Preoperative Pulmonary Function Tests Research Articles

(F)utility of preoperative pulmonary function testing in pectus excavatum to assess severity

PurposeThe utility of pulmonary function testing (PFT) in pectus excavatum (PE) has been subject to debate. Although some evidence shows improvement from preoperative to postoperative values, the clinical significance is uncertain. A high failure-to-completion rate for operative PFT (48%) was identified in our large institutional cohort. With such a high non-completion rate, we questioned the overall utility of PFT in the preoperative assessment of PE and sought to evaluate if other measures of PE severity or cardiopulmonary function could explain this finding.MethodsDemographics, clinical findings, and results from cardiac MRI, PFT (spirometry and plethysmography), and cardiopulmonary exercise tests (CPET) were reviewed in 270 patients with PE evaluated preoperatively between 2015 and 2018. Regression modeling was used to measure associations between PFT completion and cardiopulmonary function.ResultsThere were no differences in demographics, symptoms, connective tissue disorders, or multiple indices of pectus severity and cardiac deformation in PFT completers versus non-completers. While regression analysis revealed higher RVEF, LVEF, and LVEF-Z scores, lower RV-ESV/BSA, LV-ESV/BSA, and LV-ESV/BSA-Z scores, and abnormal breathing reserve in PFT completers vs. non-completers, these findings were not consistent across continuous and binary analyses.ConclusionsWe found that PFT completers were not significantly different from non-completers in most structural and functional measures of pectus deformity and cardiopulmonary function. Inability to complete PFT is not an indicator of pectus severity.

Early complications in scoliosis surgery and relation to preoperative factors: A single-center retrospective study.

In this study, we aimed to investigate the perioperative complications of the patients who underwent scoliosis surgery in our hospital and the factors that may affect the outcome. Between 2014 and 2018, scoliosis patients recorded data was examined retrospectively. Age, gender, height, body weight, comorbidity, Cobb index, scoliosis etiology, operation time, preoperative and postoperative hemoglobin, hematocrit, leukocyte, blood urea nitrogen, creatinine, coagulation value, operation time, level of instrumentation, intraoperative and postoperative blood loss, blood transfusion, intraoperative fluid administration, preoperative pulmonary function test values, blood gas values, urine outputs, hospital (LOS) and post anesthesia care unit stays, complications and mortality rates were examined. The files of 77 patients (48 female, 29 male) were retrospectively analyzed. The average age was 19.54 ± 16.32 years and 98.7% were elective surgery. The mean of LOS was 13.55 ± 9.13 days. As the preoperative hematocrit value decreases, LOS increases significantly. In patients with chronic obstructive pulmonary disease, smokers and high ASA scores, LOS is prolonged in patients with previous operations. As intraoperative colloid administration increased, crystalloid and blood products increased, it was also observed that the amount of crystalloid increased LOS. As the amount of intraoperative colloid or red blood cell administration increases, the duration of surgery and anesthesia increases, also increases the duration of post anesthesia care unit. Compared to patients with complications (n = 29) to the patients without complications (n = 47), it was found that they had longer anesthesia, and surgery times, also longer LOS times (P < .05). Our study showed that chronic obstructive pulmonary disease in the preoperative period, smoking, high ASA score, excessive use of colloid, prolonged duration of surgery and anesthesia, and long intubation durations increase the length of hospital stay. Preoperative comorbidity is directly related to postoperative complications and causes longer hospitalization after reconstructive scoliosis surgery.

A study on the outcome of preoperative pulmonary function tests on a patient undergoing rheumatic mitral valve surgery

Abstract Background and Aims: Evaluation of pulmonary function by spirometer in adult patients undergoing cardiac surgery is a simple test to assess pulmonary reserve that has important implications in operative morbidity. However, there is no established consensus regarding which patients should undergo preoperative pulmonary function tests (PFTs), including forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC). The primary aim was to evaluate the outcome of preoperative PFTs on patients undergoing rheumatic mitral valve surgery. Material and Methods: One hundred patients undergoing rheumatic mitral valve surgery, meeting the inclusion criteria, were included in this prospective observational study. The pulmonary function of the patients was assessed using a spirometer before surgery. Preoperative pulmonary artery systolic pressure (PASP) and arterial blood gas (ABG) analyses were also performed. The correlation of PFTs with early postsurgical outcome, comprising mortality within 30 days of surgery and morbidity defined as the existence of at least one of the postoperative complications, such as low cardiac output state indicated by increased requirement of inotropes, prolonged ventilation (&gt;24 hours), postoperative new-onset hemodynamically significant arrhythmias, renal dysfunction, and post-op infection, was assessed. Results: With the increasing New York Heart Association (NYHA) class of the patient, there was a decline of FEV1% and FVC%, which was statistically significant (P &lt; 0.0001). There was a significant positive correlation of FVC% with preoperative saturation of peripheral oxygen (SpO2) and preoperative saturation of peripheral carbon dioxide (PaO2) and FEV1% with preoperative SpO2 and preoperative PaO2. Patients who had postoperative prolonged ventilation had lower values of FVC% and FEV1%, which was statistically significant (P &lt; 0.001). The patients who expired had significantly lower values of FVC% and FEV1%. Conclusions: Preoperative lung function has an implication on intraoperative morbidity during cardiac surgery although a common consensus on its application is lacking. Preoperative spirometry can be one of the parameters for predicting postoperative morbidity and mortality in patients undergoing rheumatic mitral valve surgery. Spirometry might have a role to play in predicting patient outcomes in rheumatic mitral valve surgeries; however, larger well-powered studies are needed.

The Impact of Anterior Vertebral Body Tethering on Pulmonary Function.

Retrospective, single-center study. To examine pulmonary function tests (PFTs) in patients undergoing anterior vertebral body tethering (AVBT). The effect of AVBT on pulmonary status remains unclear. The authors examined preoperative and postoperative PFTs following AVBT in a retrospective, single-center cohort of patients. Outcomes were compared using percent predicted values as continuous and categorical variables (using 10% change as significant) and divided into categorical values based on the American Thoracic Society standards. Fifty-eight patients with adolescent idiopathic scoliosis were included, with a mean age of 12.5±1.4 years and a follow-up of 4.2±1.1 years. The mean thoracic curve was 47°±9°, which improved to 21°±12°. At baseline, the mean forced expiratory volume in one second (FEV1%) and forced vital capacity (FVC%) values were 79% and 82%, respectively. Four patients had normal FEV1% (≥100%), 67% had mild restrictive disease (70%-99%) and the rest had worse FEV1%. Mean FEV1 improved from 2.2 to 2.6 L ( P <0.05) and FVC improved from 2.5 to 3.0 L ( P <0.05); however, % predicted values remained unchanged (FEV1%: 79%-80%; FVC%: 82-80%, P >0.05) with mean postoperative PFTs at 37±12 months postoperative. The use of miniopen thoracotomy was not associated with worsening PFTs, but extension of the lowest instrumented vertebra below T12 was correlated with decreasing FEV1% in the bivariate analysis ( P <0.05). Patients with worse preoperative FVC% (80±13% vs. 90±11%, P =0.03) and FEV1% (77±17% vs. 87±12%, P =0.06) also had a greater likelihood of declining postoperative FEV1%. Pulmonary function in most patients undergoing AVBT remained stable (76%) or improved (14%); however, a subset may worsen (10%). Further studies are needed to identify the risk factors for this group, but worse preoperative PFTs and extension below T12 may be risk factors for worsening pulmonary function.

Association of Preoperative Lung Function with Complications after Lobectomy Using Race-Neutral and Race-Specific Normative Equations.

Rationale: Pulmonary function testing (PFT) is performed to aid patient selection before surgical resection for non-small cell lung cancer (NSCLC). The interpretation of PFT data relies on normative equations, which vary by race, but the relative strength of association of lung function using race-specific or race-neutral normative equations with postoperative pulmonary complications is unknown. Objectives: To compare the strength of association of lung function, using race-neutral or race-specific equations, with surgical complications after lobectomy for NSCLC. Methods: We studied 3,311 patients who underwent lobectomy for NSCLC and underwent preoperative PFT from 2001 to 2021. We used Global Lung Function Initiative equations to generate race-specific and race-neutral normative equations to calculate percentage predicted forced expiratory volume in 1 second (FEV1%). The primary outcome of interest was the occurrence of postoperative pulmonary complications within 30 days of surgery. We used unadjusted and race-adjusted logistic regression models and least absolute shrinkage and selection operator analyses adjusted for relevant comorbidities to measure the association of race-specific and race-neutral FEV1% with pulmonary complications. Results: Thirty-one percent of patients who underwent surgery experienced pulmonary complications. Higher FEV1, whether measured with race-neutral (odds ratio [OR], 0.98 per 1% change in FEV1% [95% confidence interval (CI), 0.98-0.99]; P < 0.001) or race-specific (OR, 0.98 per 1% change in FEV1% [95% CI, 0.98-0.98]; P < 0.001) normative equations, was associated with fewer postoperative pulmonary complications. The area under the receiver operator curve for pulmonary complications was similar for race-adjusted race-neutral (0.60) and race-specific (0.60) models. Using least absolute shrinkage and selection operator regression, higher FEV1% was similarly associated with a lower rate of pulmonary complications in race-neutral (OR, 0.99 per 1% [95% CI, 0.98-0.99]) and race-specific (OR, 0.99 per 1%; 95% CI, 0.98-0.99) models. The marginal effect of race on pulmonary complications was attenuated in all race-specific models compared with all race-neutral models. Conclusions: The choice of race-specific or race-neutral normative PFT equations does not meaningfully affect the association of lung function with pulmonary complications after lobectomy for NSCLC, but the use of race-neutral equations unmasks additional effects of self-identified race on pulmonary complications.

Clinical Outcomes After Tracheobronchoplasty With Ringed Polytetrafluoroethylene Vascular Graft

BackgroundThis report describes the surgical technique and outcomes of tracheobronchoplasty (TBP) with ringed polytetrafluoroethylene (PTFE) vascular graft. MethodsWe identified all patients who underwent PTFE-TBP for severe expiratory central airway collapse from January 1, 2018 to August 2021 at Mayo Clinic, Florida. Preoperative and postoperative St George’s Respiratory Questionnaire (SGRQ), Cough-Specific Quality of Life Questionnaire (CSQLQ), pulmonary function testing, 6-minute walk test, and blinded dynamic bronchoscopy videos at 3-month follow-up were used to assess outcomes. ResultsFourteen patients (median age, 62.5 years; 64.3% female) underwent PTFE-TBP. The median operative time was 355 minutes, median hospital length of stay was 5 days, and median intensive care unit stay was 1 day. One patient had a Clavien-Dindo grade ≥3 complication. Comparison of preoperative and postoperative questionnaire scores demonstrated improvement in median SGRQ score by 14.79 (P = .013) and CSQLQ score by 22 (P = .005). Preoperative and postoperative pulmonary function and 6-minute walk test results showed no significant difference. Postoperative bronchoscopy demonstrated improvement in median collapsibility of mid trachea by 39.6% (P < .001), distal trachea by 50% (P < .001), left main bronchus by 38.2% (P < .001), right main bronchus by 37.9% (P < .001), and bronchus intermedius by 30.7% (P < .001). ConclusionsPTFE-TBP provides significant improvement in patients' symptoms and expiratory central airway collapse as judged by preoperative and postoperative quality of life questionnaires and bronchoscopy.

Prediction of postoperative pulmonary complications in older patients undergoing lobectomy for lung cancer based on skeletal muscle mass.

This retrospective study was designed to evaluate preoperative pulmonary function test (PFT) results and skeletal muscle mass, represented by the erector spinae muscle (EM), as predictors of postoperative pulmonary complications (PPCs) in older patients undergoing lobectomy for lung cancer. The medical records, including preoperative PFT, chest computed tomography (CT) and PPCs, of patients older than 65 years undergoing lobectomy for lung cancer were retrospectively examined at Konkuk University Medical Center from January 2016 to December 2021. The sum of cross-sectional areas (CSAs) of the right and left EMs at the level of the spinous process with the 12th thoracic vertebra was used as the skeletal muscle mass (CSABoth). Data from a total of 197 patients were included in the analyses. In total, 55 patients had PPCs. The preoperative functional vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) showed significantly poorer values and the CSABoth had significantly lower values in patients with than in those without PPCs. The preoperative FVC and FEV1 showed significant positive correlations with CSABoth. Multiple logistic regression analysis identified age, diabetes mellitus (DM), preoperative FVC and CSABoth as risk factors for PPCs. The areas under the curves for FVC and CSABoth were 0.727 (95% CI, 0.650-0.803; P<0.001) and 0.685 (95% CI, 0.608-0.762; P<0.001), respectively. The optimal threshold values of FVC and CSABoth to predict PPCs based on a receiver operating characteristic curve analysis were 2.685 L (sensitivity =64.1% and specificity =61.8%) and 28.47 mm2 (sensitivity =62.0% and specificity =61.5%), respectively. PPCs in older patients undergoing lobectomy for lung cancer were associated with lower preoperative FVC and FEV1 values and a lower skeletal muscle mass. Skeletal muscle mass, represented by the EM, was significantly correlated with the preoperative FVC and FEV1. Therefore, skeletal muscle mass may be useful for the prediction of PPCs in patients undergoing lobectomy for lung cancer.

Improvement in postoperative lung function in patients with moderate to severe airway obstruction after robotic-assisted thoracoscopic tracheobronchoplasty.

The study objective was to examine pulmonary function and quality of life improvement after robotic-assisted thoracoscopic tracheobronchoplasty for patients with different degrees of obstructive airway disease. We performed a retrospective review of a prospective database of patients who underwent robotic-assisted thoracoscopic tracheobronchoplasty between 2013 and 2020. A total of 118 patients underwent robotic-assisted thoracoscopic tracheobronchoplasty. Preoperative and postoperative pulmonary function tests were available for 108 patients. Postoperative pulmonary function tests at a median of 16months demonstrated a significant increase in percent predicted forced expiratory volume in 1second (preoperative median: 76.76% predicted, postoperative: 83% predicted, P=.002). Preoperative and postoperative St George Respiratory Questionnaires were available for 64 patients with a significant decrease in postoperative score at a median of 7months (preoperative median: 61, postoperative: 41.60, P<.001). When stratified by preoperative degree of obstruction, robotic-assisted thoracoscopic tracheobronchoplasty improved forced expiratory volume in 1second in moderate to very severe obstruction with a statistically significant improvement in moderate (preoperative median: 63.91% predicted, postoperative median: 73% predicted, P=.001) and severe (preoperative median: 44% predicted, postoperative median: 57% predicted, P=.007) obstruction. St George Respiratory Questionnaire scores improved for all patients. Improvement for mild (preoperative median: 61.27, postoperative median: 36.71, P<.001) and moderate (preoperative median: 57.15, postoperative median: 47.52, P=.03) obstruction was statistically significant. Robotic-assisted thoracoscopic tracheobronchoplasty improves obstruction and symptoms. With limited follow-up, subgroup analysis showed forced expiratory volume in 1second improved in severe preoperative obstruction and quality of life improved in moderate obstruction. Future follow-up is required to determine robotic-assisted thoracoscopic tracheobronchoplasty effects on the most severe group, but we cannot conclude that increased degree of preoperative obstruction precludes surgery.

Does thoracoscopic basal pyramid segmentectomy really offer functional advantages in comparison with thoracoscopic lower lobectomy?

The functional impact of thoracoscopic basal segmentectomy in comparison with lower lobectomy has not been investigated in-depth and the aim of this study was to clarify this topic. We retrospectively analysed a cohort of patients who underwent surgery between 2015 and 2019 for non-small-cell lung cancer, peripherally located lung nodules, far enough from both the apical segment and the lobar hilum to allow an oncologically safe thoracoscopic lower lobectomy or basal segmentectomy. Pulmonary function tests (PFTs) including spirometry and plethysmography were performed 1 month after surgery and forced expiratory volume in 1 s, forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) were collected; the difference, the loss and the recovery rate of pulmonary function were calculated and compared with the Wilcoxon-Mann-Whitney test. During the study period, n = 45 and n = 16 patients for video-assisted thoracoscopic surgery (VATS) lower lobectomy and for VATS basal segmentectomy, respectively, completed the study protocol: the 2 groups were homogeneous as to preoperative variables and PFT values. Postoperative outcomes were similar and PFTs revealed significant differences between postoperative forced expiratory volume in 1 s %, FVC%, ΔFVC and ΔFVC%. The loss percentage of FVC%, DLCO% and the recovery rate was better for FVC and DLCO in the VATS basal segmentectomy group. Thoracoscopic basal segmentectomy seems to be associated with a more preserved lung function, maintaining more FVC and DLCO levels than lower lobectomy, and could be performed in selected cases ensuring also adequate oncological margins.

The Neutrophil-to-Lymphocyte Ratio and Preoperative Pulmonary Function Test Results as Predictors of In-Hospital Postoperative Complications after Hip Fracture Surgery in Older Adults.

Purpose: This study retrospectively evaluated the usefulness of the neutrophil-to-lymphocyte ratio (NLR), prognostic nutritional index (PNI), and pulmonary function test (PFT) results as objective predictors of in-hospital postoperative complications after hip fracture surgery in older adults. Methods: The patients aged >65 years who underwent hip fracture surgery under general anaesthesia were enrolled. In-hospital postoperative complications with preoperative NLR, PNI and PFT results were evaluated. The NLR was calculated as the preoperative neutrophil count/lymphocyte count in peripheral blood. The PNI was calculated as the serum albumin (g/dL) × 10 + total lymphocyte count × 0.005 (/mm3). Results: One hundred ninety nine patients were analysed. The most common postoperative complications were respiratory complications. Compared with patients who did not have postoperative complications, patients with postoperative complications had a significantly higher NLR (8.01 ± 4.70 vs. 5.12 ± 4.34, p < 0.001), whereas they had a significantly lower PNI (38.33 ± 6.80 vs. 42.67 ± 6.47, p < 0.001), preoperative functional vital capacity (FVC; 2.04 ± 0.76 vs. 2.45 ± 0.71 L, p < 0.001), and forced expiratory volume at 1 s (FEV1; 1.43 ± 0.53 vs. 1.78 ± 0.58 L, p < 0.001). Multiple logistic regression analysis identified NLR (odds ratio [OR], 1.142; 95% confidence interval [CI], 1.060−1.230; p < 0.001) and FEV1 (OR, 0.340; 95% CI, 0.191−0.603; p < 0.001) as risk factors for postoperative complications after hip fracture surgery. Conclusion: Preoperative NLR and FEV1 are objective predictors of in-hospital postoperative complications after hip fracture surgery in older patients.

NINTEDANIB CESSATION IN WAITLISTED LUNG TRANSPLANT CANDIDATES IS NOT ASSOCIATED WITH INCREASED WAITLIST MORTALITY OR PERIOPERATIVE COMPLICATIONS

NINTEDANIB CESSATION IN WAITLISTED LUNG TRANSPLANT CANDIDATES IS NOT ASSOCIATED WITH INCREASED WAITLIST MORTALITY OR PERIOPERATIVE COMPLICATIONS

Pulmonary function after thoracoplasty for adolescent idiopathic scoliosis: a systematic review and meta-analysis.

Thoracoplasty is a procedure which involves rib resection from the costovertebral junction to the apex of the rib hump deformity to address the cosmetic concerns of patients of scoliosis. There is conflicting literature on its effect on pulmonary function. The present meta-analysis was conducted to review and analyze the available literature and ascertain the effect of thoracoplasty on pulmonary function. Search was conducted according to PRISMA guidelines on three databases. After analysis of all the search results by title, abstracts and full texts-10 studies were identified for inclusion in the review. We included studies which had analyzed preoperative and postoperative pulmonary function tests (PFTs) after thoracoplasty. Pooled estimates were calculated for pulmonary function, and effect of other factors was analyzed by subgroup analysis and meta-regression. The included studies were published between 1998 and 2019. A total of 385 patients were included in these studies, with a mean age of 15.01years, with a female preponderance. Apprehension over appearance of rib hump was the most common indication for thoracoplasty. Percent-predicted forced vital capacity(FVC) and forced expiratory volume in 1s (FEV-1) were significantly decreased on follow-up. Anterior approach to corrective surgery and lower age were found to be associated with worse pulmonary function. Preoperative Cobb's angle was found to have significant impact on decrease in FEV-1 only, but not on other PFT parameters. Overall decrease in pulmonary function after thoracoplasty necessitates the need of adequate preoperative pulmonary function to mitigate its effect on patient well-being. Use of a posterior approach for corrective surgery when thoracoplasty is planned might lead to better outcomes. More research is needed to study effect of preoperative Cobb's angle on pulmonary function.

Resting Physiologic Dead Space as Predictor of Postoperative Pulmonary Complications After Robotic-Assisted Lung Resection: A Pilot Study.

Lung resection surgery carries significant risks of postoperative pulmonary complications (PPC). Cardiopulmonary exercise testing (CPET) is performed to predict risk of PPC in patients with severely reduced predicted postoperative forced expiratory volume in one second (FEV1) and diffusion of carbon monoxide (DLCO). Recently, resting end-tidal partial pressure of carbon dioxide (PETCO2) has been shown as a good predictor for increased risk of PPC. However, breath-breath breathing pattern significantly affects PETCO2. Resting physiologic dead space (VD), and physiologic dead space to tidal volume ratio (VD/VT), may be a better predictor of PPC than PETCO2. The objective of this study was to prospectively determine the utility of resting measurements of VD and VD/VT in predicting PPC in patients who underwent robotic-assisted lung resection for suspected or biopsy-proven lung malignancy. Thirty-five consecutive patients were included in the study. Patients underwent preoperative pulmonary function testing, symptom-limited CPET, and a 6-min walk test. In the first 2 min prior to the exercise portion of the CPET, we obtained resting VT, minute ventilation (E), VD (less instrument dead space), VD/VT, PETCO2, and arterial blood gases. PPC within 90 days were recorded. Fourteen (40%) patients had one or more PPC. Patients with PPC had significantly elevated resting VD compared to those without (0.318 ± 0.028 L vs. 0.230 ± 0.017 L (± SE), p < 0.006), and a trend toward increased VD/VT (0.35 ± 0.02 vs. 0.31 ± 0.02, p = 0.051). Area under the receiver operating characteristic (ROC) for VD was 0.81 (p < 0.002), VD/VT was 0.68 (p = 0.077), and PETCO2 was 0.52 (p = 0.840). Peak O2, E/ CO2 slope, pulmonary function tests, 6-min walk distance and arterial blood gases were similar between the two groups. Intensive care unit and total hospital length of stay was significantly longer in those with PPC. In conclusion, preoperative resting VD was significantly elevated in patients with PPC. The observed increase in resting VD may be a potentially useful predictor of PPC in patients undergoing robotic-assisted lung resection surgery for suspected or biopsy-proven lung malignancy. A large prospective study is needed for confirmation.

Robotic-assisted tracheobronchoplasty: Quality of life and pulmonary function assessment on intermediate follow-up.

The initial description of robotic tracheobronchoplasty for the treatment of tracheobronchomalacia demonstrated feasibility, safety, and short-term symptomatic and functional improvement. The purpose of the current study was to demonstrate intermediate outcomes in postoperative pulmonary function and quality of life after robotic tracheobronchoplasty. We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board. A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George's Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P=.002), St George's Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P<.001), and St George's Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P<.001) were apparent at a median follow-up of 13months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1second (preoperative median: 74% vs postoperative median: 82%, P=.001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P<.001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P=.02) measured at a median follow-up of 29months. Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement.

No difference in postoperative complication rates or cardiopulmonary function for early versus late scoliosis correction in Duchenne muscular dystrophy

Given reduced rates of both pulmonary function decline and scoliosis progression with steroid treatment in Duchenne muscular dystrophy (DMD), the role of early scoliosis surgery has been questioned. The purpose of this study was to compare the postoperative complication rates of early versus late scoliosis correction in DMD. This study was a retrospective cohort, conducted at an academic tertiary level children's hospital. Patients with DMD who underwent posterior scoliosis correction, with preoperative pulmonary function testing [forced vital capacity (FVC)] were included and divided into two groups by preoperative curve angles: ≤ 45° and > 45°. The primary outcome variable was postoperative complications by Clavien-Dindo classification grading. Secondary outcome variables included postoperative complications occurring after the first 90days, age at surgery, duration of wheelchair dependency preoperatively, pulmonary function, steroid utilization, shortening fraction by echocardiogram, surgery duration, intensive care unit/hospital length of stay, days intubated, infection, and percent curve correction. Two-tailed t-test and Chi-square testing were used for analysis of patient factors and Clavien-Dindo complication grade, respectively. Thirty-one patients were included with a total follow-up of 8.3 ± 3.2years, 4.8 ± 2.2years post-spinal fusion. Steroid treatment (prednisone, deflazacort) was utilized for 21 (67.7%) patients. Primary curve correction was not different between groups (65.0% vs 71.4% [p = 0.37]). There were no significant differences in Clavien-Dindo classification grades between groups (p > 0.05). For the entire cohort, the overall complication rate was higher for patients with steroid treatment (61.9% vs 10.0% [p = 0.008]). Neither forced vital capacity nor fractional shortening on echocardiogram was different between groups at final follow-up (p = 0.6 and p = 0.4, respectively). The comparable risk of perioperative complications for early and late scoliosis correction supports a "watchful waiting" approach, whereby curves less than 45° can be carefully followed while cardiopulmonary function is maintained. Patients undergoing steroid treatment should be counseled regarding the higher risk of postoperative blood transfusion and deep wound infection. III Retrospective cohort.

Evaluation of Functional Operability Prior to Lung Surgery

Cardiac and pulmonary physiologic assessment is necessary for risk stratification before any lung resection. It may uncover hidden health issues, which can be addressed first to make patients fit for surgery. It allows for the surgeon to estimate the patient's risk for major complications and at the same time for the patient to understand the procedural risks and give informed consent or even reject surgery. Recommended work-up for both to cardiac risk evaluation and preoperative pulmonary function test algorithms are based on guidelines formulated by the ERS/ESTS and ACCP 1 3 4.Basic pulmonary function tests consist of spirometry, blood gas analysis and measurement of diffusion capacity (DLCO); followed by cardiopulmonary exercise testing (CPET) which estimates or measures the patient's oxygen consumption, and split function tests such as perfusion scintigraphy. Clinical assessment of both the patient's overall status and pulmonary function allows for an adequate assessment of overall operative risk. Pulmonary function tests are affected by multiple variables and as such prone to error. It is advisable to always question the validity of every work-up and to repeat any test if necessary.

The 12 steps to a thoracoscopic anterior segment segmentectomy: Oncologically safe and sound.

The 12 steps to a thoracoscopic anterior segment segmentectomy: Oncologically safe and sound.

Influence of protective lung ventilation on arterial-to-end tidal carbon dioxide gradient during one lung ventilation: A prospective observational study

Background: One lung ventilation (OLV) results in a ventilation-perfusion (V/Q) mismatch. Protective lung ventilation (PLV) reduces postoperative pulmonary complications following OLV. However, PLV predisposes to areas of atelectasis in the ventilated lung and worsens the V/Q mismatch. Aim of Study: To evaluate the gradient between arterial carbon dioxide tension (PaCO2) and partial pressure of end-tidal carbon dioxide gas (ETCO2) during OLV using PLV. The second objective was to see if a high gradient could be predicted based on preoperative pulmonary function tests (PFTs), American Society of Anesthesiologists Physical Status (ASA-PS) or intraoperative haemodynamic changes. Patients and Methods: The PaCO2 and ETCO2 during two lung ventilation (TLV) and OLV were noted with patient in the lateral position. The PaCO2-ETCO2 gradients during TLV and OLV were calculated. The mean values of PaCO2, ETCO2 and PaCO2-ETCO2 gradient were compared for OLV and TLV. For gradients above 8 mm Hg, PFT, ASA-PS grade and blood pressure were assessed to identify any clinical association. Results: Sixty patients were enrolled in the study. The mean values of PaCO2 were 38.17 and 44.02 mm Hg during TLV and OLV respectively. The mean values of ETCO2 were 31.31 and 34.53 mm Hg during TLV and OLV respectively. The mean PaCO2-ETCO2 gradient was 6.74 and 9.71 mm Hg during TLV and OLV respectively. These values were significantly lower during TLV than OLV. Conclusion: ETCO2 does not correspond with PaCO2 during OLV using PLV. It is not possible to predict which patients will show a higher PaCO2-ETCO2 gradient. This study could not find any clinical association between the preoperative PFT, ASA-PS grade or intraoperative haemodynamics when PaCO2-ETCO2 gradient was greater than 8 mm Hg.

Impact of Postoperative ABG Analysis and ICU Weaning Protocol in Surgical Outcome of Atlanto-Axial Dislocation: It's not the Towering Sail, but the Unseen Wind that Moves the Ship.

The outcome in patients of atlanto-axial dislocation (AAD) depends on multiple factors like preoperative optimization, intraoperative distractio and cord manipulation. Certain unfocussed factors such as respiratory reserve and compensatory acclimatization to hypoxia warrant consideration. The purpose of this study is to find the association of postoperative arterial blood gas (ABG) analysis and respiratory reserve in patients of AAD with clinical outcome. We retrospectively analyzed the available records of patients, operated for AAD, at our institute (n = 66), from January 2014 to November 2018. Preoperative pulmonary function test (PFT) and the postoperative ABG analysis was noted. Timing of extubation, duration of intensive care unit (ICU) stays, and clinical outcomes (Nurick grade) were noted from the inpatient record and the last outpatient follow up. An independent t-test and analysis of variance were used to find significance. In total, 41% (n = 27) patients had body mass index of less than 18.5, and 50% (n = 33) had breath holding time of less than 20 minutes. There was improvement in mean Nurick grade from 3.17 ± 0.8 to 2.76 ± 0.7 in follow up. A trend suggesting that patients with poor preoperative PFT has more ICU duration and worse outcome. In patients with mild acid-base disorders, extubation was possible within 24 hours. Out of 26 patients with ICU duration less than 2 days, 23 patients had "good" outcome, whereas ten out of 40 patients with ICU duration of more than or equal to 2 days had "bad" outcome (P = 0.00). Patients having moderate to severe primary or mixed acid-base disorder have a probability of re-intubation or delayed extubation. A strong correlation was seen with the novel grading system (grade >6 had worse outcome).

Rocuronium-induced respiratory paralysis refractory to sugammadex in Charcot-Marie-Tooth disease

PurposeProlonged postoperative neuromuscular respiratory paralysis after administration of a nondepolarizing neuromuscular blocking agent is a serious concern during anesthetic management of patients with Charcot-Marie-Tooth disease (CMTD). Some recent reports have described rocuronium use without respiratory paralysis in CMTD patients when sugammadex was used for its reversal. We report a case in which an induction dose of rocuronium caused a prolonged respiratory paralysis in a patient with undiagnosed type 1A CMTD (CMT1A).Clinical featuresA 63-yr-old-male with an American Society of Anesthesiologists Physical Status score of III underwent a left hip arthroplasty under general anesthesia for osteoarthritis. Preoperative pulmonary function testing indicated a restrictive impairment. Anesthesia was induced with fentanyl, remifentanil, propofol, and 0.73 mg·kg-1 of rocuronium. The train-of-four (TOF) count was 0 for the 273-min duration of surgery. After repeated doses of sugammadex failed to recover the TOF count and spontaneous respirations, a total of 1,200 mg (17.3 mg·kg-1) of sugammadex, which was assumed to be a sufficient amount for capturing the residual rocuronium, was administered. Although the patient expressed that he was awake via eye blinking, he could not breathe. Thus, he was placed on mechanical ventilation for 18 hr after surgery. A postoperative neurology consultation revealed a delayed nerve conduction velocity of 20 m·sec-1 and a mutated duplication of the PMP22 gene; a diagnosis of CMT1A was made.ConclusionsOur case shows that rocuronium can cause a prolonged neuromuscular respiratory paralysis refractory to sugammadex in patients with CMT1A and impaired respiratory function. Our case may also indicate that restrictive pulmonary impairment and low nerve conduction velocity of 20 m·sec-1 are predictive factors that cause prolonged neuromuscular respiratory paralysis refractory to sugammadex in CMT1A.