Single running suture technique is associated with low rate of bronchial complications after lung transplantation.

BACKGROUND: Lung transplantation has evolved to a routinely performed surgical procedure in patients with end-stage pulmonary disease. Bronchial healing problems are rare but represent a potential life-threatening complication. Herein, we aimed to define the incidence, classification, and treatment of bronchial complications after lung transplantation. MATERIAL AND METHODS: All patients receiving lung transplantation between January 1999 and December 2017 were included in this retrospective study. All bronchial anastomoses were performed in a standardized technique using a single, polydioxanone running suture. The rate of anastomotic complications requiring an intervention, type of complication according the 2018 International Society for Heart and Lung Transplantation classification, and the clinical management were retrospectively analyzed. RESULTS: A total of 2941 anastomoses were performed in 1555 patients. The overall incidence of relevant anastomotic complications was 1.56%, 0.68% for left anastomoses, and 2.44% for right anastomoses. In 6 patients, a surgical revision or retransplantation was performed, whereas endoscopic treatment alone was sufficient in 39 patients. One patient underwent right-sided retransplantation 6 months after the first lung transplantation after failed endoscopic treatment attempts. International Society for Heart and Lung Transplantation grade "S Lc Ec" was the most common type of anastomotic complication. The overall incidence decreased within the study period from 2.4% in the era 1999 to 2003 to 0.8% in the era 2014 to 2017. We found no significant difference in overall survival of patients with and without anastomotic complications (P = .995; hazard ratio, 0.99; 95% confidence interval, 0.63-1.58). CONCLUSIONS: The single running suture technique is associated with a very low rate of true anastomotic complications. Close follow-up and early endoscopic treatment of patients with anastomotic complications result in excellent long-term outcomes.

Utilidad del esputo inducido en la práctica clínica habitual / Utility of Induced Sputum in Routine Clinical Practice

Objetivos: Determinar la utilidad general y específica (diagnóstica y/o terapéutica) del recuento de las células inflamatorias (RCI) del esputo inducido (EI) en situación de asistencia clínica real. Métodos: Estudio retrospectivo que incluyó a los 171 pacientes que durante un año se les recogió un EI para determinar su RCI en un servicio de Neumología de un hospital de referencia. Observadores independientes al equipo médico habitual establecieron si la información proporcionada por el RCI del EI fue útil en la toma de decisiones diagnósticas y terapéuticas. Resultados: Las causas más frecuentes que motivaron la solicitud del RCI del EI fueron: asma 103 (59,20%); asma de control difícil 34 (19,54%); tos crónica 19 (10,9%), y reflujo gastroesofágico 15 (8,6%). En 115 (67,3%) pacientes el RCI del EI resultó clínicamente útil (valoración general); en 98 (57,3%) proporcionó información diagnóstica, y en 85 (49,7%), información terapéutica relevante. En el asma, asma de control difícil, tos crónica y reflujo gastroesofágico fue útil en el 71,8, el 67,6, el 47,4 y el 60%, respectivamente. Conclusiones: La información proporcionada por el RCI del EI resulta de gran utilidad en la práctica clínica, particularmente en el asma y la tos crónica. Estos resultados podrían proporcionar argumentos para recomendar la incorporación de la técnica en los servicios de Neumología de referencia y en las unidades de excelencia de asma)

Objective: To determine the general and specific utility in diagnosis and/or treatment of induced sputum (IS) inflammatory cell counts in routine clinical practice. Methods: Retrospective study of 171 patients referred for clinical sputum induction over a 1-year period in the pulmonology department of a referral hospital. Independent observers established whether the information provided by IS inflammatory cell count was useful for making diagnostic and therapeutic decisions. Results: The most frequent reasons for determination of IS inflammatory cell count were: asthma 103 (59.20%); uncontrolled asthma 34 (19.54%); chronic cough 19 (10.9%), and gastroesophageal reflux 15 (8.6%). In 115 patients (67.3%) it was generally useful for diagnosis and/or treatment; in 98 patients (57.3%) it provided diagnostic information and in 85 patients (49.7%) it assisted in therapeutic decision-making. In asthma, uncontrolled asthma, chronic cough and gastroesophageal reflux, the results were useful in 71.8%, 67.6%, 47.4% and 60%, respectively. Conclusion: The information provided by IS inflammatory cell count is extremely useful in clinical practice, especially in asthma and chronic cough. These results may justify the inclusion of the IS technique in pulmonology departments and asthma units of referral centers

Stents for bronchial stenosis after lung transplantation: should they be removed?

BACKGROUND: Airway complications after lung transplantation are the major cause of morbidity, affecting up to 33% of all cases. Bronchial stenosis is the most common complication. The use of stents has been established as the most effective therapy; however, their removal is recommended after 3-6 months of use. We have been using self-expandable stents as a definitive treatment and remove them only if necessary. For this report, we evaluated the use of self-expandable stents as a definitive treatment for bronchial stenosis after lung transplantation. METHODS: We performed a retrospective cohort study to evaluate patients with bronchial stenosis from August 2003 to April 2014. Clinical and pulmonary function test data were collected. RESULTS: Two hundred lung transplants were performed, 156 of which were bilateral. Sixteen patients experienced airway complications: 4 had dehiscence, 2 necrosis, and 10 bronchial stenosis. Of these patients, 7 had undergone bilateral procedures, and 2 patients developed stenosis in both sides. Twelve anastomotic stenoses were observed. The follow-up after stenting ranged from 1 to 7 years. All patients had increased lung function, and 4 remained stable with sustained increase in pulmonary function without episodes of infection. Three patients required removal of their prosthesis 6 months to 1 year after implantation because of complications. Two patients died owing to unrelated causes. CONCLUSIONS: Definitive treatment of bronchial stenosis with self-expandable stents is a viable option. The 1st year seems to be the most crucial for determining definitive treatment, because no patients required removal of their stent after 1 year.

A spatio-temporal model for estimating the long-term effects of air pollution on respiratory hospital admissions in Greater London.

It has long been known that air pollution is harmful to human health, as many epidemiological studies have been conducted into its effects. Collectively, these studies have investigated both the acute and chronic effects of pollution, with the latter typically based on individual level cohort designs that can be expensive to implement. As a result of the increasing availability of small-area statistics, ecological spatio-temporal study designs are also being used, with which a key statistical problem is allowing for residual spatio-temporal autocorrelation that remains after the covariate effects have been removed. We present a new model for estimating the effects of air pollution on human health, which allows for residual spatio-temporal autocorrelation, and a study into the long-term effects of air pollution on human health in Greater London, England. The individual and joint effects of different pollutants are explored, via the use of single pollutant models and multiple pollutant indices.

Using geographical information systems and cartograms as a health service quality improvement tool.

INTRODUCTION: Disease prevalence can be spatially analysed to provide support for service implementation and health care planning, these analyses often display geographic variation. A key challenge is to communicate these results to decision makers, with variable levels of Geographic Information Systems (GIS) knowledge, in a way that represents the data and allows for comprehension. The present research describes the combination of established GIS methods and software tools to produce a novel technique of visualising disease admissions and to help prevent misinterpretation of data and less optimal decision making. The aim of this paper is to provide a tool that supports the ability of decision makers and service teams within health care settings to develop services more efficiently and better cater to the population; this tool has the advantage of information on the position of populations, the size of populations and the severity of disease. METHODS: A standard choropleth of the study region, London, is used to visualise total emergency admission values for Chronic Obstructive Pulmonary Disease and bronchiectasis using ESRI's ArcGIS software. Population estimates of the Lower Super Output Areas (LSOAs) are then used with the ScapeToad cartogram software tool, with the aim of visualising geography at uniform population density. An interpolation surface, in this case ArcGIS' spline tool, allows the creation of a smooth surface over the LSOA centroids for admission values on both standard and cartogram geographies. The final product of this research is the novel Cartogram Interpolation Surface (CartIS). RESULTS: The method provides a series of outputs culminating in the CartIS, applying an interpolation surface to a uniform population density. The cartogram effectively equalises the population density to remove visual bias from areas with a smaller population, while maintaining contiguous borders. CartIS decreases the number of extreme positive values not present in the underlying data as can be found in interpolation surfaces. DISCUSSION: This methodology provides a technique for combining simple GIS tools to create a novel output, CartIS, in a health service context with the key aim of improving visualisation communication techniques which highlight variation in small scale geographies across large regions. CartIS more faithfully represents the data than interpolation, and visually highlights areas of extreme value more than cartograms, when either is used in isolation.

Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery.

BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library 2008, Issue 3.Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. The risk and severity of postoperative pulmonary complications can be reduced by the judicious use of therapeutic manoeuvres that increase lung volume. Our objective was to assess the effect of incentive spirometry compared to no therapy or physiotherapy, including coughing and deep breathing, on all-cause postoperative pulmonary complications and mortality in adult patients admitted to hospital for upper abdominal surgery. OBJECTIVES: Our primary objective was to assess the effect of incentive spirometry (IS), compared to no such therapy or other therapy, on postoperative pulmonary complications and mortality in adults undergoing upper abdominal surgery.Our secondary objectives were to evaluate the effects of IS, compared to no therapy or other therapy, on other postoperative complications, adverse events, and spirometric parameters. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE, EMBASE, and LILACS (from inception to August 2013). There were no language restrictions. The date of the most recent search was 12 August 2013. The original search was performed in June 2006. SELECTION CRITERIA: We included randomized controlled trials (RCTs) of IS in adult patients admitted for any type of upper abdominal surgery, including patients undergoing laparoscopic procedures. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. MAIN RESULTS: We included 12 studies with a total of 1834 participants in this updated review. The methodological quality of the included studies was difficult to assess as it was poorly reported, so the predominant classification of bias was 'unclear'; the studies did not report on compliance with the prescribed therapy. We were able to include data from only 1160 patients in the meta-analysis. Four trials (152 patients) compared the effects of IS with no respiratory treatment. We found no statistically significant difference between the participants receiving IS and those who had no respiratory treatment for clinical complications (relative risk (RR) 0.59, 95% confidence interval (CI) 0.30 to 1.18). Two trials (194 patients) IS compared incentive spirometry with deep breathing exercises (DBE). We found no statistically significant differences between the participants receiving IS and those receiving DBE in the meta-analysis for respiratory failure (RR 0.67, 95% CI 0.04 to 10.50). Two trials (946 patients) compared IS with other chest physiotherapy. We found no statistically significant differences between the participants receiving IS compared to those receiving physiotherapy in the risk of developing a pulmonary condition or the type of complication. There was no evidence that IS is effective in the prevention of pulmonary complications. AUTHORS' CONCLUSIONS: There is low quality evidence regarding the lack of effectiveness of incentive spirometry for prevention of postoperative pulmonary complications in patients after upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field. There is a case for large RCTs with high methodological rigour in order to define any benefit from the use of incentive spirometry regarding mortality.

Eficacia del indacaterol como broncodilatador en un grupo de pacientes asmáticos / Effectiveness of Indacaterol as bronchodilator in a group of asthmatic patients

La búsqueda de nuevas opciones terapéuticas para tratar las enfermedades obstructivas bronquiales representa un reto permanente y los broncodilatadores constituyen unos de los fármacos más empleados para la atención de estos pacientes. En los últimos años han ido ganando fuerza los broncodilatadores de acción prolongada, pero el mayor efecto alcanzado era 12 h, superado por un broncodilatador nuevo salido al mercado en el año 2011, denominado indacaterol, del grupo de los beta agonistas, se diferencia de estos por la duración de su efecto que llega a alcanzar 24 h. Se realizó un estudio prospectivo, a ciego, tipo ensayo clínico, aleatorizado, con 90 pacientes asmáticos, entre 18 y 59 años de edad, que acudieron al departamento de pruebas funcionales respiratorias para estudiarles la función pulmonar. Todos recibieron de manera aleatoria indacaterol, salbutamol o placebo, y se les repitió la espirometría a los 15 min y a las 24 h de aplicado cada medicamento. Se evidenció que la respuesta broncodilatadora obtenida en los que usaron indacaterol, a las 24 h, fue muy superior a la respuesta de los que usaron otros fármacos. Se muestra además un discreto aumento de la frecuencia cardiaca y de la tensión arterial en los que usaron indacaterol y salbutamol, principalmente a los 15 min de empleados dichos medicamentos, pero dentro de los límites considerados como normales. No se evidenciaron efectos adversos

The search for new therapeutic options to treat bronchial obstructive diseases represents a permanent challenge and bronchodilators constitute one of the most used drugs in the treatment of these patients. In recent years, long acting bronchodilators have grown importance, but the greatest effect has been 12 h, superseded by a new bronchodilator that came on to the market in the year 2011 named Indacaterol, which belongs to the group of ß2-agonists and differentiates from the rest for its effect on the duration which lasts 24 hours. A randomized, essay-type, blind, prospective study was performed in 90 asthmatic patients, ranging from 18 to 59 years of age that presented to the department of respiratory functional tests for a study of their pulmonary functions. All the patients randomly received Indacaterol, Salbutamol or Placebo and spirometry was repeated 15 minutes and 24 hours after treatment. It was evidenced that the bronchodilator response obtained at the 24 hours in those patients that used Indacaterol, was higher than the response in the patients that used other drugs. The patients that used Indacterol and Salbutamol also showed a discrete increase of the cardiac frequency and blood pressure, mainly 15 minutes after receiving such drugs, but this increase is considered within the normal limits. Adverse effects were not evidenced

Eficacia del indacaterol como broncodilatador en un grupo de pacientes asmáticos / Effectiveness of Indacaterol as bronchodilator in a group of asthmatic patients

La búsqueda de nuevas opciones terapéuticas para tratar las enfermedades obstructivas bronquiales representa un reto permanente y los broncodilatadores constituyen unos de los fármacos más empleados para la atención de estos pacientes. En los últimos años han ido ganando fuerza los broncodilatadores de acción prolongada, pero el mayor efecto alcanzado era 12 h, superado por un broncodilatador nuevo salido al mercado en el año 2011, denominado indacaterol, del grupo de los beta agonistas, se diferencia de estos por la duración de su efecto que llega a alcanzar 24 h. Se realizó un estudio prospectivo, a ciego, tipo ensayo clínico, aleatorizado, con 90 pacientes asmáticos, entre 18 y 59 años de edad, que acudieron al departamento de pruebas funcionales respiratorias para estudiarles la función pulmonar. Todos recibieron de manera aleatoria indacaterol, salbutamol o placebo, y se les repitió la espirometría a los 15 min y a las 24 h de aplicado cada medicamento. Se evidenció que la respuesta broncodilatadora obtenida en los que usaron indacaterol, a las 24 h, fue muy superior a la respuesta de los que usaron otros fármacos. Se muestra además un discreto aumento de la frecuencia cardiaca y de la tensión arterial en los que usaron indacaterol y salbutamol, principalmente a los 15 min de empleados dichos medicamentos, pero dentro de los límites considerados como normales. No se evidenciaron efectos adversos(AU)

The search for new therapeutic options to treat bronchial obstructive diseases represents a permanent challenge and bronchodilators constitute one of the most used drugs in the treatment of these patients. In recent years, long acting bronchodilators have grown importance, but the greatest effect has been 12 h, superseded by a new bronchodilator that came on to the market in the year 2011 named Indacaterol, which belongs to the group of ß2-agonists and differentiates from the rest for its effect on the duration which lasts 24 hours. A randomized, essay-type, blind, prospective study was performed in 90 asthmatic patients, ranging from 18 to 59 years of age that presented to the department of respiratory functional tests for a study of their pulmonary functions. All the patients randomly received Indacaterol, Salbutamol or Placebo and spirometry was repeated 15 minutes and 24 hours after treatment. It was evidenced that the bronchodilator response obtained at the 24 hours in those patients that used Indacaterol, was higher than the response in the patients that used other drugs. The patients that used Indacterol and Salbutamol also showed a discrete increase of the cardiac frequency and blood pressure, mainly 15 minutes after receiving such drugs, but this increase is considered within the normal limits. Adverse effects were not evidenced(AU)

Assessment and prevention of exercise-induced bronchoconstriction.

The assessment of exercise-induced bronchoconstriction (EIB) in athletes requires the measurement of forced expiratory volume in 1 s (FEV(1)) before and after vigorous exercise or a surrogate of exercise such as eucapnic voluntary hyperpnoea (EVH) of dry air or mannitol dry powder. Exercise testing in a laboratory has a low sensitivity to identify EIB, and exercise testing in the field can be a challenge in itself particularly in cold weather athletes. The EVH test requires the subject to ventilate dry air containing ∼5% CO(2) for 6 min through a low-resistance circuit at a rate higher than that usually achieved on maximum exercise. A ≥10% reduction in FEV(1) is a positive response to exercise and EVH and, when sustained, is usually associated with release of inflammatory mediators of broncho constriction. Another surrogate, mannitol dry powder, given by inhalation in progressively increasing doses, is used to mimic the dehydrating stimulus of exercise hyperpnoea. A positive mannitol test is a 15% fall in FEV(1) at ≤635 mg and reveals potential for EIB. Mannitol has a high specificity for identifying a clinical diagnosis of asthma. Once a diagnosis of EIB is established, the athlete needs to know how to avoid EIB. Being treated daily with an inhaled corticosteroid to reduce airway inflammation, inhaling a ß(2) agonist or a cromone immediately before exercise, or taking a leukotriene antagonist several hours before exercise, all inhibit or prevent EIB. Other strategies include warming up prior to exercise and reducing respiratory water and heat loss by using face masks or nasal breathing.

Impact of anastomotic techniques on airway complications after lung transplant.

BACKGROUND: Airway complications are a source of morbidity and expense after lung transplant. Posttransplant stenosis can occur when the donor bronchus is rendered ischemic and is dependent upon collateral flow from the pulmonary capillary system. By shortening the donor bronchus, the tissue at risk for ischemia is reduced. In an effort to reduce airway complications, one surgeon at our institution began dividing the donor bronchus at the lobar carina. METHODS: This is a retrospective analysis of all transplanted patients over the 2-year period before and after the institution of the technique change. To adjust for covariates, we performed a propensity score analysis. Outcome endpoints were postoperative airway complications, specifically, the need for therapeutic bronchoscopy, dilation, stenting, or retransplant. RESULTS: After instituting the practice of dividing the bronchus at the lobar carina, the incidence of airway complication for the principle surgeon decreased from 13.2% (7 of 53) to 2.1% (1 of 48), resulting in an improved freedom from airway complication for that surgeon. Compared with all transplants performed during this period, the modified anastomosis resulted in fewer airway complications: 2.1% (1 of 48) versus 8.2% (19 of 231). The propensity analysis matched the 48 patients who received the modified anastomosis with 48 patients who received the standard two ring length anastomosis by surgical colleagues. The modified anastomosis group had fewer required interventions for airway complications and had significantly better freedom from airway complication when followed over time. CONCLUSIONS: Decreasing the amount of potentially ischemic tissue implanted from the donor bronchus can reduce posttransplant airway complications.

[Improving system of prevention and rehabilitation for asbestos-related broncho-pulmonary diseases in workers].

To improve a system of prevention and rehabilitation for broncho-pulmonary diseases among workers engaged into extraction and utilization of chrysotile asbestos, the authors specified major criteria for diagnosis of asbestos-related pulmonary diseases and signs of exposure to asbestos-containing dust, with definition of risk groups for broncho-pulmonary diseases. The authors formulated main concepts of prevention and rehabilitation for asbestos-related pulmonary diseases in workers engaged into asbestos industry. Special attention was paid to harmonization of all medical and technical measures aimed to prevention and liquidation of asbestos-related diseases.

Reduction in airway complications after lung transplantation with novel anastomotic technique.

BACKGROUND: Bronchial anastomotic complications develop in 31% of lung transplant recipients, leading to additional operative procedures and increased morbidity. Advances in surgical technique have thus far resulted in only modestly improved outcomes. We hypothesized that creating the bronchial anastomosis at the secondary carina using a combination of running and figure-of-eight sutures would minimize donor bronchial ischemia and airway complications. METHODS: This retrospective review of a single surgeon's operative experience from 2000 to 2007 compares a new bronchial anastomotic technique with the conventional technique. The primary outcome was the occurrence of bronchial anastomotic complications requiring invasive intervention. The secondary outcome was distal airway complications. Patients were monitored for 1 year after transplant. Recipient and donor demographic data as well as relevant variables from their preoperative, perioperative, and postoperative courses were collected for analysis. These data were compared using t tests for normally distributed continuous variables, Mann-Whitney tests for nonnormally distributed continuous variables, and χ2 tests or Fisher exact test for categoric variables. Logistic regression was used to control for covariates while comparing the primary outcome between the new and conventional bronchial anastomotic techniques. RESULTS: The analysis included 230 patients, representing 407 anastomoses. The occurrence of anastomotic complications requiring intervention and distal airway complications decreased from 18.1% to 2.3% of anastomoses and 12.2% to 4.4% of patients, respectively. After controlling for available risk factors, the new technique significantly reduced both anastomotic (p<0.001) and distal (p=0.03) airway complications. CONCLUSIONS: This new anastomotic technique dramatically reduces anastomotic and distal airway complications after lung transplantation.

Changes and current state of diagnosis of lung cancer after development of the flexible bronchofiberscope.

The flexible bronchofiberscope developed by Ikeda et al. has brought about revolutionary changes in the diagnosis and treatment of lung cancer. Advances in this device are continuing to emerge and lesions even smaller than those visible to the naked eye can now be visualized. In addition, the use of ultrasound now enables diagnosis of extramural bronchial lesions. Bronchoscopy is also used for the treatment of early hilar lung cancer, and in patients with airway stenosis due to advanced cancer, laser therapy, brachytherapy, and stenting can be performed. The bronchofiberscope is also very useful for tissue sampling from the lung periphery. Further advances in computed tomography imaging have enabled bronchoscopy under computed tomography fluoroscopy, and virtual bronchoscopy images can be generated from computed tomography imaging. Navigation systems have been developed to show the target bronchus where instruments such as forceps should be guided. Computed tomography imaging has made remarkable advances, and computed tomography now plays a central role in chest imaging, including early detection of lesions by low-dose computed tomography, qualitative diagnosis by high-resolution computed tomography and diagnosis of disease progression by contrast computed tomography. Ikeda et al. introduced the concept of personal health data recording system to manage these various images but the technology was not mature enough at that time for implementation. With modern advances in information technology, this is likely to be realized using an electronic health record system.

Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery.

BACKGROUND: Upper abdominal surgical procedures are associated with a high risk of postoperative pulmonary complications. The risk and severity of postoperative pulmonary complications can be reduced by the judicious use of therapeutic manoeuvres that increase lung volume. Our objective was to assess the effect of incentive spirometry (IS) compared to no therapy, or physiotherapy including coughing and deep breathing, on all-cause postoperative pulmonary complications and mortality in adult patients admitted for upper abdominal surgery. OBJECTIVES: To assess the effects of incentive spirometry compared to no such therapy (or other therapy) on all-cause postoperative pulmonary complications (atelectasis, acute respiratory inadequacy) and mortality in adult patients admitted for upper abdominal surgery. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE, EMBASE, and LILACS (from inception to July 2006). There were no language restrictions. SELECTION CRITERIA: We included randomized controlled trials of incentive spirometry in adult patients admitted for any type of upper abdominal surgery, including patients undergoing laparoscopic procedures. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. MAIN RESULTS: We included 11 studies with a total of 1754 participants. Many trials were of only moderate methodological quality and did not report on compliance with the prescribed therapy. Data from only 1160 patients could be included in the meta-analysis. Three trials (120 patients) compared the effects of incentive spirometry with no respiratory treatment. Two trials (194 patients) compared incentive spirometry with deep breathing exercises. Two trials (946 patients) compared incentive spirometry with other chest physiotherapy. All showed no evidence of a statistically significant effect of incentive spirometry. There was no evidence that incentive spirometry is effective in the prevention of pulmonary complications. AUTHORS' CONCLUSIONS: We found no evidence regarding the effectiveness of the use of incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field. There is a case for large randomized trials of high methodological rigour in order to define any benefit from the use of incentive spirometry regarding mortality.

Airway complications after lung transplantation: risk factors, prevention and outcome.

PURPOSE: Anastomotic complications following lung transplantation (LuTx) have been described in up to 15% of patients. Challenging to treat, they are associated with high morbidity and a mortality rate of 2-5%. The aim of this study was to analyze the incidence of complications in a consecutive series of bronchial anastomosis after LuTx at our center and to delineate the potential risk factors. METHODS: Between 1992 and 2007, 441 bronchial anastomoses were performed in 235 patients. Indications for transplantation were cystic fibrosis (35.7%) emphysema (28.1%) pulmonary fibrosis (12.8%) and pulmonary hypertension (7.7%). There were 206 sequential bilateral and 28 single transplants including lobar engraftments in 20 cases. The donor bronchus was shortened to the plane of the lobar carina including the medial wall of the intermediate bronchus. Peribronchial tissue was left untouched. Anastomosis was carried out using a continuous absorbable running suture (PDS 4/0) at the membranous and interrupted sutures at the cartilaginous part. Six elective surveillance bronchoscopies were done monthly during the first half-year post-LuTx, with detailed assessment of the pre- and post-anastomotic airways. RESULTS: One-year survival since 2000 was 90.5%. In all 441 anastomoses performed, no significant dehiscence was observed. In one patient, a small fistula was detected and closed surgically on postoperative day five. Fungal membranes were found in 50% of the anastomoses at 1 month and in 14% at 6 months. Discrete narrowing of the anastomotic lumen without need for intervention was found in 4.9% of patients at 1 month and in 2.4% at 6 months. Age, cytomegalovirus status, induction therapy, immunosuppressive regimen, ischemic time, and ventilation time had no influence on bronchial healing. CONCLUSIONS: Clinically relevant bronchial anastomotic complications after LuTx can be avoided by use of a simple standardized surgical technique. Aggressive antibiotic and antifungal therapy might play an important supportive role.