVRS, significant improvements occurred in respiratory function measures (+0.39 L in FEV(1), p < 0.002; and +/- 0.15 in RV/TLC ratio, p < 0.002) and in right ventricular function indexes measured at rest (+0.21 L in cardiac index [CI], p < 0.01; and +3.0 ml in stroke volume, p < 0.01) and during exercise (+0.9 L in CI, p < 0.002; +10.0 ml in stroke volume index, p < 0.002; and +20% in ejection fraction [EF], p < 0.002). A significant correlation was found between pre- to postoperative changes in the EF response to exercise and changes in the RV/TLC ratio (R = -0.68; p = 0.01). We conclude that a significant improvement in right ventricular performance, particularly during exercise, can occur 6 mo after bilateral LVRS.
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Affiliation(s)
- Tommaso C Mineo
- Division of Thoracic Surgery, University Tor Vergata, Rome, Italy.
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22
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Tschernko EM. Anesthesia considerations for lung volume reduction surgery. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2001; 19:591-609. [PMID: 11571908 DOI: 10.1016/s0889-8537(05)70249-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patient selection is of crucial importance for outcome after lung volume reduction surgery. The anesthesiologist should be involved actively in patient selection, because he or she is in charge of the treatment during the critical perioperative period. Patient history and status and results from chest radiographs, high-resolution CT scans, and catheterization of the right heart should be taken carefully into account in the patient selection process. Promising new results involving functional parameters may predict outcome objectively after lung volume reduction surgery in the future. Careful selection and preoperative preparation of patients also are important to avoid complications and keep the success rate high. The anesthesiologist's understanding of the principles involved is important for the successful conduct of lung volume reduction surgery. It is unclear if lung volume reduction surgery is superior to conventional therapy in the long run because the decline in lung function is progressive after the procedure. A multicenter trial comparing patients undergoing lung volume reduction surgery with patients with emphysema who are treated conventionally hopefully will clarify this important question in the future.
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Affiliation(s)
- E M Tschernko
- Department of Cardiothoracic Anesthesia and Critical Care Medicine, General Hospital Vienna, University of Vienna, Vienna, Austria.
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23
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Gruber EM, Tschernko EM, Kritzinger M, Deviatko E, Wisser W, Zurakowski D, Haider W. The effects of thoracic epidural analgesia with bupivacaine 0.25% on ventilatory mechanics in patients with severe chronic obstructive pulmonary disease. Anesth Analg 2001; 92:1015-9. [PMID: 11273942 DOI: 10.1097/00000539-200104000-00039] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Optimal analgesia is important after thoracotomy in pulmonary-limited patients to avoid pain-related pulmonary complications. Thoracic epidural anesthesia (TEA) can provide excellent pain relief. However, potential paralysis of respiratory muscles and changes in bronchial tone might be unfavorable in patients with end-stage chronic obstructive pulmonary disease (COPD). Therefore, we evaluated the effect of TEA on maximal inspiratory pressure, pattern of breathing, ventilatory mechanics, and gas exchange in 12 end-stage COPD patients. Pulmonary resistance, work of breathing, dynamic intrinsic positive end-expiratory pressure, and peak inspiratory and expiratory flow rates were evaluated by assessing esophageal pressure and airflow. An increase in minute ventilation (7.50 +/- 2.60 vs 8.70 +/- 2.10 L/min; P = 0.04) by means of increased tidal volume (0.46 +/- 0.16 vs 0.53 +/- 0.14 L/breath; P = 0.003) was detected after TEA. These changes were accompanied by an increase in peak inspiratory flow rate (0.48 +/- 0.17 vs 0.55 +/- 0.14 L/s; P = 0.02) and a decrease in pulmonary resistance (20.7 +/- 9.9 vs 16.6 +/- 8.1 cm H(2)O. L(-1). s(-1); P = 0.02). Peak expiratory flow rate, dynamic intrinsic positive end-expiratory pressure, work of breathing, PaO(2), and maximal inspiratory pressure were unchanged (all P > 0.50). We conclude that TEA with bupivacaine 0.25% can be used safely in end-stage COPD patients. IMPLICATIONS Thoracic epidural anesthesia with bupivacaine 0.25% does not impair ventilatory mechanics and inspiratory respiratory muscle strength in severely limited chronic obstructive pulmonary disease patients. Thus, thoracic epidural anesthesia can be used safely in patients with end-stage chronic obstructive pulmonary disease.
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Affiliation(s)
- E M Gruber
- Department of Cardiothoracic and Vascular Anesthesia & Intensive Care Medicine, University of Vienna, Austria
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24
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Abstract
Over the past decades, extensive literature has been published regarding surgical therapies for advanced COPD. Lung-volume reduction surgery would be an option for a significantly larger number of patients than classic bullectomy or lung transplantation. Unfortunately, the initial enthusiasm has been tempered by major questions regarding the optimal surgical approach, safety, firm selection criteria, and confirmation of long-term benefits. In fact, the long-term follow-up reported in patients undergoing classical bullectomy should serve to caution against unbridled enthusiasm for the indiscriminate application of LVRS. Those with the worst long-term outcome despite favourable short-term improvements after bullectomy have consistently been those with the lowest pulmonary function and significant emphysema in the remaining lung who appear remarkably similar to those being evaluated for LVRS. With this in mind, the National Heart, Lung and Blood Institute partnered with the Health Care Finance Administration to establish a multicenter, prospective, randomized study of intensive medical management, including pulmonary rehabilitation versus the same plus bilateral (by MS or VATS), known as the National Emphysema Treatment Trial. The primary objectives are to determine whether LVRS improves survival and exercise capacity. The secondary objectives will examine effects on pulmonary function and HRQL, compare surgical techniques, examine selection criteria for optimal response, identify criteria to determine those who are at prohibitive surgical risk, and examine long-term cost effectiveness. It is hoped that data collected from this novel, multicenter collaboration will place the role of LVRS in a clearer perspective for the physician caring for patients with advanced emphysema.
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Affiliation(s)
- K R Flaherty
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
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25
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Edelman JD, Kotloff RM. Critical Care of the Lung Volume Reduction Surgery Patient. J Intensive Care Med 2000. [DOI: 10.1046/j.1525-1489.2000.00191.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hamacher J, Russi EW, Weder W. Lung volume reduction surgery: a survey on the European experience. Chest 2000; 117:1560-7. [PMID: 10858383 DOI: 10.1378/chest.117.6.1560] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To evaluate the activity and evolution in the field of lung volume reduction surgery (LVRS) performed at surgical centers in Europe. BACKGROUND LVRS is a novel surgical therapy with the potential to improve lung function, exercise performance, and quality of life in selected patients suffering from severe pulmonary emphysema. METHODS Questionnaire addressed to 75 European thoracic surgical centers presumed to perform LVRS, and review of the literature. RESULTS Of 45 responding centers, 42 centers in 17 countries covering a population of 423 million reported performing LVRS. Until the end of 1998, 1,120 patients were reported to have undergone LVRS, corresponding to 2.6 patients/million inhabitants. Thirty-one of 40 centers (78%) perform the operation bilaterally. Most centers (83%) evaluate their activity prospectively. The average perioperative mortality rate of 4.1% is moderate. The most commonly utilized technique is video-assisted thoracoscopy, which is most frequently performed bilaterally. Two thirds of the centers treat patients with alpha(1)-antitrypsin deficiency, and half of the centers will consider patients with homogenous morphology of emphysema on CT scan for LVRS. Half of the centers also perform lung transplantation. The five largest centers have operated on 49% of all LVRS patients assessed by this survey. CONCLUSIONS LVRS is performed at few thoracic surgical centers throughout Europe, with a large variation in the operative activity between different regions. Half of the centers also perform lung transplantation. Between 1995 and 1997, the number of LVRS procedures performed per year nearly tripled but has reached a plateau since then. As five centers perform nearly half the total number of operations, an optimal exchange of knowledge with smaller centers seems important.
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Affiliation(s)
- J Hamacher
- Department of Surgery, University Hospital, Zürich, Switzerland
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27
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Abstract
Lung volume reduction surgery (LVRS) is a palliative surgical procedure for patients with severe emphysema. Resection of nonfunctional emphysematous lung tissue has been reported to relieve breathlessness and to improve quality of life for many patients by improving lung elastic recoil, respiratory muscle function, and ventilation-perfusion matching. However, the risks and benefits of LVRS remain controversial, as mainly short-term data are available for carefully selected groups of LVRS patients and no prospective, randomized trials for LVRS with pulmonary rehabilitation versus optimal medical therapy plus pulmonary rehabilitation have been reported. Bilateral staple resection for LVRS appears to be superior to use of a laser or unilateral approach in the short term, but relatively little data exist on long-term outcomes. Additional clinical investigation is required to determine whether LVRS should be a widely accepted therapy for severe emphysema.
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Affiliation(s)
- K C Meyer
- Department of Internal Medicine, University of Wisconsin Medical School, Madison, USA
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28
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Katz JA, Kallet RH, Alonso JA, Marks JD. Improved flow and pressure capabilities of the Datex-Ohmeda SmartVent anesthesia ventilator. J Clin Anesth 2000; 12:40-7. [PMID: 10773507 DOI: 10.1016/s0952-8180(99)00140-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To compare the flow and pressure capabilities of the Datex-Ohmeda SmartVent (Ohmeda 7900, Datex-Ohmeda, Madison, WI) to previous Ohmeda (7810 and 7000, Datex-Ohmeda, Madison, WI) anesthesia ventilators. To determine airway pressure and minute ventilation thresholds for intraoperative use of a critical care ventilator. DESIGN Three anesthesia ventilators and one critical care ventilator (Siemens Servo 900C, Siemens, Solna, Sweden) were studied in a lung model. Retrospective medical record review. SETTING Research Laboratory and Critical Care Unit of a Level I Trauma Center. PATIENTS 145 mechanically ventilated patients treated for acute respiratory failure who underwent 200 surgical procedures. INTERVENTIONS The effect of increasing pressure on mean inspiratory flow was determined by cycling each ventilator through increasing restrictors. Maximum minute ventilation was measured at low compliance (10-30 mL/cm H2O), positive end-expiratory pressure (PEEP) (0-20 cm H2O), and increased airway resistance (approximately 19 and approximately 36 cm H2O/L/sec) in a mechanical lung model. MEASUREMENTS AND MAIN RESULTS Flow, volume, and pressure were measured with a pulmonary mechanics monitor (BICORE CP-100, Thermo Respiratory Group, Yorba Linda, CA). Preoperative peak airway pressure and minute ventilation (VE) were extracted from the medical record. Mean inspiratory flow declined with increasing pressure in all anesthesia ventilators. The SmartVent and the 7810 produced greater mean inspiratory flow than did the 7000 ventilator. As compliance progressively decreased, the Siemens, the SmartVent, and the 7810 ventilators maintained VE compared to the 7000 ventilator. The Siemens and the SmartVent maintained VE with PEEP, compared to the 7810 and 7000 ventilators. During increased airway resistance, maximal VE was lower for all ventilators. The SmartVent met the ventilation requirements in 90% of the patients compared to 67% of patients with the 7000 ventilator. CONCLUSION The improved pressure and flow capabilities of the SmartVent increase the threshold for using a critical care ventilator intraoperatively to a peak airway pressure > 65 cm H2O and/or VE > 18 L/min.
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Affiliation(s)
- J A Katz
- Department of Anesthesia, UCSF/Mount Zion Medical Center, San Francisco, CA 94143-1605, USA.
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29
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Abstract
Cardiac and thoracic surgery cause alterations in ventilatory function that can lead to significant postoperative pulmonary complications. These complications often occur among patients with pre-existing pulmonary dysfunction and cause significantly longer hospital stays. This review explores some of the recent literature concerning this issue, including the effects of lung reduction surgery.
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Affiliation(s)
- C Weissman
- Department of Anesthesiology and Critical Care Medicine, Hadassah-University Hospital, Jerusalem, Israel.
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