Glenn Leemans

Microvascular disease in chronic thromboembolic pulmonary hypertension: a role for pulmonary veins and systemic vasculature

Limited numbers of operated patients with chronic thromboembolic pulmonary hypertension (CTEPH) are refractory to pulmonary endarterectomy (PEA) and experience persistent pulmonary hypertension (PH). We retrospectively assessed lung histology available from nine patients with persistent PH (ineffective PEA (inPEA) group) and from eight patients transplanted for distal CTEPH inaccessible by PEA (noPEA group). Microscopically observed peculiarities were compared with the histology of a recently developed CTEPH model in piglets. Pre-interventional clinical/haemodynamic data and medical history of patients from the inPEA and noPEA groups were collected and analysed. Conspicuous remodelling of small pulmonary arteries/arterioles, septal veins and pre-septal venules, including focal capillary haemangiomatosis, as well as pronounced hypertrophy and enlargement of bronchial systemic vessels, were the predominant pattern in histology from both groups. Most findings were reproduced in our porcine CTEPH model. Ink injection experiments unmasked abundant venular involvement in so-called small vessel or microvascular disease, as well as post-capillary bronchopulmonary shunting in human and experimental CTEPH. Microvascular disease is partly due to post-capillary remodelling in human and experimental CTEPH and appears to be related to bronchial-to-pulmonary venous shunting. Further studies are needed to clinically assess the functional importance of this finding. Pulmonary veins and systemic vasculature contribute to microvascular disease in CTEPH http://ow.ly/yGK4U

Airway clearance in COPD : need for a breath of fresh air? A systematic review

Background: Airway clearance is a key component of respiratory physiotherapy management for patients with excess secretions, including patients with chronic obstructive pulmonary disease (COPD). The aim of this review is to give an overview of the available evidence for the use of different airway clearance techniques (ACT) and their effects in patients with COPD. Methods: A systematic literature search was performed on CEBAM, PUBMED, Cochrane CT, Science Direct and Biomed central data bases. After screening, a total of 26 articles were included. Results: Studies that provide solid evidence of the effectiveness of different airway clearance techniques in patients with COPD are rather scarce. The available evidence indicates that active breathing techniques, such as active cycle of breathing techniques, autogenic drainage and forced expiration, can be effective in the treatment of COPD. The evidence for passive techniques such as postural drainage and percussion is low. Supporting techniques such as intrapulmonary percussive ventilation, positive expiratory pressure and non-invasive ventilation have little evidence because of the small number of studies. Little evidence is found for the combined use of active techniques and supporting techniques such as (oscillating) positive expiratory pressure, postural drainage and vibration in COPD patients. There is clearly a need for well-powered controlled clinical trials on the long-term effects of (combined) airway clearance techniques in COPD.

Acute effects of intrapulmonary percussive ventilation in COPD patients assessed by using conventional outcome parameters and a novel computational fluid dynamics technique

Objective: Chest physiotherapy enhances sputum evacuation in COPD patients. It can be applied as a single technique or as a combination of techniques including intrapulmonary percussive ventilation (IPV). Recently developed assessment techniques may provide new insights into the effect of airway clearance techniques. Participants: Five moderate to severe COPD patients (three females and two males; mean forced expiratory volume in 1 second of 39.49% predicted) who were admitted in the hospital for an acute exacerbation were included in this study. Methods: A novel imaging technique was used, together with other conventional techniques, to visualize the short-term effects of a single IPV treatment in COPD patients. Results: No significant changes were noted in the lung function parameters or arterial blood gases measured within 1 hour after the end of the IPV session. Computed tomography images detected changes in the airway patency after the IPV treatment compared with before treatment. Local resistances, calculated for the three-dimensional models, showed local changes in airway resistance. Conclusion: The effects of a single IPV session can be visualized by functional imaging. This functional imaging allows a calculation of changes in local airway resistance and local changes in airway volume in COPD patients without affecting conventional lung function parameters.

Functional Respiratory Imaging as a Tool to Personalize Respiratory Treatment in Patients With Unilateral Diaphragmatic Paralysis

A completely different treatment approach was chosen for 2 patients with unilateral diaphragmatic paralysis and complaints of dyspnea despite similar anatomic and physiologic abnormalities. These decisions were supported by results obtained by functional respiratory imaging (FRI). FRI generated functional information on lobar ventilation and local drug deposition. In the first patient, some lobes were poorly ventilated, and drug deposition simulation showed that some regions were undertreated. This patient underwent diaphragmatic plication to restore ventilation. In the second patient, all lobes were still ventilated. A conservative approach with regular follow-ups was chosen to wait for spontaneous recovery of the diaphragmatic function. Both patients improved subjectively and objectively. These cases demonstrate how novel medical imaging techniques such as FRI can be used to personalize respiratory treatment in patients with unilateral diaphragmatic paralysis.

Respiratory morbidity in children with cerebral palsy: an overview

Respiratory problems have a significant impact on morbidity and mortality in patients with cerebral palsy (CP). In particular, recurrent aspiration, impaired airway clearance, spinal and thoracic deformity, impaired lung function, poor nutritional status, and recurrent respiratory infections negatively affect respiratory status. Bronchopulmonary dysplasia may contribute to pulmonary problems, but asthma is not more common in CP than in the general population. We discuss treatment options for each of these factors. Multiple coexisting and interacting factors that influence the respiratory status of patients with CP should be recognized and effectively addressed to reduce respiratory morbidity and mortality.

JAMF-based representation for computational lung sound analysis

Obstructive lung disease is a category of respiratory disease characterized by an obstruction of the airflow, inflamed and/or easily collapsible airways, and mucus retention. Asthma, bronchiectasis, and chronic obstructive pulmonary disease (COPD) are the three main types of obstructive lung diseases. This type of diseases causes adventitious lung sounds which can be heard through lung auscultation. Physiotherapists can detect these sounds and use them to adapt their treatment. Physicians the world over are starting to rely more on computers than ever before. For lung auscultation data, this is mostly limited to representing the sound as a time-pressure graph or a spectrogram, while still doing the actual analysis themselves. Researchers however, have already shown the strength of computational lung sound analysis. In this paper, we propose the Joint Acoustic- and Modulation Frequency (JAMF) representation as a signal-processing technique for a lung-sound sensor which create a visually clean, simple and yet powerful representation which allows physicians to determine possible problems at first glance, with future possibilities for easy automatic analysis of the lung sounds.

EPA-0559 – Personalized patient education improves symptom scores in COPD (chronic obstructive pulmonary disease)

In chronic disease there is a trend towards looking at patients perspective and experience to improve health-care. A recent audit conducted with COPD-patients demonstrated a need to receive information about their disease and the need to be addressed as an individual, not as a disease. (Powell et al, Breathe, sept 2013) To examine if addressing these 2 needs can change patients disease experience, we set up a study with 15 COPD-patients included in a Pulmonary Rehabilitation Program. Ten subjects had already undergone functional lung imaging in the past, using CT thorax images. These 10 patients received some personalized information about their disease, confronting them with their own lung images during each of 4 visits, spread over a period of 6 months. On each visit they filled out self-reporting questionnaires about symptoms and Healt-Related Quality Of Life. The other 5 patients filled out the questionnaires without receiving this information. Patients receiving this personalized education, showed an improvement in the COPD Assessment Test (CAT) (p=0.023)(which measures the impact of COPD symptoms on daily life), whereas controls did not. When the two groups were taken together, we can see symptom scores (as assessed by the Saint-George Respiratory Questionnaire and the Severe Respiratory Insufficiency Questionnaire) correlate with self-efficacy (Pulmonary Rehabilitation Adepted Index of Self-Efficacy). Symptom reporting seems to correlate with self-efficacy, which is a measure for self-confidence in disease. This study shows how patient education using personalized feedback can improve patient reported symptoms, possibly by improving self-efficacy.

S108 The Effect of an Interdisciplinary Rehabilitation Programme on Daily Physical Activity For Patients with Less Advanced COPD in a Primary Care Setting: A Systematic Review

Introduction The natural course of COPD is characterised by progressive airflow limitation and complicated by the development of systemic consequences and co-morbidities. Daily physical inactivity (DPA) is believed to mediate those systemic consequences or co-morbidities. Recent research demonstrates that even in the early stages of COPD, DPA plays a role in developing systemic consequences and co-morbidities. Hence, interventions that enhance or maintain DPA in this population, such as pulmonary rehabilitation (PR), should be considered. Due to the low accessibility and high cost of PR in a specialised care setting, rehabilitation in primary care could be an added value for patients with less advanced COPD. related problems. Despite the widespread believe in the benefits of PR in a primary care setting, it remains unclear if such PR programmes are (cost) effective for patients with less advanced COPD Objective To evaluate data from clinical trials assessing the effect of PR in primary care for patients with less advanced COPD on DPA, exercise capacity (EC) and quality-of-life (QoL). Methods The electronic databases PEDro, CENTRAL, Pubmed and EMBASE were searched. Only randomised and controlled clinical trials were eligible for inclusion, provided they investigated the effects of interdisciplinary PR in primary care for patients with less advanced COPD (GOLD I-II). Independent data extraction was performed by two authors. Risk of bias was rated using the Cochrane Collaboration ‘Risk of bias’ tool. Primary outcome is the level of DPA, secondary outcomes are EC and QoL. Results Eight studies were found and methodological quality is displayed in table 1. One study objectively measured DPA by a pedometer and showed a significant improvement in DPA. EC was significantly improved in 7/8 studies. QoL is measured in all 8 studies, 3/8 had a significant improvement and two revealed to have clinical relevant effect on QoL. Abstract S108 Table 1 Conclusions PR in primary care for patients with less advanced COPD improves EC and QoL and could be beneficial in improving DPA. Since recent insights in the systemic burden of COPD and the role of DPA in this matter, future research must focus on the transfer of PR benefits to DPA, including a cost-effective analysis.