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A long storyA long story
with anwith an
unexpectedunexpected
endingending
Prof Eric MARCHANDProf Eric MARCHAND
Université ...
 MB, male, 55y admitted in emergency forMB, male, 55y admitted in emergency for
respiratory distressrespiratory distress
...
 Mobile Emergency Medical Unit called atMobile Emergency Medical Unit called at
home for acute respiratory distresshome f...
 Chest tube inserted and patientChest tube inserted and patient
transferred to the ICUtransferred to the ICU
 Patient ex...
 What would you propose to the patient ?What would you propose to the patient ?
1.1. To remain patient and maintain chest...
 Parameters to take into account :Parameters to take into account :
 Risk of recurrence is high; first event wasRisk of ...
1.1. To remain patient and maintain chest tubeTo remain patient and maintain chest tube
suctionsuction; high risk of recur...
Instillation of tetracyclinesInstillation of tetracyclines
through the chest tube…through the chest tube…
Persistent air...
 What do you propose to the patient ?What do you propose to the patient ?
1.1. Be patient and maintain chest tube suction...
1.1. Be patient and maintain chest tube suctionBe patient and maintain chest tube suction
2.2. Insert a second chest tube ...
What about a volume reductionWhat about a volume reduction
procedure ?procedure ?
1.1.No way! A pulmonary rehabilitationN...
1.1.No way! A pulmonary rehabilitationNo way! A pulmonary rehabilitation
program is needed before suchprogram is needed be...
 So what information would you need?So what information would you need?
1.1. Pulmonary function tests including staticPul...
1.1. Pulmonary function tests including static lungPulmonary function tests including static lung
volumes and diffusionvol...
 Pulmonary function tests performed 1Pulmonary function tests performed 1
month before admission, in a stable statemonth ...
 How would you quote the patient as aHow would you quote the patient as a
candidate for lung volume reductioncandidate fo...
1.1. Bad candidate, DLCO too low, high risk ofBad candidate, DLCO too low, high risk of
perioperative mortalityperioperati...
 High degree of emphysema heterogeneity;High degree of emphysema heterogeneity;
target zonestarget zones11
1. Slone RM et...
 A bilateral video assisted thoracoscopicA bilateral video assisted thoracoscopic
lung volume reduction surgerylung volum...
Pre LVRSPre LVRS Post LVRSPost LVRS
AbsAbs % pred% pred AbsAbs % pred% pred
FEVFEV11:: 0.95L0.95L 31%31% 1.39L1.39L 45%45...
Pre-LVRSPre-LVRS Post-LVRSPost-LVRS
Successfull LVRS = more space for the best parts of theSuccessfull LVRS = more space f...
ConclusionConclusion
Do not only think LVR(S) when a COPDDo not only think LVR(S) when a COPD
patient is desperately dysp...
1819.ppt
1819.ppt
1819.ppt
1819.ppt
1819.ppt
1819.ppt
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  • <number>
  • respiratory res-p(&-)r&-"tor-E
    Exposure: ik-'spO-zh&r
    Suggestive: s&g-'jes-tiv
    Bronchodilator brä[ng]-(")kO-dI-'lA-t&r
    Emphysema em(p)-f&-'zE-m&
    Predominant pri-'dä-m&-"n&nt
  • Mobile mO-b&l,
    Mechanically mi-'ka-ni-k(&-)lE
    Ventilate ven-t&-"lAt
  • Pneumothorax "nü-m&-'thor-"aks
    Complete k&m-'plEt
  • Insert in-'s&rt
    Transfer tran(t)s-'f&r
    ex·tu·bate /ek- st(y)ü- bät,
    Arrival &-'rI-v&l
    Persistent p&r-'sis-t&nt
    Eupneic yüp-'nE-ik
    Suction 's&k-sh&n
    Cm 'sen-t&-"mE-t&r
  • Thorax 'thor-"aks
  • Propose pr&-'pOz
    Remain ri-'mAn
    Maintain mAn-'tAn
  • Transcript of "1819.ppt"

    1. 1. A long storyA long story with anwith an unexpectedunexpected endingending Prof Eric MARCHANDProf Eric MARCHAND Université catholique de LouvainUniversité catholique de Louvain Service de pneumologieService de pneumologie Cliniques universitaires de Mont-GodinneCliniques universitaires de Mont-Godinne BELGIUMBELGIUM eric.marchand@pneu.ucl.ac.beeric.marchand@pneu.ucl.ac.be
    2. 2.  MB, male, 55y admitted in emergency forMB, male, 55y admitted in emergency for respiratory distressrespiratory distress  One month earlier, consulted for dyspneaOne month earlier, consulted for dyspnea At that time:At that time:  Modified MRC dyspnea scale: 2Modified MRC dyspnea scale: 2  Former smoker (45 p/y), no professional exposureFormer smoker (45 p/y), no professional exposure  No significant co-morbidityNo significant co-morbidity  Weight: 55 kg; BMI: 19.7 kg/m²Weight: 55 kg; BMI: 19.7 kg/m²  Pulmonary function tests suggestive of COPD GOLDPulmonary function tests suggestive of COPD GOLD stage III - IV (post BD FEVstage III - IV (post BD FEV11 : 0.95L = 31% pred): 0.95L = 31% pred)  6 min WT: 320 m; VAS dyspnea: 8/10; SpO6 min WT: 320 m; VAS dyspnea: 8/10; SpO22 949485%85%  BODE Index: 6BODE Index: 6  Chest X-ray showing lung hyperinflation withChest X-ray showing lung hyperinflation with emphysema predominant in the upper lobesemphysema predominant in the upper lobes  Patient was prescribed Tiotropium 18 µg od andPatient was prescribed Tiotropium 18 µg od and Salmeterol-Fluticasone 50/500 µg bidSalmeterol-Fluticasone 50/500 µg bid
    3. 3.  Mobile Emergency Medical Unit called atMobile Emergency Medical Unit called at home for acute respiratory distresshome for acute respiratory distress  Tracheal tube inserted at home andTracheal tube inserted at home and patient transferred to the emergencypatient transferred to the emergency department while mechanically ventilateddepartment while mechanically ventilated  Diminished breath sounds on the leftDiminished breath sounds on the left hemithoraxhemithorax
    4. 4.  Chest tube inserted and patientChest tube inserted and patient transferred to the ICUtransferred to the ICU  Patient extubated on the following dayPatient extubated on the following day and transferred to the pneumology unitand transferred to the pneumology unit  At arrival in the pneumology unitAt arrival in the pneumology unit  Patient is eupneicPatient is eupneic  Blood gases (OBlood gases (O22 2L/min):2L/min): pH: 7.39; PaOpH: 7.39; PaO22: 82 mmHg; PaCO: 82 mmHg; PaCO22: 43 mmHg: 43 mmHg  Persistent air leak with suction (-10 cm HPersistent air leak with suction (-10 cm H22O)O) applied to the chest tubeapplied to the chest tube  Same after 7 daysSame after 7 days
    5. 5.  What would you propose to the patient ?What would you propose to the patient ? 1.1. To remain patient and maintain chest tubeTo remain patient and maintain chest tube suctionsuction 2.2. Insert a second chest tube with the tip atInsert a second chest tube with the tip at the thoracic apex; the first one is in athe thoracic apex; the first one is in a suboptimal positionsuboptimal position 3.3. A chemical pleurodesis via the chest tubeA chemical pleurodesis via the chest tube 4.4. A video-assisted thoracoscopy with talcA video-assisted thoracoscopy with talc poudragepoudrage 5.5. A video-assisted thoracoscopy withA video-assisted thoracoscopy with aerostasis and pleural abrasionaerostasis and pleural abrasion
    6. 6.  Parameters to take into account :Parameters to take into account :  Risk of recurrence is high; first event wasRisk of recurrence is high; first event was life-threateninglife-threatening ⇒⇒ Intervention to preventIntervention to prevent recurrence is requiredrecurrence is required  Success rate, risk of pneumothorax relapseSuccess rate, risk of pneumothorax relapse  Long-term outcome; need for lungLong-term outcome; need for lung transplantation? …but prior pleurodesistransplantation? …but prior pleurodesis does not preclude successful lungdoes not preclude successful lung transplantation despite increased risk oftransplantation despite increased risk of perioperative bleedingperioperative bleeding11 1. Almoosa KF et al. Chest. 2006;129:12741. Almoosa KF et al. Chest. 2006;129:1274
    7. 7. 1.1. To remain patient and maintain chest tubeTo remain patient and maintain chest tube suctionsuction; high risk of recurrence (>40%); high risk of recurrence (>40%)11 , life, life threatening !threatening ! 2.2. Insert a second chest tube with the tip at theInsert a second chest tube with the tip at the thoracic apex;thoracic apex; the first one is in a suboptimalthe first one is in a suboptimal position;position; leak but no more pneumothorax !leak but no more pneumothorax ! Intervention to prevent recurrence needed!Intervention to prevent recurrence needed! 3.3. A chemical pleurodesis via the chest tubeA chemical pleurodesis via the chest tube;; less efficient than thoracoscopyless efficient than thoracoscopy 4.4. A video-assisted thoracoscopy with talcA video-assisted thoracoscopy with talc poudragepoudrage 5.5. A video-assisted thoracoscopy with aerostasisA video-assisted thoracoscopy with aerostasis and pleural abrasionand pleural abrasion22 1. Baumann MH and Strange C. Chest 1997;112:7891. Baumann MH and Strange C. Chest 1997;112:789 2. Tschopp JM et al. Eur Respir J 2006;28:6372. Tschopp JM et al. Eur Respir J 2006;28:637
    8. 8. Instillation of tetracyclinesInstillation of tetracyclines through the chest tube…through the chest tube… Persistent air leak after 7Persistent air leak after 7 more days…more days…
    9. 9.  What do you propose to the patient ?What do you propose to the patient ? 1.1. Be patient and maintain chest tube suctionBe patient and maintain chest tube suction 2.2. Insert a second chest tube in the lowerInsert a second chest tube in the lower thoraxthorax 3.3. VATS with aerostasis and pleural abrasionVATS with aerostasis and pleural abrasion 4.4. Muscle sparing open thoracotomy withMuscle sparing open thoracotomy with aerostasis and pleurectomyaerostasis and pleurectomy 5.5. Another procedureAnother procedure
    10. 10. 1.1. Be patient and maintain chest tube suctionBe patient and maintain chest tube suction 2.2. Insert a second chest tube in the lower thoraxInsert a second chest tube in the lower thorax 3.3. VATS with aerostasis and pleural abrasionVATS with aerostasis and pleural abrasion 4.4. Muscle sparing open thoracotomy withMuscle sparing open thoracotomy with aerostasis and pleurectomyaerostasis and pleurectomy 5.5. Another procedureAnother procedure
    11. 11. What about a volume reductionWhat about a volume reduction procedure ?procedure ? 1.1.No way! A pulmonary rehabilitationNo way! A pulmonary rehabilitation program is needed before suchprogram is needed before such procedureprocedure 2.2.Yes! Go for unilateral left LVRSYes! Go for unilateral left LVRS 3.3.Yes! Go for bilateral LVRSYes! Go for bilateral LVRS 4.4.Good idea but I need moreGood idea but I need more informationsinformations
    12. 12. 1.1.No way! A pulmonary rehabilitationNo way! A pulmonary rehabilitation program is needed before suchprogram is needed before such procedureprocedure 2.2.Yes! Go for unilateral left LVRSYes! Go for unilateral left LVRS 3.3.Yes! Go for bilateral LVRSYes! Go for bilateral LVRS 4.4.Good idea but I need moreGood idea but I need more informationinformation
    13. 13.  So what information would you need?So what information would you need? 1.1. Pulmonary function tests including staticPulmonary function tests including static lung volumes and diffusionlung volumes and diffusion 2.2. Lung scintigraphyLung scintigraphy 3.3. Cardiopulmonary exercise testing (cyclo-Cardiopulmonary exercise testing (cyclo- ergospirometry)ergospirometry) 4.4. Evaluation of the coronary reserveEvaluation of the coronary reserve
    14. 14. 1.1. Pulmonary function tests including static lungPulmonary function tests including static lung volumes and diffusionvolumes and diffusion 2.2. Lung scintigraphyLung scintigraphy 3.3. Cardiopulmonary exercise testing (cyclo-Cardiopulmonary exercise testing (cyclo- ergospirometry)ergospirometry) 4.4. Evaluation of the coronary reserveEvaluation of the coronary reserve
    15. 15.  Pulmonary function tests performed 1Pulmonary function tests performed 1 month before admission, in a stable statemonth before admission, in a stable state after administration of ipratropium andafter administration of ipratropium and fenoterol (DUOVENTfenoterol (DUOVENT®® )) AbsAbs % pred% pred  FEVFEV11:: 0.95L0.95L 31%31%  FVC:FVC: 2.65L2.65L 69%69%  FEVFEV11/FVC/FVC 36%36%  DLCODLCO 22%22%  KCOKCO 33%33%  TLCTLC 8.89L8.89L 142%142%  RV/TLCRV/TLC 67%67% 190%190%
    16. 16.  How would you quote the patient as aHow would you quote the patient as a candidate for lung volume reductioncandidate for lung volume reduction surgery?surgery? 1.1. Bad candidate, DLCO too low, high risk ofBad candidate, DLCO too low, high risk of perioperative mortalityperioperative mortality 2.2. Good candidate, go for a bilateral surgicalGood candidate, go for a bilateral surgical reductionreduction 3.3. Potentially good candidate but bad setting;Potentially good candidate but bad setting; don’t go for itdon’t go for it 4.4. Potentially good candidate but would notPotentially good candidate but would not proceed before a pulmonary rehabilitationproceed before a pulmonary rehabilitation programprogram
    17. 17. 1.1. Bad candidate, DLCO too low, high risk ofBad candidate, DLCO too low, high risk of perioperative mortalityperioperative mortality11 2.2. Good candidate, go for a bilateral surgicalGood candidate, go for a bilateral surgical reductionreduction 3.3. Potentially good candidate but bad setting;Potentially good candidate but bad setting; don’t go for itdon’t go for it22 4.4. Potentially good candidate but would notPotentially good candidate but would not proceed before a pulmonary rehabilitationproceed before a pulmonary rehabilitation programprogram33 1.1. NETT Research Group. New Engl J Med. 200;345:1075NETT Research Group. New Engl J Med. 200;345:1075 2.2. Hansson B et al. Eur Respir J. 1997;10:2650Hansson B et al. Eur Respir J. 1997;10:2650 3.3. Albert RK et al. Am J Respir Crit Care Med. 1998;158:71; Serna DL et al. JAlbert RK et al. Am J Respir Crit Care Med. 1998;158:71; Serna DL et al. J Thorac Cardiovasc Surg. 1999;118:1101; Pompeo E et al. Ann ThoracThorac Cardiovasc Surg. 1999;118:1101; Pompeo E et al. Ann Thorac Surg. 2000;70:948Surg. 2000;70:948
    18. 18.  High degree of emphysema heterogeneity;High degree of emphysema heterogeneity; target zonestarget zones11 1. Slone RM et al. Radiology 1997;204;685; Hunsaker AR et al. Radiology.1. Slone RM et al. Radiology 1997;204;685; Hunsaker AR et al. Radiology. 2002;222:4912002;222:491  Marked hyperinflation resulting in high RV/TLCMarked hyperinflation resulting in high RV/TLC ratio and concomitant lowered VCratio and concomitant lowered VC22 2. Fessler HE and Permutt S. Am J Respir Crit Care Med. 1998;157:715;2. Fessler HE and Permutt S. Am J Respir Crit Care Med. 1998;157:715; Ingenito EP et al. J Appl Physiol. 2003;94;20Ingenito EP et al. J Appl Physiol. 2003;94;20 Areas of parenchymal compression onAreas of parenchymal compression on imaging are surrogate markersimaging are surrogate markers
    19. 19.  A bilateral video assisted thoracoscopicA bilateral video assisted thoracoscopic lung volume reduction surgerylung volume reduction surgery associated with pleural abrasion isassociated with pleural abrasion is performedperformed  Prolonged air leak (left side) but patientProlonged air leak (left side) but patient discharged without chest tubedischarged without chest tube  Two months after LVRS, ambulatoryTwo months after LVRS, ambulatory controlcontrol Less dyspneicLess dyspneic Improvement inImprovement in  PFTsPFTs  6 min walk test: 380 m (+60m); VAS: 5/106 min walk test: 380 m (+60m); VAS: 5/10
    20. 20. Pre LVRSPre LVRS Post LVRSPost LVRS AbsAbs % pred% pred AbsAbs % pred% pred FEVFEV11:: 0.95L0.95L 31%31% 1.39L1.39L 45%45% FVC:FVC: 2.65L2.65L 69%69% 3.15L3.15L 82%82% FEVFEV11/FVC/FVC 36%36% 44%44% TLCTLC 8.89L8.89L 142%142% 6.89L6.89L 110%110% RV/TLCRV/TLC 67%67% 190%190% 55%55% 156%156% DLCODLCO 22%22% 44%44% KCOKCO 33%33% 61%61%
    21. 21. Pre-LVRSPre-LVRS Post-LVRSPost-LVRS Successfull LVRS = more space for the best parts of theSuccessfull LVRS = more space for the best parts of the lungs and reduced hyperinflationlungs and reduced hyperinflation
    22. 22. ConclusionConclusion Do not only think LVR(S) when a COPDDo not only think LVR(S) when a COPD patient is desperately dyspnoeicpatient is desperately dyspnoeic despite adequate maximal medicaldespite adequate maximal medical treatmenttreatment It might be useful for some of yourIt might be useful for some of your emphysematous patients to thinkemphysematous patients to think LVR(S) in other settings !LVR(S) in other settings ! PneumothoraxPneumothorax Small (mostly upper lobe) lung cancersSmall (mostly upper lobe) lung cancers11 1. McKenna RJ et al. Chest 1996;110:885, Beckles MA et al. Chest1. McKenna RJ et al. Chest 1996;110:885, Beckles MA et al. Chest
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