Ventilatory Impairment Research Articles

The relationship between ventilatory function and cognitive and behavioral impairment in ALS

Objective: To study the association between ventilatory function and cognitive and behavioral impairment in ALS patients accounting for the effects of pertinent covariates. Methods: Four hundred and eighty-one patients were identified from the Mayo Clinic Florida ALS registry who had concurrent forced vital capacity (FVC) and cognitive and behavioral testing using the ALS Cognitive Behavioral Screen (ALS-CBS). Multiple linear regression analysis was used to study the effects of FVC and relevant covariates on the ALS-CBS cognition score, subscores, and caregiver behavioral inventory. Results: FVC was positively correlated to the cognitive and behavioral subscores on the ALS-CBS (p < 0.001), and the correlation was independent of the effects of site of ALS onset, age, and years of education. Conclusion: Cognitive and behavioral function may be adversely affected by ventilatory impairment in ALS. The presence of cognitive and behavioral impairment warrants a detailed assessment of ventilatory function.

COVID-19 Pandemic in Mountainous Areas: Impact, Mitigation Strategies, and New Technologies in Search and Rescue Operations.

van Veelen, Michiel J., Anna Voegele, Simon Rauch, Marc Kaufmann, Hermann Brugger, and Giacomo Strapazzon. COVID-19 pandemic in mountainous areas: impact, mitigation strategies, and new technologies in search and rescue operations. High Alt Med Biol. 22:335–341, 2021.—Mitigating the spread of COVID-19, an airborne infection, can lead to delays in the prehospital response and impair the performance of search and rescue (SAR) services in mountainous and remote areas. We provide an overview of the developing epidemiological situation related to the COVID-19 pandemic in mountainous areas and review current protocols to determine their suitability for mountain rescue teams. We also discuss using novel technologies to reduce the adverse effects caused by COVID-19 mitigation strategies such as delays caused by donning personal protective equipment (PPE) and reduced rescuer performance due to impaired movement and ventilation. COVID-19 has spread even in mountainous and remote locations. Dedicated protocols for the use of PPE appropriate for SAR rescuers exerting physical effort in remote areas and using technologies such as drones, telemedicine, and localization and contact tracing applications could contribute to an effective and timely emergency response in mountainous and remote settings.

Effect of combination inhaled therapy on ventilation distribution measured by SPECT/CT imaging in uncontrolled asthma.

Asthma is characterized by heterogeneous ventilation as measured by three-dimensional ventilation imaging. Combination inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) treatment response is variable in asthma, and effects on regional ventilation are unknown. Our aims were to determine whether regional ventilation defects decrease after ICS/LABA treatment and whether small airways dysfunction predicts response in uncontrolled asthma. Twenty-two symptomatic participants with asthma underwent single-photon emission computed tomography (SPECT)/CT imaging with Technegas, before and after 8-wk fluticasone/formoterol (1,000/40 µg/day) treatment. Lung regions that were nonventilated, low ventilated, or well ventilated were calculated using an adaptive threshold method and were expressed as a percentage of total lung volume. Multiple-breath nitrogen washout (MBNW) was used to measure diffusion-dependent and convection-dependent small airways function (Sacin and Scond, respectively). Forced oscillation technique (FOT) was used to measure respiratory system resistance and reactance. At baseline and posttreatment, Scond z-score was related to percentage of nonventilated lung, whereas Sacin z-score was related to percentage of low-ventilated lung. Although symptoms, spirometry, FOT, and MBNW improved following treatment, there was no mean change in ventilation measured by SPECT. There was, however, a wide range of changes in SPECT ventilation such that greater percentage of nonventilated lung, older age, and higher Scond predicted a reduction in nonventilated lung after treatment. SPECT ventilation defects are overall unresponsive to ICS/LABA, but the response is variable, with improvement occurring when small airways dysfunction and ventilation defects are more severe. Persistent ventilation defects that correlate with Scond suggest that mechanisms such as non-ICS responsive inflammation or remodeling underlie these defects.NEW & NOTEWORTHY This study provides insights into the mechanisms of high-dose ICS treatment in uncontrolled asthma. Ventilation defects as measured by SPECT/CT imaging respond heterogeneously to increased ICS/LABA treatment, with improvement occurring when ventilation defects and impairment of convection-dependent small airways function are more severe. Persistent correlations between ventilation defects and measures of small airways function suggest the potential presence of ICS nonresponsive inflammation and/or remodeling.

Lung distribution of gas and blood volume in critically ill COVID-19 patients: a quantitative dual-energy computed tomography study

BackgroundCritically ill COVID-19 patients have pathophysiological lung features characterized by perfusion abnormalities. However, to date no study has evaluated whether the changes in the distribution of pulmonary gas and blood volume are associated with the severity of gas-exchange impairment and the type of respiratory support (non-invasive versus invasive) in patients with severe COVID-19 pneumonia.MethodsThis was a single-center, retrospective cohort study conducted in a tertiary care hospital in Northern Italy during the first pandemic wave. Pulmonary gas and blood distribution was assessed using a technique for quantitative analysis of dual-energy computed tomography. Lung aeration loss (reflected by percentage of normally aerated lung tissue) and the extent of gas:blood volume mismatch (percentage of non-aerated, perfused lung tissue—shunt; aerated, non-perfused dead space; and non-aerated/non-perfused regions) were evaluated in critically ill COVID-19 patients with different clinical severity as reflected by the need for non-invasive or invasive respiratory support.ResultsThirty-five patients admitted to the intensive care unit between February 29th and May 30th, 2020 were included. Patients requiring invasive versus non-invasive mechanical ventilation had both a lower percentage of normally aerated lung tissue (median [interquartile range] 33% [24–49%] vs. 63% [44–68%], p < 0.001); and a larger extent of gas:blood volume mismatch (43% [30–49%] vs. 25% [14–28%], p = 0.001), due to higher shunt (23% [15–32%] vs. 5% [2–16%], p = 0.001) and non-aerated/non perfused regions (5% [3–10%] vs. 1% [0–2%], p = 0.001). The PaO2/FiO2 ratio correlated positively with normally aerated tissue (ρ = 0.730, p < 0.001) and negatively with the extent of gas-blood volume mismatch (ρ = − 0.633, p < 0.001).ConclusionsIn critically ill patients with severe COVID-19 pneumonia, the need for invasive mechanical ventilation and oxygenation impairment were associated with loss of aeration and the extent of gas:blood volume mismatch.Graphic abstract

Damage control in the emergency department, a bridge to life.

Patients with hemodynamic instability have a sustained systolic blood pressure less or equal to 90 mmHg, a heart rate greater or equal to 120 beats per minute and an acute compromise of the ventilation/oxygenation ratio and/or an altered state of consciousness upon admission. These patients have higher mortality rates due to massive hemorrhage, airway injury and/or impaired ventilation. Damage control resuscitation is a systematic approach that aims to limit physiologic deterioration through strategies that address the physiologic debt of trauma. This article aims to describe the experience earned by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia in the management of the severely injured trauma patient in the emergency department following the basic principles of damage control surgery. Since bleeding is the main cause of death, the management of the severely injured trauma patient in the emergency department requires a multidisciplinary team that performs damage control maneuvers aimed at rapidly controlling bleeding, hemostatic resuscitation, and/or prompt transfer to the operating room, if required.

호흡재활의 이해

Pulmonary rehabilitation is consisted of breathing retraining, respiratory muscle rest, airway secretion elimination, reconditioning exercise, psychosocial support, nutritional support, adequate ventilator support, and patient education. And there are many techniques and devices to relieve and control the symptoms of respiratory diseases and to prevent from respiratory complications. Among them, the point of pulmonary rehabilitation is the non-invasive respiratory care by using respiratory muscle aids. All patients with impairment of pulmonary function can be differentiated into those who have primarily oxygenation impairment from predominantly intrinsic lung or obstructive diseases, and those with mechanical or restrictive lung disease on the basis of respiratory muscle dysfunction and ventilation impairment. The patients with primarily ventilatory impairment can benefit considerably from the use of both inspiratory and expiratory muscle aids. If we understand the pathophysiology of each pulmonary problem and evaluate the patient carefully and timely, we can minimize the respiratory complications through proper ventilatory and coughing support. Reduced respiratory complications can actually decrease the mortality rate. In conclusion, use of non-invasive respiratory aids, taking into account the characterization of respiratory pathophysiology, have made it possible to enhance quality of life as well as prolong the life span.

Dead space estimates may not be independently associated with 28-day mortality in COVID-19 ARDS

BackgroundEstimates for dead space ventilation have been shown to be independently associated with an increased risk of mortality in the acute respiratory distress syndrome and small case series of COVID-19-related ARDS.MethodsSecondary analysis from the PRoVENT-COVID study. The PRoVENT-COVID is a national, multicenter, retrospective observational study done at 22 intensive care units in the Netherlands. Consecutive patients aged at least 18 years were eligible for participation if they had received invasive ventilation for COVID-19 at a participating ICU during the first month of the national outbreak in the Netherlands. The aim was to quantify the dynamics and determine the prognostic value of surrogate markers of wasted ventilation in patients with COVID-19-related ARDS.ResultsA total of 927 consecutive patients admitted with COVID-19-related ARDS were included in this study. Estimations of wasted ventilation such as the estimated dead space fraction (by Harris–Benedict and direct method) and ventilatory ratio were significantly higher in non-survivors than survivors at baseline and during the following days of mechanical ventilation (p < 0.001). The end-tidal-to-arterial PCO2 ratio was lower in non-survivors than in survivors (p < 0.001). As ARDS severity increased, mortality increased with successive tertiles of dead space fraction by Harris–Benedict and by direct estimation, and with an increase in the VR. The same trend was observed with decreased levels in the tertiles for the end-tidal-to-arterial PCO2 ratio. After adjustment for a base risk model that included chronic comorbidities and ventilation- and oxygenation-parameters, none of the dead space estimates measured at the start of ventilation or the following days were significantly associated with 28-day mortality.ConclusionsThere is significant impairment of ventilation in the early course of COVID-19-related ARDS but quantification of this impairment does not add prognostic information when added to a baseline risk model.Trial registration: ISRCTN04346342. Registered 15 April 2020. Retrospectively registered.

Adenosine-regulated mechanisms in the pathogenesis of ventilation disorders in patients with pulmonary tuberculosis

Uncovering involvement of the purinergic system in the pathogenesis of ventilation disorders (VD) may provide additional information about the pathophysiological mechanisms leading to the development of VD in pulmonary tuberculosis (PT). The aim was to identify a relationship between the parameters of adenosine metabolism, inflammatory response and altered ventilation metabolism in PT patients. Materials and methods. Obstructive and mixed PT patients were assigned to subgroups with/without VD for assessing adenosine deaminase activity (ADA-1, 2) in serum, mononuclear cells, neutrophils; ecto-5’-nucleotidase (ecto-5’-NT); CD26 (dipeptidyl peptidase-4, DPP-4), phagocyte oxidative burst measured by NO generation. Results. PT patients showed decreased ADA-1 and CD26 (DPP-4), but increased ADA-2. Elevated intracellular adenosine concentration was found in mononuclear cells in patients lacking VD, whereas patients with mixed and obstructive VD — had it in neutrophils. Mononuclear cells of patients with PT lacking VD as well as with obstructive VD type had decreased NO3– concentration. Neutrophil hyperactivity was recorded in all groups of PT patients. Patients with PT lacking VD as well as with mixed VD type showed that the parameters of external respiration were associated with activity of extra-/intracellular ADA, whereas obstructive VD was caused by excessive formation of serum adenosine. Changes in respiratory function in PT were associated with decreased level of serum NO radicals, impaired nitrogen-dependent bactericidal phagocyte activity, and overproduced neutrophil oxygen radicals. Conclusion. Purinergic regulation is involved in regulating inflammatory and compensatory processes in PT patients as well as impaired ventilation efficiency. The most severe respiratory disorders observed in PT patients with mixed VD type are associated with the most prominent changes in nucleotidase activity, particularly ecto-ADA-2 and DPP-4/CD26.

Lung Function Impairment in Construction Workers – Influence of Smoking and Exposure Duration

AIM: The objective of the study was to assess the influence of exposure duration and smoking on ventilatory impairment among construction workers. METHODS: A cross-sectional study was performed, including 83 construction workers aged 18–64 years, compared to equivalent number of office controls matched by age, workplace exposure duration, and smoking status. Data on chronic respiratory symptoms, work history, and smoking status were collected by standardized questionnaire, while lung functional testing of the examined subjects was performed by spirometry. RESULTS: Mean values of spirometric parameters were lower in construction workers compared to controls with statistical significance registered for maximal expiratory flow (MEF25), MEF50, and MEF75. Lung functions of construction workers have been found to decrease in relation to exposure duration but reached significance only for small airways changes. There was a significant difference in detected ventilatory impairment between exposed workers and controls for any type of ventilatory impairment, as well as obstructive and combined ventilatory pattern and obstructive ventilatory pattern in small airways. Obstructive ventilatory impairment was significantly associated with life-time smoking in construction workers, while obstructive ventilatory pattern in small airways was significantly associated with life-time smoking. The combined effect of daily smoking, life-time smoking, and number of cigarettes smoked daily was shown to have a significant influence in their development. The risk for obstructive ventilatory pattern in small airways among exposed subjects was about 4 fold higher in those exposed more than 20 years (odds ratio [OR] = 3.68 [1.01–14.59] confidence interval [CI] 95%), and about 2.5 fold higher in smokers (OR = 2.57 [0.92-7.25] CI 95%). Exposure duration, smoking and age had independent effect only on small airways changes and force expiratory volume in the 1st s/force vital capacity %. CONCLUSION: Our data suggest the importance of the joint effect of job exposure in construction and daily smoking on the development of lung function impairment and airflow limitation, being dominant, especially on small airways.

Opioid-Induced In-Hospital Deaths: A 10-Year Review of Australian Coroners' Cases Exploring Similarities and Lessons Learnt.

Although opioids are the cornerstone of moderate-to-severe acute pain management they are appropriately recognised as high-risk medicines. Patient and health service delivery factors can contribute to an increased risk of death associated with excessive sedation and respiratory impairment. Despite increasing awareness of opioid-induced ventilation impairment (OIVI), no reliable method consistently identifies individual characteristics and factors that increase mortality risk due to respiratory depression events. This study assessed similarities in available coronial inquest cases reviewing opioid-related deaths in Australian hospitals from 2010 to 2020. Cases included for review were in-hospital deaths that identified patient factors, clinical errors and service delivery factors that resulted in opioid therapy contributing to the death. Of the 2879 coroner’s inquest reports reviewed across six Australian states, 15 met the criteria for inclusion. Coroner’s inquest reports were analysed qualitatively to identify common themes, contributing patient and service delivery factors and recommendations. Descriptive statistics were used to summarise shared features between cases. All cases included had at least one, but often more, service delivery factors contributing to the death, including insufficient observations, prescribing/administration error, poor escalation and reduced communication. Wider awareness of the individual characteristics that pose increased risk of OIVI, greater uptake of formal, evidence-based pain management guidelines and improved documentation and observations may reduce OIVI mortality rates.

Efficacy of preoperative inhaled LAMA/LABA combinations in patients with lung cancer and untreated COPD.

Chronic obstructive pulmonary disease (COPD) is associated with a high incidence of postoperative pulmonary complications (PPCs). When untreated COPD is found before lung cancer surgery, we have been actively intervening therapeutically with inhaled long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) combinations. We investigated the efficacy of preoperative LAMA/LABA treatment. We reviewed data from 261 patients who underwent pulmonary resection for primary lung cancer. Of these, 59 patients showed unrecognized obstructive ventilatory impairment on respiratory function testing. We administered inhaled drugs for 38 patients, of whom 22 patients treated with LAMA/LABA combinations and diagnosed with COPD were retrospectively analyzed regarding improvement of respiratory function and postoperative course. Median duration of LAMA/LABA treatment was 19.5 days (interquartile range (IQR), 10.5-28.3 days). Percentage predicted vital capacity (%VC) (pretreatment: 95.6%, IQR 91.9-111.7 vs. posttreatment 102.8%, IQR 92.3-113.0), forced expiratory volume in 1 s (FEV1) (1.76 L, 1.43-2.12 vs. 2.00 L, 1.78-2.40), forced VC (FVC) (2.96 L, 2.64-3.47 vs. 3.22 L, 2.95-3.74) and percentage predicted FEV1 (80.1%, 68.4-97.0 vs. 91.6%, 80.3-101.9) were all significantly improved (P<0.05 each). FEV1/FVC tended to be improved, but not significantly. No significant difference in improvement of respiratory function was seen between short-term (≤2 weeks) and normal-term (>2 weeks) treatment. PPCs occurred in 4 of 22 patients (18.2%), showing no significant difference compared to patients with COPD previously treated with inhaled drugs (2/20; 10.0%). Respiratory function is improved by preoperative LAMA/LABA treatment even in the short term. Starting treatment allows even COPD patients diagnosed on preoperative screening to experience the same frequency of PPCs as previously treated patients.

Early lung complications in the post-transplant period of the liver

This subject underlines the most important perioperative factors that predispose to early post-liver transplant respiratory complications. Despite advances in surgical techniques and anesthesiological management the lung may still suffer throughout the perioperative period from various types of injury, with different ensuing ventilatory impairments, and different clinical outcomes. The incidence, etiology, pathophysiological features, clinical manifestations, preventing measures, and outcomes of post-operative respiratory disorders in this setting are also reported.

Use of Area under the Expiratory Flow-volume Curve and Rectangular Area Ratio in Detecting Ventilatory Impairments in Spirometry: A Pilot Study

Purpose: This study aimed at demonstrating the reliability of surface area under the maximum expiratory flow volume curve (Aex) and rectangular area ratio (RAR) to define the type of ventilatory impairment and assessing potential clinical value of Aex ratio (measured / predicted Aex) to indicate the severity of ventilatory obstruction. Methods: Spirometric data of 75 subjects were analyzed by qualified pulmonologists to distinguish between different spirometric patterns representing expert decision. Computerized graphic analysis methodology was used, Aex was used to calculate other parameters (area of concavity and RAR) and an algorithm for diagnosis was proposed. For validation of the proposed grading and cutoff values, we compared them with expert decision using classification and regression trees (CART). Results: According to calculated parameters, obstructive pattern is realized if area of concavity (Au) has positive value and RAR is less than 0.5. While convexity/linearity is indicated if RAR ≥ 0.5 and Au has negative value or equal zero, indicating normal or restrictive pattern. Aex ratio was selected as second-best predictor of restriction at a cut-off value of 49%. Furthermore, the diagnostic performance of Aex ratio in predicting moderate-to-severe obstructive lung disease was excellent. Conclusion: The proposed computerized technique succeeded using RAR and Aex in differentiating between restriction, obstruction and normal patterns. Additionally, Aex ratio may be a valid parameter to grade the severity of obstruction.

Rare Complication of Nasogastric Tube Knotting around Endotracheal Tube in an Anesthetized Patient Undergoing Surgery

We report a case of successful management of a rare incidence and avoidance of complication of Ryle's tube knotting around endotracheal tube. A vigilant anesthesia team prevented fatal complications of intraoperative accidental extubation and ventilation impairment which could have resulted into respiratory distress.

Multi-Institutional Prospective Cohort Study of Patients With Pulmonary Hypertension Associated With Respiratory Diseases.

There is limited evidence for pulmonary arterial hypertension (PAH)-targeted therapy in patients with pulmonary hypertension associated with respiratory disease (R-PH). Therefore, we conducted a multicenter prospective study of patients with R-PH to examine real-world characteristics of responders by evaluating demographics, treatment backgrounds, and prognosis. Among the 281 patients with R-PH included in this study, there was a treatment-naïve cohort of 183 patients with normal pulmonary arterial wedge pressure and 1 of 4 major diseases (chronic obstructive pulmonary diseases, interstitial pneumonia [IP], IP with connective tissue disease, or combined pulmonary fibrosis with emphysema); 43% of patients had mild ventilatory impairment (MVI), whereas 52% had a severe form of PH. 68% received PAH-targeted therapies (mainly phosphodiesterase-5 inhibitors). Among patients with MVI, those treated initially (i.e., within 2 months of the first right heart catheterization) had better survival than patients not treated initially (3-year survival 70.6% vs. 34.2%; P=0.01); there was no significant difference in survival in the group with severe ventilatory impairment (49.6% vs. 32.1%; P=0.38). Responders to PAH-targeted therapy were more prevalent in the group with MVI. This first Japanese registry of R-PH showed that a high proportion of patients with MVI (PAH phenotype) had better survival if they received initial treatment with PAH-targeted therapies. Responders were predominant in the group with MVI.

Concomitant inpatient prescribing of strong opioids with sedatives: Associations with comorbid conditions.

Co‐prescribing of opioids and sedatives is a known risk factor for opioid‐induced ventilatory impairment (OIVI). Prevalence data for sedative and opioid co‐prescription in inpatients in Australia are unknown. Our objective was to determine the prevalence of inpatient sedative and opioid co‐prescribing and to identify factors associated with co‐prescription. We conducted a retrospective cross‐sectional study from July 2017 to October 2017 across four South Australian hospitals utilizing a centralized electronic health record. Multivariate analysis was used to identify characteristics predictive of co‐prescribing of a strong opioid (fentanyl, hydromorphone, morphine, and oxycodone) and sedative medications (benzodiazepines, antiepileptics, antipsychotics, and tricyclic antidepressants). Of the 6170 inpatients, 2795 (45.3%) were prescribed a strong opioid and of those, 1889 (30.6% of all inpatients) were co‐prescribed a sedative. Of those prescribed a strong opioid, five (0.18%) developed OIVI. Patients prescribed a strong opioid had a 27–77% increased likelihood of being prescribed a sedative. Factors predictive of sedative co‐prescribing included the presence of disease of the central nervous system adjusted OR (aOR) 8.66 [95% CI 5.83–12.9] and respiratory disease aOR 1.42 [95% CI 1.17–1.72]. Nearly, one third of all hospital inpatients were co‐prescribed a strong opioid and a sedative medication. Patients with comorbidities resulting in increased risk of respiratory depression/OIVI were more likely to have sedative co‐prescription. Clinicians should be aware of the effects of high‐risk medications and ensure that systems and monitoring are in place that help mitigate adverse outcomes.

Ventilatory Impairments Associated with Parkinson’s Disease: A Systematic Review and Meta-Analysis

Background: The peripheral and central repercussions of Parkinson’s disease (PD) affect the neuromuscular system producing a loss of muscle strength that can influence the respiratory system. Although several studies have examined various respiratory aspects of PD, to the best of our knowledge no study to date has systematically reviewed the existing data. Objectives: To examine the available literature related to the respiratory impairment in PD patients. Methods: We used PRISMA guidelines when reporting this review. We searched Pubmed, Cinhal, SciELO, and Cochrane Library, from inception until August 2018. Main variables assessed were forced vital capacity percent predicted (FVC%) and forced expiratory volume in 1 s percent predicted (FEV₁%) for PD patients. Results: Six studies were included in this systematic review and meta-analysis. The obtained results concluded that PD patients present poorer pulmonary function when compared to healthy controls. When PD patients were compared between ON and OFF states, the results reviewed are in favour of the ON state. In the meta-analysis performed for FVC% and FEV₁%, the results fail to find significant differences between PD patients and controls (p = 0.336 and p = 0.281, respectively), and between PD ON and OFF states (p = 0.109 and p = 0.059, respectively). Conclusions: We conclude that PD patients have impaired respiratory capacities that are related to the PD severity, time since diagnosis, and OFF state. Adequate follow-up of the respiratory function and studies focused on PD phenotypes have to be considered in future studies.

Surgical outcomes of primary lung cancers following esophagectomy for primary esophageal carcinoma.

The aim of this retrospective study is to evaluate the perioperative complications and prognosis of patients with a history of resected esophageal carcinoma who subsequently underwent pulmonary resection of a primary lung cancer. The study cohort comprised 23 patients who had undergone curative resection of a primary lung cancer following esophagectomy for a primary esophageal carcinoma. Clinical characteristics and surgical outcomes were analyzed. The initial treatment for esophageal carcinoma was esophagectomy by thoracotomy in 10 patients and video assisted thoracoscopic surgery in 13. The treatments for lung cancer comprised wedge resection in three patients, segmentectomy in seven and lobectomy in 13. The pulmonary resections were performed by thoracotomy in six and video assisted thoracoscopic surgery in 17. The average operating time for the lung cancer surgeries was 202min and average blood loss 122ml. There were no perioperative deaths or severe complications. Three- and Five-year overall survival rates were 78.0% and 68.2%. According to univariate survival analysis, age, restrictive ventilatory impairment and histology of lung cancer were significant predictors of poor prognosis (all P<0.05). Significantly more of the patients with than without restrictive ventilatory impairment died of other diseases (P=0.0036). Pulmonary resection for primary lung cancers following esophagectomy for esophageal carcinoma is acceptable in selected patients. Such surgery requires caution concerning intrathoracic adhesions and postoperative prolonged air leakage. Patients with restrictive ventilatory impairment had a poorer prognosis, and the indication for surgery in these patients should be carefully considered.

The effects of total pleural covering on pneumothorax recurrence and pulmonary function in lymphangioleiomyomatosis patients without history of pleurodesis or thoracic surgeries for pneumothorax.

BackgroundTotal pleural covering (TPC) is an innovative surgical procedure in which the entire visceral pleura is wrapped with sheets of oxidized regenerated cellulose (ORC) mesh under video-assisted thoracoscopic surgery. We have previously reported that TPC could successfully prevent pneumothorax recurrence in patients with lymphangioleiomyomatosis (LAM). However, the actual efficacy and preventive effect of TPC on pneumothorax recurrence remains unclear as many LAM patients already had pleural adhesion prior to TPC that was induced by thoracic surgery and/or pleurodesis. The purpose of this study is to evaluate the effects of TPC on pneumothorax recurrence and pulmonary function in LAM patients with no history of thoracic surgeries or pleurodesis.MethodsWe retrospectively reviewed medical charts of 52 patients (60 hemithoraces) who underwent TPC at our center, from January 2003 to September 2019, as a first surgical intervention for pneumothorax.ResultsPneumothorax recurrence occurred in 12 patients [14 of 60 hemithoraces (23.3%)] during the observation period [27 months (14.7; 56.4) = median (lower; upper quartiles)]. The probability of recurrence-free hemithorax post TPC was 81.1% at 2.5 years and 64.1% at 5 years. TPC did not produce a significant decrease in either VC %predicted (pred) or FEV1/FVC. The pre- vs. post-TPC median (lower; upper quartiles) VC %pred was 85.7% (79.7; 98.0) vs. 87.2% (72.3; 95.6), P=0.535 and the FEV1/FVC was 84.6% (75.7; 89.6) vs. 83.0% (71.8; 87.0), P=0.667. Mechanistic/mammalian target of rapamycin (mTOR) inhibitors (mTORI) were subsequently initiated in 19 patients (36.5%) because of the progression of LAM. The postoperative FEV1%pred was significantly lower in patients who required mTORI than in those who did not [68.1% (57.3; 82.9) vs. 88.7% (84.6; 89.8), P=0.020]; the decline rate in FEV1%pred/year from pre to post TPC was significantly greater in LAM patients who required mTORI than in those who did not [−9.37% (−4.73; 12.9) vs. −1.94% (1.52; −4.50), P=0.029]. Postoperative complications were found in 25 of 52 hemithoraces (48.1%).ConclusionsTPC can prevent pneumothorax recurrence without causing ventilatory impairment or severe pleural symphysis in LAM patients. TPC is an effective treatment option for LAM-associated pneumothorax based on its efficacy and safety.

Clinical profile of designer drug “Strox” intoxicated cases presented to Poison control center Ain Shams University, Egypt from first of January 2017 to end of January 2018

Introduction: Drug addiction is considered one of the serious problems. Clinical profile of drug dependence is continuously changing taking new shape, new drugs and routes. From 2004, illicit drug manufacturers began to produce herbal smoking substances under a wide range of brand names. Recently over the past two to three years, the drug abuse market in Egypt was invaded by a new herbal preparation, called “Strox” that gained favor among abusers and rapidly spread. Aim of Study: to evaluate the strox toxicity cases including; the presenting symptoms and signs, the lines of treatment and highlight the outcomes secondary to strox exposure, also correlate the presenting clinical pictures with strox structure. Methodology: A cross sectional observational study carried out at Poison Control Center Ain Shams University (PCC-ASU). The study included all strox intoxicated patients presented to PCC-ASU from the first of Jan. 2017 to the end of Jan. 2018, and the obtained seized Strox packages screened by Gas Chromatography (GC). Results: there were 84 patients. The mean age was 25±9.8 year. The median of delay time was 2-4 hours. Disturbed conscious level observed in 45% of patients, chest pain (37%), shortness of breathing (32%). Hypoxemia was evident in 65% of cases, associated with Hypercapnia and respiratory acidosis in 50 % of cases. No observed changes regarding serum electrolytes, renal function or random blood sugar. ST segment depression and T wave inversion were reported in 6% of cases. All patients were admitted and received supportive treatment. Gas chromatographic analysis of some Strox packages revealed the presence of xylene, methylene dioxy methamphetamine, and trihexyphenidyl. Conclusion: Patients with Strox smoking presented with transient coma, hallucinations, impaired ventilation, and chest pain. The displayed picture was attributed to a mixture of xylene, MDMA, and the central anti-cholinergic trihexiphenidyl. The picture was confirmed by gas chromatography analysis of seized strox package.