RESUMO
BACKGROUND: Sildenafil may be of benefit for selected patients with pulmonary hypertension associated with parenchymal lung and cardiac diseases. However the medium term benefits of this treatment for such patients is unclear. PATIENTS AND METHODS: 16 consecutive patients with secondary pulmonary hypertension who had been on maximal appropriate therapy received Sildenafil 50 mg tds following assessment which included right heart catheter, 2D echocardiography and six minute walk test. Right heart catheterisation, 2D echocardiography and six minute walk test were performed after eight weeks treatment, at 12 months and at six monthly intervals thereafter. Baseline medications were continued. RESULTS: 16 patients with pulmonary hypertension associated with inoperable chronic pulmonary thromboembolism (6 patients), valvular heart disease (4), chronic obstructive pulmonary disease (3), idiopathic pulmonary fibrosis (2), and obstructive sleep apnoea (1) were studied. The age range was 42 to 81 (median 68) years and the period of follow up was 12 to 51 (median 22) months. Six minute walk increased significantly, p=0.002, from baseline to long term follow up. The improvement in 14 patients ranged from 14 m to 300 m with a percentage increase of 5% to 567% increase. In one patient there was no change and in one patient the six minute walk test fell as a consequence of progression of known arthritis. The mean pulmonary artery pressure was significantly reduced at long term follow up (p=0008). The pulmonary vascular resistance (PVR) fell in eleven patients, this reduction ranged from 0.2 woods units to 8.7 woods units (mean reduction 3.3 woods units). The percentage reduction in PVR ranged from 7% to 71% with a mean reduction of 43%. In five patients the pulmonary vascular resistance increased. 2D echocardiography showed a sustained improvement in right ventricular function in 11 patients. There were no deaths during follow up. CONCLUSION: Sildenafil may have a role for selected patients with pulmonary hypertension associated with cardiac and pulmonary diseases. The medication seems well tolerated and for some patients is effective within 8 weeks and results in a sustained long term improvement in haemodynamics and exercise capacity.
Assuntos
Pressão Sanguínea/efeitos dos fármacos , Hipertensão Pulmonar/tratamento farmacológico , Piperazinas/farmacologia , Sulfonas/farmacologia , Vasodilatadores/farmacologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Ecocardiografia , Feminino , Seguimentos , Doenças das Valvas Cardíacas/complicações , Humanos , Hipertensão Pulmonar/etiologia , Pneumopatias/complicações , Masculino , Pessoa de Meia-Idade , Piperazinas/efeitos adversos , Piperazinas/uso terapêutico , Purinas/efeitos adversos , Purinas/farmacologia , Purinas/uso terapêutico , Citrato de Sildenafila , Síndromes da Apneia do Sono/complicações , Sulfonas/efeitos adversos , Sulfonas/uso terapêutico , Fatores de Tempo , Resistência Vascular/efeitos dos fármacos , Vasodilatadores/efeitos adversos , Vasodilatadores/uso terapêuticoRESUMO
BACKGROUND: Sildenafil offers potential to treat patients with pulmonary hypertension by selectively inhibiting phosphodiesterase type five pathways in the lung. It is recommended for selected patients with pulmonary arterial hypertension, but its role in the management of pulmonary hypertension associated with parenchymal lung disease is unclear. PATIENTS AND METHODS: Seven patients (68-86 years) with end stage chronic obstructive pulmonary disease (COPD, 4) and idiopathic pulmonary fibrosis (IPF, 3) were referred to our unit. All patients had a long-term history of chronic lung disease and were on maximal appropriate therapy prescribed by their referring pulmonologist. Thromboembolic disease was excluded by pulmonary angiography and all patients had had high resolution thoracic CT scan. At assessment right heart catheterisation, 2D echocardiography and 6-min walk test were performed prior to commencement of sildenafil 50mg tds. Their medication was otherwise unchanged. After 8 weeks treatment, right heart catheterisation, 2D echocardiography and 6-min walk test were repeated. RESULTS: The pulmonary vascular resistance was reduced in six patients (from 13, 3, 3, 6.5, 3.5 and 10.5 wood units to 9.7, 2.5, 2.8, 4.4, 2.5 and 5.4 wood units, respectively). Six-minute walk test increased in six patients (from 110 m, 210 m, 80 m, 30 m, 210 m and 80 m to 130 m, 312 m, 120 m, 82 m, 244 m and 100 m, respectively). One patient with COPD did not demonstrate a favourable response although their cardiac output increased on sildenafil therapy. 2D echocardiography showed a reduction in estimated PA pressure in six patients with an improvement in right ventricular systolic function in two COPD patients. CONCLUSION: Our results suggest that sildenafil may have a role for selected patients with COPD and IPF who have pulmonary hypertension.
Assuntos
Hipertensão Pulmonar/tratamento farmacológico , Inibidores de Fosfodiesterase/uso terapêutico , Piperazinas/uso terapêutico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Fibrose Pulmonar/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Ecocardiografia , Teste de Esforço , Feminino , Humanos , Hipertensão Pulmonar/fisiopatologia , Masculino , Inibidores de Fosfodiesterase/farmacologia , Piperazinas/farmacologia , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Fibrose Pulmonar/fisiopatologia , Purinas , Citrato de Sildenafila , Sulfonas , Resultado do Tratamento , CaminhadaRESUMO
Sildenafil, a phosphodiesterase type-5 inhibitor, offers potential to treat pulmonary hypertension associated with a variety of conditions. We assessed the early impact of sildenafil on a cohort of patients referred to our unit who had severe pulmonary hypertension secondary to chronic thromboembolic disease which was not amenable to pulmonary thromboendarterectomy and who also had coexisting left ventricular dysfunction. Six patients were studied. Diagnosis of pulmonary embolic disease was made by ventilation perfusion scanning and/or CT pulmonary angiography. All patients were anticoagulated with oral coumarin derivatives and none were considered suitable for pulmonary thromboendarterectomy. Pulmonary hypertension was diagnosed by right heart catheterisation and each patient had Medical Research Council (MRC) dyspnoea score and New York Heart Association (NYHA) class noted and 2D echocardiography prior to commencement of sildenafil 50 mg three times a day. After 6 weeks of sildenafil therapy, right heart catheterisation and 2D echocardiography were repeated, and MRC dyspnoea score, NYHA class and exercise capacity were recorded. All patients demonstrated an improvement in mean pulmonary artery pressure, mean pulmonary capillary wedge pressure, MRC dyspnoea score, NYHA class and gas transfer. No adverse effects of sildenafil were noted. Our data suggests that sildenafil is an effective and well-tolerated therapy for patients with severe pulmonary hypertension associated with pulmonary thromboembolic disease and impaired left ventricular function, producing beneficial effects as early as 6 weeks.
Assuntos
Hipertensão Pulmonar/tratamento farmacológico , Piperazinas/uso terapêutico , Vasodilatadores/uso terapêutico , Disfunção Ventricular Esquerda/complicações , Adulto , Idoso , Débito Cardíaco/efeitos dos fármacos , Feminino , Humanos , Hipertensão Pulmonar/classificação , Hipertensão Pulmonar/complicações , Masculino , Pessoa de Meia-Idade , Pressão Propulsora Pulmonar/efeitos dos fármacos , Purinas , Citrato de Sildenafila , Sulfonas , Resultado do TratamentoRESUMO
With increasing use of expandable metallic stents to manage patients with a variety of endobronchial pathologies, some will have a subsequent need for tracheostomy insertion. We describe a successful technique to insert a tracheostomy using rigid and fibre-optic bronchoscopy in a patient who had an 8 cm expandable metallic tracheal stent deployed previously on account of tracheomalacia.
Assuntos
Obstrução das Vias Respiratórias/cirurgia , Stents , Traqueostomia/métodos , Idoso , Dissecção Aórtica/cirurgia , Aneurisma Aórtico/cirurgia , Broncopatias/complicações , Broncopatias/terapia , Feminino , Humanos , Traqueostomia/instrumentação , Resultado do TratamentoRESUMO
Covered metallic endobronchial stents are increasingly used in the management of diverse large airway pathology and once deployed they are considered permanent. Long-term complications of stent fracture and airway granulation tissue formation may necessitate stent removal. We describe successful endoscopic removal of the Ultraflex expandable tracheal metallic stents (Microvasive; Boston Scientific, Natick, MA) in 5 patients at 105, 84, 50, 38, and 21 months after deployment, with excellent tracheal healing and clearance of granulation tissue noted at 6 weeks after removal in each patient.
Assuntos
Broncoscopia/métodos , Materiais Revestidos Biocompatíveis , Remoção de Dispositivo/métodos , Falha de Equipamento , Tecido de Granulação/cirurgia , Stents , Traqueia/cirurgia , Neoplasias da Traqueia/terapia , Estenose Traqueal/terapia , Cicatrização/fisiologia , Adulto , Feminino , Humanos , Terapia a Laser , Masculino , Pessoa de Meia-Idade , Reoperação , Traqueia/lesões , Traqueostomia/efeitos adversosRESUMO
BACKGROUND: Right heart catheterization (RHC) is important in the evaluation of pulmonary hypertension, but is not without risk. HYPOTHESIS: We wished to assess the safety, efficacy, and tolerability of RHC performed via the internal jugular vein (IJV) at our tertiary cardiothoracic center. METHODS: A retrospective review of the medical records for all patients undergoing RHC via the IJV between January 1, 2007 and July 31, 2009 was performed. We do not routinely use ultrasound guidance or stop anticoagulation. Operators with a median experience of 450 procedures performed the RHCs. RESULTS: Right heart catheterization was performed on 349 patients with a median age of 66 years (range, 17-89), median mean pulmonary artery pressure of 30 mm Hg (range, 8-69), and a median internationalized normal ratio of 2.5. Of 349 patients, we were unable to obtain intravenous access in only 1 patient; 342 (98%) patients tolerated RHC with local anesthetic alone; and 6 patients required additional sedation with benzodiazepines. The median time for the procedure was 15 minutes. Complications occurred in 6 patients (1.7%) and included carotid puncture (n = 3), sinus bradycardia below 45 beats/min, which responded promptly to atropine and intravenous fluid (n = 2), and complete heart block without hemodynamic compromise (n = 1). There were no pneumothoraxes, pulmonary hemorrhage, or deaths related to the procedure. CONCLUSION: Right heart catheterization via the IJV is quick, safe, and well tolerated. It is not associated with an increased risk of pneumothorax or other complications when performed by experienced operators.
Assuntos
Pressão Sanguínea , Cateterismo Cardíaco/métodos , Hipertensão Pulmonar/diagnóstico , Veias Jugulares , Artéria Pulmonar/fisiopatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bradicardia/etiologia , Cateterismo Cardíaco/efeitos adversos , Lesões das Artérias Carótidas/etiologia , Competência Clínica , Feminino , Bloqueio Cardíaco/etiologia , Humanos , Hipertensão Pulmonar/fisiopatologia , Londres , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Adulto JovemRESUMO
Postoperative bronchopleural fistula is uncommon, but it is associated with a high mortality and morbidity, and a prolonged hospital stay. Surgical treatment is gold standard, but it can prove challenging especially in the presence of infection. We describe three cases of bronchopleural fistula that developed after surgery for lung cancer in 1 patient and for bronchiectasis in 2 patients. All were successfully treated endoscopically by direct application of albumin-glutaraldehyde tissue adhesive (BioGlue; Cryolife Inc, Kennesaw, GA) through a rigid bronchoscope. Complete resolution was obtained in each patient within 24 hours.
Assuntos
Fístula Brônquica/terapia , Doenças Pleurais/terapia , Proteínas , Fístula do Sistema Respiratório/terapia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Indução de RemissãoRESUMO
BACKGROUND: With increasing availability many centers are deploying expandable metallic stents to manage patients with diverse endobronchial disorders. Although these devices have an important role in malignant disease their usefulness in benign large airway disorders is less defined. METHODS: Between 1997 and 2005, 31 patients aged 34 to 83 years with benign large airway compromise secondary to tracheomalacia (n = 7), posttracheostomy stricture (n = 8), posttracheostomy rupture (n = 2), postpneumonectomy bronchopleural fistula (n = 2), stricture after lung transplantation (n = 3), lobectomy, tuberculosis, traumatic injury to right main bronchus (n = 1 patient each), and external compression of the airway secondary to achalasia, multinodular goiter, aortic aneurysm, right brachiocephalic artery aneurysm, right interrupted aortic arch, and dissecting aneurysm (n = 1 patient each) who were medically unfit for formal surgical intervention were treated by Ultraflex stent deployment. The range of follow-up was 1 week to 96 months. Stents were deployed under anesthesia using rigid bronchoscopy. RESULTS: Complications included granulation tissue formation (n = 11) treated with Nd: YAG laser ablation, stent migration (n = 1; stent removed, another deployed), metal fatigue (n = 1), stent removal (n = 1), mucus plugging (n = 2), and halitosis (n = 6) difficult to treat despite antibiotics. Thirteen patients died of unrelated causes between 1 week and 15 months after stent deployment. CONCLUSIONS: Endobronchial metallic stents should be considered only for selected patients with large airway compromise secondary to benign airway diseases for whom other medical comorbidities contraindicate formal airway surgery. Once deployed, they are difficult to remove, are associated with significant complications, and require prospective bronchoscopic surveillance and often further therapeutic intervention.
Assuntos
Broncopatias/terapia , Stents , Doenças da Traqueia/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma/complicações , Antibioticoprofilaxia , Brônquios/lesões , Broncopatias/etiologia , Fístula Brônquica/complicações , Broncoscopia , Comorbidade , Remoção de Dispositivo , Desenho de Equipamento , Falha de Equipamento , Feminino , Migração de Corpo Estranho/etiologia , Bócio Nodular/complicações , Tecido de Granulação/patologia , Halitose/etiologia , Humanos , Transplante de Pulmão , Masculino , Pessoa de Meia-Idade , Doenças Pleurais/complicações , Pneumonectomia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Fístula do Sistema Respiratório/complicações , Ruptura/terapia , Stents/efeitos adversos , Doenças da Traqueia/etiologia , Estenose Traqueal/etiologia , Estenose Traqueal/terapia , Traqueostomia , Resultado do Tratamento , Tuberculose/complicaçõesAssuntos
Fibrinolíticos/uso terapêutico , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica , Adulto , Feminino , Fibrinolíticos/efeitos adversos , Hemodinâmica , Humanos , Nascido Vivo , Seleção de Pacientes , Gravidez , Complicações Cardiovasculares na Gravidez/fisiopatologia , Embolia Pulmonar/fisiopatologia , Medição de Risco , Terapia Trombolítica/efeitos adversos , Resultado do TratamentoRESUMO
A 69-year-old man who had a left pneumonectomy for nonsmall cell lung cancer had a bronchopulmonary fistula develop that recurred after surgical closure. He had multiple organ failure develop precluding further operative intervention. Successful resolution of the fistula was achieved using a novel application of a covered expandable metallic stent.
Assuntos
Fístula/cirurgia , Pneumopatias/cirurgia , Doenças Pleurais/cirurgia , Pneumonectomia , Complicações Pós-Operatórias/cirurgia , Idoso , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Fístula/etiologia , Humanos , Pneumopatias/etiologia , Neoplasias Pulmonares/cirurgia , Masculino , Doenças Pleurais/etiologia , StentsRESUMO
BACKGROUND: Between March 1997 and March 2004 we deployed 80 Ultraflex metallic expandable stents (Boston Scientific, Waterson, MA) in 69 patients under direct vision using rigid bronchoscopy. We report our medium- to long-term experience in patients for whom these stents were deployed. METHODS: To date 15 patients have been followed for more than 1 year (median 41 months, range 12 to 83 months) after stent deployment. Indications for stenting in these patients were neoplasia (5), stricture (5), airway malacia (1), iatrogenic tracheal tear (1), and compression from an aortic aneurysm (1), a right interrupted aortic arch (1), and a right brachiocephalic artery aneurysm with tracheomalacia (1). Ten tracheal stents (9 covered, 1 uncovered) and 10 bronchial stents (8 uncovered, 2 covered) were inserted, and 5 patients received two stents. RESULTS: Five of these patients experienced no long-term problems. Complications included troublesome halitosis (5), which was difficult to treat despite various antibiotic regimes; granulation tissue formation above and below the stent that was successfully treated with low-power Nd:YAG laser therapy (7); and metal fatigue (1). We did not encounter stent migration. CONCLUSIONS: We conclude that Ultraflex expandable metallic stents have an important role in the management of selected patients with diverse endobronchial pathologies and are well tolerated in the long-term. Although associated granulation tissue can be successfully treated with Nd:YAG laser, halitosis can be a difficult problem to address.