Alpha1-antitrypsin deficiency (AATD) disease is associated with several inflammatory conditions due to unprotected proteolytic activity of neutrophil elastase and proteinase 3. We observed that patients with ATTD develop early complications post-transplant. The aim of the study was to identify potential differences in outcomes between AATD and emphysema without AATD (E) following lung transplant. We retrospectively reviewed the data of 41 patients (27 E and 14 AATD) transplanted between 2005 and 2017. Data collection includes functional baseline of recipients and complications as primary outcome, and secondary end points of survival. The majority (79%) of AATD patients received double lung transplant. Main complications in AATD cohort included 3 bowel ischemia and perforation, 1 liver cirrhosis and 4 anastomotic complications causing death in 2 patients. Comparison rate of FEV1 decline in AATD and E group in year 1, 5 and 10 showed no statistical difference (P=0.18; P=0.67), same as FEV1 pre and post-transplant between groups. Mortality was higher in AATD (36%) compare to E (30%). Survival curve showed no difference between both groups with median survival AATD 10.8 years (95% CI 0.54 to 5.336) and E 6.4 years (95% CI 0.19 to 1.86, P=0.64). AATD transplant recipients are predisposed to complications related to their primary underlying disease when compare to E group. However, FEV1 decline had similar trends in both groups with no difference in overall survival.
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease whose distinctive feature is the development of symmetrical polyarthritis. It has a prevalence of ∼1% in the general population, predominating in females and peaking between the ages of 30 and 50 years; it is found worldwide,
Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease. LVRS has recently been commissioned by the NHS England. In this study, a costing model was developed to analyse cost and resource implications of different LVRS procedures.
Abstract Background The deep serratus anterior plane block (SAPB) is a promising novel regional anaesthesia technique for blockade of the anterolateral chest wall. Evidence for the efficacy of SAPB versus other analgesic techniques in thoracic surgery remains inadequate. Aims This study compared ultrasound‐guided continuous SAPB with a surgically placed continuous thoracic paravertebral block (SPVB) technique in patients undergoing videoscopic‐assisted thoracic surgery (VATS). Methods In a single‐centre, double‐blinded, randomized, non‐inferiority study, we allocated 40 patients undergoing VATS to either SAPB or SPVB, with both groups receiving otherwise standardized treatment, including multimodal analgesia. The primary outcome was 48‐hr opioid consumption. Secondary outcomes included numerical rating scale (NRS) for postoperative pain, patient‐reported worst pain score (WPS) as well as functional measures (including mobilization distance and cough strength). Results A 48‐hr opioid consumption for the SAPB group was non‐inferior compared with SPVB. SAPB was associated with improved NRS pain scores at rest, with cough and with movement at 24 hr postoperatively ( p = .007, p = .001 and p = .012, respectively). SAPB was also associated with a lower WPS ( p = .008). Day 1 walking distance was improved in the SAPB group ( p = .012), whereas the difference in cough strength did not reach statistical significance ( p = .071). There was no difference in haemodynamics, opioid side effects, length of hospital stay or patient satisfaction between the two groups. Conclusions The SAPB, as part of a multimodal analgesia regimen, is non‐inferior in terms of 48‐hr opioid consumption compared to SPVB and is associated with improved functional measures in thoracic surgical patients. ClinicalTrials.gov Identifier: NCT03768193. Significance The SAPB interfascial plane block is an efficacious alternative method of opioid‐sparing analgesia in high‐risk thoracic surgical patients as part of an enhanced recovery programme.
COPD affects millions of people worldwide. Patients with advanced COPD have a high symptom burden. Breathlessness, cough and fatigue are frequent daily symptoms. Guidelines often focus on pharmacological treatment, especially inhaler therapy, but other approaches in combination with medications offer symptomatic benefit. In this review, we take a multidisciplinary approach with contributions from pulmonary physicians, cardiothoracic surgeons and a physiotherapist. The following areas are addressed: oxygen therapy and noninvasive ventilation (NIV), dyspnoea management, surgical and bronchoscopic options, lung transplantation and palliative care. Oxygen therapy prescribed within guidelines improves mortality in patients with COPD. NIV guidelines offer only low-certainty instruction on the use of this therapy on the basis of the limited available evidence. Dyspnoea management can take place through pulmonary rehabilitation. Specific criteria aid decisions on referral for lung volume reduction treatments through surgical or bronchoscopic approaches. Lung transplantation requires precise disease severity assessment to determine which patients have the most urgent need for lung transplantation and are likely to have the longest survival. The palliative approach runs in parallel with these other treatments, focusing on symptoms and aiming to improve the quality of life of patients and their families facing the problems associated with life-threatening illness. In combination with appropriate medication and an individual approach to symptom management, patients' experiences can be optimised. Educational aims To understand the multidisciplinary approach to management of patients with advanced COPD. To recognise the parallel approaches to oxygen, NIV and dyspnoea management with consideration of more interventional options with lung volume reduction therapy or lung transplantation. To understand the high level of symptomatology present in advanced COPD and the relevance of palliative care alongside optimal medical management.
Effective restoration of extensive tracheal damage arising from cancer, stenosis, infection or congenital abnormalities remains an unmet clinical need in respiratory medicine. The trachea is a 10–11 cm long fibrocartilaginous tube of the lower respiratory tract, with 16–20 tracheal cartilages anterolaterally and a dynamic trachealis muscle posteriorly. Tracheal resection is commonly offered to patients suffering from short-length tracheal defects, but replacement is required when the trauma exceeds 50% of total length of the trachea in adults and 30% in children. Recently, tissue engineering (TE) has shown promise to fabricate biocompatible tissue-engineered tracheal implants for tracheal replacement and regeneration. However, its widespread use is hampered by inadequate re-epithelialisation, poor mechanical properties, insufficient revascularisation and unsatisfactory durability, leading to little success in the clinical use of tissue-engineered tracheal implants to date. Here, we describe in detail the historical attempts and the lessons learned for tracheal TE approaches by contextualising the clinical needs and essential requirements for a functional tracheal graft. TE manufacturing approaches explored to date and the clinical translation of both TE and non-TE strategies for tracheal regeneration are summarised to fully understand the big picture of tracheal TE and its impact on clinical treatment of extensive tracheal defects.
Abstract Background: Physical activity (PA) is a well-established therapeutic modality for the maintenance and improvement of long-term health in cystic fibrosis (CF). Healthcare professionals (HCP) are considered credible and well-placed messengers for the delivery of PA advice. Limited research exists investigating the extent of PA prescription within CF care. This study aimed to identify Irish HCP i) knowledge and practice of, and ii) motivators and barriers to PA prescription, and iii) proposed strategies to optimize PA promotion and prescription in CF populations. Methods: HCP from six designated CF centres in Ireland and members of the national physiotherapy CF clinical interest group were invited to participate. Following an expression of interest, each HCP (n=81) received an email containing the plain language statement and link to the online survey. 48 HCP (physiotherapists n=24, other n=24) completed the 30-item investigator-developed survey, which included multiple choice single answer, matrix style and open-ended questions. Results: Most HCP (81%) acknowledged that discussing PA with CF patients was part of their professional role. Almost all physiotherapists (95%) reported having sufficient knowledge regarding PA prescription, compared to 17% of other HCP. All physiotherapists reported discussing PA at every patient interaction, with 81% employing the current consensus guidelines, compared to 33% and 5% of other HCP, respectively. Among the most common barriers reported by HCP to recommending PA to their CF patients were; lack of motivation and compliance among patients to adhere to PA advice, limited availability of PA programmes to refer their patients to, limited time with patients during clinic visits and a lack of knowledge regarding PA prescription for CF care. Three-quarters of HCP reported a need to improve PA services for CF patients in Ireland. Conclusion: As people with CF are living longer, it is imperative that HCP are expanding their scope of practice to include discussions around PA at every patient visit. Formal educational opportunities in the form of continuing professional development programmes are warranted for CF HCP to optimize long-term patient management and outcomes. There is also a need to develop patient-centered and evidence-based PA programmes underpinned by theories of behaviour change to enhance motivation and compliance among CF patients.
Summary Airway management for tracheal resection and reconstruction can be challenging. 'LET Flow' is a novel technique using a high‐flow oxygen delivery device attached directly to a laryngeal mask or tracheal tube that may provide apnoeic oxygenation during surgery on an open trachea. We report a case where a high‐flow oxygen device, AIRVO TM 2 (Fisher & Paykel Healthcare, Aukland, New Zealand), was attached to a size three laryngeal mask airway and 100% oxygen at a flow‐rate of 40 l.min ‐1 delivered across an open trachea. This permitted 42 minutes of uninterrupted surgery in an apnoeic female patient with subglottic tracheal stenosis. Oxygen saturations remained above 96% during the apnoeic period and arterial blood gas parameters within acceptable limits. To avoid possible barotrauma or volutrauma as complete tracheal closure approached, flow was reduced to 10 l.min ‐1 followed by laryngeal mask cuff deflation. Mechanical ventilation recommenced at tracheal closure. 'LET Flow' provided optimal surgical conditions by removing an airway device from the operative field. No urgent interruption of surgery or rescue mechanical ventilation was required.
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