News - Part 6

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Sternotomy

Iwasaki et al described another method of tho-racoscopic plication involving stapling across the apex of the lung, folding the lung at the staple line, and then restapling across the fold, holding the lung in a folded position. Twenty patients with emphysema had unilateral thoracoscopic lung reduction by this method of fold plication. Postoperative air leak lasted 0 to 5 days (1.7 days). FEV1 increased from 24.2 to 42.4% predicted with improvement in dyspnea in all patients. One patient had a spontaneous pneumothorax on day 7. Link Read more »

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Thoracoscopic Techniques

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Thoracoscopic TechniquesLausberg et al recently reported a method of radiofrequency-induced fenestrations in segmental bronchi to enhance expiratory airflow in emphysematous lungs. Twelve explanted emphysematous lungs removed during lung transplantation were studied in a ventilation chamber ex vivo. Three to five fenestrations were made in segmental or subsegmental bronchi adjacent to lung parenchyma with a radiofrequency catheter (Exhale RF Probe; Bronchus Technologies; Mountain View, CA) inserted via a fiberoptic bronchoscope. Patency of the bronchopulmonary fenestrations was maintained with uncovered coronary stents (3 mm in diameter, 15 mm in length). Mean FEV1 measured in the experimental pressurized ventilation chamber increased from 245 to 447 mL (83% increase, p < 0.001) following creation of the stented fenestration. In vivo animal studies of this procedure are underway. Read more »

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Total lung capacity

The nebulized papain produced histologically confirmed emphysema. Total lung capacity (TLC), RV, and RV/TLC increased in all animals. Lung compliance increased as well. After intubation and ventilation with 100% oxygen, selected lung subsegments were lavaged with “antisurfactant” solution via a multichannel, balloon-tipped catheter inserted through a fiberoptic bronchoscope. Following suction, a fibrin-based sealant was injected into the selected subsegment with bronchoscopic confirmation of effective sealing. Animals treated with this method of bron-choscopic volume reduction had significant reductions in TLC (64% return to baseline) and RV (72% return to baseline), with decreased compliance. Visual atelectasis was apparent at autopsy. These results were similar to those in a group of sheep treated with surgical lung volume reduction. Sterile lung abscesses developed in two of four of the sheep treated with bronchoscopic volume reduction. Only 11 of 20 subsegments treated exhibited sustained collapse. Reading here Read more »

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Bronchopleural fistula

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Bronchopleural fistulaIn an animal study, 21 valves were inserted into the upper lobes of five healthy swine. After 4 to 6 days, bronchoscopy and fluoroscopy confirmed proper positioning of the valves. One valve in each of the four swine was easily removed and replaced bronchoscopically. No complications were observed. At thoracotomy 4 to 6 days after valve insertion, visual confirmation of volume reduction was observed. so Read more »

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Procedure

Twenty-five endobronchial valves were inserted over a guide-wire placed bronchoscopically under general IV anesthesia with pressure-limited ventilation. Valves were inserted unilaterally in all segmental bronchi leading to the upper lobe most affected by emphysema in each patient. Median procedure time was 1 h (range 0.5 to 2.5 h). All patients were extubated immediately following the procedure. Read more »

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Bronchus

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: BronchusThe Emphasys Endobronchial Valve consists of a silicone duckbill, one-way valve attached to a nitinol self-expanding stent retainer with silicone seals to occlude the bronchus around the valve (Fig 1). The valve is inserted into the intended segmental or subsegmental bronchus via a delivery housing device over a guidewire placed via a fiberoptic bronchoscope in a manner similar to stent insertion (Fig 2, 3). The bronchoscope should be reinserted to confirm proper positioning before deployment of the valve from the delivery device. Position adjustments or removal (if necessary) can be accomplished with a biopsy forceps. Read more »

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction: Bronchoscopic Methods

The demonstrated benefits of LVRS and the rigors of surgical lung volume reduction have led investigators and medical equipment manufacturers to develop minimally invasive techniques to achieve lung volume reduction without open thoracotomy. Devices and techniques under study include bronchial occlusion devices inserted via fiberoptic bronchoscopy, promotion of focal atelectasis and fibrosis by bronchoscopic injection of polymers into emphysematous regions of lung, bronchopulmonary fenestrations to enhance expiratory flow, and thoraco-scopic plication or compression of emphysematous lung. The goal of all of these procedures is to replicate the benefit of LVRS without the trauma, risks, and extended recovery of open LVRS. Read more »

New and Emerging Minimally Invasive Techniques for Lung Volume Reduction

New and Emerging Minimally Invasive Techniques for Lung Volume ReductionEmphysema is characterized by destruction of alveolar walls distal to the terminal bronchioles. This process leads to enlargement of distal air spaces with development of emphysematous blebs, cysts, and bullae. Because capillary-rich alveolar walls are also destroyed in areas of emphysema, these enlarged air spaces have very high ventilation/perfusion
(V/Q) ratios creating physiologic dead space. Increased dead space ventilation reduces efficiency of breathing, resulting in increased work and impaired gas exchange. Read more »

Assessment of Symptoms and Exercise Capacity in Cyanotic Patients With Congenital Heart Disease: Study Limitations

Due to the shunting of oxygen-poor and carbon dioxide-rich blood into the systemic circulation, a compensatory hyperventilation resulting in an appropriate alveolar and pulmonary venous hypocapnia did occur. Since shunt volume does increase with progressive exercise in Eisenmenger syndrome, alveolar hyperventilation increases proportionally to shunt volume in order to maintain a normal PaC02, whereas Pa02 cannot be improved by hyperventilation in central cardiac right-to-left shunt. Considering the stable PaC02 at maximal exercise performance, an increasing hypoxic contribution to ventilatory control appears unlikely. other
It should be emphasized that the interpretation of our findings is based on noninvasive measurements. Therefore, some of the conclusions are based on assumptions with respect to exercise physiology in these complex lesions. Read more »

Assessment of Symptoms and Exercise Capacity in Cyanotic Patients With Congenital Heart Disease: Acid-Base Balance and Ventilation

Assessment of Symptoms and Exercise Capacity in Cyanotic Patients With Congenital Heart Disease: Acid-Base Balance and VentilationDespite this possible role of increased dead space ventilation, the major impact on ventilatory efficiency in cyanotic patients is most likely due to alveolar hyperventilation. Considering the correlation of end-tidal partial pressures for oxygen and carbon dioxide with ventilatory efficiency under exercise among patients and control subjects (Fig 4), alveolar hyperventilation with resulting alveolar hy-pocapnia can be expected as the most important mechanism influencing ventilatory efficiency in our patients. comments Read more »

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