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Station 1: Respiratory
Published in Saira Ghafur, Parminder K Judge, Richard Kitchen, Samuel Blows, Fiona Moss, The MRCP PACES Handbook, 2017
Saira Ghafur, Parminder K Judge, Richard Kitchen, Samuel Blows, Fiona Moss
What surgical interventions can be offered to patients with COPD? Bullectomy: In symptomatic patients who ha ve a large bulla and FEV1 <50% predicted.Lung volume reduction surgery (LVRS): This can be considered in patients who have upper-zone dominant emphysema, FEV1 >20% predicted, PaCO2 <7.3 kPa and transfer factor of the lung for carbon monoxide (TLCO) >20%.Lung transplantation.
Other Treatments for Dyspnea
Published in Donald A. Mahler, Denis E. O’Donnell, Dyspnea, 2014
A bulla is an air-filled space at least 1 cm in diameter located in the lung parenchyma. Compressive forces of the bulla can compromise ventilation and perfusion of adjacent lung tissue as well as activate lung and chest wall mechanoreceptors to cause breathlessness. Resection of a giant bulla not only enables the compressed lung to re-expand but also decreases lung volumes; this lung deflation allows the vertical muscles fibers of the diaphragm to lengthen and improve mechanical function. Candidates for bullectomy should be symptomatic despite optimal medical therapy, have a single well-defined giant bulla with adjacent vascular crowding, and relatively normal lung parenchyma in other lung zones [65]. It is recommended that the bulla should occupy at least one-third of the hemithorax for a favorable outcome [66].
Endobronchial valve therapy for severe emphysema: an overview of valve-related complications and its management
Published in Expert Review of Respiratory Medicine, 2020
T. David Koster, Karin Klooster, Nick H. T. Ten Hacken, Marlies van Dijk, Dirk-Jan Slebos
In case of a persistent air leak despite the removal of valves, other options should be considered, comparable to the standard care of a pneumothorax. However, in the majority of the patients this is not necessary. This includes mechanical or chemical pleurodesis or use of a Heimlich valve. Furthermore, one-way valves can be used to treat persistent air leaks. In this case, valve insertion in the targeted airways leading to the region of the air leakage may lead to a resolution or reduction of the air leak [42,46]. Furthermore, video-assisted thoracoscopic surgery (VATS) with bullectomy can be performed to treat the air leak [42]. However, the choice of and timing of therapy are dependent on both clinical parameters, patient preference, and the availability of several options within the institution [42].
Veno-venous extracorporeal membrane oxygenation for the acute respiratory distress syndrome: a bridge too far?
Published in Acta Cardiologica, 2021
Alexander Smith, Cliff Morgan, Stéphane Ledot, James Doyle, Tina Xu, Lynn Shedden, Maurizioassariello Passariello, Brijesh Patel, Anne-Marie Doyle, Susanna Price, Christophe Vandenbriele, Suveer Singh
The patient had a prolonged admission on ECMO with protective mechanical lung ventilation. He was given high dose methylprednisolone as a strategy to resolve persisting non-infective consolidation. He had slow improvement in parenchymal ground glass changes and the development of progressive bilateral cavitations complicated by pneumothoraxes requiring pleural drainage (Figure 1). Video-assisted thoracoscopic bullectomy was considered but ruled out due to uncertainties of benefit to physiological reserve and the perioperative risk in the acute setting.
Current opinion and comparison of surgical procedures for the treatment of primary spontaneous pneumothorax
Published in Expert Review of Respiratory Medicine, 2022
Kenji Tsuboshima, Masatoshi Kurihara, Kuniaki Seyama
For special ports, Yang et al. demonstrated the use of a single-incision laparoscopic surgery port, also used in cholecystectomy, for uniportal VATS [64]. A 25-mm skin incision was made in the fifth ICS on the midaxillary line. They used a 5-mm 30-degree thoracoscope and a roticulator endograsper. Comparing the uniportal VATS (n = 27) and three-port VATS (n = 13), there were no significant differences in the mean operation time, hospital stay, and visual analog pain scale. Meanwhile, the uniportal VATS group had a significantly lower incidence of paresthesia and a significantly higher satisfaction rate regarding wound scarring than the three-port VATS group. At 4 months postoperatively, the postoperative recurrence rates were 3.7% and 7.7%, respectively, with no significant difference. Yamazaki et al. placed a wound protector on a 2-cm single incision in 100 patients with PSP in 2015 [55]. Bullectomy was performed using a 5-mm flexible thoracoscope, endograsper, and an endoscopic linear stapler. There was no conversion to thoracotomy, and no severe adverse events occurred. Four patients (4.0%) had recurrent pneumothorax during the median follow-up of 28 months. Yoshizawa et al. compared 161 cases of uniportal VATS and 71 cases of three-port VATS [56]. For uniportal VATS, a 25- to 30-mm incision was made in the fifth or sixth ICS on the anterior axial line. They introduced a 5-mm flexible thoracoscope and instruments from the same incision into the thoracic cavity. Then, they occasionally made a 3-mm incision for needlescopic forceps in the third ICS on the anterior axial line. After resecting the bullae, a PGA sheet was applied to the staple lines with fibrin glue to prevent postoperative air leakage and reduce the recurrence rate. The operation time and the duration of postoperative drainage were significantly longer in the uniportal VATS group than in the three-port VATS group. The postoperative recurrence rates were 2.5% and 4.2%, respectively, with no statistical difference. Masmoudi et al. (2017) described the feasibility of uniportal VATS for spontaneous pneumothorax in 351 cases [57]. Bullectomy with partial pleurectomy, pleural abrasion, or talc pleurodesis was performed. Sixty-seven patients (19%) presented with complications. In 43 patients in the pleurectomy group, seven (16.3%) developed postoperative hemothorax, requiring repeat surgery. Pneumothorax recurred in 3.6% of the cases within a mean of 24 months. A 1.5- to 2-cm skin incision was made at the sixth intercostal space along the middle axillary line. Chen et al. also described the feasibility of uniportal VATS in 30 patients with PSP in 2011 [58]. A 25-mm skin incision was made for uniportal VATS by articulating the graspers. They compared 10 patients who underwent uniportal VATS and 20 patients who underwent three-port VATS. The visual analog scores for the assessment of pain were significantly lower in the uniportal VATS group in the first 24 h after surgery. There were no recurrences during the follow-up period, which lasted at least 3 months.