Pulmonary Reexpansion Research Articles

Phyisiotherapy as a Treatment of Progressive Spinal Amyotrophy type I: a case report

Introduction: The Progressive Spinal Amyotrophy is an autosomal recessive hereditary disease characterized by the spinal cord motoneurons degeneration, as the type I the most severe. PURPOSE: To describe a physical therapy treatment in a child with type I Progressive Spinal Amyotrophy. Methodology: Descriptive study of a case report of a patient with Progressive Spinal Amyotrophy in physical treatment at the Hospital Santo Antonio Maria Zaccaria in Braganca, Para. The data was collected from the medical records and the by caregiver. Results and Discussion: M.C.O.P, 6 years old girl, presents Progressive Spinal Amyotrophy type I, excellent cognition, wheelchair user, presents quadriparesis with little trunk control, degree of muscle strength between 1 and 2 at the Oxford scale, ligament laxity, contractures, thoracolumbar kyphoscoliosis, reduction of range of motion in lower limbs, ineffective cough and Forced Vital Spirometry of 800ml (54%). The child receives multiprofessional treatment with an Orthopedist; Pneumologist; Cardiologist; Child Neurologist and Physical Therapist since she was 2 years old. Her actual physical therapy treatment protocol consists of: active-assisted kinesiotherapy for the limbs, cervical spine and abdomen (2 sets of 10 repetitions), trunk stabilization exercises (2 sets of 1 minute), and pulmonary re-expansion with Infant Voldyne (3 sets of 5 repetitions), 3 times a week. Studies demonstrate the importance of a multidisciplinary treatment in children with muscular atrophy, highlighting the physical therapy in the disease delay, quality of life and survival. As is observed in the present study, the multidisciplinary treatment has increased the lifetime of the child, because children with this disease normally have as 2 ou 3 years, instead of the patient, that are 6 years old. Conclusion: The physical therapy treatment goal in patients with Progressive Spinal Amyotrophy is to avoid early complications through prophylactic management of disfunctions, therefore increasing lifetime and quality of life in the patients.

Facteurs pronostiques dans les décortications pleuropulmonaires pour pyothorax tuberculeux

Tuberculous pyothorax or empyema is one of the serious forms of tuberculosis and still poses public health problems. Through a series of patients who undergone pleuropulmonary decortication, we propose our model of management and determine the main factors prognostic. We retrospectively retrieved for 8years 93cases of patients with pleuropulmonary decortication for tuberculous pyothorax confirmed by histological examination pre- or postoperatively. There were 33women and 60men with an average age of 28.4years±10.35. In all cases, the radiological findings showed a pachypleuritis associated with an enclosed pyothorax in 79.6% of cases (n=74), a free cavity pyothorax in 8.6% of cases (n=8) and a passive atelectasis in all these cases. Chest tube was performed before surgery in 91.4% of cases (n=85) until the effusion was completely drained. The univariate analysis of the results of the surgery allowed to determine 4factors of good prognosis: preoperative preparation (including chest tube with total drying of the empyema, respiratory physiotherapy and weight gain) P=0.04, complete peroperative pulmonary re-expansion P=0.03, the lowest stay in intensive care unit P=0.02and the follow-up P=0.01. Pleuropulmonary decortication is a safe therapeutic alternative in the late stages of tuberculous empyema with acceptable morbimortality.

Time analysis of pulmonary reexpansion after the acute foreign body airway obstruction removal in miniature pigs

Objective To investigate the time of spontaneous recovery of atelectasis after removing the acute airway foreign bodies in miniature pigs. Methods Twenty-two miniature pigs were inserted into the occlusion stent in the right lower lobe bronchus by using bronchoscopy. After confirming the formation of atelectasis, the occlusion stent was removed and the imaging changes were observed for 3 weeks continuously. Results Atelectasis was formed within 1 week after the airway occlusion stent implantation in miniature pigs. Pulmonary reexpansion was observed obviously on week 3 after removal of airway occlusion stent (P<0.05). Conclusions The spontaneous recovery time of atelectasis, which caused by an acute foreign body airway obstruction within 1 week, may take 3 weeks at least. Key words: Tracheal diseases/SU; Foreign bodies/SU; Stents/AE; Atelectasis/ET/RA/PP

Outcome of long-term complications after permanent metallic left bronchial stenting in children.

We describe the way we treated 7 children with critical long-term complications after metallic balloon-expandable stenting in the left mainstem bronchus. Endoscopic follow-up included a first bronchoscopy 3 weeks after stenting, then monthly for 3 months, every 4-6 months up to 1 year and at scheduled times to calibrate stent diameter up to final calibration. When major complications occurred, patients underwent chest computed tomographic angiography. In 1 of the 7 children (median age 2.8 years), metallic left bronchial stenting served as a bridge to surgery. After a median 4-year follow-up, all 7 children experienced recurrent stent ovalizations with stent breakage in 3 and erosion in 1. In 4 children, computed tomographic angiography showed abundant peribronchial fibrous tissue, in 2 left mediastinal rotation and in 1 displacement along the left bronchus after pulmonary re-expansion as the cause of stent-related complication. Of the 7 children, 6 underwent surgery (5 posterior aortopexy and 1 section of the ligamentum arteriosus) and 3 required nitinol stents placement within the metallic ones. One patient completed the follow-up, and 1 patient was lost to follow-up. All 5 remaining children still have permanent bronchial stents in place, patent and re-epithelialized after a median 10.5-year follow-up. There were no deaths. Satisfactory anatomical relationships when children have stents placed in the left mainstem bronchus alone do not guarantee the final success. Several mechanisms intervene to cause critical stent-related complications in children during growth. Permanent metallic stents should be used carefully, and only in selected patients.

P1.04-004 Bronchocopic Cryosurgery with Carbon Dioxide; Experience in an Oncology Clinic in Colombia

The bronchoscopic cryosurgery with carbon dioxide is a groundbreaking tool in the diagnostic treatment of respiratory diseases. It has shown to be of great usefulness at a reasonable cost, with multiple indications and few side effects. We described the experience in an oncology institution in Colombia. Medical histories, Bronchoscopies and images were review from patients subjected to Bronchoscopic Cryosurgery. The procedures were performed at the “High-Tech Western Oncologist Clinic” in Pereira, Colombia with a highly trained medical staff from this clinic and from Neumovida Clinic from Armenia. Rigid and flexible Bronchoscopy video was made, and the equipment used in the cryotherapy was the Erbe Cryo 2 with the cryoprobe of 1.9 and 2.4 mm. 71 patients were found, 44 men, 27 women. Tracheal Recanalization to 11 patients, Bronchial Cryorecanalization to 24, Bronchial Cryobiopsy to 13, Tracheal Cryobiopsy to 7 and Pulmonary Cryobiopsy to 16 patients. Cryorecanalization was performed to 15 patients with tumors in the right lung and 9 in the left lung. Permeabilization of the Bronchial lumen was achieved to 22 patients at the same time the Bronchoscopy was being done. In 2 patients with Bronchial Obstruction the same procedure was achieved a week later. Pulmonary re-expansion and symptomatic control were achieved in 31 patients. Permeabilization of the bronchial lumen was achieved in 2 patients but not pulmonary re expansion. Silicone prosthesis were implanted to 9 patients with Tracheal lesions and 18 patients with Bronchial lesions. Differences between genders were not shown. There were not any important clinical complications associated with the procedures. Moderate bleeding with the pulmonary biopsy was control locally. In general the post-operative evolution of the patients was satisfactory. The Bronchoscopic Cryosurgery has clear indications in patients with Central Airway Tumors, just as the diagnostic, therapeutic and palliatives purposes and in patients with interstitial compromise of presumable neoplasic or infectious origin. In our casuistry, the objective was achieved in all the patients that underwent the procedures such as tracheobronchial recanalization and extraction of tracheal, bronchial or pulmonary tissue with a significant symptomatic improvement with a low risk and low morbidity

Reexpansion pulmonary edema

Key points: (a) Reexpansion pulmonary edema-RxPE– is a rare form of acute lung injury, with an incidence of approximately 1% following evacuation of a pneumothorax; (b) RxPE usually follows rapid reinflation of collapsed lung parenchyma; (c) The most common factor associated with RxPE is the duration of lung collapse– more than 3 days seems to be the critical amount of time; (d) The pathophysiologic changes associated with RxPE are complex and not yet fully understood; (e) The pathologic process results from a combination of rapid pulmonary reexpansion with concurrent mechanical alveolar injury, decrease in surfactant and regional lung tissue hypoxemia, inflammatory cell migration and release of inflammatory mediators, and the resulting changes in capillary-alveolar barrier occurring concurrently with increased capillary/hydrostatic pressures; (f) Clinical manifestations of RxPE vary from minimal symptoms to life-threatening hypoxia and cardio-respiratory collapse; (g) The patient may experience dyspnea, thoracic pain, cough with or without pink/foamy sputum, cyanosis, rales and stertors on auscultation. Other clinical symptoms may include fever, nausea, vomiting, tachycardia, and hypotension; (h) The symptoms of RxPE usually appear within the first two hours following pulmonary reexpansion, but may be delayed by as many as 24-48 h; (i) RxPE usually lasts clinically for as long as 1-2 days, but may take anywhere from 5 to 7 days to resolve; (j) Critical care practitioners should be familiar with the most common factors involved in the pathogenesis of RxPE; (k) The knowledge of these predisposing factors and the ability to effectively treat RxPE are important to prevention and treatment of this potentially fatal condition. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Stawicki SP, Sarani B, Braslow BM. Reexpansion pulmonary edema. OPUS 12 Scientist2008;2(2):29-31.

Efficacy of intermittent ventilation performed in lungs on operated side for prevention of reexpansion pulmonary edema after pulmonary resection

Objective To evaluate the efficacy of intermittent ventilation performed in lungs on the operated side for prevention of reexpansion pulmonary edema after pulmonary resection. Methods Forty patients of both sexes, aged 16-32 yr, with body mass index of 18-25 kg/m2, of ASA physical status Ⅰ or Ⅱ, scheduled for elective thoracoscope-assisted pulmonary resection, were randomly divided into 2 groups(n=20 each)using a random number table: control group(group C)and intermittent ventilation performed in lungs on the operated side group(group V). After induction of anesthesia, the patients were tracheally intubated and mechanically ventilated.After correct positioning was confirmed by fiberoptic bronchoscopy, one-lung ventilation was performed instead.One-lung ventilation was performed routinely in group C. In group V, the lung on the operated side was ventilated intermittently for 30 s with the tidal volume set at 2 ml/kg and respiration rate at 20 bpm, the bronchial tube was then opened, and the process was repeated at 10 min intervals until the diseased tissues were removed.After resection of diseased tissues, the specimens of normal tissues around the area were obtained for determination of the expression of aquaporin 1(AQP-1)and AQP-5 in lung tissues.The development of pulmonary atelectasis, hyoxemia and reexpansion pulmonary edema was recorded within 24 h after surgery. Results Compared with group C, AQP-1 and AQP-5 expression was significantly up-regulated, the incidence of atelectasis and reexpansion pulmonary edema was decreased within 24 h after surgery, while no significant change was found in the incidence of hyoxemia in group V. Conclusion Intermittent ventilation performed in lungs on the operated side can effectively prevent the development of reexpansion pulmonary edema during one-lung ventilation in the patients undergoing pulmonary resection. Key words: Respiration, artificial; Pulmonary edema; Postoperative complications

Minimally invasive technique in treatment of progressive hemothorax: a report of 62 cases

Objective To evaluate the advantages of minimally invasive technique for treatment of progressive hemothorax.Methods The study enrolled 62 patients with progressive hemothorax treated by minimally invasive surgery between October 2009 and March 2012.According to the treatment methods,the patients were classified to thoracoscope group (n =47) and urethral catheter balloon blockage group (n =15).Postoperative drainage volume and recovery were detected in both groups.Results All patients in thoracoscope group were healed with the mean operation time of 54 minutes (range,30-120 minutes).Mean effusion removed within thoracic cavity was 1 260 ml (range,700-2 000 ml).Postoperative bedside chest radiography revealed good pulmonary reexpansion without effusion or pneumatosis within thoracic cavity.All patients in urethral catheter balloon blockage group were healed.Chest drainage within postoperative 3 hours was mean 260 ml of fresh blood (range,100-500 ml) and thereafter no more massive bloody fluid discharge occurred.Meanwhile,chest CT reexamination revealed no increase of chest effusion.Conclusion Minimally invasive technique in treatment of progressive hemothorax patients with moderate or less effusion provides accurate effect,minor trauma,rapid recovery,and few complications and hence deserves clinical application. Key words: Hemothorax ; Thoracoscopes; Surgical procedures, minimally invasive; Foley catheter blockage technique

A Migrant, Round-Shape, Intrathoracic Mass

A round lesion was detected incidentally in the right intrathoracic region of 53-year-old male. Despite the fact that the lesion (39 9 45-mm in diameter) presented radiological findings consistent with benign disease— round shape with fat density (H.U.-35) (Fig. 1a, b) and no 18-FDG uptake on a PET/CT scan—a fine-needle aspiration biopsy was unsuccessfully attempted to achieve a definitive diagnosis. The procedure was complicated by pneumothorax that required chest tube placement. However, after complete pulmonary reexpansion, the mass had apparently migrated to the posterior costodiaphragmatic recess as shown by CT (Fig. 1c, d). The lesion (a white, oval, smooth lesion without a vascular pedicle; Fig. 2) was finally removed through single-port thoracoscopy, and the definitive diagnosis was pleural lipoma (central steatonecrotic core surrounded by a fibrinous sheath). Pleural lipomas are an extremely rare entity and usually arise from the parietal or mediastinal pleura [1, 2]. In the present case, the tumor originated from the visceral pleura of the great fissure and ‘‘felt down’’ within the thoracic cavity as consequence of iatrogenic pneumothorax.

Novo dispositivo EPAP subaquático no pós-operatório de cirurgia de revascularização do miocárdio

INTRODUÇÃO: A prevalência de cirurgias cardíacas é alta e acarreta custos elevados em decorrência de complicações secundárias. Dentre as principais complicações, estão as alterações pulmonares. A fisioterapia respiratória desempenha função relevante nas intervenções cirúrgicas, atuando na remoção de secreções pulmonares e na reexpansão pulmonar, por meio de tratamento com pressão positiva expiratória final (EPAP). OBJETIVO: Descrever um novo dispositivo EPAP (pressão positiva expiratória final) subaquático, desenvolvido com o objetivo de reverter atelectasias e complicações pós-operatórias, em pacientes submetidos à cirurgia de revascularização do miocárdio (RM). MATERIAIS E MÉTODOS: O dispositivo foi testado em um conjunto amostral reduzido, não probabilístico e intencional, envolvendo 17 pacientes (seis atenderam aos critérios de inclusão), internados na Unidade Coronariana, com idade entre 55 e 65 anos; pós-desmame de ventilação mecânica pós-cirúrgica; lúcidos, orientados e contactuantes; com o sistema cognitivo preservado e sem deformidades orofaciais. Os parâmetros medidos foram: saturação de oxigênio (SpO2) e frequência cardíaca, volume expiratório forçado no primeiro segundo (VEF1), capacidade vital forçada (CVF), fluxo expiratório máximo, ou Peak Flow (PEF), pressão arterial diastólica e sistólica. Realizou-se, ainda, o exame radiográfico torácico, a ausculta pulmonar e, por observação do fole torácico, a frequência respiratória; ainda, observou-se a queixa principal e o volume de expectoração. RESULTADOS: Os dados espirométricos não mostraram valores significativos, mas os sinais vitais mantiveram-se normais. CONCLUSÃO: Os resultados obtidos indicam que o EPAP subaquático melhora a saturação de oxigênio, auxilia na remoção de secreções por meio da ventilação colateral e expectoração, otimiza a ausculta pulmonar, reduz a queixa principal "dor" pelo aumento progressivo da mobilidade torácica, tornando a respiração menos superficial. Além disso, reverte atelectasias, tornando-se essencial no tratamento de alterações respiratórias pós-operatórias de revascularização de miocárdio.

Evaluation of respiratory conditions in early phase of hematopoietic stem cell transplantation

ObjectivesTo investigate the effectiveness of respiratory physiotherapy based on clinical evidence and analyze the improvement in respiratory parameters.MethodsA prospective study was carried out in the Bone Marrow Transplant Unit of the Universidade Estadual de Campinas (UNICAMP). Two different previously established respiratory physiotherapy protocols were applied from days D-1 to D+7 that aimed to improve airway clearance, pulmonary re-expansion and the strengthening of respiratory muscles. Group A were subjected to diaphragmatic proprioceptive stimulation, breathing exercises, incentive spirometry with Respiron®, inspiratory muscle training with the Threshold® Inspiratory Muscle Training device, bronchial hygienization with Shaker® and cough stimulation. Group B performed a protocol that only used incentive spirometry. The parameters analyzed were: tidal volume, minute volume, maximal inspiratory pressure, maximal expiratory pressure, oxygen saturation, heart rate and respiratory frequency.ResultsSixty-seven patients submitted to myeloablative hematopoietic stem cell transplantation were included in this study. Among these, thirty-nine were evaluated and randomized in the two groups. There were significant differences between the groups for tidal volume at D+2 (p-value = 0.007) and maximal inspiratory pressure (p-value = 0.03), maximal expiratory pressure (p-value = 0.03) and tidal volume (p-value = 0.004) at D+7.ConclusionsOn comparing Group A with Group B, the authors concluded that the protocol of respiratory physiotherapy applied in this study resulted in an improvement in ventilation and in respiratory muscle strength of patients submitted to hematopoietic stem cell transplantation.

Lung ultrasound in the reexpansion of pulmonary atelectasis

A 60-year-old man was admitted to our hospital complaining of dyspnea and productive cough that had been present for 24 h. One year prior, the patient had been diagnosed with amyotrophic lateral sclerosis. On admission, he was bedridden, had a tracheotomy, was ventilatordependent and fed by enteral nutrition by means of a gastrostomy tube. The vital signs were: blood pressure 120/80 mmHg, heart rate 110 beats/min, temperature 37 C. Percutaneous oxygen saturation was 85% on 80% ventilator-delivered oxygen. Physical examination revealed decreased breath sounds over the right lung and rales compatible with the presence of bronchial secretions over the left lung. A Chest x-ray study showed an opacification of the lower half of the right lung fields with mild homolateral mediastinal displacement suggesting pulmonary atelectasis (Fig. 1). Electrocardiography was unremarkable. Blood gas analysis revealed hypocapnic respiratory failure. Other laboratory tests were normal except for a mild leucocytosis. The emergency physician performed a lung ultrasound (US), which confirmed the presence of a right pulmonary atelectasis appearing as an area of pulmonary parenchyma with a tissue-like pattern and abolished lung sliding in the presence of lung pulse (Fig. 2, Online Resource 1). In order to remove secretions, a bronchoscopy was performed while simultaneously checking for adequate pulmonary reexpansion with US imaging. As airway clearing progressed, the US study showed the appearance of an air bronchogram near the hilar pulmonary structures (Fig. 3, Online Resource 2), gradually advancing toward the peripheral parenchyma (Fig. 4, Online Resource 3) till pulmonary reexpansion was completed, as evidenced by the appearance of lung sliding and the disappearance of the tissue-like pattern (Fig. 5, Online Resource 4). After the procedure, the oxygen saturation was 95% on 40% ventilator-delivered oxygen. The physical examination revealed bilateral breath sounds.

Comparação do índice de respiração rápida e superficial (IRRS) calculado de forma direta e indireta no pós-operatório de cirurgia cardíaca

To compare and to analyze whether the values of rapid shallow breathing index (RSBI) determined by a ventilator display and a digital ventilometer were correlated. Twenty-two adult patients (17 males and 5 females) in the postoperative period of cardiac surgery and in mechanical ventilation were studied. Prior to the data collection, each patient was evaluated, received physical therapy, in order to promote bronchial hygiene and pulmonary reexpansion, and was positioned in elevated dorsal recumbent at 45º. After these procedures, minute ventilation (MV) and respiratory rate (RR) obtained from mechanical ventilator display and digital ventilometer were recorded. The RSBI was calculated by the ratio of RR and tidal volume (VT). Paired t-test was used to compare related variables. The intra-class correlation coefficients (ICCs) were used to measure the reproducibility of the scores. A significant difference was found between the RSBI obtained from the ventilator and by the digital ventilometer (p=0.011). A high agreement for the RSBI (ICC=0.86), for the RR (ICC=0.80) for the VT (ICC=0.79) and a moderate agreement for the MV (ICC=0.74) were observed. The p-value was <0.05 for all variables. There were a significant agreement between the RSBI obtained from the ventilator display and the digital ventilometer. Article registered on the Australian New Zealand Clinical Trials Registry (ANZCTR) under the number ACTRN12610000756022.

Clinical analyses of forty cases of chronic obstructive pulmonary disease complicated with spontaneous pneumothorax

Objective To study diagnosis situation of forty cases with chronic obstructive pulmonary and spontaneous pneumothorax.Methods Forty cases( admitted from 2005 to 2009 ) of COPD and spontaneous pneumothorax treated in our hospital was retrospectively analyzed.15 cases had pumping decompression by pleural puncture,18 cases had closed thoracic drainage.7 cases of pulmonary compression area ＜ 20% and closed type of pneummothorax with adsolute bed rest and oxygen inhalation for pulmonary reexpansion,3 cases of sugical operation due to invalid conservative treatment.Results X-ray examination was most fundamental and most important examination diagnosing COPD and spontaneous pneumothorax.The diagnosis could not be completely confirmed,the further examination of chest CT should be per-formed.After the diagnosis,must conservative,chest cavity treatments and so on closed type drainage,chest cavity puncture pumping air or surgical operation.Conclusion Patients with chronic obstructive pulmonary disease and spontaneous pneumothorax have poorphysical condition,heavy illness status and fast change Leaks,the error diagnostic rate to be high,easily by primary affection cover,Line of X and so on inspections avoid leaking,the error diagnostic as soon as possible,by complex therapy primarily,strengthens the oxygen uptake,the anti-inf lammatory,the spasmolysis to breathe heavily evenly,the nutrition support and so on auxiliary treatment,raises the cure rate,cuts the mortality rate. Key words: Chronic obstructive pulmonary disease; Spontaneous pneumothorax; Clinical analysis

Streptokinaz Allerjisine Bağlı Tek Taraflı Akut Pulmoner Ödem

We report an unusual case of immune-mediated unilateral acute pulmonary edema (APE) following streptokinase administration for acute ST segment elevation myocardial infarction. To our knowledge, no report of overt unilateral APE is associated with streptokinase hypersensitivity during myocardial infarction therapy or following it. We stopped the streptokinase infusion because patient's blood pressure and oxygen saturation dropped as soon as streptokinase was administered. Then patient's antero-posterior chest X-ray showed that unilateral APE (Figure 1, Unilateral acute pulmonary edema, Antero-Posterior chest X-ray ). We did not find any other cause such as pulmonary embolism, heart failure, mitral regurgitation or re-expansion except streptokinase hypersensitivity reaction in our case for unilateral APE. Patient was treated with steroids, antihistaminics plus diuretics and then his clinical status improved. Hypersensitivity reactions to streptokinase are uncommon and usually minor; in the ISIS-2 trial only 4.4% of patients suffered from an allergic reactions to streptokinase.1 Allergic reac- tions induced by streptokinase may be manifest as urticaria, bronchospasm, angioneurotic or periorbital edema or unilateral interstitial edema in lungs.2 Patients with a history of prior exposure to streptokinase, infections with streptococci, and chronic allergic reactions are at risk for either by inducing an allergic response or by neutralising the streptokinase and making it ineffective.

Liquid ventilation:preventive intervention against cardiopulmonary bypass4nduced lung injury

Prevention or reduction of cardiopulmonary bypass-induced pulmonary injury has become critically important researching aspect of cardiovascular anesthesia.Artificial circulation,ischemia/reperfusion injury and pulmonary re-expansion after collapse are the key elements to induce pulmonary inflammatory reaction.Liquid ventilation using perfluorocarbon has been shown to improve oxygenation after acute lung injury.Liquid ventilation can effectively reduce neutrophil infiltration and reactive oxygen species production in the lungs,thus exerting protective effects against acute lung injury. Key words: Perfluoro carbon; Liquid ventilation; Lung injury; Cardiopulmonary bypass

Spontaneous pneumothorax: review of 130 cases

Spontaneous pneumothorax is a frequent affliction. The primary type principally affects males in the third decade of life, while the secondary type affects elderly patients with lung disease. When reviewing the cases of pneumothorax registered by the Thoracic Surgery Unit of the Hospital of Navarra, we found an incidence similar to other countries in our geographic area, and a biphasic distribution of the disease with the incidence peaks in youth and old age that we have mentioned. The disease is more frequent in males, smokers, and during the winter months. An account is given of the physiological mechanisms responsible for the formation of bullas in puberty. The first step in treatment is pleural drainage, the aim of which is to achieve pulmonary re-expansion and the re-establishment of the integrity of the visceral pleura. Although there are controversies regarding the definitive treatment, we carry out surgical resection of the pulmonary bullas in cases of relapse or when the CAT indicates a high risk of relapse, or resection of the pulmonary vertex following a second episode in spite of the non-existence of lesions in the CAT. We do not carry out pleurodesis, except in elderly patients who are not susceptible to surgery. Our results are similar to those obtained by other groups with respect to relapses, low morbidity and nil mortality in primary spontaneous pneumothorax.

Long-term functional results after surgical treatment of parapneumonic thoracic empyema

Retrospective evaluation of long-term functional results of surgical treatment of chronic pleural empyema. Two different surgical procedures (debridement vs. decortication) and approaches (VATS vs. thoracotomy) were analyzed. Three end-points were considered: short-term surgical results, short- and long-term radiological results, clinico-functional long-term results. Fifty-one debridement (52% VATS, 48% thoracotomy) and 68 decortication were performed. Postoperative mortality and morbidity were 1.5% and 24%, respectively. Older age (>70 years old) had worse postoperative morbidity (P=0.048). Video-assisted thoracic surgery (VATS) debridement had lower postoperative hospital stay (P=0.006) and shorter duration of chest drainage (P=0.006). The infectious process was resolved in all patients. All patients presented a postoperative radiological improvement, 63 patients (60%) with a complete pulmonary re-expansion. Sixty patients (58%) referred a complete respiratory recovery. VATS debridement had a greater improvement in subjective dyspnea degree (P=0.041). The long-term spirometric evaluation was normal in 58 patients (56%). Age >70 years old resulted the only variable associated to poor long-term results (FEV(1)% < 60% and/or MRC grade > or = 2) at multivariate analysis. Surgical treatment of pleural empyema achieves excellent long-term respiratory outcomes. VATS is associated to less postoperative mortality and shorter postoperative hospital stay. In elderly patients, postoperative morbidity could be higher and long-term functional improvement less warranted.

POLYMORPHONUCLEAR LEUKOCYTES ARE ACTIVATED DURING ATELECTASIS BEFORE LUNG REEXPANSION IN RAT

Although reexpansion of a collapsed lung often causes pulmonary edema, the pathogenesis of the condition is not yet fully understood. To determine whether inflammatory changes occur in the pulmonary circulation during atelectasis and study the mechanism underlying the development of reexpansion pulmonary edema, we used a rat model in which the left lung was collapsed by bronchial occlusion for 1 h and then reexpanded and ventilated for an additional 1 h. We evaluated the accumulation of polymorphonuclear leukocytes (PMNs) in the lung and the production of reactive oxygen species (ROS) in the pulmonary circulation using a fluorescent imaging technique. We also used confocal laser scanning microscopy and computerized image analysis to evaluate the membrane translocation of p47-phox, one of the nicotinamide adenine dinucleotide phosphate (reduced form) oxidase subunits, in PMNs sequestered in the lung. Polymorphonuclear leukocytes accumulated in the lung during atelectasis, and p47-phox was translocated to the plasma membrane, but no ROS production was observed. Marked PMN ROS production was observed after reexpansion of the collapsed lung with air. Little ROS production was observed when the lung was reexpanded with nitrogen. During atelectasis, PMNs accumulate in the lung, where they are primed for respiratory bursting. After pulmonary reexpansion, oxygen is supplied from the alveoli, and PMN respiratory bursting occurs.

Spontaneous Pneumothorax in Tuberous Sclerosis

A 28-year-old woman with tuberous sclerosis presented with sudden onset of dyspnea and discomfort in the right chest and back. On examination she had tachycardia, tachypnea, and hypoxia, with an absence of breath sounds on the right side. An anteroposterior chest radiograph showed a complete pneumothorax (Panel A, arrowheads), which resolved with a tube thoracostomy. Computed tomographic scans of the chest from previous hospitalizations showed a diffuse cystic intrapulmonary disease pattern consistent with pulmonary lymphangioleiomyomatosis (Panel B, arrows). After successful pulmonary re-expansion, the patient was discharged, but she returned within 1 week with bilateral pneumothoraxes. Pleurodesis was successful on the . . .