Fredrik Borchsenius

High-intensity training following lung cancer surgery: a randomised controlled trial

Background Many patients with lung cancer are deconditioned with poor physical fitness. Lung resection reduces physical fitness further, impairing the patients ability to function in daily life. Methods We conducted a single-blind randomised controlled trial of high-intensity endurance and strength training (60 min, three times a week, 20 weeks), starting 5–7 weeks after surgery. The control group received standard postoperative care. The primary outcome was the change in peak oxygen uptake measured directly during walking until exhaustion. Other outcomes included changes in pulmonary function, muscular strength by one-repetition maximum (1RM), total muscle mass measured by dual energy X-ray absorptiometry, daily physical functioning and quality of life (QoL). Results The intention-to-treat analysis of the 61 randomised patients showed that the exercise group had a greater increase in peak oxygen uptake (3.4 mL/kg/min between-group difference, p=0.002), carbon monoxide transfer factor (Tlco) (5.2% predicted, p=0.007), 1RM leg press (29.5 kg, p<0.001), chair stand (2.1 times p<0.001), stair run (4.3 steps, p=0.002) and total muscle mass (1.36 kg, p=0.012) compared with the controls. The mean±SD QoL (SF-36) physical component summary score was 51.8±5.5 and 43.3±11.3 (p=0.006), and the mental component summary score was 55.5±5.3 and 46.6±14.0 (p=0.015) in the exercise and control groups, respectively. Conclusions In patients recently operated for lung cancer, high-intensity endurance and strength training was well tolerated and induced clinically significant improvements in peak oxygen uptake, Tlco, muscular strength, total muscle mass, functional fitness and QoL. This study may provide a basis for exercise therapy after lung cancer surgery. Trial registration number NCT01748981.

Lung function and dyspnea in patients with permanent atrial fibrillation

BACKGROUND Reduced forced expiratory volume in one second (FEV(1)) has been associated with new-onset atrial fibrillation (AF), and AF patients often complain of dyspnea. We hypothesized that patients with permanent AF had reduced lung function compared to subjects in sinus rhythm. METHODS The participants were 75year-olds from the general population. FEV(1), forced vital capacity (FVC), maximal voluntary ventilation (MVV), total lung capacity by single breath (TLC(SB)), single-breath diffusing capacity of the lung for carbon monoxide (DLCO(SB)) and exercise testing with peak oxygen uptake (VO(2) peak) were assessed. The slope of minute ventilation over carbon dioxide output defined ventilatory efficiency. The Symptom Checklist-frequency and severity questionnaire assessed dyspnea. RESULTS AF patients had significantly higher number (%) of subjects below the 5th percentile of predicted FEV(1) (7 (27) versus 3 (4), p=0.005), FVC (6 (23) versus 2 (3), p=0.006) and TLC(SB) (11 (42) versus 12 (18), p=0.014) compared to control subjects, also after adjustment for smoking and obesity, or if disregarding subjects with chronic heart failure. The dyspnea frequency and severity scores correlated with VO(2) peak (r=-0.6, p<0.01) in AF patients, and in control subjects with % predicted FEV(1), MVV and TLC(SB) (r=-0.3, p<0.05). CONCLUSION More patients with permanent AF had lung function below normal range than control subjects in sinus rhythm, irrespective of smoking, obesity or chronic heart failure. Dyspnea, however, was related to exercise capacity rather than to lung function in AF patients.

Specific allergen immunotherapy: effect on IgE, IgG4 and chemokines in patients with allergic rhinitis

ABSTRACT Background: Allergen-specific immunotherapy (SIT) is considered as the most effective treatment for Immunoglobulin E (IgE)-mediated allergies. However, how specific immunotherapy attenuates allergic responses is still not clear, but could potentially involve cytokines as well as IgG4-mediated responses. Based on the role of chemokines in IgE-mediated inflammation, we examined the SIT-induced chemokine response in patients with allergic rhinitis. Methods: We included 35 patients with allergic rhinitis; 20 patients received SIT and 15 patients were not treated with specific immunotherapy. The patients were followed for 3 years. Blood samples were collected before SIT and 3, 5, 7 and 21 weeks and 1, 2 and 3 years after the start of therapy. Total IgE, specific IgE, IgG4 and chemokine levels were assessed. Results: Our main findings were: (i) SIT was associated with an early increase in total and specific IgE during the first 7 weeks, with a subsequent decline, accompanied by a marked increase in specific IgG4 when IgE started to decline; (ii) these SIT-induced responses were accompanied by and in some degree correlated with increased plasma concentrations of the chemokines, monocyte chemoattractant protein (MCP)-1, and eotaxin; and (iii) within the SIT group, these correlations with chemokines were restricted to IgE and IgG4 against birch tree pollen. Conclusion: Our findings further support a role for IgG4-mediated mechanisms in the beneficial effects of SIT in patients with allergic rhinitis (AR) and that increased levels of certain chemokines also could be of importance for the effect of such therapy.

Reduction in cardiorespiratory fitness after lung resection is not related to the number of lung segments removed

Aim To evaluate the effect of lung cancer surgery on cardiorespiratory fitness (CRF), and to assess the agreement between the predicted postoperative (ppo) V̇O2peak and actually measured postoperative peak oxygen uptake (V̇O2peak). Methods Before and 4–6 weeks after lung cancer surgery, 70 patients (35 women) underwent measurements of pulmonary function and CRF via a cardiopulmonary exercise test. In addition, the 23 non-exercising patients underwent measurements after 6 months. The ppo V̇O2peak calculated from the number of functional segments removed was compared with the actually measured postoperative values of V̇O2peak for accuracy and precision. Results After surgery, the V̇O2peak decreased from 23.9±5.8 to 19.2±5.5 mL/kg/min (−19.6±15.7%) (p<0.001). The breathing reserve increased by 5% (p=0.001); the oxygen saturation remained unchanged (p=0.30); the oxygen pulse decreased by −1.9 mL/beat (p<0.001); the haemoglobin concentration decreased by 0.7 g/dL (p=0.001). The oxygen pulse was the strongest predictor for change in V̇O2peak; adjusted linear squared: r2=0.77. Six months after surgery, the V̇O2peak remained unchanged (−3±15%, p=0.27). The ppo V̇O2peak (mL/kg/min) was 18.6±5.4, and the actually measured V̇O2peak was 19.2±5.5 (p=0.24). However, the limits of agreement were large (CI −7.4 to 8.2). The segment method miscalculated the ppo V̇O2peak by more than ±10 and ±20% in 54% and 25% of the patients, respectively. Conclusions The reduction in V̇O2peak and lack of improvement 6 months after lung cancer surgery cannot be explained by the loss of functional lung tissue. Predicting postoperative V̇O2peak based on the amount of lung tissue removed is not recommendable due to poor precision. Trial registration number NCT01748981.

The obstructive siblings: Relapsing polychondritis without chondritis?

Progressive narrowing of the central airways due to diffuse inflammation is a potential life-threatening condition. A number of diseases have been described as possible causes. We present two siblings with severe central airway obstruction. Despite considerable efforts we have not been able to match the clinical appearance of our patients with the diagnostic criteria of any of the disease entities known to cause this condition.

Manual ventilation and open suction procedures contribute to negative pressures in a mechanical lung model

Introduction Removal of pulmonary secretions in mechanically ventilated patients usually requires suction with closed catheter systems or flexible bronchoscopes. Manual ventilation is occasionally performed during such procedures if clinicians suspect inadequate ventilation. Suctioning can also be performed with the ventilator entirely disconnected from the endotracheal tube (ETT). The aim of this study was to investigate if these two procedures generate negative airway pressures, which may contribute to atelectasis. Methods The effects of device insertion and suctioning in ETTs were examined in a mechanical lung model with a pressure transducer inserted distal to ETTs of 9 mm, 8 mm and 7 mm internal diameter (ID). A 16 Fr bronchoscope and 12, 14 and 16 Fr suction catheters were used at two different vacuum levels during manual ventilation and with the ETTs disconnected. Results During manual ventilation with ETTs of 9 mm, 8 mm and 7 mm ID, and bronchoscopic suctioning at moderate suction level, peak pressure (PPEAK) dropped from 23, 22 and 24.5 cm H2O to 16, 16 and 15 cm H2O, respectively. Maximum suction reduced PPEAK to 20, 17 and 11 cm H2O, respectively, and the end-expiratory pressure fell from 5, 5.5 and 4.5 cm H2O to –2, –6 and –17 cm H2O. Suctioning through disconnected ETTs (open suction procedure) gave negative model airway pressures throughout the duration of the procedures. Conclusions Manual ventilation and open suction procedures induce negative end-expiratory pressure during endotracheal suctioning, which may have clinical implications in patients who need high PEEP (positive end-expiratory pressure).

Bronchial wheezing predicts inflammation and respiratory failure in fire smoke victims

Acute fire smoke inhalation injury involves inflammatory mediators whose roles are poorly understood. We carried out a prospective observational study of fire smoke victims to identify clinical and biochemical markers that may predict pulmonary dysfunction and investigated possible correlations between dysfunction and cytokines in bronchoalveolar lavage (BAL) fluid and blood.