Cecilia M. Smith

Management of chronic sinusitis in cystic fibrosis.

Chronic rhinosinusitis is extremely common in patients with cystic fibrosis. It causes numerous problems in these patients and can put them at risk for life‐threatening illness. Potential problems include nasal obstruction, congestion, sinus pain and pressure, infection (usually with Pseudomonas organisms), hyposmia or anosmia, and the seeding of bacteria into the lower respiratory tract. Cystic fibrosis patients with chronically infected sinuses are at increased risk for pneumonia following lung transplantation. A prophylactic protocol has been developed for the management of chronic sinusitis in patients with cystic fibrosis. These patients are fully evaluated at the Nasal Dysfunction Clinic of the University of California, San Diego (UCSD), Medical Center. Based on the results of the evaluation, they are treated with endoscopic sinus surgery, partial middle turbinectomy, septoplasty, and a large middle meatal maxillary antrostomy. Surgery is followed by a rigorous regimen of pulsatile hypotonic saline nasal irrigation to wash away tenacious cystic secretions. Tobramycin (Nebcin®) is given once daily in the nasal irrigant to inhibit the growth of Pseudomonas organisms. At the USCD Nasal Dysfunction Clinic, this prepulmonary transplantation protocol is now used in all cystic fibrosis patients with chronic sinusitis.

Primary diagnosis predicts prognosis of lung transplant candidates

Optimal timing for consideration of lung transplantation remains unknown. This study examined survival in patients with end-stage lung disease awaiting transplantation. Primary disease group and relevant indicators were evaluated. Ninety-three patients who met selection criteria for lung transplantation were included in this retrospective review. Of this total, 31% underwent transplantation, 38% remain waiting, and 31% died. Results demonstrate that the six-month actuarial survival rate was 89% for Eisenmengers syndrome, 81% for emphysema, 74% for cystic fibrosis, 60% for primary pulmonary hypertension, and 38% for interstitial lung disease. Parameters found to be significant included a higher mean right atrial pressure in primary pulmonary hypertension patients who died awaiting transplantation, and lower forced expiratory volume in one second and forced vital capacity measurements in cystic fibrosis patients who died awaiting transplantation. We conclude that primary disease significantly affects survival in candidates awaiting transplantation. Reliable indicators predictive of survival are not available. Earlier referral for consideration of lung transplantation is recommended.

Volume reduction of the native lung after single-lung transplantation for emphysema

Emphysema is currently the most frequent indication for single-lung transplantation. A decade ago, however, it was postulated that after single-lung transplantation the emphysematous contralateral lung would be preferentially ventilated, with consequent mediastinal shift and compression of the graft. Conversely, the attenuated capillary bed of the diseased lung would necessitate preferential perfusion of the graft. 1 The theoretic prospect of wholesale ventilation-perfusion mismatch has not been a significant concern in clinical practice, and during this period the combination of ongoing restrictions in the donor pool, the accumulation of excellent functional outcomes after unilateral transplantation, and the higher operative morbidity associated with bilateral procedures has compelled increasing use of single-lung transplantation for the management of end-stage emphysema. Because graft function is the preeminent factor when pulmonary mechanics and gas exchange are assessed at successively remote intervals after single-lung transplantation, the fate of the retained native lung has not been well summarized, and we are unaware of any series describing the discrete effects of the residual emphysematous lung on pulmonary allograft function. We present a case of progressive pulmonary dysfunction associated with marked hyperinflation of the native lung in a single-lung recipient, with successful management by a unilateral volume-reduction operation. One of us (M. M.) underwent a right single-lung transplant for emphysema in 1991, and after an uneventful postoperative course was able to resume his medical practice. Within 3 years, however, dyspnea and exercise intolerance recurred. There was no improvement despite treatment of a concurrent infection, and empirical augmentation of the immunosuppressive regimen afforded only transient relief. Supplemental oxygen was administered at rest and during exercise. The chest radiograph demonstrated marked hyperinflation of the native lung, with mediastinal displacement and depression of the left hemidiaphragm (Fig. 1, A). Consecutive pulmonary function studies documented serial reductions in expiratory flow and vital capacity while residual volume and functional residual capacity were concurrently expanding (Table I). Volume reduction of the native lung was proposed as an alternative to retransplantation.

Airway management during anesthesia for double-lung transplantation using a single-lumen endotracheal tube with an enclosed bronchial blocker

Abstract The approach to airway management in patients undergoing lung transplantation is dependent on the type of transplant procedure (combined heart-lung, single-lung, or double-lung technique), the site of the airway anastomosis (trachea or mainstem bronchus), and whether cardiopulmonary bypass (CPB) will be used. Modifications of the original operative technique for double-lung transplantation 1,2 have been introduced recently including the use of bilateral bronchial anastomoses 3 and sequential single-lung transplantation. 4 The respective advantages of these techniques include the improved collateral blood supply at the donor bronchial anastomosic sites, thereby decreasing the risk of ischemic airway complications, and the potential elimination of the need for CPB. Specific strategies for airway management during double-lung transplantation have not been previously addressed. This report describes recent experience with a patient who underwent double-lung transplantation without CPB using a single-lumen endotracheal tube with enclosed bronchial blocker (Univent tube, Fuji Systems Corporation, Tokyo, Japan).

Potentiation of cyclosporine nephrotoxicity by nafcillin in lung transplant recipients.

The interaction between nafcillin and cyclosporine was examined in lung transplant recipients receiving cyclosporine-based immunosuppression. Nine recipients received nafcillin for one week posttransplant and 10 recipients did not receive nafcillin. Age, sex, pretransplant renal function, type of transplant procedure, use of cardiopulmonary bypass, and initial cyclosporine dose were not significantly different between groups. The degree of renal dysfunction during the early postoperative period was significantly greater in the lung recipients receiving nafcillin. Although cyclosporine doses were significantly higher in the nafcillin group, this was not reflected by differences in cyclosporine levels. No difference in survival or incidence of allograft rejection was seen—however, the incidence of viral infection was significantly higher in the patients who received nafcillin. Based on our findings the use of an alternative antibiotic for antistaphylococcal prophylaxis in transplant recipients receiving cyclosporine is recommended.

Sequence of bronchoalveolar lavage and histopathologic findings in rat lungs early in inhalation asbestos exposure

To assess the early cellular inflammatory response of the lungs, 7 rats per group were exposed nose-only to 13 mg/m3 of chrysotile asbestos, 7 h/day for 2, 4, or 6 wk. Lung histopathology and bronchoalveolar lavage (BAL) were analyzed. In exposed animals, dose-related bronchiolitis and fibrosis were found that were not seen in control rats (p less than 0.001). In exposed rats, total BAL cells were increased six-to sevenfold over matched controls, and more cells were retrieved with longer exposure (p less than 0.001). In the BAL, counts of macrophages, lymphocytes, and polymorphonuclear cells (PMNs) were each elevated in the exposed rats (each p less than 0.001). PMNs seen histologically and in the BAL may be related to the time period examined. PMNs and lymphocytes observed throughout this 6-wk study support the idea that these cells may have an important role in the early events of asbestos lung injury.