Iván Caviedes

Tratamiento de complicaciones en la vía aérea postrasplante pulmonar

OBJECTIVE To describe our experience in airway complications following lung transplant and to suggest a management algorithm, using different tools from the Interventional Pulmonology armamentarium. METHOD Retrospective chart review of all airway complications following lung transplant from January 1999 to July 2007. RESULTS During that period 223 patients underwent lung transplantation, with a total of 345 anastomoses in the airway. Seventy anastomoses (20.23%) had complications requiring endoscopic treatment. The total number of endoscopic interventions were 631 in 52 patients. Thirty three patients had a combination of bronchial stenosis and bronchomalacia. Eighteen patients had bronchial stenosis only and 1 patient had dehiscence of the anastomosis. Balloon dilation was most commonly transiently effective and ultimately 47 patients required stent placement. The most common complication associated with the use of stent was granulation tissue formation, seen in 57.3% of patients. After stent placement, the forced expiratory volume in 1(st) second (FEV(1)) improved significantly. CONCLUSION Airway complications after lung transplant are frequent. Balloon dilation was effective only in a few patients with bronchial stenosis, although the majority ultimately needed a stent. Airway repermeabilization after stent placement improved FEV(1). Based on our experience, we propose a management algorithm for airway complications after lung transplant.

Treatment of Airway Complications Following Lung Transplantation

Abstract Objective To describe our experience in airway complications following lung transplantation and to suggest a management strategy using different interventional bronchoscopic techniques. Method Retrospective analysis of all airway complications following lung transplantation from January 1999 to July 2007. Results During this period, 223 patients underwent lung transplantation, with a total of 345 airway anastomoses. In 70 (20.23%), there were complications requiring endoscopic intervention. A total of 631 procedures were carried out in 52 patients. Thirty-three patients presented a combination of bronchial stenosis and bronchomalacia, 18 patients had bronchial stenosis alone and 1 patient presented dehiscence of the anastomosis. In most cases, pneumatic balloon dilatation was effective, although temporarily, and ultimately 47 patients required endobronchial stent placement. The most common complication associated with the use of stents was granulation tissue formation, seen in 57.3% of patients. After stent placement, forced expiratory volume in one second (FEV 1 ) improved significantly. Conclusion Airway complications after lung transplantation are frequent. Balloon dilatation was effective in only a few patients with bronchial stenosis, requiring stent placement in most. Airway permeabilization after endobronchial stent placement improved FEV 1 in these patients. Based on our experience, we propose a management strategy for airway complications after lung transplantation.

Ventilatory inefficiency as a limiting factor for exercise in patients with COPD.

BACKGROUND: Ventilatory inefficiency increases ventilatory demand; corresponds to an abnormal increase in the ratio of minute ventilation (V̇E) to CO2 production (V̇CO2); represents increased dead space, deregulation of respiratory control, and early lactic threshold; and is associated with expiratory flow limitation that enhances dynamic hyperinflation and may limit exercise capacity. OBJECTIVE: To evaluate the influence of ventilatory inefficiency over exercise capacity in COPD patients. METHODS: Prospective study of 35 COPD subjects with different levels of severity, in whom cardiopulmonary stress test was performed. Ventilatory inefficiency was represented by the V̇E/V̇CO2 relation. Its influence over maximal oxygen consumption (V̇O2max), power (W), and ventilatory threshold was evaluated. Surrogate parameters of cardiac function, like oxygen pulse (V̇O2/heart rate) and circulatory power (%V̇O2max × peak systolic pressure), were also evaluated. RESULTS: Cardiopulmonary stress test was stopped due to dyspnea with elevated V̇E and marked reduction of breathing reserve. A severe increase in V̇E/V̇CO2 (mean ± SD 35.9 ± 5.6), a decrease of V̇O2max (mean ± SD 75.2 ± 20%), and a decrease of W (mean ± SD 68.6 ± 23.3%) were demonstrated. Twenty-eight patients presented dynamic hyperinflation. Linear regression showed a reduction of 2.04% on V̇O2max (P < .001), 2.6% on W (P < .001), 1% on V̇O2/heart rate (P = .049), and 322.7 units on circulatory power (P = .02) per each unit of increment in V̇E/V̇CO2, respectively. CONCLUSIONS: Ventilatory inefficiency correlates with a reduction in exercise capacity in COPD patients. Including this parameter in the evaluation of exercise limitation in this patient population may mean a contribution toward the understanding of its pathophysiology.

Tracheostomy Tube Placement: Early and Late Complications

Tracheostomy tube placement is a therapeutic procedure that has gained increased favor over the past decade. Upper airway obstructions, failure to liberate from the ventilator, and debilitating neurological conditions are only a few indications for tracheostomy tube placement. Tracheostomy tubes can be placed either surgically or percutaneously. A percutaneous approach offers fewer surgical site infections and postsurgical bleeding than a surgical approach. A surgical placement posses a lower risk of injury to the posterior tracheal wall and spontaneous decannulation is less common. Late complications of both approaches include stenosis, malacia, along with tracheoesophageal, tracheoinnominate, and tracheocutaneous fistulas. This review describes the indications and methods of placement of tracheostomy tubes along with early and late complications that may occur following placement.

Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging in lung cancer

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic test with a high diagnostic yield for suspicious central pulmonary lesions and for mediastinal lymph node staging. The main objective of this study was to describe the diagnostic yield of EBUS-TBNA for mediastinal lymph node staging in patients with suspected lung cancer. METHODS: Prospective study of patients undergoing EBUS-TBNA for diagnosis. Patients ≥ 18 years of age were recruited between July of 2010 and August of 2013. We recorded demographic variables, radiological characteristics provided by axial CT of the chest, location of the lesion in the mediastinum as per the International Association for the Study of Lung Cancer classification, and definitive diagnostic result (EBUS with a diagnostic biopsy or a definitive diagnostic method). RESULTS: Our analysis included 354 biopsies, from 145 patients. Of those 145 patients, 54.48% were male. The mean age was 63.75 years. The mean lymph node size was 15.03 mm, and 90 lymph nodes were smaller than 10.0 mm. The EBUS-TBNA method showed a sensitivity of 91.17%, a specificity of 100.0%, and a negative predictive value of 92.9%. The most common histological diagnosis was adenocarcinoma. CONCLUSIONS: EBUS-TBNA is a diagnostic tool that yields satisfactory results in the staging of neoplastic mediastinal lesions.

Dendriform Pulmonary Ossification

Dendriform pulmonary ossification is a rare condition often diagnosed by either surgery or postmortem examination. We report a 43-y-old man with a history of nonproductive cough for 1 y. His physical examination was unremarkable. Chest computed tomography showed multiple bilateral micronodules in both lower lobes; however, the patients pulmonary function was normal. Flexible bronchoscopy with transbronchial biopsies revealed branching ossification. Pulmonary ossification is a chronic process characterized by progressive metaplastic ossification. We reviewed a total of 42 cases of dendriform pulmonary ossification reported in the medical literature: most of these cases were diagnosed by autopsy. Despite its rarity, dendriform pulmonary ossification should be considered in the differential diagnosis of diffuse lung disease. Bronchoscopy with transbronchial biopsies must be considered as a potential diagnostic procedure.

Predictive Models for Pulmonary Function Changes After Radiotherapy for Breast Cancer and Lymphoma

PURPOSE To propose multivariate predictive models for changes in pulmonary function tests (ΔPFTs) with respect to preradiotherapy (pre-RT) values in patients undergoing RT for breast cancer and lymphoma. METHODS AND MATERIALS A prospective study was designed to measure ΔPFTs of patients undergoing RT. Sixty-six patients were included. Spirometry, lung capacity (measured by helium dilution), and diffusing capacity of carbon monoxide tests were used to measure lung function. Two lung definitions were considered: paired lung vs. irradiated lung (IL). Correlation analysis of dosimetric parameters (mean lung dose and the percentage of lung volume receiving more than a threshold dose) and ΔPFTs was carried out to find the best dosimetric predictor. Chemotherapy, age, smoking, and the selected dose-volume parameter were considered as single and interaction terms in a multivariate analysis. Stability of results was checked by bootstrapping. RESULTS Both lung definitions proved to be similar. Modeling was carried out for IL. Acute and late damage showed the highest correlations with volumes irradiated above ~20 Gy (maximum R(2) = 0.28) and ~40 Gy (maximum R(2) = 0.21), respectively. RT alone induced a minor and transitory restrictive defect (p = 0.013). Doxorubicin-cyclophosphamide-paclitaxel (Taxol), when administered pre-RT, induced a late, large restrictive effect, independent of RT (p = 0.031). Bootstrap values confirmed the results. CONCLUSIONS None of the dose-volume parameters was a perfect predictor of outcome. Thus, different predictor models for ΔPFTs were derived for the IL, which incorporated other nondosimetric parameters mainly through interaction terms. Late ΔPFTs seem to behave more serially than early ones. Large restrictive defects were demonstrated in patients pretreated with doxorubicin-cyclophosphamide-paclitaxel.

Intracardiac metastasis of lung adenocarcinoma diagnosed by convex-probe EBUS

A 52-year-old woman, former smoker with no relevant medical history, presented with 2 months symptom of right hip pain that limited her walking. This was associated with dyspnoea Medical Research Council modified 2 and occasional dry cough. Physical examination revealed normal cardiopulmonary examination, and tenderness in the right proximal femur. Chest X-ray demonstrated a right lower lobe nodule. Chest CT scan showed scattered pulmonary nodules bilaterally, smaller than 20 mm, enlarged mediastinal lymph nodes and …

Nasolaryngoscopic validation of a set of clinical predictors of aspiration in a critical care setting.

BackgroundAspiration is frequent in patients with acute neurologic disorders and swallowing dysfunction. Its incidence in stroke, as high as 51%, increases mortality by up to 3 times. Pneumonia, its main complication, further increases morbidity, mortality, and patient care costs. The objective of this study was to evaluate a set of bedside predictors of aspiration [“wet voice,” 3-oz water swallow test, and cervical auscultation in an intensive care unit (ICU)] and compare them with nasolaryngoscopy as the gold standard. MethodsWe conducted a prospective, nonblinded study of bedside predictors of aspiration risks in 65 consecutive ICU patients with an acute neurologic disorder or a severe medical or surgical condition with decreased level of consciousness. ResultsEndoscopic aspiration was detected in 17 patients. Sensitivities for wet voice, 3-oz water swallow test, and cervical auscultation were 58.82%, 88.23%, and 82.35%; specificities were 78.26%, 62.50%, and 80.43%. Positive predictive values were 50%, 45.45%, and 60.86%, and negative predictive values were 83.72%, 93.75%, and 92.50%, respectively. Positive likelihood ratios were 2.70, 2.35, and 4.20, respectively. The association of 2 positive clinical predictors, wet voice and cervical auscultation or wet voice and 3-oz water swallow test, improved specificity to 92.85% and 84.61%, positive predictive values to 83.33% and 69.23%, and likelihood ratios to 10.76 and 5.85, respectively. ConclusionsBedside clinical predictors for aspiration risks are a useful screening tool for ICU patients presenting with risk factors for this complication.

Non-answered questions in patients with endobronchial valve placement for lung volume reduction

Endoscopic lung volume reduction is a minimally invasive procedure performed to reduce the space occupied by the emphysemas’ lobes. This procedure has been demonstrated to be beneficial for patients with advanced chronic obstructive pulmonary disease and severe hyperinflation. The use of endobronchial valves is increasing, as well as the number of reports of adverse events. The most common complications after the procedure are a pneumothorax, bleeding, infections, the need for valve removal, and valve expulsion. We have recently treated a patient who achieved immediate left upper lobe atelectasis but developed a pneumothorax on the 6th day and near-fatal kinking of the left lower lobe bronchus. This patient had asphyctic episodes probably due to a functional left pneumonectomy. We should consider this unusual complication in patients undergoing endoscopic lung volume reduction whose condition worsens after achieving complete lobar atelectasis.