Rosa Cordovilla

Utility of standardized exercise oximetry to predict cardiopulmonary morbidity after lung resection

OBJECTIVES To evaluate if desaturation, measured by finger oximetry on standardized exercise, accurately predicts cardiopulmonary morbidity after pulmonary resection. METHODS A prospective observational clinical study was carried out on 81 consecutive lung carcinoma patients scheduled for pulmonary resection from February 1998 to March 1999. Finger oximetry was monitored during an incremental to exhaustion cycle exercise test. The presence or absence of desaturation (cut-off value 90%) during exercise was recorded. Other independent analyzed variables were: age of the patient (over 75th percentile), body-mass index (BMI) (over 75th percentile), presence of major cardiovascular co-morbidity, and calculated postoperative FEV1% (under 25th percentile) according to the number of resected segments (ppoFEV1%). Postoperative cardiopulmonary morbidity was the evaluated dependent outcome. Fishers exact test and risk calculation on contingency tables were used for statistical analysis. RESULTS A lobectomy was performed in 62 cases, a pneumonectomy was performed in 16 cases, and a segmentectomy was performed in three cases. The mean age of the patients was 63.6 years (SD 10.3, range 34-79 years, 75th percentile 72 years), the mean BMI was 25.9 (SD 4.9, range 16.9-38.1, 75th percentile 29.3), and the mean ppoFEV1% was 64.1 (SD 2016.1, range 29.5-98.6, 25th percentile 50.5). In 14 patients exercise desaturation was registered. Postoperative cardiopulmonary morbidity was presented in 32 cases (five deaths). No correlation was found between postoperative morbidity and any of the following variables: age of the patient, BMI, and co-morbidity. On univariate analysis only low ppoFEV1% (P<0.001) was associated with the outcome, so no multivariate analysis has been carried out. CONCLUSIONS We have shown that desaturation during standardized exercise in this series adds no relevant information to predict postoperative cardiorespiratory morbidity after lung resection.

Uso del drenaje pleural permanente en el manejo ambulatorio del derrame pleural maligno recidivante

BACKGROUND AND OBJECTIVE To analyse the effectiveness and safety of the indwelling pleural catheter in the management of recurrent malignant pleural effusion. PATIENTS AND METHODS A prospective multicentre study was performed in 63 consecutive outpatients from four Spanish hospitals. A total of 43 men and 20 women were included, with a median age of 67 years. In seven of the cases treatment with pleurodesis had failed; in five other cases their lung was trapped; in another five cases after repeat therapeutic thoracocentesis, and the rest of them as a preference choice to pleurodesis. All patients had an indwelling pleural catheter inserted (PleurX), Denver Biomedical). RESULTS Most of patients (94.5%) reported an improvement in their respiratory symptoms (cough and dyspnoea) and their ability to function independently. Average length of the catheterisation was 45 days (6-222). Average amount of drained pleural effusion was 75ml, with a frequency of drainage of between 3 and 4 times per week and once fortnightly. Spontaneous pleurodesis was achieved following 34.9% of procedures. No complications occurred during the insertion of the catheter. The post-catheterisation complications were empyema (3 cases), chest pain (2 cases), and tumour metastasis (3 cases). CONCLUSIONS The use of an indwelling pleural catheter is an effective palliative treatment in the outpatient management for patients suffering malignant pleural effusion. It is also a simple treatment that can be easily applied, does not require hospitalisation and can be easily managed by the patient at home, with a low rate of complications.

Demoras diagnósticas en el cáncer de pulmón

Objetivo: Estudio de los factores clinicos y demograficos asociados a las demoras diagnosticas del cancer de pulmon (CP). Pacientes y metodos: Estudio prospectivo de dos anos de evolucion de pacientes ingresados en la planta de neumologia por sospecha de CP. Se estudiaron variables demograficas, de atencion sanitaria, habitat y demoras en las exploraciones. Se definieron los tiempos diagnosticos siguientes: de consulta (desde el primer sintoma hasta la visita del primer medico), medio (el que va desde la visita medica hasta el ingreso) y diagnostico (desde el ingreso hasta el diagnostico histologico y la estadificacion clinica). Resultados: Se estudio a 113 pacientes con una edad media de 65 anos (intervalo, 36-90), de los que 103 eran varones y 10, mujeres. Los sintomas mas frecuentes por los que consulto el paciente fueron: tos (10,6%), hemoptisis (19,5%), dolor toracico (26,5%) y disnea (9,7%). El 72% de los pacientes consultaba por primera vez al medico de atencion primaria (MAP), el 22% a urgencias del hospital y el 6% al neumologo. El 44% realizo entre dos y tres visitas al medico. Las medias ± desviaciones tipicas, en dias, de los diferentes tiempos fueron: consulta, 30,3 ± 60; diagnostico, 18,6 ± 19; medio, 37,9 ± 63, y total, 85,7 ± 87. El tiempo medio, el tiempo hasta el diagnostico y el tiempo total fueron inferiores cuando el paciente fue remitido, por el MAP, a urgencias o ingresado directamente en el hospital (p < 0,001). Solo el 25,7% de los CP estadificados eran resecables quirurgicamente. Conclusiones: Los tiempos de demora diagnostica en el CP son elevados. La actitud del MAP y su relacion con la atencion especializada es importante para su reduccion.

Quality-of-Life assessment in malignant pleural effusion treated with indwelling pleural catheter: A prospective study:

Background: Malignant pleural effusion is a clinical problem that impairs Quality of Life in patients with advanced malignancies. An indwelling pleural catheter is an alternative treatment to palliate some of the symptoms. Aim: To evaluate the Quality of Life of outpatients with malignant pleural effusion who were treated with an indwelling pleural catheter. Questionnaire compliance, catheter patency time, and survival were analyzed. Design: A multicenter observational study was conducted across five hospitals in Spain. Quality of Life was assessed at three different time points (before catheter placement and at 30 and 60 days post-placement) using the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire QLQ-C30. For lung cancer patients, the QLQ-LC13 was also used. Participants: Patients with recurrent malignant pleural effusion treated with an indwelling pleural catheter. Results: A total of 51 outpatients completed the baseline QLQ-C30 questionnaire. Of these, 28 completed the questionnaire at 30 days. Of these 28 patients, 13 completed the questionnaire at 60 days. Scores showed a significant improvement in symptoms scales at 30 days (p = 0.03). Global health status and functional scales showed a non-significant trend to improvement at 30 and 60 days. A total of 27 lung cancer patients completed the QLQ-LC13 questionnaire. Items assessing dyspnea showed a significant improvement following catheter placement (p = 0.002). Conclusion: Indwelling pleural catheter is useful for palliative management of recurrent malignant pleural effusion in that it benefits Quality of Life in outpatients with advanced malignancies. In lung cancer patients, scores indicated that indwelling pleural catheter also provides significant relief of dyspnea.

Management of a transbronchial cryobiopsy using the i-gel ® airway and the Arndt endobronchial blocker

To the Editor, The practice of anesthesiology is moving beyond the operating room and increasingly into the venue of various interventional medical specialties, including cardiology, radiology, gastroenterology, and pulmonology. Interventional pulmonologists are frequently performing transbronchial cryobiopsy procedures that often require various degrees of sedation or general anesthesia. Initially, this procedure was mainly used in the treatment and excision of endobronchial lesions, particularly in cases of bronchial obstruction. Nevertheless, it is now an emerging technique performed by pulmonologists to diagnose focal and diffuse lung diseases, including neoplastic and interstitial lung diseases as well as pulmonary infections and lung rejection following transplantation. The use of the cryotherapy probe allows sampling of well-preserved tissue that tends to be superior quality to that obtained through traditional forceps biopsy via a flexible bronchoscope. For example, the tissue is often devoid of the crush artifact commonly seen with a traditional forceps technique. Cryobiopsy offers additional advantages as it may reduce operative time, improve diagnostic yields, and potentially decrease complications. Additionally, the cryotherapy probe may facilitate the sampling of airway lesions positioned tangentially to the bronchoscope. The disadvantage of cryobiopsy is that tracheal intubation is often recommended because the samples attached to the cryoprobe cannot be retracted through the bronchoscope and thus requires removal of both cryoprobe and bronchoscope as a single unit. For that reason, it is important to have a secure airway in place to facilitate rapid control of any potential bleeding. Absolute contraindications to cryobiopsy include severe hypoxia, status asthmaticus, poor patient cooperation, massive hemoptysis, and uncorrectable bleeding diathesis. In our institution, we carry out cryobiopsy under general anesthesia. This facilitates better conditions for performing the technique, including an optimized field of view in a non-combative patient. In addition, it allows for better control of the airway in case of a bleeding emergency. For these procedures, we use standard intraoperative monitors as well as the bispectral index (BIS). Anesthesia induction is performed with propofol 2.5-3 mg kg and remifentanil 1 lg kg, both administered slowly over one minute. Once an adequate depth of anesthesia has been achieved, an i-gel supraglottic airway (Intersurgical Ltd, Berkshire, UK) is inserted according to the manufacturer’s instructions. Next, an Arndt endobronchial blocker with spherical balloon (C-AEBS-9.0-78-SPH-AS; Cook Medical Inc, Bloomington, IN, USA) is advanced through the blocker port of the Arndt Multiport Adapter , and a 6.0-mm diameter fibreoptic bronchoscope (with a 3.0-mm operating channel), which had been introduced through the fibreoptic port, is passed J. A. Sastre, MD, PhD (&) Department of Anesthesiology, Salamanca University Hospital and IBSAL, Salamanca, Spain e-mail: josealfsastre@hotmail.com

Use of Indwelling Pleural Catheter in the Outpatient Management of Recurrent Malignant Pleural Effusion

Introduction: To analyse the effectiveness and safety of the indwelling pleural catheter in the management of recurrent malignant pleural effusion. Patients and methods: A prospective multicentre study was performed in 63 consecutive outpatients from four Spanish hospitals. A total of 43 men and 20 women were included, with a median age of 67 years. In seven of the cases treatment with pleurodesis had failed; in fi ve other cases their lung was trapped; in another fi ve cases after repeat therapeutic thoracocentesis, and the rest of them as a preference choice to pleurodesis. All patients had an indwelling pleural catheter inserted (PleurX

Etiología de las bronquiectasias en una cohorte de 2.047 pacientes. Análisis del registro histórico español

INTRODUCTION Bronchiectasis is caused by many diseases. Establishing its etiology is important for clinical and prognostic reasons. The aim of this study was to evaluate the etiology of bronchiectasis in a large patient sample and its possible relationship with demographic, clinical or severity factors, and to analyze differences between idiopathic disease, post-infectious disease, and disease caused by other factors. METHODS Multicenter, cross-sectional study of the SEPAR Spanish Historical Registry (RHEBQ-SEPAR). Adult patients with bronchiectasis followed by pulmonologists were included prospectively. Etiological studies were based on guidelines and standardized diagnostic tests included in the register, which were later included in the SEPAR guidelines on bronchiectasis. RESULTS A total of 2,047 patients from 36 Spanish hospitals were analyzed. Mean age was 64.9years and 54.9% were women. Etiology was identified in 75.8% of cases (post-Infection: 30%; cystic fibrosis: 12.5%; immunodeficiencies: 9.4%; COPD: 7.8%; asthma: 5.4%; ciliary dyskinesia: 2.9%, and systemic diseases: 1.4%). The different etiologies presented different demographic, clinical, and microbiological factors. Post-infectious bronchiectasis and bronchiectasis caused by COPD and asthma were associated with an increased risk of poorer lung function. Patients with post-infectious bronchiectasis were older and were diagnosed later. Idiopathic bronchiectasis was more common in female non-smokers and was associated with better lung function, a higher body mass index, and a lower rate of Pseudomonas aeruginosa than bronchiectasis of known etiology. CONCLUSIONS The etiology of bronchiectasis was identified in a large proportion of patients included in the RHEBQ-SEPAR registry. Different phenotypes associated with different causes could be identified.

Determinants of false-negative results in non-small-cell lung cancer staging by endobronchial ultrasound-guided needle aspiration

OBJECTIVES False-negative results of endobronchial ultrasound-guided transbronchial needle aspiration in non-small-cell lung cancer staging have shown significant variability in previous studies. The aim of this study was to identify procedure- and tumour-related determinants of endobronchial ultrasound-guided transbronchial needle aspiration false-negative results. METHODS We conducted a prospective study that included non-small-cell lung cancer patients staged as N0/N1 by endobronchial ultrasound-guided transbronchial needle aspiration and undergoing therapeutic surgery. The frequency of false-negative results in the mediastinum was calculated. Procedure-related, first, and tumour-related, second, determinants of false-negative results in stations reachable and non-reachable by endobronchial ultrasound were determined by multivariate logistic regression. RESULTS False-negative endobronchial ultrasound-guided transbronchial needle aspiration results were identified in 23 of 165 enrolled patients (13.9%), mainly in stations reachable by endobronchial ultrasound (17 cases, 10.3%). False-negative results were related to the extensiveness of endobronchial ultrasound sampling: their prevalence was low (2.4%) when sampling of three mediastinal stations was satisfactory, but rose above 10% when this requirement was not fulfilled (P = 0.043). In the multivariate analysis, abnormal mediastinum on computer tomography/positron emission tomography [odds ratio (OR) 7.77, 95% confidence interval (CI) 2.19-27.51, P = 0.001] and extensiveness of satisfactory sampling of mediastinal stations (OR 0.37, 95% CI 0.16-0.89, P = 0.026) were statistically significant risk factors for false-negative results in stations reachable by endobronchial ultrasound. False-negative results in non-reachable nodes were associated with a left-sided location of the tumour (OR 10.11, 95% CI 1.17-87.52, P = 0.036). CONCLUSIONS The presence of false-negative ultrasound-guided transbronchial needle aspiration results were observed in nearly 15% of non-small-cell lung cancer patients but in only 3% when satisfactory samples were obtained from three mediastinal stations. False-negative results in stations reachable by endobronchial ultrasound were associated with the extensiveness of sampling, and in stations out of reach of endobronchial ultrasound with left-sided tumours. These results suggest that satisfactory sampling of at least three mediastinal stations by EBUS-TBNA may be a quality criterion to be recommended for EBUS-TBNA staging.

Válvulas endobronquiales para el tratamiento de la fuga aérea persistente, una alternativa al tratamiento quirúrgico

INTRODUCTION Persistent air leak is frustrating for both patients and physicians, above all leaks with a high risk of surgery. Insertion of endobronchial valves could be an alternative to surgery. The aim of this study is to describe our experience in these valves and analyse their efficacy in a series of patients with persistent air leaks. MATERIAL AND METHODS The valves are inserted by means of flexible bronchoscopy under conscious sedation and local anesthesia. A preliminary bronchoscopy identifies the air leak by bronchial occlusion using a balloon catheter. A successful outcome is defined as complete disappearance of the leak following removal of the chest drain, without the need for further surgery. RESULTS From November 2010 to December 2013, 8 patients with persistent air leaks were treated with endobronchial valves. The number of valves used ranged from 1 to 4 (median 2), with a median duration of air leak prior to placement of 15.5 days. There were no complications and the resolution of the leak was complete in 6 of 8 patients (75%). The median duration of drainage after insertion of the valves was 13 days and the median time to removal of 52.5 days. CONCLUSIONS Insertion of endobronchial valves is a safe and effective method for treating persistent air leaks, and a valid alternative to surgery.

Cumplimiento de la legislación antitabaco en instituciones oficiales

La prevencion del tabaquismo abarca aspectos muy amplios y se basa en el establecimiento de normas legislativas destinadas a promover la salud publica mediante la proteccion de los no fumadores frente al humo del tabaco y la disuasion a los fumadores acerca de su consumo, y tambien en el establecimiento de politicas destinadas a aumentar la informacion y formacion de ambos (fumadores y no fumadores) sobre los efectos nocivos del tabaco. En Espana la principal legislacion antitabaco es el Real Decreto 192/1988 del Ministerio de Sanidad y Consumo sobre limitaciones en la venta y uso de tabaco para la proteccion de la salud de la poblacion. Otras normas complementarias de la citada ley han sido promulgadas posteriormente por las distintas administraciones publicas implicadas. A partir de la informacion cientifica que ha ido acumulandose durante los ultimos anos, la legislacion se ha modificado considerablemente en dos direcciones: homogeneizandose las normas existentes entre distintos paises y aumentando la restriccion en la publicidad y consumo del tabaco. En Espana, distintos sectores sociales y cientificos han solicitado el endurecimiento de la actual legislacion. Sin embargo, son escasas las valoraciones realizadas acerca del grado de vigilancia y cumplimiento (y por tanto de su eficacia) de la legislacion actual. El objetivo de este trabajo ha sido conocer el nivel de cumplimiento de este Real Decreto en las instituciones oficiales de Salamanca. Hemos visitado 30 centros y hemos observado que existen carteles que prohiben el uso del tabaco en el 80% de estos centros; a pesar de esto el porcentaje de gente fumando en los mismos es elevado: un 43% entre los trabajadores (ninguno de los cuales pertenecia a centros educativos ni sanitarios) y un 37% entre el publico. No hay carteles informativos sobre la nocividad del tabaco en ninguno de los centros que se incluyeron en el estudio. Parece necesario limitar aun mas la venta y el consumo de tabaco en lugares publicos vigilando el cumplimiento de las normas restrictivas existentes, y aumentando la informacion (a toda la poblacion) sobre los efectos nocivos del tabaco, para conseguir aumentar la colaboracion de todos (fumadores y no fumadores) y alcanzar un ambiente libre de humo.