Thomas Wibmer

Endobronchial tumor debulking with a flexible cryoprobe for immediate treatment of malignant stenosis

OBJECTIVE In addition to use of a laser, argon plasma coagulation, electrocautery, or coring with a rigid bronchoscope, tumor debulking with a flexible cryoprobe is used for therapeutic bronchoscopy with an immediate effect for endobronchial pathologies. We performed this analysis to determine the usefulness, efficacy, and safety of the flexible cryorecanalization in a large population under routine conditions. METHODS We identified 225 bronchoscopic interventions that were done as cryorecanalization with a flexible cryoprobe. All patients had symptomatic airway stenosis. We determined the endoscopic success rate and safety (bleeding and perforation) of the procedure. RESULTS Successful cryorecanalization was achieved in 205 (91.1%) of 225 patients. The flexible cryoprobe was used with all patients, in most patients in combination with flexible bronchoscopy and only in a minority (n = 31, 13.8%) in combination with a rigid bronchoscope. Additional interventional techniques used were endobronchial stents (n = 11, 4.9%) and argon plasma coagulation (n = 37, 16.4%). Mild bleeding (if ice-cold NaCl or epinephrine solution was necessary) occurred in 9 (4.0%) patients, moderate bleeding (if argon plasma coagulation or a bronchus blocker was required) occurred in 18 (8.0%) patients, and severe bleeding (events with hemodynamic instability) never occurred. CONCLUSIONS Cryorecanalization with the flexible cryoprobe for treatment of symptomatic endobronchial tumor stenosis is a safe technique with a high success rate and immediate treatment effect.

Omalizumab in patients with severe asthma: the XCLUSIVE study.

Background and Aims:  Although the efficacy and safety of omalizumab (OMA) in uncontrolled severe allergic asthma has been demonstrated in several randomised controlled trials (RCTs), information on the treatment in a practice‐related setting is limited. Thus, the purpose of this prospective multi‐centre study (XCLUSIVE) was to investigate the efficacy, compliance and utilisation of OMA therapy in real‐life clinical practice in Germany.

Circulating biomarkers of tissue remodelling in pulmonary hypertension.

Objective: Besides persisting high pulmonary arterial pressure and increased pulmonary vascular resistance, remodelling of pulmonary tissues and subsequently the right heart are the key pathomechanisms of pulmonary hypertension (PH). Extracellular matrix maintenance in this context plays a central role. Methods: We tested the hypothesis that plasma concentration of matrix metalloproteinase (MMP)-2, tissue inhibitor of matrix metalloproteinases (TIMP)-4 and tenascin C (TNC) might be useful as biomarkers for assessing the severity of PH. Therefore, the concentrations of MMP-2, TIMP-4, TNC and N-terminal b-type natriuretic peptide (NT-proBNP) of 36 PH patients were compared with those of 44 age- and gender-matched healthy volunteers. Additionally, lung function, 6-min walk distance and right heart function were assessed. Results: In PH patients, significantly elevated plasma levels of MMP-2, TIMP-4, TNC and NT-proBNP were detected. In particular, TIMP-4 was significantly increased in patients with higher NYHA classification, and in patients with severe right ventricular hypertrophy. Conclusion: Monitoring of plasma TIMP-4 and to a lesser extent of MMP-2 and TNC levels in PH patients might help to assess the beneficial effects of PH pharmacotherapy on tissue remodelling.

Isolated IgG4-related interstitial lung disease: unusual histological and radiological features of a pathologically proven case

IgG4-related lung disease is commonly associated with autoimmune pancreatitis. Recently, isolated IgG4-related interstitial lung disease (ILD) without other organ involvement has newly been reported in two cases with clinical features of nonspecific interstitial pneumonitis (NSIP).We report the first case of an isolated IgG4-related ILD in a 78-year-old man with dry cough and dyspnea, whose clinical findings proved to be different from NSIP. Serum IgG4 levels were increased. Chest CT scan revealed bilateral consolidations especially in the lower lobes, enlarged mediastinal and hilar lymph nodes and pleural effusions. Video-assisted thoracoscopic (VATS) lung biopsy revealed a pattern similar to usual interstitial pneumonia (UIP) and an abundant IgG4-positive plasma cell infiltration. He was effectively treated by steroid therapy.Increasing recognition of IgG4 related diseases has led to a growing number of new entities. The novel concept of isolated IgG4-related ILD as a pulmonary manifestation of a systemic IgG4-related disorder should be taken into account as a possible differential diagnosis of ILD and mass-forming lesions, even when no other organ manifestation is clinically apparent at the time of diagnosis. Lung specific diagnostic criteria and algorithms are required to enhance diagnostic accuracy in cases of possible IgG4-related ILD.

Effects of Nasal Positive Expiratory Pressure on Dynamic Hyperinflation and 6-Minute Walk Test in Patients With COPD

INTRODUCTION: Dynamic hyperinflation is an important target in the treatment of COPD. There is increasing evidence that positive expiratory pressure (PEP) could reduce dynamic hyperinflation during exercise. PEP application through a nasal mask and a flow resistance device might have the potential to be used during daily physical activities as an auxiliary strategy of ventilatory assistance. The aim of this study was to determine the effects of nasal PEP on lung volumes during physical exercise in patients with COPD. METHODS: Twenty subjects (mean ± SD age 69.4 ± 6.4 years) with stable mild-to-severe COPD were randomized to undergo physical exercise with nasal PEP breathing, followed by physical exercise with habitual breathing, or vice versa. Physical exercise was induced by a standard 6-min walk test (6MWT) protocol. PEP was applied by means of a silicone nasal mask loaded with a fixed-orifice flow resistor. Body plethysmography was performed immediately pre-exercise and post-exercise. RESULTS: Differences in mean pre- to post-exercise changes in total lung capacity (−0.63 ± 0.80 L, P = .002), functional residual capacity (−0.48 ± 0.86 L, P = .021), residual volume (−0.56 ± 0.75 L, P = .004), SpO2 (−1.7 ± 3.4%, P = .041), and 6MWT distance (−30.8 ± 30.0 m, P = .001) were statistically significant between the experimental and the control interventions. CONCLUSIONS: The use of flow-dependent expiratory pressure, applied with a nasal mask and a PEP device, might promote significant reduction of dynamic hyperinflation during walking exercise. Further studies are warranted addressing improvements in endurance performance under regular application of nasal PEP during physical activities.

Blood pressure monitoring during exercise: Comparison of pulse transit time and volume clamp methods

During physical exercise, pulse transit time (PTT), expressed as the interval between ventricular electrical activity and peripheral pulse wave, may provide a surrogate estimate for blood pressure by the use of specific calibration procedures. The objective of this study was to determine systolic blood pressure (SBP) values derived from the PTT method and from an established method of non-invasive continuous blood pressure measurement based on the volume clamp technique, and to compare their agreement with sphygmomanometry during exercise tests. In 18 subjects, electrocardiogram (ECG) and finger-photoplethysmography were continuously recorded during maximal cycle exercise tests. Intermittent and continuous blood pressure measurements were simultaneously taken using automated sphygmomanometry and a Portapres Model-2 device, respectively. PTT was calculated for each ECG R-wave and the corresponding steepest upstroke slope in the photoplethysmogram, and was transformed to a continuous blood pressure estimate using multipoint nonlinear regression calibration based on the individual subjects sphygmomanometer readings. Bland–Altman limits of agreement between PTT-derived SBP estimates and sphygmomanometer values were –24.7 to 24.1 mmHg, and between Portapres and sphygmomanometer SBP values were –42.0 to 70.1 mmHg. For beat-to-beat SBP estimation during exercise, PTT measurement combined with multipoint nonlinear regression calibration based on intermittent sphygmomanometry may be an alternative to volume clamp devices.

[Erdheim-chester disease: a rare cause of interstitial lung disease].

ZusammenfassungHintergrund:Die Erdheim-Chester-Erkrankung ist eine seltene Non-Langerhans-Zell-Histiozytose mit Multiorganbefall unklarer Genese. Typisch ist ein osteosklerotischer Befall der langen Röhrenknochen. Klinische Symptome werden aber meist durch Befall anderer Organe wie Lunge, Herz und Retroperitoneum hervorgerufen.Fallbeschreibung:Ein 58-jähriger Mann stellte sich wegen Abgeschlagenheit, nachlassender Belastbarkeit, diffuser Schmerzen der unteren Extremität, Dyspnoe und trockenen Hustens vor. Die körperliche Untersuchung war unauffällig. Im Röntgenbild des Thorax fiel eine ausgedehnte interstitielle Zeichnungsvermehrung auf. In der Computertomographie fanden sich fibrotische Lungengerüstveränderungen, eine periaortale Fibrose der thorakalen Aorta und eine retroperitoneale Fibrose. Mittels chirurgischer Lungenbiopsie wurde die Diagnose einer Erdheim-Chester-Erkrankung gesichert. Eine Steroidtherapie wurde nicht toleriert. Nach einem therapiefreien Intervall von 18 Monaten kam es zu einer Progredienz der Erkrankung. Unter einer Cyclophosphamidtherapie konnte der Krankheitsverlauf stabilisiert werden.Schlussfolgerung:Bei ausgedehnten pulmonalen fibrotischen Veränderungen sollte man bei gleichzeitigem Nachweis anderer Organmanifestationen wie periaortaler oder retroperitonealer Fibrose und insbesondere bei osteosklerotischen symmetrischen Knochenveränderungen an die Erdheim-Chester-Erkrankung denken. Unter einer immunsuppressiven Therapie kann es zu einer Stabilisierung oder sogar Besserung der Erkrankung kommen.AbstractBackground:Erdheim-Chester disease is a rare non-Langerhans’ cell histiocytosis of unknown etiology with typical osteosclerotic long-bone findings. However, clinical symptoms are mostly due to disease involvement of other tissues, particularly of the lung, heart and retroperitoneum.Case Report:A 58-year-old man presented with fatigue, diffuse pain of the lower extremities, dyspnea, and a dry cough. Physical examination was unremarkable. Chest X-ray revealed an extensive bilateral pulmonary inter interstitial process. Computed tomography demonstrated pulmonary fibrosis, periaortic fibrosis of the thoracic aorta, and retroperitoneal fibrosis. The diagnosis of Erdheim-Chester disease was confirmed by minimally invasive lung biopsy. Steroid therapy was not tolerated. Following a stable interval of 18 months there was a disease progression, which could be stabilized after the initiation of cyclophosphamide therapy.Conclusion:In patients with extensive pulmonary fibrosis and coincidence of other organ manifestations such as periaortic or retroperitoneal fibrosis and particularly in case of symmetrical osteosclerotic bone lesions, Erdheim-Chester disease should be considered. Immunosuppressive therapy can lead to a stabilization or even improvement of the disease.

Therapy of exophytic bronchial tumorous stenosis by flexible cryoprobe

To the Editors: We read with interest the article by Vergnon et al. 1 in the European Respiratory Journal , about the place of cryotherapy, brachytherapy and photodynamic therapy in the therapeutic bronchoscopy of lung cancers. The article describes indications and limitations of cryotherapy. In the opinion of Vergnon et al. 1, the effect of cryotherapy is delayed and is, therefore, not useful for the immediate debulking of an obstructive endoluminal bronchial tumour. For these cases, Vergnon et al. 1 advise coring of the tumour with the rigid bronchoscope and subsequent laser therapy or electrocautery. The indication for cryotherapy in this setting is seen as a treatment option for any remaining infiltrative parts of the tumour into the bronchial wall, but not as a …

Pulmonary pulse transit time: a novel echocardiographic indicator of hemodynamic and vascular alterations in pulmonary hypertension and pulmonary fibrosis.

Pulse transit time (PTT) is generally assumed to be a surrogate marker for blood pressure changes and arterial stiffness. The aim was to evaluate whether pulmonary PTT (pPTT) may be noninvasively measured by Doppler echocardiography and whether it might be valuable for detecting pulmonary hemodynamic and vascular alterations.

Relation of Exercise Capacity With Lung Volumes Before and After 6-Minute Walk Test in Subjects With COPD

INTRODUCTION: There is growing evidence that exercise-induced variation in lung volumes is an important source of ventilatory limitation and is linked to exercise intolerance in COPD. The aim of this study was to compare the correlations of walk distance and lung volumes measured before and after a 6-min walk test (6MWT) in subjects with COPD. METHODS: Forty-five subjects with stable COPD (mean pre-bronchodilator FEV1: 47 ± 18% predicted) underwent a 6MWT. Body plethysmography was performed immediately pre- and post-6MWT. RESULTS: Correlations were generally stronger between 6-min walk distance and post-6MWT lung volumes than between 6-min walk distance and pre-6MWT lung volumes, except for FEV1. These differences in Pearson correlation coefficients were significant for residual volume expressed as percent of total lung capacity (−0.67 vs −0.58, P = .043), percent of predicted residual volume expressed as percent of total lung capacity (−0.68 vs −0.59, P = .026), inspiratory vital capacity (0.65 vs 0.54, P = .019), percent of predicted inspiratory vital capacity (0.49 vs 0.38, P = .037), and percent of predicted functional residual capacity (−0.62 vs −0.47, P = .023). CONCLUSIONS: In subjects with stable COPD, lung volumes measured immediately after 6MWT are more closely related to exercise limitation than baseline lung volumes measured before 6MWT, except for FEV1. Therefore, pulmonary function testing immediately after exercise should be included in future studies on COPD for the assessment of exercise-induced ventilatory constraints to physical performance that cannot be adequately assessed from baseline pulmonary function testing at rest.