Necrotizing fasciitis of the chest wall: A clinical case report and literature review.

Necrotizing fasciitis of the chest wall is a very rare pathology, but with significant mortality, representing a therapeutic challenge. All international reports indicate the need for early diagnosis and an aggressive medical-surgical attitude in order to improve the prognosis. In addition to a review of literature, we present a case developed secondary to a thoracic pleural drainage for pyopneumothorax associated with significant bronchopleural fistula in a destroyed tuberculous left lung. Along with medical treatment, extensive surgical debridement was required. Despite drainage incisions and negative pressure wound therapy (NPWT), the evolution of the fasciitis was difficult, due to bronchopleurocutaneous fistula. Thus, the Azorin procedure (transcervical mediastinoscopic closure of the left main bronchus) was performed. Once this procedure was completed, the inflammatory phenomena were controlled which allowed for a second step consisting of left pneumonectomy, with the application of specific methods for the prevention of bronchial fistula. The clinical case was a therapeutic challenge requiring a complex, staged, multidisciplinary approach due to both the immunocompromised terrain and the severity of the lesions. In conclusion, early recognition and aggressive and combined application of medical and surgical treatment methods can ensure therapeutic success.

Monaldi cavernostomy for lung aspergillosis: A case report.

Pulmonary aspergillosis in patients with respiratory failure can severely affect the pulmonary functional status and may aggravate it through pulmonary suppuration, by recruitment of new parenchyma and hemoptysis, which can sometimes be massive, with lethal risk by flooding the bronchus. The treatment consists of a combination of medical therapy, surgery and interventional radiology. In small lesions, less than 2-3 cm, medical therapy methods may be sufficient; however, in invasive forms (larger than 3 cm) surgical resection is necessary. Surgical resection is the ideal treatment; nevertheless, when lung function does not allow it, action must be taken to eliminate the favorable conditions of the infection. In such cases, whenever the lung cavity is peripheral, a cavernostomy may be performed. Four cases of lung cavernous lesions colonized with aspergillus, in which the need for a therapeutic gesture was imposed by repeated small to medium hemoptysis and by the progression of respiratory failure, were evaluated, one of which is presented in the current study. Cavernostomy closure can be realized either surgically with muscle flap or spontaneously by scarring, after closure of the bronchial fistulas by epithelization and granulation. There were no recurrences of hemoptysis or suppurative phenomena. There was one death, a patient with severe respiratory failure caused by superinfection with nonspecific germs. However, in the case presented in this study, the patient recovered following cavernostomy, which seems to be an effective and safe method for cases in which lung resection is not feasible.

The pleural effusion in ovarian tumors: Often a diagnosis challenge.

Pleural effusions associated with ovarian tumors are not always malignant. Neoplastic etiology of pleural efussion needs histopathological confirmation. We present three cases that illustrate various etiologies for pleural effusions in patients with ovarian tumors: thromboembolism, malignancy and Meigs syndrome. For these patients, it is essential to establish the correct etiology of the pleurisy, since it may change the therapeutic approach. All the cases must be carefully assessed and all the efforts must be done by a multidisciplinary team in order to offer the best solution for each case.

[Evidences related to pulmonary rehabilitation in the respiratory pathology]. / Evidente legate de reabilitarea pulmonara în patologia respiratorie.

Pulmonary rehabilitation represents a modern therapeutic approach of respiratory diseases, with a multidisciplinary character, including: physical training, therapeutic education, psychosocial counseling, and nutritional approach. Pulmonary rehabilitation addresses to any patient suffering from pulmonary pathology whose quality of life is affected by the respiratory symptoms, regardless of the degree of functional impairment. This article is an analysis of evidences from the medical literature on outcomes of rehabilitation programs conducted in various lung diseases. The main indication of pulmonary rehabilitation is the chronic obstructive pulmonary disease - COPD (stable state and exacerbation) in which most studies were carried out. Pulmonary rehabilitation in patients with other respiratory pathology has its reason in the pathophysiological changes that they undergo (impaired lung function and gas exchange, muscle atrophy and deconditioning etc.) leading to symptoms, lower exercise tolerance and decrease daily physical activity, all of which ultimately result in impaired quality of life. The role of rehabilitation is reviewed in the following diseases: post-surgical lung volume reduction for emphysema, asthma, bronchiectasis, interstitial lung disease, cystic fibrosis, lung cancer, neuromuscular disease, intensive care, obstructive sleep apnea, pulmonary hypertension, post-tuberculous sequelae, lung transplantation.

[Iatrogenic tracheal stenosis in patients with COPD: a medico-surgical challenge]. / Stenoza traheala iatrogena la pacientul cu BPOC: o provocare medico-chirurgicala.

This study analyzes a series of iatrogenic tracheal stenosis occurring in patients with COPD exacerbation which required oro-tracheal intubation. The tracheal stenosis occurred on average after 24 days of intubation and were clinically severe. Treatment algorithm first included bronchoscopic interventional techniques with an immediate success rate of 37%, but the results were unstable in time, requiring tracheal stenting. The surgical approach, which generally is the first choice in the treatment of tracheal stenosis, had discouraging results in these patients, with a low rate of success (20%) and an increased incidence of restenosis. The only solution for those postoperative complications was, again, interventional bronchoscopy. In conclusion, while for various other etiologies of tracheal stenosis the surgical resection is the first choice of treatment, in COPD patients interventional bronchoscopy often remains the only way of solving.

[Respiratory muscle training in pulmonary rehabilitation]. / Antrenamentul muschilor respiratori în reabilitarea pulmonara.

Respiratory muscles are essential in maintaining normal ventilation and adequate gas exchanges. Any imbalance in their function can lead to clinical symptoms: dyspnea, hypercapnia, exercise intolerance, ineffective cough. In the pulmonary rehabilitation a particular area is represented by the respiratory muscle training in various lung diseases. Inspiratory muscles training, particularly in COPD patients, has a beneficial effect, resulting in increased strength and endurance of respiratory muscles, decreased dyspnea level, improved quality of life and exercise tolerance. It is a therapy that can be used alone or in combination with generalized physical training, especially in patients with inspiratory muscle weakness.

Benefits of a 7-week outpatient pulmonary rehabilitation program in COPD patients.

BACKGROUND: Respiratory rehabilitation programs (RR) are essential tools in the management of COPD. AIM: We present the results of a 7-week outpatient rehabilitation program in terms of dyspnea, exercise tolerance and quality of life. MATERIAL AND METHOD: The following parameters were evaluated before and after RR: dyspnea (mMRC scale), pulmonary function (FEVI, RV- residual volume), exercise tolerance (6MWT- 6 minutes walk test, CPET - cardiopulmonary exercise test), quality of life (SGROQ questionnaire). The RR program was outpatient, hospital based (7 weeks, 3 sessions/ week) and included: exercise training, therapeutic education, and psychological support. RESULTS: 25 patients, COPD stage II-IV GOLD (mean FEVI 44.5 +/-13% predicted), mean age 60.4 +/-12 years, 7 females, average BMI 27.14+/-4 kg/m2, average RV residual volume 221.55+/-86% predicted. Mean 6MWTdistance: 407.48 +/- 84 m and mean maximum power (Pmax) obtained on CPET: 75.67+/-30 Watts. All patients were symptomatic with significant dyspnea (3.06+/-0.7 on mMRC scale) and showed a significant impairment of quality of life: SGRO score 46.23+/- 14. At the end of RR program: dyspnea decreased with 0.67points on mMRC scale (p = 0.000), 6MWT distance increased with 58.5 m (p = 0.0071), Pmax obtained during CPET increased with 11.2 W, without reaching statistical significance (p> 0.05). SGRO score decreased by 5.59 points (p = 0.02). There were no significant improvements in FEV1 and RV values (p> 0.05). CONCLUSION: In our COPD patients, the 7 week outpatient rehabilitation program was effective, leading to improvement ofsymptoms, exercise tolerance and quality of life.

The contribution of exercise testing in the prescription and outcome evaluation of exercise training in pulmonary rehabilitation.

Pulmonary rehabilitation is a comprehensive therapeutic intervention with proven efficacy in relieving symptoms and increasing exercise tolerance in patients with chronic respiratory diseases.One of the main components of a pulmonary rehabilitation program is lower limbs exercise training. There are several ways of establishing the optimal intensity of the exercise training, using the target heart rate, symptom scores, walking tests and laboratory exercise tests with or without ventilation or gas exchange measurements. Each of these methods has advantages and disadvantages.The gold standard in exercise capacity evaluation is cardiopulmonary exercise testing (CPET) which brings a high level of objectivity in exercise tolerance evaluation and provides information on mechanisms responsible for its decline; this allows a better training prescription and a correct evaluation of rehabilitation outcomes.

[Therapeutical approach in severe exacerbation of COPD associating obstructive sleep apnoea and obesity]. / Atitudine terapeutica în exacerbarea severa a BPOC care asociaza sindrom de apnee în somn si obezitate.

COPD exacerbations with respiratory acidosis are difficult to manage, especially when OSA and obesity are associated. The solution is the use of noninvasive ventilation associated with oxygenotherapy in order to correct the hypercapnia, hypoxemia and respiratory acidosis and to prevent the invasive mechanical ventilation. Early respiratory rehabilitation and the use of a domiciliary ventilatory support after the acute episode could be a part of the management for these patients. We present a modality of therapeutical approach through a clinical case.

Rare form of semi-invasive aspergillosis in immunocompetent patient: case report.

Chronic necrotizing or semi-invasive aspergillosis represents a disease commonly occurred in patients with mild immunodeficiency. We report a case of chronic necrotizing pulmonary aspergillosis in immunocompetent patient without underlying disease. The discovery of the disease was made accidentally, by finding a nodular opacity on a routine chest X-ray. The diagnostic was confirmed by pathological and bacteriological examination. With specific antifungal treatment, no complete eradication was obtained and the patient has a slow evolution with many relapses.