Significant Improvement In Dyspnea Research Articles

Effects of mindful breathing training combined with diary-based rehabilitation guidance in lung cancer patients undergoing surgery: A randomized controlled trial

Background and purposeLung cancer surgery patients experience severe physical and mental symptoms, which seriously affect their quality of life and prognosis. Mindful breathing training is a promising strategy to improve their symptoms, but its effectiveness is affected by training compliance, and diary-based rehabilitation instruction has been shown to help improve training compliance. Therefore, the aim of this study was to evaluate the effects of mindful breathing training combined with diary-based rehabilitation guidance on improving perioperative outcomes in lung cancer surgery patients. Materials and methodsThis single-center, assessor-blinded, prospective, three-arm randomized controlled trial was conducted from November 1, 2021 to November 1, 2022. Patients diagnosed with primary non-small cell lung cancer and scheduled for thoracoscopic surgery were randomly allocated to the combined intervention group, the mindful breathing group or the control group, with 34 patients in each group. The control group received routine care, while the mindful breathing group received mindful breathing training and routine care. The combined intervention group received both mindful breathing training and diary-based rehabilitation guidance, along with routine care. ResultsThe per-protocol analysis revealed that patients in the mindful breathing group experienced statistically significant improvements in dyspnea, fatigue and anxiety. Patients in the combined intervention group had statistically significant improvements in dyspnea, fatigue, anxiety, depression, exercise self-efficacy and training compliance. ConclusionThis study provides evidence that mindful breathing training combined with diary-based rehabilitation guidance can be effective in improving perioperative outcomes in lung cancer patients. It can be applied in clinical practice in the future.

A rare case of phrenic nerve palsy after cervical spine surgery

Abstract Phrenic nerve palsy is a rare complication of cervical spine surgery. There are very few previously reported cases of unilateral diaphragmatic paralysis following posterior cervical spine surgery. We present a case of a 61-year-old man with cervical canal stenosis and myelopathy for which we performed C3–C6 laminectomy and lateral mass screw fixation. Postoperatively the patient developed right C5 palsy affecting his deltoid function which gradually improved. The patient developed respiratory distress postoperatively and was found to have an elevated hemidiaphragm secondary to phrenic nerve palsy. He was treated with respiratory support, with significant improvement in dyspnea. It is a very rare case of unilateral diaphragmatic paralysis causing dyspnea due to phrenic nerve palsy following cervical spine surgery. This rare complication should be kept in mind when assessing any patient with respiratory distress following cervical spine surgery.

Long-Term Patient-Reported Symptom Improvement and Quality of Life after Transthoracic Diaphragm Plication in Adults.

Open and robotic-assisted transthoracic approaches for diaphragm plication are accepted surgical interventions for diaphragm paralysis and eventration. However, long-term patient-reported symptom improvement and quality of life (QOL) remains unclear. A telephone-based survey was developed focusing on postoperative symptom improvement and QOL. Patients who underwent open or robotic-assisted transthoracic diaphragm plication (2008-2020) across three institutions were invited to participate. Patients who responded and provided consent were surveyed. Likert responses on symptom severity were dichotomized and rates before and after surgery were compared using McNemar's test. Forty-one percent of patients participated (43 of 105 responded, mean age 61.0 years, 67.4% male, 37.2% robotic-assisted surgery), with an average time between surgery and survey of 4.1 ± 3.2 years. Patients reported significant improvement in dyspnea while lying flat (67.4% pre- vs 27.9% postoperative, p < 0.001), dyspnea at rest (55.8% pre- vs 11.6% postoperative, p < 0.001), dyspnea with activity (90.7% pre- vs 55.8% postoperative, p < 0.001), dyspnea while bending over (79.1% pre- vs 34.9% postoperative, p < 0.001), and fatigue (67.4% pre- vs 41.9% postoperative, p = 0.008). There was no statistical improvement in chronic cough. 86% of patients reported improved overall QOL, 79% had increased exercise capacity, and 86% would recommend surgery to a friend with a similar problem. Analysis comparing open and robotic-assisted approaches found no statistically significant differences in symptom improvement or QOL responses between the groups. Patients report significantly improved dyspneic and fatigue symptoms after transthoracic diaphragm plication, regardless of open or robotic-assisted approach. The majority of patients report improved QOL and exercise capacity.

Workup of difficult-to-treat asthma: implications from treatable traits.

Traditional stepwise approach usually adjusts the treatment regimen based on changes in asthma symptoms and severity to achieve good asthma control. However, due to the generalized heterogeneity and complexity of asthma, its therapeutic efficacy in difficult-to-treat asthma is limited. Recently, a precision medicine approach based on the identification and intervention of treatable traits of chronic airway disease has been proposed and appears to be of greater benefit to asthmatics. We reported a 71-year-old male with uncontrolled asthma and multiple exacerbations over the past year. He complained of persistent dyspnea despite high-dose of inhaled corticosteroids plus other controllers. Does this patient have some potential treatable traits contributing to difficult-to-treat asthma? Through a multidimensional assessment of three domains including pulmonary, extrapulmonary, and behavioral/risk factors, 15 treatable traits were identified in the patient, mainly including airflow limitation, eosinophilic airway inflammation, small airway dysfunction, exacerbation prone, dilated cardiomyopathy, diabetes mellitus, inhaler device polypharmacy, smoking, and the absence of an asthma action plan. After targeted treatment for these treatable traits, the patient experienced significant improvement in dyspnea and he could maintain good asthma control with low-dose inhaled corticosteroids and long-acting β2-agonist. This study shows that, in response to the limitation of a stepwise approach to therapy, treatable traits is a new strategy where patients are individually assessed for a specified set of treatable problems, and an individualized treatment program is developed and implemented based on this multidimensional assessment, especially for difficult-to-treat asthma.

Effect of Long-Term Oxygen Therapy in Chronic Obstructive Pulmonary Disease: A Prospective Clinical Study

Introduction: Long-Term Oxygen Therapy (LTOT) has the potential to improve the mortality and morbidity in Chronic Obstructive Pulmonary Disease (COPD) patients. Aim: To assess the effect of LTOT on the Quality of Life (QoL) in stable COPD patients with severe resting hypoxemia. Materials and Methods: This was a prospective observational study conducted in a tertiary care teaching hospital in Kozhikode, Kerala, on stable COPD patients with severe hypoxemia who were newly initiated on home LTOT for ≥15 hours per day. Health Related Quality of Life (HRQoL), modified Medical Research Council (mMRC) grade of dyspnoea, frequency of exacerbations and adherence to treatment on LTOT were studied. Total of 60 patients were followed-up for one year. Significance of mean was tested using paired t-test and association between qualitative variables was tested using Chi-square test. The p-value &lt;0.05 was considered statistically significant. Results: Out of all, 7 patients died during the study period and 53 patients were included in the final analysis. The mean total St.George’s Respiratory Questionnaire (SGRQ) scores at 3, 6 and 12 months improved to 53.73±13.2, 53.97±13.22 and 54.63±13.16, respectively, from a baseline score of 72.51±8.88. At the end of 12 months of LTOT, 22 (41.51%) patients did not have exacerbations and 31 (58.49%) patients had exacerbations. There was no statistically significant improvement in dyspnoea after one year of LTOT. Among the 53 patients, who completed one year follow-up, 36 (67.92%) participants were adherent and remaining 17 (32.07%) participants were non adherent to LTOT. Conclusion: LTOT improves the HRQoL in stable COPD patients with severe hypoxemia. Use of domiciliary oxygen for at least 15 hours per day can reduce the number of COPD exacerbations.

Effectiveness of an Inpatient Virtual Reality-Based Pulmonary Rehabilitation Program among COVID-19 Patients on Symptoms of Anxiety, Depression and Quality of Life: Preliminary Results from a Randomized Controlled Trial.

Forms of rehabilitation for patients after COVID-19 are gaining interest. The purpose of this study was to investigate and compare an innovative in-hospital pulmonary rehabilitation programs augmented with training elements performed in virtual reality. This randomized controlled study included 32 patients enrolled in post-COVID-19 rehabilitation at a Public Hospital in Poland. The rehabilitation models included exercise capacity training on a cycle ergometer, breathing and general fitness workout, resistance training, and relaxation. The forms of training and relaxation differed between the groups: the experimental group employed virtual reality, and the control group used a traditional form of therapy. Exercise tolerance was assessed using a 6 min walk test (6 MWT), while psychological parameters were evaluated using the Hospital Anxiety and Depression Scale (HADS) and the brief World Health Organization Quality of Life Scale (WHOQOL-BRIEF). The analysis of the post-rehabilitation results showed a statistically significant improvement in both groups regarding depression (VR: 6.9 (3.9) vs. 4.7 (3.5), p = 0.008; CG: 7.64 (4.5) vs. 6.6 (4.8), p = 0.017) and anxiety (VR: 8.6 (4.6) vs. 5.6 (3.3), p &lt; 0.001; CG: 9.57 (6.0) vs. 8 (4.8), p = 0.003). No statistically significant improvements in quality of life were noted in both groups. Moreover, the analysis showed a statistically significant improvement in the exercise capacity in both groups after completion of the rehabilitation program, expressed as a distance in the 6 MWT, as well as a statistically significant improvement in dyspnea in the VR group. To conclude, the analysis of the preliminary data revealed that a 3-week hospital-based pulmonary rehabilitation program for COVID-19 patients led to an improvement in exercise tolerance as well as a reduction in the symptoms of anxiety and depression. The virtual reality-based form of training delivery, despite its attractiveness, did not significantly affect patients' performance.

Long-Term Patient-Reported Symptom Improvement and Quality of Life after Transthoracic Diaphragm Plication in Adults

INTRODUCTION: Open and robotic-assisted transthoracic approaches for diaphragm plication are accepted surgical interventions for diaphragm paralysis and eventration. However, long-term patient-reported symptom improvement and quality of life (QOL) remains unclear. METHODS: A telephone-based survey was developed focusing on postoperative symptom improvement and QOL. Patients who underwent open or robotic-assisted transthoracic diaphragm plication (2008−2020) across three institutions were invited to participate. A telephone survey was conducted with patients who responded and provided consent. Likert responses on symptom severity were dichotomized and rates before and after surgery were compared using McNemar’s test. RESULTS: 41% of patients participated (43/105, mean age 61.0 years, 67.4% male, 37.2% robotic-assisted surgery), with an average time between surgery and survey of 4.1 ± 3.2 years. Patients reported significant improvement in dyspnea while lying flat (67.4% preop vs 27.9% postop, p < 0.001), dyspnea at rest (55.8% preop vs 11.6% postop, p < 0.001), dyspnea with activity (90.7% preop vs 55.8% postop, p < 0.001), dyspnea while bending over (79.1% preop vs 34.9% postop, p < 0.001), and fatigue (67.4% preop vs 41.9% postop, p = 0.008). Chronic cough did not improve (Figure). 86% of patients reported improved overall QOL, 79% had increased exercise capacity, and 86% would recommend surgery to a friend with a similar problem. Analysis comparing open and robotic-assisted approaches found no statistically significant differences in symptom improvement or QOL responses between the groups.FigureCONCLUSION: Patients report significantly improved dyspneic and fatigue symptoms following transthoracic diaphragm plication, regardless of open or robotic-assisted approach. A high number of patients report improved QOL and exercise capacity.

Patterns and predictors of dyspnoea following left ventricular assist device implantation.

Dyspnoea is a common symptom of heart failure (HF) that often prompts patients to seek treatment. Implantation of a left ventricular assist device (LVAD) has been associated with reduced dyspnoea but it is unclear if all patients experience similar improvements in dyspnoea over time following LVAD implantation. Our aim was to identify distinct trajectories of dyspnoea symptoms over time following LVAD implantation and predictors of dyspnoea trajectory. We hypothesized that at least two, distinct trajectories of dyspnoea would be observed following LVAD implantation. This was a secondary analysis of data from the Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure study. In the parent study, sociodemographic and clinical data were collected prior to LVAD implantation and at 1, 3, and 6 months following LVAD implantation from a sample (n = 101) of patients with advanced HF. Latent growth mixture modelling was performed to identify distinct trajectories of dyspnoea symptoms. Backwards stepwise logistic regression was used to identify predictors of dyspnoea trajectory. Two, distinct trajectories of dyspnoea symptoms were identified: sustained improvement and unsustained improvement. Participants who experienced sustained improvement (86.7% of sample) demonstrated large, significant improvement in dyspnoea from pre-implantation to 3 months post-implant followed by smaller, non-significant improvement from 3 to 6 months. Participants who experienced unsustained improvement (13.3% of sample) demonstrated initial improvement from pre-implantation to 3 months post-implantation followed by worsening of dyspnoea from 3 to 6 months. Greater depressive symptoms at baseline and living alone were significant predictors of unsustained improvement. Patients experience different patterns of dyspnoea over time following LVAD implantation. Clinicians should inquire about living arrangements and depressive symptoms at each visit to determine risk of unsustained improvement in dyspnoea.

Clinical and sonographic evaluation of the diaphragm after plication in adults with unilateral eventration: a retrospective study

BackgroundWe aim to assess the role of diaphragm ultrasonography in evaluating the outcome of surgical diaphragmatic plication in adults with symptomatic unilateral diaphragmatic eventration.ResultsForty patients with symptomatic unilateral diaphragmatic eventration underwent surgical diaphragmatic plication between 2015 and 2020. The etiology was idiopathic in 34 (85%) cases, and 37 (92.5%) of them were suffering from dyspnea. Diaphragm ultrasonography showed no diaphragmatic movement on the affected side in 10 (25%) patients and a paradoxical movement in 30 (75%) patients. Surgical diaphragmatic plication was done successfully in all cases. Postoperative complications were reported in 3 (7.5%) cases, with no mortality. There was a highly significant improvement in dyspnea at 1 week and 6 months follow-up. CXR showed a highly significant decrease in the mean height of eventration at 1 week 3.7 ± 1.2 cm (P < 0.001), and 6 months 2.6 ± 0.9 cm (P < 0.001), compared to preoperative values (10.1 ± 2.8 cm). diaphragm ultrasonography showed normal motility of the plicated cupola in all cases, and there was a highly significant decrease in the mean height of eventration at 1 week (3.1 ± 1.1 cm, P < 0.001), and 6 months (2.3 ± 0.5 cm, P < 0.001) compared to preoperative values (10.3 ± 2.2 cm). There was a highly significant increase in the diaphragm thickness at 1 week (2.7 ± 0.3 mm, P < 0.001), and 6 months (2.9 ± 0.2 mm, P < 0.001), compared to the preoperative value. There was a highly significant improvement in the degree of excursion 1 week (25 ± 4.3 mm, P < 0.001), and 6 months (28 ± 5.2 mm, P < 0.001), compared to the preoperative value (15 ± 6.2 mm). No fluid collection or surroundings organ injuries were detected. The mean FVC and FEV1 showed a highly significant improvement at 1 week (66.7 ± 6%, 78.2 ± 9.8%), and 6 months (68.8 ± 5.7%, 80.4 ± 10.3%), compared to the preoperative value (58.8 ± 8% and 70.9 ± 10.3%).ConclusionsSurgical diaphragmatic plication is an effective and safe procedure that can be performed to treat symptomatic adults with unilateral diaphragmatic eventration. Diaphragm ultrasonography can be used as a simple bedside test to evaluate unilateral diaphragmatic eventration cases and their postoperative follow-up.

Quality of life in patients with malignant pleural effusion treated with an indwelling pleural catheter in an emerging country

BackgroundThe use of Indwelling Pleural Catheter (IPC) in the care of patients with Malignant Pleural Effusion (MPE) is well established, however studies involving public health systems of low and middle-income countries are still lacking. This study aimed to determine the effect of IPC on the respiratory symptoms and Quality of Life (QoL) of patients with MPE in the setting of a Brazilian public health system. MethodsFrom August 2015 to November 2019, patients with MPE underwent IPC placement and were prospectively followed. QoL and respiratory symptoms were assessed by the EORTC questionnaires (QLQ-30; LC13) and Visual Analogue Scale (VAS), respectively, at pre-treatment, 30 , and 60 days after IPC placement. Results56 patients were enrolled with 57 catheters inserted. The mean age was 63 (23‒88) years, of which 17 (30%) were men and 39 (70%) were women. Breast 24 (42%) and lung 21 (37%) were the main primary neoplasms. Cellulitis was the most common complication and all patients recovered with appropriate antimicrobial therapy. QoL did not change significantly over time, however, the VAS showed a significant improvement in dyspnea (+1.2: -0.5; p = 0.001). ConclusionIPC relieves respiratory symptoms without compromising the QoL, with a low complication rate. It represents a suitable option for patients with MPE and short LE in an emerging country.

Effect of new reflexology maneuver on lung function and functional ability of chronic obstructive pulmonary disease patients in pulmonary rehabilitation program: A randomized control trial

Introduction. Chronic obstructive pulmonary disease (COPD) is a complex disease that requires multidisciplinary interventions provided by a team work of care providers working closely. Pulmonary rehabilitation should be considered a part of integrated patient management. Aim. The main goal of this study was to search for the effectiveness of introducing new reflexology maneuver as main component in pulmonary rehabilitation program (PRP). Material and Methods. Randomized control trial was done on 35 COPD patients of both genders their ages ranged from 50-70 with different degrees of functional severity. Patients were grouped into two groups; Reflexology Group (20 patients) including patients underwent classic PRP with addition of the new reflexology maneuver&amp; control group(15 patients) who underwent classic PRP without reflexology maneuver.Outcomes were mentioned as refinement of pulmonary function,exercise tolerance and capacity measured by 6-min walk test,dyspnea score measured by the Modified British Medical Research Council (mMRC) Questionnaire, health status assigned by Combined Assessment test (CAT) score and parameters of blood gases. Results. Comparison between different variables in both groups before PRP and reflexology revealed statistically significant differences as regards the mean values of forced vital capacity (FVC) only, although the same comparison after full course of PRP and reflexology assigned statistically significant differences as regards the mean values of partial pressure of O2 (PO2), partial pressure of CO2 (PCO2), oxygen saturation (SaO2),forced expiratory volume in 1sec (FEV1), dyspnea &amp;CAT score considering (p &lt; 0.05). Conclusion. With addition of reflexology to PRP the comprehensive PR program outcomes in COPD patients resulted in significant improvement in dyspnea, blood gases, FEV1 and CAT score.

Multimodal Exercise Program: A Pilot Randomized Trial for Patients With Lung Cancer Receiving Surgical Treatment.

Curative lung resection is the best option for patients with stage I-III lung cancer, and the best exercise intervention in these patients has not been determined. This pilot study explored whether a short-term pre- and postsurgery multimodal exercise program affected dyspnea, exercise capacity, inspiratory capacity, anxiety, and depression. A total of 101 patients were randomly allocated into the combined intervention group (n = 34), the breathing exercise group (n = 32), or the control group (n = 35). During hospitalization, patients in the two intervention groups received one or more kinds of exercise intervention, and patients in the control group only received usual care. Outcomes were assessed at admission, on the day before surgery, and at discharge. Both intervention groups achieved significant improvements in dyspnea, exercise capacity, and inspiratory capacity, and patients in the combined intervention group exhibited greater improvements in outcomes as compared to those randomized to the breathing exercise group.

Effect of muscle training on dyspnea in patients with chronic obstructive pulmonary disease: A meta-analysis of randomized controlled trials.

Background:Rehabilitation training is beneficial for patients with chronic obstructive pulmonary disease (COPD). This study was aimed at evaluating the efficacy of muscle training on dyspnea.Methods:We used 5 common databases for conducting a meta-analysis included PubMed, the Cochrane Library, Science Direct, Web of Science and Clinical Trials.gov, and eligible randomized controlled trials (RCTs) were included. The main results of include studies were dyspnea of patients who had a clinical diagnosis of COPD measured using Borg score and Medical Research Council (MRC) or modified Medical Research Council (mMRC) scale as the criteria before and after intervention. The intervention measures included respiratory or expiratory muscles or upper limb (UL) or lower limb (LL) training. The mean differences (MD) with the 95% confidence interval (CI) were considered for summary statistics. We also assessed risk of bias using the Cochrane collaboration's tool, and the value of I2 was applied to evaluate the heterogeneity of the trials.Results:Fourteen RCTs with 18 interventions (n = 860 participants) were included. Muscle training significantly improved dyspnea during exercise and in the daily life of patients with COPD (MD, 95% CI: −0.58, −0.84 to −0.32, P < .0001 and −0.44, −0.65 to −0.24, P < .0001, respectively). In the subgroup analyses, the trials that used respiratory muscle and UL trainings significantly improved dyspnea during exercise (MD, 95% CI: −0.72, −1.13 to −0.31, P = .0005 and −0.53, −0.91 to −0.15, P = .007, respectively). The studies also showed that the participants in the rehabilitation group, who received respiratory muscle and UL trainings, had a significant improvement of dyspnea in daily life (MD, 95% CI: −0.38, −0.67 to −0.09, P = .01 and −0.51, −0.80 to −0.22, P = .0007, respectively).Conclusion:There were some limitations that most of the subjects in this study were patients with moderate to severe COPD and were male, and the training period and duration were different. The analyses revealed that respiratory muscle and UL trainings can improve dyspnea in patients with COPD during exercise and in daily life.

Time course of exercise capacity in patients recovering from COVID-19-associated pneumonia.

ABSTRACT Objective:High prevalences of muscle weakness and impaired physical performance in hospitalized patients recovering from COVID-19-associated pneumonia have been reported. Our objective was to determine whether the level of exercise capacity after discharge would affect long-term functional outcomes in these patients. Methods:From three to five weeks after discharge from acute care hospitals (T0), patients underwent a six-minute walk test (6MWT) and were divided into two groups according to the distance walked in percentage of predicted values: <75% group and ≥75% group. At T0 and three months later (T1), patients completed the Short Physical Performance Battery and the Euro Quality of Life Visual Analogue Scale, and pulmonary function and respiratory muscle function were assessed. In addition, a repeat 6MWT was also performed at T1. Results:At T0, 6MWD values and Short Physical Performance Battery scores were lower in the <75% group than in the ≥75% group. No differences were found in the Euro Quality of Life Visual Analogue Scale scores, pulmonary function variables, respiratory muscle function variables, length of hospital stay, or previous treatment. At T1, both groups improved their exercise capacity, but only the subjects in the <75% group showed significant improvements in dyspnea and lower extremity function. Exercise capacity and functional status values returned to predicted values in all of the patients in both groups. Conclusions:Four weeks after discharge, COVID-19 survivors with exercise limitation showed no significant differences in physiological or clinical characteristics or in perceived health status when compared with patients without exercise limitation. Three months later, those patients recovered their exercise capacity.

Phrenic nerve palsy after cervical laminectomy and fusion

BackgroundPhrenic nerve palsy is a rare complication of cervical spine surgery. There are no previously reported cases of unilateral diaphragmatic paralysis following posterior cervical spine surgery. Here, we present a case of a 69 year-old Caucasian male with severe cervical stenosis with myelopathy who underwent posterior spinal instrumentation and fusion (PSIF) from C2 to T2, with laminectomies at C3-C7. OutcomeThe patient developed respiratory distress post-operatively and was found to have an elevated hemidiaphragm secondary to phrenic nerve palsy. He was treated with respiratory support, with significant improvement in dyspnea. He was also noted to have a left C5 palsy affecting his deltoid function and proximal upper extremity sensation which gradually improved. ConclusionsThis is the first reported case of unilateral diaphragmatic paralysis causing dyspnea due to phrenic nerve palsy following cervical spine surgery. This rare complication should be kept in mind when assessing any patient with respiratory distress following cervical spine surgery.

Persistent unexplained chest pain and dyspnea in a patient with coronary artery disease: a case report

BackgroundNeurogenic orthostatic hypotension, a sustained decrease in blood pressure upon standing, is caused by autonomic nervous system failure and characterized by an insufficient increase in heart rate needed to maintain blood pressure upon standing. In this case, neurogenic orthostatic hypotension symptoms preceded a diagnosis of Parkinson disease. A diagnosis of underlying neurogenic orthostatic hypotension significantly changed the course of treatment for this patient.Case presentationAn 84-year-old woman was referred to a cardiologist by her primary care practitioner for evaluation of exertional dyspnea and chest pain upon walking a few feet. Her medical history included hypertension, hypothyroidism, and osteoarthritis. Based on her continued symptoms, the patient underwent 2 cardiac catheterizations for coronary artery stenosis. After the catheterizations, exertional dyspnea and chest pain continued, and subsequently, dysphagia to solid foods and episodic dizziness developed. Orthostatic evaluation showed a supine blood pressure of 150/80 mmHg with a heart rate of 70 beats per min. Upon standing for 3 min, the patient’s blood pressure decreased to 110/74 mmHg with a heart rate of 76 beats per min. The diagnostic criteria for orthostatic hypotension were met, and the lack of an adequate compensatory heart rate increase upon standing was consistent with a neurogenic cause (ie, neurogenic orthostatic hypotension), which was supported by tilt-table testing results. Although nonpharmacologic treatments were initially successful, episodes of lightheadedness, chest pain, and dyspnea upon standing became more frequent, and the patient was prescribed droxidopa (200 mg; 3 times daily). Droxidopa significantly improved her symptoms, with the patient reporting resolution of her chest pain and significant improvement of dyspnea and dizziness. She was diagnosed with Parkinson disease approximately 6 months later.ConclusionsThis case highlights the importance of evaluating and identifying potential causes of symptoms of cardiovascular disease when persistent symptoms do not improve after cardiac interventions. This case complements findings demonstrating that signs of autonomic failure, such as neurogenic orthostatic hypotension, may precede the motor symptoms of Parkinson disease. Importantly, this case provides real-world evidence for the efficacy of droxidopa to treat the symptoms of neurogenic orthostatic hypotension, after an appropriate diagnosis.

Benefits of Pulmonary Rehabilitation in Patients with COPD with Use and without the Use of Supplemental Oxygen During Exercise

Objective:To determine the effects of a pulmonary rehabilitation program in patients with COPD who use and do not use supplemental oxygen during exercise.Materials and Methods:Prospective longitudinal descriptive study on 59 patients with COPD who were part of a pulmonary rehabilitation program and who were classified into two groups: a group that required supplemental oxygen during rehabilitation and another that did not.Results:31 patients were linked to the group that used oxygen during rehabilitation and 28 patients who did not use it. The average age was 69.1 ± 10.6 years old. The mMRC dyspnea decreased 0.7 ± 0.2 (p = 0.000) in the group that used oxygen and 0.8 ± 0.1 (p = 0.000) in the group that did not use it. The distance increased 45.9 meters ± 7.2 (p = 0.000) in the group that used oxygen and 65.2 meters ± 16.3 (p = 0.001) in the group that did not use it.Conclusion:Both groups showed significant improvements in dyspnea and aerobic capacity, however, there was a greater increase in the group that did not use oxygen.

P264 Alcohol septal ablation in hypertrophic obstructive cardiomyopathy with mitral insufficiency of mixed mechanism

Abstract Alcohol septal ablation is a percutaneous intervention for hypertrophic obstructive cardiomyopathy, aiming to relieve symptoms, as an alternative to surgical myomectomy, in optimally treated but still symptomatic patients, with high surgical risk. We present the case of 65-year-old female, with persistently elevated blood pressure, presenting with severe dyspnea and angina on exertion and frequent episodes of paroxysmal nocturnal dyspnea. Clinical examination revealed an intense left parasternal systolic murmur. Electrocardiographic findings were sinus rhythm and negative T waves in V2-V6. Transthoracic echocardiography showed a small LV cavity with severe asymmetric left ventricular hypertrophy (maximum basal interventricular septum thickness of 26 mm), with important obstruction in the left ventricular outflow tract - resting gradient 77mmHg, provoked gradient 100mmHg. TOE evaluation of the mitral valve revealed significant mitral regurgitation, with intermitent telesystolic anterior motion of the anterior mitral leaflet and also P2 scallop prolapse. Further evaluation revealed a 60% stenosis of left anterior descending (LAD) artery of second segment, 60% stenosis of the left internal carotid artery, chronic renal disease (creatinine clearance 80ml/min), and moderate pulmonary hypertension. Although surgery was initially proposed to the patient, given the high operative risk (EUROSCORE II 8.45%) for a complete surgical procedure (myomectomy, mitral valve repair and coronary bypass), we attempted a stepwise approach to alleviate her symptoms. Intensive medical treatment improved blood pressure control while angioplasty of the LAD alleviated her angina. Echo-guided alcohol ablation of the interventricular septal wall was performed. Catheter-based contrast injection of a secondary septal branch of the LAD produced a subendocardial contrast in the contact area of anterior mitral valve leaflet; subsequently, embolizing the artery, producing an isolated necrosis at this level, with equalizing the pressure curves between LV and aorta. Postintervention, initial gradients were 50mmHg at rest, 100mmHg on postextrasystolic measurement. Systolic movement of the anterior leaflet maintained a mezotelesystolic pattern. At 3-months follow-up, LVOT gradients were 27/100mmHg, without any increase in pulmonary artery pressure, but with significant improvement of dyspnea. Further risk assessment by Holter ECG monitoring identified non-sustained ventricular tachycardia, so an ICD was implanted. The modest reduction in gradient was associated with significant clinical improvement in the patient’s symptomatology. This procedure has been refined in the last years, especially with the introduction of myocardial contrast echocardiography for better localizing the area at risk of infarction and to reduce the amount of alcohol used. Alcohol septal ablation may be part of a stepwise plan to improve symptoms, with lower procedural risks as compared to classic surgery.

Effects of Different Modes of Upper Limb Training in Individuals With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis.

ObjectiveTo determine effects of different modes of upper limb training on dyspnea and quality of life of individuals with chronic obstructive pulmonary disease (COPD) having different disease severity.MethodsRandomized clinical trials were retrieved from five electronic databases. Risk of bias and quality of evidence were assessed using the Cochrane Collaboration’s tool and the GRADE approach, respectively. Effects of upper limb training compared to control were identified using standardized mean difference and 95% confidence interval.ResultsFifteen studies with 514 subjects were included. When compared to control, upper limb endurance and strength training with moderate quality of evidence resulted in significant improvement in dyspnea. However, quality of life was not significantly different between upper limb training of all modes of and the control. The upper limb training was more effective in reducing dyspnea in patients with severe COPD than in those with mild to moderate levels of COPD. Although quality of life was slightly improved by upper limb training for those with moderate or severe level of COPD, such improvement did not reach a significant level when compared to the control.ConclusionUpper limb endurance and strength training could significantly improve dyspnea in individuals with chronic obstructive pulmonary disease. Thus, incorporating the upper limb training into pulmonary rehabilitation is recommended to reduce dyspnea, especially for those with severe patients. Further studies with larger sample size and standardized training protocol are needed to confirm these finding (Registration No. CRD42018102805).

SQUAMOUS CELL CARCINOMA PRESENTING WITH OBSTRUCTION OF THE SUPERIOR VENA CAVA AND CENTRAL AIRWAYS

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: One mechanism by which cancer causes morbidity/mortality is by mass effect with distortion, compression, or occlusion of nearby anatomical structures. Within the chest, tumors can exert these effects on the airways and vascular structures. This case illustrates the need for urgent intervention in a patient presenting with severe compression of multiple intrathoracic structures. CASE PRESENTATION: A 54 year-old man with chronic tobacco use and limited exposure to healthcare presented to the hospital with gradually progressive shortness of breath over several months, followed by facial swelling, severe wheezing, and recurrent syncope over the past few days. Exam was remarkable for facial flushing and diffuse inspiratory/expiratory wheezing. Laryngoscopy was performed, which did not suggest critical airway edema. Computed tomography (CT) of the chest demonstrated a large right-sided suprahilar mass, with severe compression of the superior vena cava (SVC) and right mainstem bronchus (RMB) and bronchus intermedius, narrowing of the right pulmonary artery and vein, and complete collapse of the right upper lobe. The patient underwent urgent placement of an 11x59mm balloon-expandable covered stent within the SVC, after which the patient reported improvement in facial swelling but minimal improvement in dyspnea. Next, he underwent bronchoscopy, which demonstrated significant extrinsic compression within the right mainstem bronchus; transbronchial needle aspirates of lymph nodes from Stations 4R and 7 were obtained, from which pathology results were consistent with squamous cell carcinoma (SCC). Because of the degree of bronchial compression, and the need for chemotherapy and radiation therapy which could temporarily cause tumoral inflammation and worsen compression/collapse of the right lung, bronchoscopy was repeated, and this time a 12x40mm self-expandable partially-covered stent was placed within the right mainstem bronchus. After this, the patient reported significant improvement in dyspnea, and was discharged to home in stable condition. DISCUSSION: This case describes pulmonary SCC presenting with symptoms of acute SVC syndrome and central airway compression. Lung cancer associated with either of these conditions has dramatically increased morbidity/mortality. In malignant SVC syndrome, stent placement has been shown to reduce SVC pressure and improve symptoms; there is moderate risk of stent re-obstruction. Though not free of risks, endobronchial stent placement can prevent the impending occlusion of a central airway, when surgical or endobronchial resection/debulking is not possible. In recent years, there have been numerous advances in the technology and variety of endobronchial stents for multiple indications. CONCLUSIONS: Malignant extrinsic compression of the SVC and central airways is associated with high morbidity/mortality and can be managed urgently and safely with stent placement. Reference #1: Avasarala SK, Freitag L, & Mehta AC. Metallic endobronchial stents: A contemporary resurrection [published online ahead of print December 11, 2018]. CHEST. doi:10.101/j.chest.2018.12.001. Reference #2: Niu S, Xu YS, Cheng L, & Cao C. Stent insertion for malignant superior vena cava syndrome: Effectiveness and long-term survival. Vascular and Interventional Radiology 2017, 122: 633-638. Reference #3: Mudambi L, Miller R, & Eapen GA. Malignant central airway obstruction. Journal of Thoracic Disease 2017, 9(10): 1087-1110. DISCLOSURES: No relevant relationships by Gabriel Ryan, source=Web Response