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Rationale: Nontuberculous mycobacteria (NTM) are prevalent among patients with bronchiectasis. However, the long-term natural history of patients with NTM and bronchiectasis is not well described. Objectives: To assess the impact of NTM on 5-year clinical outcomes and mortality in patients with bronchiectasis. Methods: Patients in the Bronchiectasis and NTM Research Registry with ⩾5 years of follow-up were eligible. Data were collected for all-cause mortality, lung function, exacerbations, hospitalizations, and disease severity. Outcomes were compared between patients with and without NTM at baseline. Mortality was assessed using Cox proportional hazards models and the log-rank test. Measurements and Main Results: In total, 2,634 patients were included: 1,549 (58.8%) with and 1,085 (41.2%) without NTM at baseline. All-cause mortality (95% confidence interval) at Year 5 was 12.1% (10.5%, 13.7%) overall, 12.6% (10.5%, 14.8%) in patients with NTM, and 11.5% (9.0%, 13.9%) in patients without NTM. Independent predictors of 5-year mortality were baseline FEV1 percent predicted, age, hospitalization within 2 years before baseline, body mass index, and sex (all P < 0.01). The probabilities of acquiring NTM or Pseudomonas aeruginosa were approximately 4% and 3% per year, respectively. Spirometry, exacerbations, and hospitalizations were similar, regardless of NTM status, except that annual exacerbations were lower in patients with NTM (P < 0.05). Conclusions: Outcomes, including exacerbations, hospitalizations, rate of loss of lung function, and mortality rate, were similar across 5 years in patients with bronchiectasis with or without NTM.
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Bronquiectasia , Infecciones por Mycobacterium no Tuberculosas , Sistema de Registros , Humanos , Bronquiectasia/mortalidad , Bronquiectasia/fisiopatología , Bronquiectasia/epidemiología , Masculino , Femenino , Persona de Mediana Edad , Anciano , Infecciones por Mycobacterium no Tuberculosas/mortalidad , Infecciones por Mycobacterium no Tuberculosas/epidemiología , Estados Unidos/epidemiología , Hospitalización/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Micobacterias no Tuberculosas , Progresión de la EnfermedadRESUMEN
BACKGROUND AND OBJECTIVE: Currently, computed tomography-guided transthoracic biopsy (CTTB) is the most accurate diagnostic approach for pulmonary nodules suspected of malignancy. Traditional bronchoscopy has shown suboptimal diagnostic sensitivity, but the emergence of robotic-assisted bronchoscopy (RAB) has the potential to improve diagnostic accuracy, maximize diagnostic yield and complete mediastinal and hilar staging in a single procedure. We aim to assess the efficacy and diagnostic performance of RAB compared to CTTB for diagnosing pulmonary nodules suspected of lung cancer. METHODS: A multicenter retrospective review of consecutive patients who underwent RAB and CTTB for evaluating pulmonary nodules from January 2019 to March 2021 at Mayo Clinic Florida and Mayo Clinic Rochester, United States. Clinical and demographic information, nodule characteristics, outcomes and complications were compared between RAB and CTTB. RESULTS: A total of 225 patients were included: 113 in the RAB group and 112 in the CTTB group. Overall diagnostic yield was 87.6% for RAB and 88.4% for CTTB. For malignant disease, RAB had a sensitivity of 82.1% and a specificity of 100%, CTTB had a sensitivity of 88.5% and a specificity of 100%. Complication rate was significantly higher for CTTB compared to RAB (17% vs. 4.4%; p = 0.002). CONCLUSION: RAB, when available, can be as accurate as CTTB for sampling pulmonary nodules with similar or reduced complications and should be considered as a means for nodule biopsy, particularly when mediastinal staging is also clinically warranted.
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Neoplasias Pulmonares , Nódulos Pulmonares Múltiples , Procedimientos Quirúrgicos Robotizados , Nódulo Pulmonar Solitario , Humanos , Broncoscopía/métodos , Nódulos Pulmonares Múltiples/diagnóstico por imagen , Nódulos Pulmonares Múltiples/patología , Biopsia Guiada por Imagen/métodos , Tomografía Computarizada por Rayos X/métodos , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/patología , Estudios Retrospectivos , Nódulo Pulmonar Solitario/diagnóstico por imagen , Nódulo Pulmonar Solitario/patología , Pulmón/diagnóstico por imagen , Pulmón/patologíaRESUMEN
Bronchoscopic biopsy of peripheral pulmonary nodules has evolved in recent years with the emergence of new technologies such as shape-sensing robotic-assisted bronchoscopy. The use of three-dimensional (3D) fluoroscopy for intraoperative visualization of the biopsy tool in relation to the target nodule aims to overcome computed tomography-to-body divergence encountered during the procedure and allows for more accurate sampling to improve adequacy and diagnostic performance. Until recently, the robotic-assisted navigation plan and 3D imaging function as separate systems. We present a case where intraoperative 3D fluoroscopy images were integrated to the robotic bronchoscopy navigation system, resulting in a single, dynamic, real-time 3D virtual plan showing readjusted paths toward the lesion displayed in the robotic bronchoscopy navigation system, allowing in this case, biopsying two bilateral pulmonary nodules, resulting in different diagnosis within the same endoscopic procedure.
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Neoplasias Pulmonares , Nódulos Pulmonares Múltiples , Procedimientos Quirúrgicos Robotizados , Humanos , Broncoscopía/métodos , Nódulos Pulmonares Múltiples/diagnóstico por imagen , Nódulos Pulmonares Múltiples/cirugía , Tomografía Computarizada por Rayos X , Fluoroscopía/métodos , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/cirugíaRESUMEN
BACKGROUND: Pulmonary nodules in elderly patients are commonly encountered in clinical practice. Tissue sampling with image guided transthoracic needle aspiration is often performed but may be complicated by pneumothorax or bleeding. To understand the outcomes of transthoracic needle aspiration in the elderly, we retrospectively reviewed outcomes of patients age 75 or greater in a single tertiary center. METHODS: Four-hundred eleven patients age 75 or greater with a pulmonary nodule identified on computed tomography who underwent needle aspiration of the lung were studied. Diagnostic yield and procedural complications were assessed for each patient and subgroups analysis of those age 85 or greater was performed. RESULTS: Malignancy was confirmed in 70% of subjects and a benign diagnosis identified in 9%. Of the 411 patents, 203 (49.4%) experienced a complication; 150 patients (36.5%) developed a pneumothorax and 79 (19.2%) had bleeding. No patient required transfusion, experienced persistent air leak or massive hemoptysis, air embolism or death. Post procedural hospitalization was required in 36 patients (8.8%) with a median hospital stay of 2 days. No factors were identified to be associated with occurrence of a complication (all p ≥ 0.16) and complications were not increased in those 85 or greater. CONCLUSION: Our results suggest that in an elderly population, image guided needle aspiration of a pulmonary nodule provides diagnostic findings in most patients. Procedural complications following are not uncommon but the severity and long-term impact are limited. The occurrence of complications is similar in those age 75-84 and age 85 and older.
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Biopsia con Aguja/efectos adversos , Neoplasias Pulmonares/patología , Complicaciones Posoperatorias/epidemiología , Nódulo Pulmonar Solitario/patología , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: A history of penicillin allergy is associated with an increased risk of nosocomial infections because patients are exposed to non-beta lactam antibiotics. Ruling out inaccurate penicillin allergy during hospitalization decreases prescription of beta lactam antibiotics. However, the utilization of penicillin allergy testing and timeliness in relation to initiation of antibiotics is not known. OBJECTIVE: Our aim was to describe the proportion and characteristics of patients who underwent inpatient penicillin allergy testing in a hospital without a guideline or infrastructure for inpatient penicillin allergy testing. METHODS: We performed a retrospective chart review of patients admitted to our institution between January 1, 2008, and December 31, 2015, who underwent penicillin allergy testing. RESULTS: Forty-nine patients were identified; 27 (55.1%) were women. The median age was 61.5 years (interquartile range [IQR], 48.5-71 years). The median Charlson-Comorbidity index score was 4 (IQR, 2-5.5). Of these patients, 42.86% (21) were admitted to the intensive care unit, 79.6% of allergy consults were requested by infectious disease physicians, and 87.8% of patients were receiving non-beta lactam antibiotics at the time of testing. The patients received a median of 5 days of antibiotics before testing (range, 0-16 days; IQR, 3-7 days). Antimicrobial therapy was changed in 78.0% of the patients (32), of whom 68.3% (21/32) was attributable to penicillin allergy testing. CONCLUSION: Inpatient penicillin allergy testing is a critical component of antibiotic stewardship; however, an adequate infrastructure is essential for timely evaluation. Inpatient penicillin allergy evaluation requires a multidisciplinary approach focused on patient selection; risk stratification; and optimization of a timely, safe, and cost-effective approach to optimize patient outcomes.
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Hipersensibilidad a las Drogas/epidemiología , Pacientes Internos , Monitoreo Fisiológico/estadística & datos numéricos , Anciano , Alérgenos/inmunología , Hipersensibilidad a las Drogas/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Penicilinas/inmunología , Pautas de la Práctica en Medicina , Calidad de la Atención de Salud , Estudios Retrospectivos , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: CD4 count at start of combination antiretroviral therapy (ART) is strongly associated with short-term survival, but its association with longer-term survival is less well characterized. METHODS: We estimated mortality rates (MRs) by time since start of ART (<0.5, 0.5-0.9, 1-2.9, 3-4.9, 5-9.9, and ≥10 years) among patients from 18 European and North American cohorts who started ART during 1996-2001. Piecewise exponential models stratified by cohort were used to estimate crude and adjusted (for sex, age, transmission risk, period of starting ART [1996-1997, 1998-1999, 2000-2001], and AIDS and human immunodeficiency virus type 1 RNA at baseline) mortality rate ratios (MRRs) by CD4 count at start of ART (0-49, 50-99, 100-199, 200-349, 350-499, ≥500 cells/µL) overall and separately according to time since start of ART. RESULTS: A total of 6344 of 37 496 patients died during 359 219 years of follow-up. The MR per 1000 person-years was 32.8 (95% confidence interval [CI], 30.2-35.5) during the first 6 months, declining to 16.0 (95% CI, 15.4-16.8) during 5-9.9 years and 14.2 (95% CI, 13.3-15.1) after 10 years' duration of ART. During the first year of ART, there was a strong inverse association of CD4 count at start of ART with mortality. This diminished over the next 4 years. The adjusted MRR per CD4 group was 0.97 (95% CI, .94-1.00; P = .054) and 1.02 (95% CI, .98-1.07; P = .32) among patients followed for 5-9.9 and ≥10 years, respectively. CONCLUSIONS: After surviving 5 years of ART, the mortality of patients who started ART with low baseline CD4 count converged with mortality of patients with intermediate and high baseline CD4 counts.
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Antirretrovirales/uso terapéutico , Recuento de Linfocito CD4 , Infecciones por VIH/inmunología , Infecciones por VIH/mortalidad , Adolescente , Adulto , Estudios de Cohortes , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/epidemiología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Adulto JovenRESUMEN
OBJECTIVE: The objective of our study was to define the prevalence of osteoporosis and osteopenia in patients with noncystic fibrosis bronchiectasis (NCFB). METHODS: We conducted a retrospective chart review of all patients with physician-diagnosed NCFB evaluated at Mayo Clinic Florida between January 1, 2011 and June 3, 2013. RESULTS: A total of 113 patients with physician-diagnosed NCFB and confirmatory findings on computed tomography scan were identified. The cohort was overwhelmingly women (90%) with a mean age of 72 ± 10.6 and a body mass index of 24.8 ± 6.8. The medical history indicated that 30% (34) had osteoporosis, 39% (44) had osteopenia, and 9% (10) had normal bone density. In 25 (22%) of the subjects, bone density was unknown or undocumented. Most were never smokers (55.7%) or past smokers (41.6%) and airflow obstruction was present in 58% of the 84 subjects who had undergone pulmonary function tests. In total, 57 patients (50.44%) and 45 patients (39.82%) had been prescribed proton pump inhibitors and inhaled corticosteroids, respectively. Bone mineral density testing was performed during the study period in 70 (62%) of the subjects. Decreased bone density consistent with osteoporosis was present in 19 (27%); 41 (59%) had osteopenia, and bone density was normal in 10 (14%) subjects. Diminished bone density was present in 82.8% (24/29) of patients younger than age 70, with 27.6% (8/29) having osteoporosis. There was a greater incidence of diminished bone density in those with reduced body mass index (100% vs 82%), but this difference did not reach statistical significance (P = 0.10). Forty-seven and 32% of patients with diminished bone density were using proton pump inhibitor therapy and inhaled corticosteroids, respectively. CONCLUSIONS: This study suggested that diminished bone density is common in patients with bronchiectasis, with >85% of this cohort having osteoporosis or osteopenia confirmed by bone density testing. Although the prevalence of both bronchiectasis and diminished bone density increases with advancing age and female sex, these data suggest a greater prevalence than expected based on demographic risks. Medications that may predispose individuals to diminished bone density are not uncommonly prescribed in patients with bronchiectasis. Provider awareness of the substantial prevalence of diminished bone density in patients with bronchiectasis may improve patient care by prompting appropriate screening for and treatment of osteoporosis and osteopenia. In light of these observations, judicious use of medications that may predispose to diminished bone density is warranted.
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Enfermedades Óseas Metabólicas/epidemiología , Bronquiectasia/complicaciones , Osteoporosis/epidemiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Índice de Masa Corporal , Densidad Ósea , Enfermedades Óseas Metabólicas/etiología , Bronquiectasia/fisiopatología , Femenino , Florida/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Osteoporosis/etiología , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Factores SexualesRESUMEN
Non-cystic fibrosis bronchiectasis is a chronic inflammatory airway disease that results in permanent lung damage and can correlate with considerable clinical and economic burden. There are gaps in knowledge surrounding bronchiectasis, for which there are no published US-based treatment guidelines or FDA-approved therapies. Given the current challenges and gaps in care, the authors of this article convened for an AJMC® roundtable in March 2024. This publication summarizes the main findings of that roundtable and situates them in a scholarly context. Panelists agreed that patients with unexplained chronic cough or fatigue, purulent sputum production, hemoptysis, or repeated infection should undergo CT scanning to assess the presence of bronchiectasis, which has been estimated to affect approximately 364,000 to 558,000 individuals at least 18 years of age. They noted that disease symptoms and treatment burden can considerably diminish patient health-related quality of life (HRQOL) and that an exacerbation uniformly signifies deteriorating health and substantially impacts disease progression, hospitalization rates, and mortality. Absent an FDA-approved therapy, panelists' top management priorities were preventing or reducing exacerbations and maintaining or improving HRQOL. Panelists concluded that providers are ill-equipped to change the course of this heterogenous disease and that there is a real need for options to manage symptoms, for US-based guidelines, and for more research into epidemiology, etiology, and treatment.
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Bronquiectasia , Calidad de Vida , Bronquiectasia/terapia , Bronquiectasia/tratamiento farmacológico , Humanos , Progresión de la Enfermedad , Tomografía Computarizada por Rayos XRESUMEN
Expiratory central airway collapse (ECAC) comprising excessive central airway collapse (EDAC) and tracheobronchomalacia. Treatment is challenging for severe cases that are not candidates for surgical management. We report a case of severe ECAC successfully managed with continuous positive airway pressure (CPAP) therapy. A 75-year-old female patient status post right pneumonectomy, presented with chronic cough. Dynamic bronchoscopy evaluation showed severe EDAC which improved with intraprocedural noninvasive positive pressure (NIPPV) therapy. Due to patients' comorbidities, she was not a candidate to surgical tracheobronchoplasty. Therefore, we attempted pneumatic stenting with long-term CPAP therapy resulting in improvement of symptoms and functional capacity. The long-term efficacy of pneumatic stenting has not been clearly established yet. Literature review of management of ECAC with NIPPV consist primarily of case reports and there is only one clinical trial being conducted to assess the efficacy of CPAP therapy in ECAC. While NIPPV arises as a sufficient alternative for management of severe ECAC, larger scale studies are needed to prove the real efficacy of NIPPV in this setting.
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Despite available technology and supportive evidence in the literature, the integration of telemedicine interventions in the US health care system has remained sluggish for decades. The COVID-19 pandemic catalyzed widespread utilization of virtual visits and remote monitoring in urgent, primary, and specialist care settings out of sheer necessity. Specifically, in the rheumatology subspecialty, a lack of available providers and a patient community hindered by mobility and access issues have underscored the value of telemedicine. For these reasons, a solutions-focused, multistakeholder virtual roundtable meeting convened by the Frances Hamburger Institute for Community Rheumatology (FHI) identified telemedicine as a critical area for intervention to improve the quality and cost-effectiveness of patient-centered care. Building upon stakeholder experience and published findings, the Patient-Centered Rheumatology Collaborative identified the continued deregulation of policy barriers and the facilitation of sustainable coverage and reimbursement as critical steps toward establishing a robust infrastructure for telemedicine post pandemic. FHI roundtable attendees acknowledged several remaining telemedicine access barriers concerning traditionally underserved patient populations that will need to be addressed to realize the full potential of telemedicine. These recommendations are in concordance with those of other recent consensus groups, and they legitimize the formation of collaborative frameworks among payers, providers, and other key stakeholders to advance care in rheumatology.
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COVID-19 , Telemedicina , Humanos , COVID-19/epidemiología , Pandemias , Atención a la Salud , Área sin Atención MédicaRESUMEN
Robotic-assisted bronchoscopy (RAB) improves endoscopic diagnostic yield of solitary pulmonary nodules (SPN). Needle-based confocal laser endomicroscopy (nCLE) is an emerging technology that allows high-resolution, in-vivo, real-time assessment of living tissues at a cellular and subcellular level. Their combined use has been scarcely reported. We used them simultaneously in three patients with SPNs. For each, the nodule was evaluated with nCLE and sampled for pathology, followed by mediastinal staging. Median age was 77 years (67% male). Median nodule minimum size was 1.8 cm and maximum was 2.1 cm. nCLE detected abnormal patterns suggestive of malignancy for all nodules and pathology confirmed primary lung adenocarcinomas in two patients and lung primary squamous cell carcinoma in the other. The combined use of RAB with nCLE may potentially enhance the differentiation of malignant cells in real-time and increase sample adequacy, accuracy, and diagnostic yield when biopsying a suspicious pulmonary lesion.
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Common respiratory symptoms, including dyspnea, cough, sputum production, and recurrent infections, frequently remain without a clear cause and may be the result of expiratory central airway collapse (ECAC). Establishing the diagnosis and appropriate treatment plan for patients with ECAC is challenging and benefits from a multidisciplinary approach. A coordinator role is crucial in this process to ensure optimal patient-centered outcomes. We describe the coordination of care in the process of diagnosing and treating ECAC. The coordinator leads the organization of the multiple services involved in the care of patients with ECAC, including pulmonary medicine, interventional pulmonology, radiology, and thoracic surgery, as well as hospital inpatient staff. From initial screening to evaluation and management with airway stents and corrective treatment with tracheobronchoplasty, the ECAC coordinator oversees the entire process of care for patients with ECAC.
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Obstrucción de las Vías Aéreas , Traqueobroncomalacia , Humanos , Traqueobroncomalacia/diagnóstico , Traqueobroncomalacia/terapia , Sistema Respiratorio , Espiración , Stents , Disnea , Broncoscopía , Obstrucción de las Vías Aéreas/diagnósticoRESUMEN
BACKGROUND: Nebulized drug delivery is a cornerstone of therapy for obstructive lung disease, but the ideal nebulizer design is uncertain. The breath-actuated nebulizer (BAN) may be superior to conventional nebulizers. This study compared the BAN to standard nebulizer with regard to efficacy, safety, and patient and respiratory therapist (RT) satisfaction. METHODS: Adults admitted to the hospital and for whom nebulizer therapy was prescribed were enrolled. Subjects were randomly assigned to either AeroEclipse II or standard nebulizer and were surveyed at the completion of each treatment. BAN delivered albuterol 2.5 mg or albuterol 2.5 mg plus ipratropium 0.25 mg. Standard nebulizer delivered albuterol 2.5 mg or albuterol plus ipratropium 0.5 mg. An RT assessed each subject's heart rate, respiratory rate, and peak expiratory flow rate prior to and following treatment. Treatment time and adverse events were recorded. Each RT was asked to assess his/her satisfaction with each of the nebulizers. RESULTS: Twenty-eight subjects were studied. The mean age was 69 years. Fifty-four percent of the subjects indicated that overall the BAN was superior to conventional nebulizer therapy; 68% indicated that duration was preferable with the BAN. RTs were more satisfied with the BAN, based on overall performance, treatment duration, and ease of use. There were no significant differences in heart rate, peak expiratory flow rate, or respiratory rate before or after nebulization therapy with either device. The duration of treatment was significantly lower with the BAN (4.1 min vs 9.9 min, P < .001). Additionally, the BAN was associated with a lower occurrence of adverse events. CONCLUSIONS: Patients and RTs expressed greater satisfaction with the BAN, compared with standard nebulizer. Pre- and post-treatment vital signs did not differ between groups, but use of the BAN was associated with a shorter duration and a lower occurrence of adverse events. Taken together, these data support the use of the BAN for nebulized medication delivery.
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Albuterol/administración & dosificación , Broncodilatadores/administración & dosificación , Ipratropio/administración & dosificación , Enfermedades Pulmonares Obstructivas/tratamiento farmacológico , Nebulizadores y Vaporizadores , Administración por Inhalación , Anciano , Albuterol/uso terapéutico , Broncodilatadores/uso terapéutico , Estudios Cruzados , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Ipratropio/uso terapéutico , Masculino , Seguridad del Paciente , Satisfacción del Paciente , Proyectos Piloto , Estudios Prospectivos , Pruebas de Función Respiratoria , Estadísticas no ParamétricasRESUMEN
OBJECTIVE: To investigate the radiographic resolution of acute pulmonary embolism (PE) using contrast-enhanced computed tomography (CECT) examinations in patients diagnosed with acute PE while hospitalized with coronavirus disease 2019 (COVID-19) and to understand the mid-term and long-term implications of anticoagulation therapy. METHODS: We identified patients with acute PE per CECT and at least one follow-up CECT from March 11, 2020, to May 27, 2021, using a prospective registry of all hospitalized patients with COVID-19 infection receiving care within a multicenter Health System. Initial and follow-up CECT examinations were reviewed independently by two radiologists to evaluate for PE resolution. The Modified Miller Score was used to assess for thrombus burden at diagnosis and on follow-up. RESULTS: Of the 6070 hospitalized patients with COVID-19 infection, 5.7% (348/6070) were diagnosed with acute PE and 13.5% (47/348) had a follow-up CECT examination. The mean ± standard deviation time to follow-up imaging was 44 ± 48 days (range, 3-161 days). Of 47 patients, 47 (72.3%) had radiographic resolution of PE, with a mean time to follow-up of 48 ± 43 days (range, 6-239 days). All patients received anticoagulation monotherapy for a mean of 149 ± 95 days and this included apixaban (63.8%), warfarin (12.8%), and rivaroxaban (8.5%), among others. The mean Modified Miller Score at PE diagnosis and follow-up was 4.8 ± 4.2 (range, 1-14) and 1.4 ± 3.3 (range, 0-16; P < .0001), respectively. Nine patients (19%) died at a mean of 13 ± 8 days after follow-up CECT (range, 1-27 days) and at a mean of 28 ± 16 days after admission (range, 11-68 days). Seen of the nine deaths (78%) deaths were associated with progression of COVID-19 pneumonia. CONCLUSIONS: Hospitalized patients with COVID-19 have a clinically apparent 5.7% rate of developing PE. In patients with follow-up imaging, 72.3% had radiographic thrombus resolution at a mean of 44 days while on anticoagulation. Prospective studies of the natural history of PEs with COVID-19 that include systematic follow-up imaging are warranted to help guide anticoagulation recommendations.
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Anticoagulantes , Tratamiento Farmacológico de COVID-19 , COVID-19 , Embolia Pulmonar , Enfermedad Aguda , Anticoagulantes/uso terapéutico , COVID-19/complicaciones , Humanos , Estudios Prospectivos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/tratamiento farmacológico , Resultado del TratamientoRESUMEN
The coexistence of expiratory central airway collapse and diaphragmatic paralysis presents a diagnostic and treatment challenge. Both entities are underrecognized causes of dyspnea, cough, sputum production, and orthopnea. Optimal treatment must be individualized and is best achieved by a multidisciplinary team. We present a case of a patient with profound functional impairment from dyspnea and hypoxemia due to expiratory central airway collapse, complicated by bronchiectasis from recurrent respiratory infections, and diaphragmatic paralysis.
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BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) commonly have comorbidities which may impact both symptoms and prognosis. Endoscopic lung volume reduction (ELVR) with endobronchial valves (EBV) is an innovative, effective and safe treatment for patients with severe emphysema who remain symptomatic despite optimal medical therapy. OBJECTIVES: To evaluate medical comorbidities associated with increased risk of complications after EBV procedure. METHOD: This was a retrospective cohort review of patients with severe, heterogeneous emphysema who underwent Zephyr® EBV installation for ELVR. Demographics, baseline comorbidities, dyspnea scores, data regarding procedure, pulmonary function test, minimal clinically important difference and post-EBV complications were recorded. RESULTS: Of a total 82 participants, 24 were identified as having a post procedure complication. There was a significant difference in the incidence of type 2 diabetes mellitus (T2DM) at baseline (25%) in complication group compared with non-complication group (5.1%) (p value = 0.01). There was also a significant difference between baseline coronary artery disease (CAD) in those with (58.3%) or without (29.3%) complication (p = 0.01). Multivariate analysis of other covariables, identified associations of both CAD and T2DM with a heightened risk of complication (adjusted OR 4.19 CI: 1.23-14.2, p value = 0.02 and adjusted OR of 6.1 CI: 1.3-26.1, p value = 0.02 respectively). CONCLUSIONS: Our study found that patients with severe, heterogeneous emphysema who undergo ELVR utilizing Zephyr® EBV and suffer complications during post-procedure period are more likely to have CAD or T2DM as baseline comorbidity. These data suggest that baseline CAD and T2DM might be predictive of increased risk of complications following ELVR with EBV.
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Enfermedad de la Arteria Coronaria , Diabetes Mellitus Tipo 2 , Enfisema , Enfisema Pulmonar , Broncoscopía , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/cirugía , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/epidemiología , Humanos , Neumonectomía , Enfisema Pulmonar/epidemiología , Enfisema Pulmonar/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Chronic obstructive pulmonary disease (COPD) is common and has significant morbidity and mortality as the fourth leading cause of death in the United States. In many patients, particularly those with emphysema, COPD is characterized by markedly increased residual volume contributing to exertional dyspnea. Current therapies have limited efficacy. Surgical resection of diseased areas of the lung to reduce residual volume was effective in identified subgroups but also had significant mortality in and suboptimal cost effectiveness. Lung-volume reduction, using bronchoscopic techniques, has shown substantial benefits in a broader patient population with less morbidity and mortality. This review is meant to spread the awareness about bronchoscopic lung-volume reduction and to promote its consideration and early referral for patients with advanced COPD and emphysema frequently encountered by both primary care physicians and specialists. A search was conducted on PubMed (MEDLINE), EMbase, and Cochrane library for original studies, using the following keywords: "lung-volume reduction." "endobronchial valves," "intrabronchial valves," "bronchoscopic lung-volume reduction," and "endoscopic lung-volume reduction." We included reports from systematic reviews, narrative reviews, clinical trials, and observational studies. Two reviewers evaluated potential references. A total of 27 references were included in our review. Included studies report experience in the diagnosis and bronchoscopic treatment for emphysema; case reports and non-English or non-Spanish studies were excluded.
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Broncoscopía , Neumonectomía/métodos , Enfisema Pulmonar/cirugía , Humanos , Selección de Paciente , Complicaciones Posoperatorias , Calidad de VidaRESUMEN
COPD may cause profound dyspnea, functional impairment, and reduced quality of life. Available pharmacologic therapy provides suboptimal symptom improvement in many patients. Bronchoscopic lung volume reduction (BLVR), achieved with endobronchial valve placement, can effectively improve dyspnea and functional status in appropriately selected patients. Operationalizing a safe and effective BLVR program requires appropriate oversight, which can be achieved by a BLVR nurse coordinator (NC). By identifying and developing screening practices, coordinating multidisciplinary diagnostic evaluation, and establishing safe efficient patient flow throughout the entire care process, a BLVR NC can optimize patient care, safety, experience, efficiency, and overall outcomes. This article details the role of our NC to facilitate extrapolation to other institutions.