Lung volume reduction in chronic obstructive pulmonary disease

Pathognomonic features of advanced emphysema include a markedly reduced alveolar surface area due to the formation of blebs and bullae and significantly reduced elastic recoil. The aim of lung volume  reduction, which can be achieved by either surgery or endoscopic techniques, is volume loss of the targeted, diseased region(s) and redirecting airflow to less affected regions. Lung volume reduction surgery (LVRS) entails reducing the lung volume by wedge excision of  emphysematous tissue. LVRS  carries significant morbidity and mortality, but can offer survival benefit and increased exercise capacity in selected patients with predominantly upper-lobe emphysema and low exercise capacity. Endoscopic lung volume reduction (ELVR) refers to bronchoscopically inducing volume loss to  improve pulmonary mechanics and compliance, thereby reducing the work of breathing. Globally, this technique is increasingly used as treatment for advanced  emphysema with the objective of obtaining similar functional advantages to surgical lung volume reduction, while decreasing risks and costs. Current evidence  suggests that patients with either homogeneous or  heterogeneous disease may benefit from ELVR. It remains paramount that a systematic approach is followed and selection criteria are met, given the high costs and potential complications related to both LVRS and ELVR

Tricyclic antidepressant overdose necessitating ICU admission

Tricyclic antidepressant (TCA) overdose necessitating intensive care unit (ICU) admission remains a significant problem in the Western Cape. In this retrospective study, we reviewed the course of life-threatening TCA overdose in our centre to identify potential prognostic indicators. TCA levels >1 000 ng/ml were associated with QT and QRS prolongation and convulsions. However, no single parameter predicted non-survival. The overall mortalityof TCA overdose was very low. Our findings should encourage clinicians to offer medical care including ICU admission, if necessary, to patients with TCA overdose

Case Report: The real value of endobronchial ultrasound

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a standard procedure worldwide, used in conjunction with bronchoscopy to obtain biopsies for mediastinal disorders. A 67-year-old man with a 40 pack-year smoking history presented with a 2-year history of hoarseness and weight loss. He also had a history of asbestos exposure. On examination under anaesthesia a lesion of the right false vocal fold was found and histology showed a moderately differentiated infiltrating keratinising squamous carcinoma. The question posed was whether this mass could be ascribed to metastatic supraglottic carcinoma or if it was indeed a metachronous primary bronchus carcinoma, as the treatment of these two malignancies differs significantly. Traditional bronchoscopy with TBNA is the least invasive procedure to obtain a cytological diagnosis, but the proximity of the aorta and pulmonary arteries and the mass being 14 mm from the bronchus would have made sampling by means of this procedure near impossible. We used EBUS to localise the mass and noted the position of the major vessels on Doppler ultrasound. Real-time ultrasound guidance allowed us to bridge the tissue plane between the mass and bronchial lumen using the longer EBUS needle and to obtain a fine-needle aspirate of the mass, which proved to be a keratinising squamous carcinoma. We describe this case in which EBUS-TBNA was pivotal in reducing the number of invasive procedures in a patient with metastatic supraglottic carcinoma

The impact of HIV infection on the presentation of lung cancer in South Africa

Background. Despite the very high background prevalence of HIV and smoking-related diseases in sub-Saharan Africa, very little is known about the presentation of lung cancer in HIV-infected individuals.Methods. We prospectively compared HIV-positive (n=44) and HIV-negative lung cancer patients (n=425) with regard to demographics, cell type, performance status and tumour node metastasis staging at initial presentation.Results. HIV-positive patients were found to be younger than HIV-negative (mean 54.1 (standard deviation 8.4) years v. 60.5 (10) years, p<0.01), more likely to have squamous cell carcinoma (43.2% v. 30.1%, p=0.07) and significantly more likely to have a poor Eastern Cooperative Oncology Group (ECOG) performance status of ≥3 (47.7% v. 29.4%, p=0.02). In the case of non-small cell-lung cancer, they were also significantly less likely to have early stage lung cancer (0% v. 10.3%, p=0.02)  compared with HIV-negative patients.Conclusions. HIV-positive lung cancer patients were younger, significantly more likely to have a poor performance status at presentation and significantly less likely to have early stage lung cancer when compared with HIV-negative patients

Validation of a severity-of-illness score in patients with tuberculosis requiring intensive care unit admission

Background. There is a paucity of data on the determinants of mortality due to tuberculosis (TB) in the intensive care unit (ICU).Objective. To develop a simple severity-of-illness score for use in patients with TB admitted to an ICU.Methods. A scoring system was generated by retrospectively identifying the four most significant and clinically unrelated predictors of mortality from an existing prospectively collected dataset (January 2012 - May 2013), and combining these with known predictors of poor outcome.Results. Of 83 patients admitted with TB, 38 (45.8%) died in the ICU. The four parameters identified from the retrospective analysis were: (i) HIV co-infection with a CD4 cell count <200/ƒÊL; (ii) a raised creatinine level: (iii) a chest radiograph showing diffuse parenchymal infiltrates/miliary pattern; and (iv) absence of TB treatment on admission. These were combined with septic shock and a low arterial partial pressure of oxygen/fractional inspired oxygen (P:F) ratio to generate a six-point severity-of-illness score (one point for each parameter). The scores for survivors were significantly lower than those for  non-survivors (mean (standard deviation) 2.27 (1.47) v. 3.58 (1.08); p<0.01). A score of .2 was associated with significantly higher mortality than a score of <2 (7.1% v. 46.4%; odds ratio (OR) 15.03; 95% confidence interval (CI) 1.86 - 121.32; p<0.01), whereas a score of .3 was associated with a significantly higher mortality than a score of <3 (64.6% v. 20.0%; OR 7.29; 95% CI 2.64 - 20.18; p<0.01).Conclusion. The proposed scoring system identified patients at increased risk of dying from TB in the ICU. Further prospective studies are indicated to validate its use

The impact of an electronic clinical decision support for pulmonary embolism imaging on the efficiency of computed tomography pulmonary angiography utilisation in a resource-limited setting

Background. Pulmonary embolism (PE) is associated with high morbidity and mortality. Effective intervention requires prompt diagnosis. Computed tomography pulmonary angiography (CTPA) is sensitive and specific for PE and is the investigation of choice. Inappropriate CTPA utilisation results in unnecessary high radiation exposure and is costly. State-of-the-art electronic radiology workflow can provide clinical decision support (CDS) for specialised imaging requests, but there has been limited work on the clinical impact of CDS in PE, particularly in resource-constrained environments.Objective. To determine the impact of an electronic CDS for PE on the efficiency of CTPA utilisation in a resource-limited setting.Methods. In preparation, a PE diagnostic algorithm was distributed to hospital clinicians, explaining the combined role of the validated modified Wells score and the quantitative D-dimer test in defining the pre-test probability of PE. Thereafter, an automated, electronic CDS was introduced for all CTPA requests. Total CTPA referrals and the proportion positive for PE were assessed for three study phases: (i) prediagnostic algorithm; (ii) post-algorithm, pre-CDS; and (iii) post-CDS.Results. The proportion of CTPAs positive for PE after CDS implementation was almost double that prior to introduction of the diagnostic algorithm (phase 1 v. 3, 17.4% v. 30.7%; p=0.036), with a correspondingly significant decrease in the proportion of non-positive CTPAs (phases 1 v. 3, 82.6% v. 69.3%; p=0.015) During phases 2 and 3, no CTPAs were requested for patients with a modified Wells score of ≤4 and a documented negative D-dimer, indicating adherence to the algorithm.Conclusion. Implementing an electronic CDS for PE significantly increased the efficiency of CTPA utilisation and significantly decreased the proportion of inappropriate scans

The diagnostic accuracy of integrated positron emission tomography/computed tomography in the evaluation of pulmonary mass lesions in a tuberculosis-endemic area

Background. Integrated positron emission tomography/computed tomography (PET-CT) is a  well-validated modality for assessing pulmonary mass lesions and specifically for estimating risk of malignancy. Tuberculosis (TB) is known to cause false-positive PET-CT findings.Objective. To investigate the utility of PET-CT in the evaluation of pulmonary mass lesions and nodules in a high TB prevalence setting.Methods. All patients referred for the evaluation of a solitary pulmonary nodule or mass and who  underwent PET-CT scanning over a 3-year period were included. The PET-CT findings, including maximum  standardised uptake value (SUVmax), were compared with the gold standard (tissue or microbiological diagnosis). The sensitivity, specificity, positive and negative predictive values and diagnostic accuracy for malignant disease were calculated according to the SUVmax cut-off of 2.5 and a proposed cut-off  obtained from a receiver operating characteristic (ROC) curve.Results. Forty-nine patients (mean (standard deviation) age 60.1 (10.2) years; 29 males) were included, of whom 30 had malignancy. Using an SUVmax cut-off of 2.5, PET-CT had a sensitivity, specificity,  positive and negative predictive value and diagnostic accuracy for malignancy of 93.3%, 36.8%, 70.0%, 77.8% and 71.4%, respectively. After a ROC curve analysis, a suggested SUVmax cut-off of 5.0 improved the specificity to 78.9% and the diagnostic accuracy to 86.7%, with a small reduction in sensitivity to 90.0%.Conclusions. The diagnostic accuracy of PET-CT in the evaluation of pulmonary mass lesions using the conventional SUVmax cut-off of 2.5 was reduced in a TB-endemic area. An SUVmax cut-off of 5.0 has a higher specificity and diagnostic accuracy for malignancy, with a comparable sensitivity

Recommendations for the use of endoscopic lung volume reduction in South Africa: Role in the treatment of emphysema

Emphysema is a very common cause of morbidity and mortality in South Africa (SA). Therapeutic options in severe emphysema are limited. Endoscopic lung volume reduction (ELVR) is increasingly being used internationally for the treatment of advanced emphysema in a subset of patients with advanced disease, aiming to obtain the same functional advantages as surgical lung volume reduction while reducing risks and costs. In addition to endobronchial valves, ELVR using endobronchial coils is now available in SA. The high cost of these interventions underscores the need for careful patient selection to best identify those who may or may not benefit from ELVR-related procedures. The Assembly on Interventional Pulmonology of the South African Thoracic Society appointed a committee comprising both local and international experts to extensively review all relevant evidence and provide advice on the use of ELVR in SA based on published evidence, expert opinion and local access to the various devices

The prevalence of pulmonary hypertension after successful tuberculosis treatment in a community sample of adult patients

There are an estimated 155 million survivors of tuberculosis (TB). Clinical experience suggests that post-pulmonary tuberculosis lung disease (PTLD) is an important cause of group 3 pulmonary hypertension (PH). However, TB is not listed as a cause of PH in most guidelines. A cross-sectional, community-based study was conducted in non-health care seeking adults who had successfully completed TB treatment. Subjects underwent questionnaires, spirometry, a six-minute walk distance test (6MWD) and transthoracic echocardiography (TTE). Screen probable PH was defined on TTE as an estimated pulmonary artery peak systolic pressure (PASP) of ≥40mmHg. One hundred adults (71 males) were enrolled, with a mean age of 42 years (SD 13.8 years) and a median of one TB episode (IQR: 1 -2). Co-morbidities included hypertension (21%), diabetes (16%), HIV (10%) and asthma/COPD (5%). Only 25% had no residual symptoms after TB. Probable PH was found in 9%, while 7% had borderline raised PASP values (PASP 35-40mmHg). An association was found between PH and the number of previous TB episodes, with each additional episode of TB increasing the odds of PH-post-TB 2.13-fold (CI 1.17-3.88; P=0.013). All of those found to have PH were smokers or ex-smokers yielding an unadjusted odds ratio for PH-post-TB of 3.67 (95%CI 0.77-17.46). There was no statistical difference in spirometry or 6MWD, between those with and without PH. Neither symptoms nor co-morbidities demonstrated significant association with PH. PH after TB was a common finding in this community-based population. Further research is needed to confirm and determine the significance of these findings

South african thoracic society position statement on post-acute sequelae of SARS-CoV-2 infection

• Post-acute coronavirus disease-19 (COVID-19) respiratory symptoms are common and may be caused by a variety of factors including, among others, cardiac and respiratory dysfunction. • A detailed history and examination with appropriate investigations is imperative to define the exact nature of the dysfunction. • Limited data exist to guide evidence-based approaches to treatment. • Injudicious use of corticosteroids is cautioned against as well as indiscriminate use of off-label drugs