Lobar Collapse Therapy Using Endobronchial Valves as a New Complementary Approach to Treat Cavities in Multidrug-Resistant Tuberculosis and Difficult-to-Treat Tuberculosis: A Case Series.

BACKGROUND: The poor treatment outcomes of multidrug-resistant tuberculosis (TB) and the emergence of extensively drug-resistant TB and extremely and totally drug-resistant TB highlight the urgent need for new antituberculous drugs and other adjuvant treatment approaches. OBJECTIVES: We have treated cavitary tuberculosis by the application of endobronchial one-way valves (Zephyr®; Pulmonx Inc., Redwood City, Calif., USA) to induce lobar volume reduction as an adjunct to drug treatment. This report describes the feasibility, effectiveness and safety of the procedure. METHODS: Patients with severe lung destruction, one or more cavities or those who were ineligible for surgical resection and showed an unsatisfactory response to standard drug treatments were enrolled. During bronchoscopy, endobronchial valves were implanted in the lobar or segmental bronchi in order to induce atelectasis and reduce the cavity size. RESULTS: Four TB patients and 1 patient with atypical mycobacteriosis were treated. The mean patient age was 52.6 years. Complete cavity collapses were observed on CT scans in 4 of the 5 cases. All patients showed improvements in their clinical status, and sputum smears became negative within 3-5 months. There were no severe short- or long-term complications. The valves were removed in 3 of the 5 patients after 8 months on average; there was no relapse after 15 months of follow-up. CONCLUSION: These data suggest that endobronchial valves are likely to be useful adjuncts to the treatment of therapeutically difficult patients. More data are required to confirm our findings.

The history of surgery for pulmonary tuberculosis.

Thoracic surgical procedures evolved from surgical management of tuberculosis; lung resections, muscle flaps, and thoracoscopy all began with efforts to control the disease. The discovery of antituberculosis drugs in 1944 to 1946 made sanatorium therapy and collapse therapy in all its forms obsolete and changed thoracic surgery dramatically. Currently, management of tuberculosis is primarily medical, and surgery has a minimal role. Today surgery is usually only performed in patients with tuberculosis when the diagnosis is necessary, who have complications or sequelae of the disease, or who have active disease resistant to therapy.

Pulmonary tuberculosis: contributions of radiology in diagnosis and treatment.

This review records the important place that radiologic examinations have had in the diagnosis and treatment of pulmonary tuberculosis in the past nine decades. Very soon after the discovery of x-rays it became apparent that chest roentgenograms would be a help in identifying pulmonary lesions. As the quality of the examinations improved, the benefits became significantly better. Earlier lesions were diagnosed. Follow-up studies after medical or surgical treatment were increasingly helpful. Newly developed techniques allowed demonstration of extrapulmonary complications. Radiologic monitoring of collapse therapy played a critical role in the successes achieved. Even after the medical conquest of active tuberculous lesions by drug therapy, identification of new lesions and follow-up of treated patients remains a significant role for radiology. Control of this once fatal and widely feared disease depends on continued early recognition and appropriate treatment.

Two forgotten pioneers. James Carson and George Bodington.

James Carson, a Scot, graduated from Edinburgh in 1799. He settled in Liverpool where he became a successful and respected physician and where he also found time to pursue a longstanding interest in physiology and to conduct certain important experiments. He read a series of papers on these experiments and their import before the Literary and Philosophical Society of Liverpool of which the two most important were On the elasticity of the lungs and On lesions of the lungs. In the first he clarified the mechanics of respiration while in the second he suggested that this knowledge might be employed to produce temporary collapse of the lung as a therapeutic measure. Two attempts at a clinical trial were defeated by widespread pleural adhesions but the first recorded attempts at artificial pneumothorax had been made. George Bodington, a Warwickshire man, after serving a surgical apprenticeship studied at St Bartholomew's Hospital and obtained the licence of the Society of Apothecaries in 1825. He later practised near Sutton Coldfield where he was known as an acute observer and a thoughtful and fluent speaker. In 1840 he published an essay on the treatment and cure of pulmonary consumption in which he roundly condemned the current therapy and advocated instead fresh air in abundance, gentle exercise in the open, an adequate and varied diet, and a minimum of medicaments. Violently attacked by the reviewers he became discouraged about tuberculosis and devoted the remainder of his professional life to the care of the mentally ill.