Emphysematous Group Research Articles

Thoracoscopic Treatment of Giant Pulmonary Bullae

BackgroundGiant pulmonary bullae (GPB) is rare. The aim of this study was to evaluate the functional results of video-assisted thoracic surgery (VATS) in the treatment of GPB and the factors associated with complications following VATS resection for GPB. Materials and methodsFrom January 2010 to January 2015, 44 GPB patients underwent surgery with VATS. Individual GPB patient characteristics and surgical outcomes were evaluated. The patients were separated into two groups (an emphysematous group and a nonemphysematous group), and differences between the respective groups were investigated. ResultsAlthough there were no mortalities within a 30-d postoperative period among the 44 GPB patients treated surgically with VATS, 28 experienced postoperative complications, of which the most common were air leaks. VATS for GPB resulted in obvious improvements in symptoms and lung function in the majority of cases. Among 26 patients with preoperative dyspnea, the symptoms of 22 patients (84.62%) improved after treatment with VATS resection for GPB, and the mean forced expiratory volume in 1 s increased from 2.24 L preoperatively to 2.5 L postoperatively (P = 0.02). The complication rate of patients aged >48 y, who smoked and had emphysema, was significantly higher than that of those who did not smoke and did not have emphysema (79.2% versus 45%, P = 0.019; 85.7% versus 25%, P < 0.05; 88% versus 31.6%, P < 0.05). These characteristics could be associated with complications. ConclusionsVATS resection is a safe and effective treatment for GPB and leads to improvements in symptoms and lung function. Patients >48 y, who smoked and had emphysema, were more likely to experience postoperative complications. There could be a relationship between these characteristics and the patients’ postoperative complications.

Assessment of lung functions using impulse oscillometry before and after bronchoscopic lung volume reduction with histoacryl gel

BackgroundMany forms of bronchoscopic lung volume reduction were introduced as a treatment for patients with emphysema surpassing the surgical management and its fatality. Biological bronchoscopic lung volume reduction (BBLVR) proved to be a safe and competent solution inducing collapse of the emphysematous segment(s). Impulse oscillometry (IOS) constitutes an effortless but underused surrogate to spirometry in assessment of pulmonary function. Therefore, the aim of this study was to evaluate the use of IOS before and after BBLVR with histoacryl gel in comparison with spirometry among patients with emphysema.Patients and methodsA prospective comparative follow-up study was performed at Kobry El-Kobba Military Hospital. A total of 30 patients with radiological evidence of heterogenous emphysema or emphysematous bullae were enrolled during the period from July 2014 to April 2015. BBLVR was accomplished by the instillation of the histoacryl gel into the affected segment(s) using standard technique. Clinical, radiological, and functional assessments were done before and 4 weeks after the procedure.ResultsAfter BBLVR, the following outcome was measured: 6-min walk test, partial pressure of O2 in arterial blood, forced expiratory volume in the first second, resistance at 5 Hz, resistance at 20 Hz, and reactance at 5 Hz. They improved with statistical significance among all the patients. There was a negative correlation between forced vital capacity and resistance at 5 Hz in the heterogenous emphysema group (ρ=0.47 and P<0.025); however, the forced expiratory volume at first second showed positive correlation with reactance at 5 Hz in emphysematous bullae group (ρ=0.82 and P<0.023).ConclusionBBLVR with histoacryl gel is associated with improvement in exercise capacity and lung functions. IOS provided comprehensive assessment of the pulmonary functions, which was in good correlation with spirometry.

Detection of the mild emphysema by quantification of lung respiratory airways with hyperpolarized xenon diffusion MRI.

To demonstrate the feasibility to quantify the lung respiratory airway in vivo with hyperpolarized xenon diffusion magnetic resonance imaging (MRI), which is able to detect mild emphysema in the rat model. The lung respiratory airways were quantified in vivo using hyperpolarized xenon diffusion MRI (7T) with eight b values (5, 10, 15, 20, 25, 30, 35, 40 s/cm2 ) in five control rats and five mild emphysematous rats, which were induced by elastase. The morphological results from histology were acquired and used for comparison. The parameters DL (longitudinal diffusion coefficient), r (internal radius), h (alveolar sleeve depth), Lm (mean linear intercept), and S/V (surface area to lung volume ratio) derived from the hyperpolarized xenon diffusion MRI in the emphysematous group showed significant differences from those in the control group (P < 0.05). Additionally, these parameters correlated well with the Lm obtained by the traditional histological sections (Pearson's correlation coefficients >0.8). The lung respiratory airways can be quantified by hyperpolarized xenon diffusion MRI, showing the potential for mild emphysema diagnosis. Also, the study suggested that the hyperpolarized xenon DL is more sensitive than DT (transverse diffusion coefficient) to detect mild emphysema. 1 J. Magn. Reson. Imaging 2017;45:879-888.

Follow-up studies on chronic obstructive pulmonary disease among Ookunojima poison gas workers

A high prevalence of chronic bronchitis has been reported among former employees of a poison gas factory in Ookunojima. The author has studied changes in clinical features by analyzing chest X-ray, sputa and respiratory function in 72 cases whose clinical courses could be observed for the 10 year period from 1981 to 1991. FEV1.0 in the patients with emphysematous change on chest X-ray was significantly decreased as compared to that of patients with inflammatory change and those with normal findings. FEV1.0 in the obstructive and infectious-obstructive type groups, in terms of clinical classification of chronic bronchitis, was significantly decreased as compared to that of simple and inflammatory types. These results show that the obstructive ventilation disorder in these two groups is progressive. Next, the author analyzed CT findings of the whole lung in 93 cases, including the former 72 cases. %(I-E) represents the alteration ratio of whole lung field CT numbers during full inspiration and full expiration. %(I-E) in the emphysematous group was significantly decreased as compared to the other two groups. %(I-E) showed a good correlation with FEV1.0 (r = 0.645), FEV1.0% (r = 0.500) and V50/V25(r = 0.523). This parameter was considered to be useful for evaluation of the obstructive ventilation disorder in these cases. The chronic bronchitis in these poison gas workers has been reported to be predominantly inflammatory and to have a variable clinical course. However, our results show that progression of the obstructive ventilation disorder caused by emphysematous change produces long term deterioration of pulmonary function in poison gas workers.

Cortical bone dynamics, strength, and densitometry after induction of emphysema in hamsters.

Recent evidence suggests that patients suffering from chronic obstructive pulmonary disease are also at an increased risk of developing osteoporosis. The pathophysiological mechanism(s) linking these progressive diseases is unknown. The goal of this investigation was to determine whether there were alterations in bone mineral density and content, cortical bone structure and strength, and indexes of bone formation and resorption in the elastase-induced emphysematous hamster. At 3 wk after induction of emphysema, the femoral bone mineral content was 8% less (P = 0.026) and the femoral fracture strength was 6% less (P = 0.032) in the emphysematous hamster than in controls. The cortical area was 8.4% less (P = 0.013) and the periosteal mineral appositional rate was 27% less (P = 0.05) than in controls. Additionally, the endocortical eroded surface in the emphysematous group was about twice that in the control group (P = 0.003). Differences in some indexes of bone formation and resorption, paralleled by differences in bone structure and strength, were observed 3 wk after induction of emphysema. These differences in skeletal metabolism and strength may help explain some of the skeletal changes associated with chronic obstructive pulmonary disease in humans.

Mitochondrial electron transport chain function is enhanced in inspiratory muscles of patients with chronic obstructive pulmonary disease.

In chronic obstructive pulmonary disease, inspiratory muscles face increased resistive and elastic workloads and therefore increased energy requirements. The adaptive response of these muscles to this higher energy demand includes increased oxidative enzymes and changes in contractile protein expression but the consequences on mitochondrial function and energy metabolism have not been assessed so far. We investigated the in situ properties of the mitochondria of costal diaphragm and external intercostal muscles using the skinned fiber technique in 9 emphysematous and 11 age-matched control patients. Biopsies obtained during thoracic surgery were placed in an oxygraphic chamber to measure maximal oxygen uptake. We observed that the maximal oxidative capacity of diaphragm and external intercostal muscles increased significantly in the emphysematous group compared with the control group (+135 and +37%, respectively). Significant correlations were found between the maximal oxidative capacity and patients' pulmonary indexes of obstruction (diaphragm: r = -0.637, intercostal: r = -0.667, p < 0.005) and hyperinflation (diaphragm: r = 0.639, p < 0.003, intercostal: r = 0.634, p < 0.01). Slow myosin heavy chain isoform increased in the diaphragm of the emphysematous group, with significant relationships between indexes of obstruction and hyperinflation and activities of biochemical mitochondrial markers. Thus, severe emphysema was associated with increased mitochondrial capacity and efficiency in the inspiratory muscles, supporting an endurance training-like effect.

Imaging of ventilation in chronic obstructive pulmonary disease.

Patterns of radioaerosol deposition in patients with COPD may be interpreted on the basis of derangements in convective ventilation. Thus, in patients with asthma, central deposition is consistently associated with increased airway resistance, in the absence of acute attack, indicating that in this condition major airways are usually the site of bronchial constriction. In patients with chronic bronchitis, inhomogeneous and spotty deposition patterns are strongly associated with indexes of uneven and wasted ventilation and may be explained on the basis of destruction or obstruction of peripheral airways. Spotty deposition is ascribed to very uneven convective ventilation reduced to a limited number of air streams, as opposed to the normal situation of a very high number of air streams giving rise to the uniform pattern of radioaerosol deposition. Patients with emphysema show less distinctive patterns of deposition and may resemble those of the patients with asthma and chronic bronchitis. Nevertheless, the deposition features are very useful to better characterize the patient even in the emphysematous group. From the practical point of view, the features of aerosol deposition provide useful information for evaluation and treatment of the patient with COPD. They may also prove useful to better define and characterize the different disease entities grouped as COPD.

Histochemical and biochemical correlates of ventilatory muscle fatigue in emphysematous hamsters.

Histochemical and biochemical characteristics of the ventilatory muscles were evaluated in control and elastase-induced emphysematous hamsters. The emphysematous group was divided into sedentary and endurance-trained groups. Endurance training consisted of treadmill running, 1 h a day, 7 d a week. The experimental period lasted 24 wk. Histochemically, the diaphragm from the sedentary emphysematous hamsters revealed a selective fast fiber atrophy which was prevented by endurance training. Training also led to a hypertrophy of the slow, high oxidative fibers. The external intercostals from both emphysematous groups revealed an increased proportion of fast oxidative fibers at the expense of a decreased number of fast glycolytic fibers. However, the fast fibers in both emphysematous groups were significantly atrophied as compared with controls. The internal intercostals revealed no adaptive changes in either size or proportion distribution of the various fiber types. Biochemically, the diaphragm of the emphysematous animals had a significantly improved oxidative potential as measured by citrate synthase, and a reduced glycolytic capacity as indicated by phosphofructokinase activity, compared with controls. The magnitudes of the biochemical changes were similar in both emphysematous groups and were consistent for diaphragmatic samples taken from the costal and crural segments. The combined internal and external intercostals also underwent significant biochemical increases in their oxidative capacity. In addition, training of the emphysematous group led to an increased glycolytic potential of the intercostals.

DIAGNOSIS OF PULMONARY EMPHYSEMA BY COMPUTERISED TOMOGRAPHY

Eleven patients with peripheral bronchial carcinoma had computerised tomographic (CT) scans before operation. The resected specimens from six of these patients showed mild centri-acinar emphysema. Preoperatively the two groups had not differed significantly in spirometric findings or lung volumes. The frequency distribution curves of EMI numbers within the lung fields of patients who proved to have centri-acinar emphysema differed significantly from those of the group who did not, there being more pixels in the EMI range -450 to -500 in the emphysematous group (p<0·001). Detailed assessment of lung density by CT scanning may be useful in the diagnosis of emphysema in life.

Internal surface area and number of respiratory air spaces in elastase-induced emphysema in hamsters.

A stereologic study of the characteristics of the respiratory air spaces was carried out in 16 hamsters with emphysema induced by 0.2 mg of porcine pancreatic elastase per 100 g of body weight given endotracheally; 8 untreated hamsters served as control animals. The total number of alveoli was decreased from a mean ± SE of 5.10 ± 0.31 × 106 in the normal animals to 2.18 ± 0.27 × 106 in the emphysematous animals. The average ± SE mean linear intercept was 55 ± 1 × 10−4 cm for the normal group and 105 ± 4 × 10−4 cm for the emphysematous group. The mean ± SE internal surface area calculated from the mean linear intercept was 3,830 ± 125 cm2 for the normal group and 2,794 ± 85 cm2 for the emphysematous group; the comparable values calculated by the air space density method were 6,221 ± 183 and 4,281 ± 127 cm2, respectively. The mean internal surface area of the emphysematous lungs was 73 per cent of normal by the mean linear intercept method and 67 per cent of normal by the air space density method; the inter...

EMPHYSEMA AND ITS RELATION TO AGE

To establish whether a correlation existed between emphysema and age, 24 lungs were used to measure the alveolar membrane fenestrations; the average area of 100 fenestrae was then plotted against age. Eighteen of these lungs were from patients 17 to 86 years of age with no history of respiratory ailments, whereas 6 lungs were from patients in whom an antemortem diagnosis of emphysema had been made. A significant, positive correlation between age and the area of fenestrae (t = 2.4; P < 0.05) was found in the group of 18 lungs from patients with no respiratory ailments. The same could not be said categorically about the lungs from the emphysematous group, because the number of lungs examined was too small. We postulate that the pores of Kohn are part of the degenerating emphysematous process and are the first stage in the formation of fenestrae. A possible mechanism for the formation of fenestrae and their classification into 4 grades is presented.

Use of cuffed endotracheal tubes for severe exacerbations of chronic airway obstruction.

Forty-five patients hospitalized for acute exacerbations of chronic airway obstruction required continuous respirator therapy through cuffed endotracheal tubes. Two thirds of this group were treate...

Regional lung function in patients with obstructive lung diseases.

Regional lung function was measured, using radioactive xenon-133, in a group of normal subjects and in three carefully defined groups of patients with obstructive lung disease. When compared with the normal subjects, patients in the emphysematous group showed a relative reduction of ventilation and perfusion to the upper zones, while patients having chronic bronchitis without cardiac or respiratory failure showed a predominantly lower zone defect. In the group of patients with chronic bronchitis with cardiac and respiratory failure no consistent pattern was found.

Panlobular Emphysema: Anatomy and Pathodynamics

Based upon the structural concept of the secondary lobule of Miller, it is apparent that a common anatomic pattern of emphysema involving principally the terminal air ducts and sacs may be recognized on a localized or generalized basis. This form of emphysema we have labelled the panlobular type, as the entire secondary lobule of Miller shows overdistension and air sac rupture, and in advanced cases uniform bullous fields. An accompaniment of advancing degrees of emphysema is the presence of numerous alveolar fenestrations of major importance in the progression of this form of irreversible lung distension. Panlobular emphysema is a morphologic denominator common to such heterogeneous conditions as primary kyphotic chest deformities, localized hilar scleroses or neoplastic states producing laryngeal or large bronchial airway deformities and congenital lobar emphysema. Less well-defined is the airway obstruction in chronic bronchitis and bronchiectasis observed in many cases of established panlobular emphysema. An additional emphysematous group without structural bronchial deformity was also found. These were usually associated with lesser degrees of emphysema. Bronchial disturbances may produce not only an obstructive airway mechanism leading to air trapping, but indirectly influence surface tension phenomena within the lung or impair clearance of entrapped pollutants and in this way initiate erosion of the air sac membranes. Hypertrophy of the right ventricle was a frequent companion of established cases of generalized panlobular emphysema. The air-to-blood exchanging surface—the pulmonary contribution to homeostasis—is progressively destroyed through alveolar sac dissolution with the concurrent loss of the perfusing lung bed being responsible for the common clinical manifestations of cor pulmonale. Other determinants involved in the development of cor pulmonale are pathologic by-passes from artery to vein, bronchopulmonary shunting particularly in emphysema with fibrosis and a decompensating portal azygos-pulmonary vein system. These morphologic findings reflect the primary importance of the pulmonary-cardiac disease in the natural history of this form of emphysema.