Preoperative inhalation therapy for patients with chronic obstructive pulmonary disease undergoing lung surgery: a retrospective study.

BACKGROUND: Research shows that even the short-term administration of inhaled drugs immediately before surgery can improve respiratory function in surgical candidates with chronic obstructive pulmonary disease (COPD). However, the long-term efficacies of different types of long-acting inhaled agents when used during a short preoperative period remain unclear. Therefore, we evaluated the efficacies of short-term, preoperative long-acting muscarinic antagonists (LAMAs), inhaled corticosteroids with long-acting ß2-agonists (ICSs/LABAs), and long-acting muscarinic antagonists with long-acting ß2-agonists (LAMAs/LABAs) in patients with COPD after lung resection. METHODS: Patients who underwent anatomical lung resections between April 2010 and March 2020 were divided into the non-COPD (193 patients) and COPD (241 patients) groups. The COPD group underwent preoperative treatment with either a LAMA (51 patients), an ICS/LABA (112 patients), or a LAMA/LABA (78 patients) for almost 1 month, with pulmonary function tests performed initially, just before surgery, and at 1 and 6 months after surgery. Improvement in preoperative respiratory function by inhalation therapy and the maintenance of improvement in respiratory function after surgery were examined in each group. RESULTS: The COPD group had significantly higher proportions of men, older patients, smokers, and histopathologic types except for adenocarcinoma than the non-COPD group; however, there were neither differences in sex, age, percentage of smokers, or histopathologic type among the inhalant groups within the COPD group nor were there differences in percentage of GOLD stage, preoperative inhalation period, or percentage of resected lobes in lobectomy. Preoperative increases in forced expiratory volume in 1.0 s (FEV1.0) were significantly higher in the COPD group (129.07 ± 11.29 mL) than in the non-COPD group (-2.32 ± 12.93 mL) (p < 0.0001). At 6 months, there was no significant difference in residual FEV1.0 between the COPD-LAMA/LABA (2017.46 ± 62.43 mL) and non-COPD groups (2046.93 ± 40.53 mL). The FEV1.0 reduction rate was more suppressed in the COPD-LAMA/LABA group than in the non-COPD group at 1 and 6 months after surgery. CONCLUSIONS: Short-term, preoperative, inhaled pharmacotherapies, particularly LAMAs/LABAs, were effective at improving respiratory function in patients with COPD; thus, these agents are recommended for use in this population.

Evaluation of bronchoscopic lung volume reduction coil treatment results in patients with severe emphysema.

INTRODUCTION: Bronchoscopic lung volume reduction coil (BLVR-C) implantation is an alternative therapeutic approach that can be applied together with medical treatment for patients with severe emphysema. BLVR-C is both easier and safer in terms of complications than volume reduction surgery. This study aimed to evaluate medium-term outcomes following BLVR-C treatment. METHODS: Forty patients who underwent BLVR-C between September 2013 and March 2014 were reviewed retrospectively. We compared changes between the baseline and 6-month post-procedural results with respect to pulmonary function tests, a 6-min walk test (6MWT), chronic obstructive pulmonary disease (COPD) assessment test (CAT), St. George's Respiratory Questionnaire (SGRQ), and pulmonary artery pressure (PAP) and arterial blood gas analyses. Secondary outcomes included procedure-related and follow-up complications. RESULTS: An average of 9.5 (range: 5-11) coils were placed per lung in an average procedural duration of 20.8 ± 7.0 min (range: 9-45) min. Six months after BLVR-C treatment, significant improvements were observed in patients' pulmonary function tests and quality of life. Changes were observed in the forced exhalation volume in 1 s (+150 mL), residual volume (-14.5%), 6MWT (+48 m), SGRQ (-10.5) and CAT Score (-7.5). Changes in the PAP and partial pressure of carbon dioxide values were not significant, and pneumothorax did not occur. In a 6-month follow-up, 11 cases of COPD exacerbation (41.4%), 7 cases of pneumonia (16.9%) and 1 death (2%) occurred. Treatment in 1 case was postponed because of hypotension and bradycardia during the process. CONCLUSION: BLVR-C treatment appears to be effective over the medium-term and safe for patients with severe emphysema.

Risk stratification by the lower limit of normal of FEV1/FVC for postoperative outcomes in patients with COPD undergoing thoracic surgery.

BACKGROUND: Mounting evidence suggests that airway obstruction defined by the lower limit of normal (LLN) of forced expiration volume in 1s (FEV1)/forced vital capacity (FVC) might be an important predictor of mortality in patients with an FEV1/FVC ratio below 0.70. Although better risk stratification for postoperative outcomes in patients with chronic obstructive pulmonary disease (COPD) undergoing thoracic surgery is warranted, whether an FEV1/FVC ratio below 0.70 but above the LLN (i.e., in-between) could identify patients at risk for adverse postoperative outcomes has not been fully evaluated. METHODS: To determine the clinical impact of this "in-between" group of patients with COPD, we evaluated whether classification of the in-between group and the COPD group with FEV1/FVC ratios below 0.70 and below the LLN could provide more accurate risk stratification for postoperative outcomes in COPD patients undergoing thoracic surgery. RESULTS: The criterion of LLN classified 302 patients with an FEV1/FVC ratio below 0.70 into either the in-between group (124 cases) or the COPD group (178 cases). The COPD group showed a 3-fold increase in prolonged oxygen therapy (POT) and a 50% increase in prolonged postoperative stay (PPS), as compared with the in-between group, with an adjusted odds ratio of 3.068 (95% confidence interval: 1.806-5.213) for POT. CONCLUSIONS: Based on the finding that the in-between group could independently identify patients at risk for adverse postoperative outcomes, LLN assessment of the FEV1/FVC ratio might provide more accurate risk stratification in COPD patients undergoing thoracic surgery.

Preoperative pulmonary rehabilitation in patients with lung cancer and chronic obstructive pulmonary disease.

OBJECTIVES: Impaired cardiopulmonary reserve is the main cause of inoperability in non-small-cell lung cancer (NSCLC). This study aims to evaluate the role of a preoperative pulmonary rehabilitation (PPR) programme in the improvement of functional parameters, which can enable an increase in the number of patients eligible for surgery. METHODS: From January 2008 to June 2011, we observed a uniform group of 27 patients with NSCLC and chronic obstructive pulmonary disease (COPD). It showed: (i) a body mass index of 21.5 ± 2 kg/m2;; (ii) forced expiratory volume in 1 s (FEV(1)) of 1.14 ± 0.7 l; (iii) maximal peak of oxygen consumption (VO(2)max) of 12.9 ± 1.8 ml/kg/min; (iv) carbon monoxide diffusing capacity (DLCO) of 72 ± 3% predicted; (v) stage IB of lung cancer. All patients underwent a 4-week PPR programme, 6 days a week and were re-evaluated before inclusion for surgery. RESULTS: The rehabilitation programme was completed by all patients and extended by 2 weeks in nine patients, in order to obtain a further functional improvement. A statistically significant increase has been in the values of PaO(2) (60 ± 10 vs 82 ± 12 mmHg), of VO(2)max (12.9 ± 1.8 vs 19.2 ± 2.1 ml/kg/min, P = 0.00001) and of FEV(1) (1.14 ± 0.7 vs 1.65 ± 0.8 l, P = 0.02). All patients underwent a lobectomy, with a postoperative morbidity of 15%. CONCLUSIONS: A 4 to 6-week PPR programme prepares the NSCLC and COPD patients properly for the surgical approach, reducing the functional limitations of inoperability.

[Bronchoscopic autologous blood injection for lung volume reduction].

Bronchoscopic lung volume reduction (BLVR) for emphysematous lung diseases has attracted clinical attention. We evaluated the newly developed procedure of BLVR performed by transbronchial infusion of autologous blood. The subjects were 4 patients with a mean age of 57 years with emphysematous lung diseases, consisting of 1 with emphysematous bulla, 1 with lymphangioleiomyomatosis and 2 with advanced emphysema. Informed consent was obtained from all patients, and the Institutional Review Board of Ethics approved the treatment protocol. Intervention was performed as follows: A catheter was inserted into the target area through a flexible bronchoscope under fluoroscopic guidance, and autologous blood followed by thrombin solution was infused via the catheter. This simple procedure was repeated to several different areas as necessary. This BLVR therapy was well tolerated in all 4 patients. There were no severe complications. Symptomatic improvement was noted in all patients. Spirometry showed a mean increase in FVC from 2.68 to 2.75L and FEV1 from 1.10 to 1.25 L, whereas body plethysmography showed a mean reduction in FRC from 5.09 to 4.75L and TLC from 7.18 to 6.80 L. No consistent change in D(Lco)/VA was observed. Arterial blood gas value and the 6-minute walk distance improved in 3 and 2 patients, respectively. This bronchoscopic approach is minimally invasive, easy and inexpensive. BLVR by injection of autologous blood appears to represent a good therapeutic option, and warrants further investigation.

Long-term beneficial effects of lung volume reduction surgery on quality of life in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation, which results in exertional dyspnea and physical disability. Subsequently, those cause a difficulty in performing routine activities of daily living and affect their health-related quality of life (HRQOL). Lung volume reduction surgery (LVRS) has been reported to be an effective treatment for selected patients with advanced COPD to improve pulmonary function, lung mechanics, exercise tolerance, and dyspnea. However, the long-term effects of LVRS on HRQOL have not been fully investigated. Therefore the effects of LVRS on generic and disease-specific HRQOL were assessed in patients with COPD following LVRS for 36 months. Nineteen patients (65.1 +/- 7.0 [mean +/- S.D.] years old) who underwent pulmonary rehabilitation plus LVRS (LVRS group), and 8 patients (67.2 +/- 5.8 years old) who did pulmonary rehabilitation but not LVRS (Medical group) were studied. In both groups, optimal medication was given throughout this period. Generic HRQOL and disease-specific HRQOL were evaluated before rehabilitation, and 3, 12, 24, and 36 months after LVRS. Following LVRS, the generic HRQOL was significantly improved and the disease-specific HRQOL was maintained up to 36 months. In Medical group, disease-specific HRQOL rapidly deteriorated. In conclusion, the long-term effects of LVRS on HRQOL in COPD patients were maintained up to 36 months compared with Medical group. Both generic and disease-specific HRQOL changed differently, suggesting the importance of both assessments especially in long-term follow up.

[COPD-nonpharmacological treatment]. / COPD-nichtmedikamentöse Therapie.

The modern concept of chronic obstructive pulmonary disease (COPD) goes far beyond pure medical therapy. Solely treating obstruction and inflammation of the airways does not correspond to the complexity of this illness which now is considered a systemic disease. Therapeutic planning comprises prevention, early physiotherapy and physical training, educational measures, and, in advanced stages, long-term oxygen therapy, mechanical support of the ventilatory muscular system by noninvasive ventilation and surgical measures. To stop smoking is the most important preventive measure which succeeds in up to 40% when carried through consequently. COPD will eventually lead to a steadily decreasing cardiopulmonary performance. Physical training therefore is of utmost importance. Physical training will be accompanied by ventilatory and physiotherapy, a sophisticated dietary treatment, as well as education and motivation of the patient in order to develop competence in self-management. Further treatments in advanced stages consist of long-term oxygen therapy and intermittent noninvasive ventilation. The latter is the treatment of choice for acute respiratory insufficiency. Operative treatments like lung volume reduction and lung transplantation are only indicated in selected cases.

Pulmonary rehabilitation and COPD.

Pulmonary rehabilitation has been well established and increasingly recommended in disease management plans for patients with chronic obstructive pulmonary disease. Key elements include a multidisciplinary approach to care, focus on the individual patient, and attention to emotional and social as well as physical aspects of health. Appropriate candidates are symptomatic patients with chronic lung disease who are aware of their disability and motivated to participate actively in their own health care. Pulmonary rehabilitation has also been useful for patients with other types of chronic lung diseases. Program components include a careful patient evaluation, education, instruction in respiratory and chest physiotherapy techniques, exercise training, and psychosocial support. Benefits demonstrated in a growing body of evidence include improvement in symptoms, exercise tolerance, and quality of life and reduction in utilization of health care resources. Pulmonary rehabilitation has also been included as an adjunct to surgical programs such as lung transplantation and lung volume reduction surgery.

The energy intake that is needed for weight gain in COPD candidates for lung transplantation.

Many patients with chronic obstructive pulmonary disease (COPD) have increased resting energy expenditure (REE) and may have an increased need for energy during activity. However, in terms of total energy balance, the influence of differences in REE may be compensated for by differences in daily energy expenditure. Energy needs may therefore be difficult to predict by measuring REE. The aim of this study was to predict the energy intake necessary for weight gain following dietary counselling. We studied 42 COPD patients (n = 27 underweight, n = 15 normal-weight) who were being considered for lung transplantation and had completed an intervention lasting a mean of 22 weeks. In the underweight patients, the dietary intervention consisted of dietary counselling for weight gain, while, in the normal-weight patients it focused on weight maintenance. It has been shown that a weight gain of over 2 kg in patients with COPD improves the prognosis and this was obtained in 52% of our patients. The mean (SD) increase in energy intake in the responders was 3448 (1310) kJ, while it was 635 (2454) kJ, p < 0.01 in the non-responders. Patients who used or had free access to nutritional supplements did not show greater success than patients who only used ordinary foods. Based on the relationship between the dependent variable (kg weight change) and the independent variable (energy intake), we can use linear regression to predict that an energy intake of 180% of REE predicted or 186 kJ/kg (44 kcal/kg) is necessary to obtain a weight gain of 2 kg.