Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European multicentre study.

The safety of talc pleurodesis is under dispute following reports of talc-induced acute respiratory distress syndrome (ARDS) and death. We investigated the safety of large-particle talc for thoracoscopic pleurodesis to prevent recurrence of primary spontaneous pneumothorax (PSP). 418 patients with recurrent PSP were enrolled between 2002 and 2008 in nine centres in Europe and South Africa. The main exclusion criteria were infection, heart disease and coagulation disorders. Serious adverse events (ARDS, death or other) were recorded up to 30 days after the procedure. Oxygen saturation, supplemental oxygen use and temperature were recorded daily at baseline and after thoracoscopic pleurodesis (2 g graded talc). During the 30-day observation period following talc poudrage, no ARDS (95% CI 0.0-0.9%), intensive care unit admission or death were recorded. Seven patients presented with minor complications (1.7%, 95% CI 0.7-3.4%). After pleurodesis, mean body temperature increased by 0.41°C (95% CI 0.33-0.48°C; p<0.001) at day 1 and returned to baseline value at day 5. Pleural drains were removed after day 4 in 80% of patients. Serious adverse events, including ARDS or death, did not occur in this large, multicentre cohort. Thoracoscopic talc poudrage using larger particle talc to prevent recurrence of PSPS can be considered safe.

Impact of aerobic exercise capacity and procedure-related factors in lung cancer surgery.

Over the past decades, major progress in patient selection, surgical techniques and anaesthetic management have largely contributed to improved outcome in lung cancer surgery. The purpose of this study was to identify predictors of post-operative cardiopulmonary morbidity in patients with a forced expiratory volume in 1 s <80% predicted, who underwent cardiopulmonary exercise testing (CPET). In this observational study, 210 consecutive patients with lung cancer underwent CPET with completed data over a 9-yr period (2001-2009). Cardiopulmonary complications occurred in 46 (22%) patients, including four (1.9%) deaths. On logistic regression analysis, peak oxygen uptake (peak V'(O2) and anaesthesia duration were independent risk factors of both cardiovascular and pulmonary complications; age and the extent of lung resection were additional predictors of cardiovascular complications, whereas tidal volume during one-lung ventilation was a predictor of pulmonary complications. Compared with patients with peak V'(O2) >17 mL·kg⁻¹·min⁻¹, those with a peak V'(O2) <10 mL·kg⁻¹·min⁻¹ had a four-fold higher incidence of cardiac and pulmonary morbidity. Our data support the use of pre-operative CPET and the application of an intra-operative protective ventilation strategy. Further studies should evaluate whether pre-operative physical training can improve post-operative outcome.

Prevalence of airflow obstruction in smokers and never-smokers in Switzerland.

The aim of the present study was to measure age-specific prevalence of airflow obstruction in Switzerland in smokers and never-smokers using pulmonary function tests and respiratory symptoms from 6,126 subjects participating in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults. The lower limit of normal of the forced expiratory volume in 1 s/forced vital capacity ratio was used to define airflow obstruction. Severity of airflow obstruction was graded according to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Prevalence of airflow obstruction ranged from 2.5% in subjects aged 30-39 yrs to 8.0% in those aged ≥ 70 yrs. In multivariate analysis, age (OR 2.8, ≥ 70 yrs versus 30-39 yrs), smoking (OR 1.8) and asthma (OR 6.7) were associated with airflow obstruction. Never-smokers constituted 29.3% of subjects with airflow obstruction. Never-smokers with airflow obstruction were younger, more likely to be male and reported asthma more frequently than obstructive smokers. Obstructive smokers and never-smokers had similar level of symptoms and quality of life impairment. The prevalence of airflow obstruction in Switzerland is similar to other developed countries. Never-smokers account for a third of the prevalence, which is higher proportion than elsewhere. Airflow obstruction in never-smokers deserves attention because of its frequency and its similar health impact to that in smokers.

Longitudinal change of prebronchodilator spirometric obstruction and health outcomes: results from the SAPALDIA cohort.

BACKGROUND: Understanding the prognostic meaning of early stages of chronic obstructive pulmonary disease (COPD) in the general population is relevant for discussions about underdiagnosis. To date, COPD prevalence and incidence have often been estimated using prebrochodilation spirometry instead of postbronchodilation spirometry. In the SAPALDIA (Swiss Study on Air Pollution and Lung Disease in Adults) cohort, time course, clinical relevance and determinants of severity stages of obstruction were investigated using prebronchodilator spirometry. METHODS: Incident obstruction was defined as an FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio >or=0.70 at baseline and <0.70 at follow-up, and non-persistence was defined inversely. Determinants were assessed in 5490 adults with spirometry and respiratory symptom data in 1991 and 2002 using Poisson regression controlling for self-declared asthma and wheezing. Change in obstruction severity (defined analogously to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification) over 11 years was related to shortness of breath and health service utilisation for respiratory problems by logistic models. RESULTS: The incidence rate of obstruction was 14.2 cases/1000 person years. 20.9% of obstructive cases (n = 113/540) were non-persistent. Age, smoking, chronic bronchitis and non-current asthma were determinants of incidence. After adjustment for asthma, only progressive stage I or persistent stage II obstruction was associated with shortness of breath (OR 1.71, 95% CI 0.83 to 3.54; OR 3.11, 95% CI 1.50 to 6.42, respectively) and health service utilisation for respiratory problems (OR 2.49, 95% CI 1.02 to 6.10; OR 4.17 95% CI 1.91 to 9.13, respectively) at follow-up. CONCLUSIONS: The observed non-persistence of obstruction suggests that prebronchodilation spirometry, as used in epidemiological studies, might misclassify COPD. Future epidemiological studies should consider both prebronchodilation and postbronchodilation measurements and take specific clinical factors related to asthma and COPD into consideration for estimation of disease burden and prediction of health outcomes.

[Pulmonary rehabilitation: a multidisciplinary and comprehensive intervention]. / La réadaptation pulmonaire: une médecine pluridisciplinaire de pointe.

Pulmonary rehabilitation is an evidence-based, multidisciplinary and comprehensive intervention for chronic pulmonary diseases, adressed to symptomatic patients and to patients with impairment of activities of daily life. The major outcomes of this intervention are an increased exercise capacity, a decrease in dyspnea and thereby a better quality of life. Underweight patients may benefit from a caloric and protein supplementation. Smoking cessation programs should be integrated in any pulmonary rehabilitation program.

[Bronchopleural fistula: a serious complication after thoracic surgery]. / La fistule bronchopteurale: une complication grave de la chirurgie thoracique.

Postsurgical bronchopleural fistula (BPF) is a serious complication accompanied with a high mortality, requiring early and correct diagnosis. The acute form of BPF is usually a technical failure of the surgical stump requiring an immediate surgical reoperation. The subacute or chronic BPF is more difficult to diagnose because of non specific symptoms. It requires well targeted antibiotics depending on microbiology, an adequate drainage of the thoracic cavity and very often repeated surgical or endoscopic procedures.

Titrated sedation with propofol or midazolam for flexible bronchoscopy: a randomised trial.

In this study, we questioned whether propofol provided clinical benefits compared with midazolam in terms of neuropsychometric recovery, safety profile and patient tolerance. Patients, aged >18 yrs, were randomised to receive midazolam or propofol, given by non-anaesthetist physicians to achieve moderate levels of sedation as assessed by the electroencephalographic bispectral index (BIS; between 70 and 85). The primary end-point was the time delay until recovery of the BIS above 90. Other end-points included a neuropsychometric continuous performance test (CPT), serious respiratory adverse events, patient tolerance and physician satisfaction. Neuropsychometric recovery was improved in the propofol compared to the midazolam group as evidenced by faster normalisation of BIS index (5.4+/-4.7 min versus 11.7+/-10.2 min; p = 0.001) and better results at the CPT. In the midazolam group, 15% of patients presented profound sedation precluding CPT completion and one patient required mechanical ventilatory support. Patient tolerance was significantly better in the propofol group, whereas the operator's assessment was comparable in both groups. Compared with midazolam, propofol provided a higher quality of sedation in terms of neuropsychometric recovery and patient tolerance. BIS-guided propofol administration represents a safe sedation technique that can be performed by the non-anaesthesiologist.

Management of spontaneous pneumothorax: state of the art.

Spontaneous pneumothorax remains a significant health problem. However, with time, there have been improvements in pathogenesis, diagnostic procedures and both medical and surgical approaches to treatment. Owing to better imaging techniques, it is now clear that there is almost no normal visceral pleura in the case of spontaneous pneumothorax, and that blebs and bullae are not always the cause of pneumothorax. In first episodes of primary spontaneous pneumothorax, observation and simple aspiration are established first-line therapies, as proven by randomised controlled trials. Aspiration should be better promoted in daily medical practice. In the case of recurrent or persistent pneumothorax, simple talc poudrage under thoracoscopy has been shown to be safe, cost-effective and no more painful than a conservative treatment using a chest tube. There are also new experimental data showing that talc poudrage, as used in Europe, does not lead to serious side-effects and is currently the best available pleural sclerosing agent. Alternatively, surgical techniques have considerably improved, and are now less invasive, especially due to the development of video-assisted thoracoscopic surgery. Studies suggest that video-assisted thoracoscopic surgery may be more cost-effective than chest tube drainage in spontaneous pneumothorax requiring chest tube drainage, although it is more expensive than simple thoracoscopy and requires general anaesthesia, double-lumen tube intubation and ventilation. Recommendations are made regarding the treatment of pneumothorax. In secondary or complicated primary pneumothorax, i.e. recurrent or persistent pneumothorax, some diffuse treatment of the visceral pleura should be offered, either by talc poudrage under thoracoscopy or by video-assisted thoracoscopic surgery. Moreover, all of these new techniques should be better standardised to permit comparison in randomised controlled studies.

[Treatment of pulmonary diseases from the 20th to the 21st century]. / Traitement des maladies pulmonaires: du 20ème au 21ème siècle.

In the 21st century, the treatment of pulmonary diseases will undergo fundamental change. The treatment of patients in general and of pulmonary diseases in particular will transcend the vertical and fragmented approach based on analytical and reductionistic disease concepts to emphasize holistic care given by an interdisciplinary team. Extended life expectancies, understandably ones that represent significant progress in 20th century medicine, will lead to considerably higher costs in the healthcare system and to a redistribution of therapeutic resources. Healthcare centers will form that are better equipped to handle the true needs of the patients and provide better continuity of care. Likewise, this nascent century will bring forth one irreversible sociological change, namely the better informed and better educated patient who, by demanding access to medical information in order to profit from modern technological advances, will become an active partner of the healthcare professionals. The Swiss Lung League, which is celebrating its 100th anniversary this year, has been able to tackle the real pulmonological challenges of the 20th century by taking on a pioneering role in the fight against tuberculosis, smoking and setting benchmarks by providing patients with sophisticated respiratory technology like mechanical home ventilation. Unlike other medical disciplines, it recognized early on the importance of working within a healthcare network. Its strength derives from a synergy of the cantonal leagues' medical and social commitment and the Pulmonological Society's scientific support. Indeed, this trend can be observed all over Europe and the USA. This partnership is self-perpetuating and has adapted its own mentalities and structures to scientific progress and the changing needs of pulmonary patients.

Influence of thoracic epidural analgesia on cardiovascular autonomic control after thoracic surgery.

BACKGROUND: Thoracic epidural analgesia (TEA) is effective in alleviating pain after major thoracoabdominal surgery and may also reduce postoperative mortality and morbidity. This study investigated cardiovascular autonomic control in patients undergoing elective thoracic surgery and its modulation by continuous TEA. METHODS: Thirty-eight patients were randomly assigned to receive patient-controlled analgesia (PCA group) or thoracic epidural analgesia (TEA group) with doses of bupivacaine (0.25% during operation, 0.125% after operation) and fentanyl (2 microg ml(-1)). Heart rate variability (HRV), baroreflex function and pressure response to nitroglycerine and phenylephrine were assessed before operation, 4 h after the end of surgery (POD 0) and on the first and second postoperative days (POD 1 and POD 2). RESULTS: Early after surgery, all HRV variables and baroreflex sensitivities were markedly decreased in both groups. In the TEA group, total HRV and its high-frequency components (HF) increased towards preoperative values at POD 1 and POD 2, whereas the ratio of low to high frequencies (LF/HF) was significantly reduced (mean (SD), -44 (15)% at POD 0, -38 (17)% at POD 1, -37 (18%) at POD 2) and associated with blunting of the postoperative increase in heart rate and blood pressure. In the PCA group, the ratio of LF/HF remained unchanged and the decrements in HRV variables persisted until POD 2. In the two groups, baroreflex sensitivities and pressure responses recovered preoperative values at POD 2. CONCLUSIONS: In contrast with PCA management, TEA using low concentrations of bupivacaine and fentanyl blunted cardiac sympathetic neural drive, resulting in vagal predominance, while HRV variables were better restored after surgery.

Management of postpneumonectomy Aspergillus empyema extending into the thoracic wall: a plea for radical surgery and caution when using liposomal amphotericin B.

Semi-invasive aspergillosis is a rare disease leading to severe complications even in fully immunocompetent patients. The therapeutic role of systemic and intrapleural antifungal agents remains not well known. We report herein the case of a 54-year-old woman who developed Aspergillus empyema invading the thoracic wall and subcutaneous tissues after completion pneumonectomy for aspergilloma. She initially was treated conservatively with systemic and intrapleural amphotericin B without any success and developed a severe anaphylactic reaction to intravenous liposomal amphotericin B (Ambisome). She then underwent an open-window thoracotomy with intrathoracic transposition of a latissimus dorsi muscle flap and was started on itraconazole therapy. The thoracostomy was closed after 6 months and the patient is doing well without any signs of recurrent infection after 3 years.

Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study.

Simple thoracoscopic talcage (TT) is a safe and effective treatment of primary spontaneous pneumothorax (PSP). However, its efficacy has not previously been estimated in comparison with standard conservative therapy (pleural drainage (PD)). In this prospective randomised comparison of two well-established procedures of treating PSP requiring at least a chest tube, cost-effectiveness, safety and pain control was evaluated in 108 patients with PSP (61 TT and 47 PD). Patients in both groups had comparable clinical characteristics. Drainage and hospitalisation duration were similar in TT and PD patients. There were no complications in either group. The immediate success rate was different: after prolonged drainage (>7 days), 10 out of 47 PD patients, but only 1 out of 61 TT patients required a TT as a second procedure. Total costs of hospitalisation including any treatment procedure were not significantly different between TT and PD patients. Pain, measured daily by visual analogue scales, was statistically higher during the first 3 days in TT patients but not in those patients receiving opiates. One month after leaving hospital, there was no significant difference in residual pain or full working ability: 20 out of 58 (34%) versus 10 out of 47 (21%) and 36 out of 61 (59%) versus 26 out of 39 (67%) in TT versus PD groups, respectively. After 5 yrs of follow-up, there had been only three out of 59 (5%) recurrences of pneumothorax after TT, but 16 out of 47 (34%) after conservative treatment by PD. Cost calculation favoured TT pleurodesis especially with regard to recurrences. In conclusion, thoracoscopic talc pleurodesis under local anaesthesia is superior to conservative treatment by chest tube drainage in cases of primary spontaneous pneumothorax that fail simple aspiration, provided there is efficient control of pain by opioids.

Treatment of primary spontaneous pneumothorax by simple talcage under medical thoracoscopy.

Medical thoracoscopy under local anesthesia with simple talc poudrage is a safe and cost-effective technique to prevent recurrences in the case of primary spontaneous pneumothorax. Pathogenesis of primary spontaneous pneumothorax, i.e. a pneumothorax occurring without any underlying lung disease, remains unclear; there is no proof that the air leak leading to air escape into the visceral pleura is located in blebs or bullae visualized during the procedure. Therefore we do not have any evidence that blebs or small bullae cauterization or resection adds any further benefit to pleurodesis. Pulmonologists doing thoracoscopic talc pleurodesis should learn to better control pain due to thoracoscopic talcage as it has been shown that thoracoscopic talcage is not more painful than a chest tube drainage in patients providing they receive at least some opioids. There is also a debate on the best surgical approach to treat pneumothorax but minithoracotomy with pleurectomy remains the gold standard although more expensive and associated with some morbidity or mortality.

Management and outcome of patients undergoing thoracic surgery in a regional chest medical centre.

BACKGROUND AND OBJECTIVE: The main objective of this study was to assess mortality and morbidity after thoracic surgery in a medical centre, without resident chest surgeons and anaesthesiologists, and to determine specific risk factors. METHODS: A prospective cohort study using a local database which includes patients' clinical characteristics, results of preoperative investigations, surgical and anaesthesia data and all postoperative complications was undertaken. Two hundred and seventy-three consecutive patients undergoing thoracic surgery from 1992 to 1999 were studied. The referral chest medical centre was without resident thoracic surgeons or anaesthesiologists; postoperative care was led by local chest physicians according to standardized protocols and in close collaboration with university-based surgeons and anaesthesiologists. RESULTS: The majority of patients had lung cancer (71%) and underwent resection of at least one lobe (62%). Thirty-day mortality rate was 2.2% and one or more complications occurred in 74 patients (27%). Three patients had to be transferred to a university hospital for further treatment. Univariate predictors of complications included age (> 70 years), history of smoking, body mass index, as well as the extent and duration of surgery. After multiple logistic regression analysis, smoking (current or past), prolonged surgery (>120 min) and major lung resection (pneumonectomy or bilobectomy) remained the only independent risk factors. CONCLUSIONS: Overall perioperative mortality and morbidity rates did not exceed those reported from large teaching hospitals. In selected patients, thoracic surgery can be safely performed in a specialized chest medical centre without on-site surgeons and anaesthesiologists.

Perioperative medical management and outcome following thymectomy for myasthenia gravis.

PURPOSE: To describe the evolution of the perioperative management of myasthenia gravis (MG) patients undergoing thymectomy and to question the need for systematic postoperative ventilation. CLINICAL FEATURES: We collected data retrospectively from 36 consecutive MG patients who underwent thymectomy over a 21-yr period, via transthoracic, -cervical or -sternal incisions (n=5, n=7, n=24, respectively). From 1980 to 1993, a balanced anesthetic technique (n=24) included various inhalational agents with opiates and myorelaxants (in eight cases); 22 patients were admitted to the intensive care unit (ICU). Since 1994, i.v. propofol was combined with epidural bupivacaine and sufentanil (n=12); all patients were admitted to the postanesthesia care unit. Short-term postoperative ventilation (median time four hours, range from three to 48 hr) was required in eight patients who had longer hospital stay (median stay=12 days, range (8-28) vs five days (4-15) for patients with early extubation, P <0.05) but similar clinical improvement six months after thymectomy. Postoperative ventilatory support was required more frequently when a balanced anesthetic technique was used (odds ratio=4.2 (1.1-9.7), P=0.03) and particularly when myorelaxants were given (odds ratio=13.9 (2.1-89.8), P=0.009). Leventhal's scoring system had low sensitivity (22.2%) and positive predictive values (25%). CONCLUSIONS: Our data show that the severity of MG failed to predict the need for postoperative ventilation. A combined anesthetic technique was a safe and cost-effective alternative to balanced anesthesia as it provided optimal operating conditions and resulted in fewer admissions in ICU and shorter hospital stays.

Exercise capacity and extent of resection as predictors of surgical risk in lung cancer.

Lung resection remains the most effective treatment for non-small cell lung cancer (NSCLC). However, there is no consensus about reliable operative risk assessment in these patients. The aim of this study was to identify predictors of postoperative complications and death after lung resection for NSCLC. In this prospective trial, 125 of 142 (88%) consecutive NSCLC patients from 1990 to August 1997 had complete data sets. All underwent functional assessment including spirometry and cardiopulmonary exercise tests and lung resection via thoracotomy. Complications occurred in 31 of 125 (25%) patients including 2 (1.6%) deaths. On logistic regression analysis, only maximal oxygen uptake (V'O2,max) x kg body weight(-1) expressed as a percentage of the predicted value (p<0.0001) and the estimated extent of lung tissue resection (p=0.02) were independent predictors of postoperative complications. Six of seven patients with a V'O2,max x kg body weight(-1) of <60% pred, but only eight of 65 with values >90% pred, exhibited postoperative complications. Maximal oxygen uptake and the estimated extent of lung tissue resection are independent predictors of postoperative complications. These simple parameters should be integrated into the preoperative decision analysis for operability in patients undergoing lung resection for lung cancer.