Nutritional status and lung transplantation : an intriguing problem

Pulmonary transplantation (LTx) is a viable treatment option for patients with final stage lung disease such as cystic fibrosis (CF), chronic obstructive pulmonary disease (COPD) and interstitial lung disease (1,2). Advances in surgical techniques, pre- and post-operative management have improved overall survival of lung-transplanted patients over the past decades. Despite these developments, lung transplantation has still significantly higher morbidity and mortality than transplants of other solid organs such as kidney and liver. For these reasons, several studies have been conducted to investigate factors that potentially affect the prognosis of patients who undergo LTx (3)

The Series on "How to Deal with Early Stage Lung Cancer: Sublobar Resections as A Possible Choice (Report of the 2019 Spring Meeting of Italian Society of Thoracic Surgery)?"

This series is the result of the work of different specialists from all around Italy and from Fudan University in Shanghai, who gathered in Milan on April 2019, to attend the Spring Meeting of Italian Society of Thoracic Surgery (SICT). The meeting discussed new evidences suggesting sublobar resection as the elective surgical treatment of early stage lung cancer

Selection of Candidates for Lung Transplantation: The First Italian Consensus Statement

Lung transplantation is a well-established treatment for selected patients with advanced chronic respiratory insufficiency. Recognizing those patients with end-stage lung disease who might benefit from lung transplantation is a crucial task. Considering the presence of inadequate evidence-based practice, international and national scientific societies provided consensus opinions regarding the appropriate timing of listing. The Study Group for Thoracic Organs Transplantation (branch of the Italian Society for Organs Transplantation) promoted and realized a Delphi conference among the Italian lung transplantation centers to provide guidance to clinical practice based on international recommendations. The experts from the nine Italian centers completed two rounds of standardized questionnaires (answer rate, 100%): 42 statements received a consensus >= 80%. The selected statements presented in this article are intended to assist Italian clinicians in selecting patients for lung transplantation

Lung transplantation from donation after controlled cardiocirculatory death: Systematic review and meta-analysis

Background: The interest in donation after cardiocirculatory death (DCD) donors for lung transplantation (LT) has been recently rekindled due to lung allograft shortage. Clinical outcomes following DCD have proved satisfactory. The aim of this systematic review is to provide a thorough analysis of published experience regarding outcomes of LT after controlled DCD compared with donation after brain death (DBD) donors. Methods: We performed a literature search in Cochrane Database of Systematic Reviews, PubMed and Web of Science using the items "lung transplantation" AND "donation after circulatory death" on November 1, 2018. The full text of relevant articles was evaluated by two authors independently. Quality assessment was performed using the NIH protocol for case-control and case series studies. A pooled Odds ratio (OR) and mean differences with inverse variance weighting using DerSimonian-Laird random effect models were computed to account for between-trial variance (tau 2). Results: Of the 508 articles identified with our search, 9 regarding controlled donation after cardiac death (cDCD) were included in the systematic review, including 2973 patients (403 who received graft from DCD and 2570 who had DBD). Both 1-year survival and 2 and 3-grade primary graft dysfunction (PGD) were balanced between the two cohorts (OR = 1.00 and 1.03 respectively); OR for airway complications was 2.07 against cDCD. We also report an OR = 0.57 for chronic lung allograft dysfunction (CLAD) and an OR = 0.57 for 5-year survival against cDCD. Conclusions: Our meta-analysis shows no significant difference between recipients after cDCD or DBD regarding 1-year survival, PGD and 1-year freedom from CLAD. Airway complications and long-term survival were both related with transplantation after cDCD, but these statistical associations need further research

Sniff test: does what we measure at the nose reflect what happens in the chest wall?

Nasal pressure measured during sniff (SNIP) is a technically simple voluntary test. Since the contraction of the diaphragm expands the abdomen, the volume variation during sniff manoeuvre should therefore be predominantly abdominal in order to be considered a specific index of diaphragm strength. We aimed to verify if and how SNIP varied according to thoraco-abdominal volume variations. We measured abdominal volume variations, using opto-electronic plethysmography, during quiet breathing (ABQB) and sniff manoeuvres (ABSN) in supine position on 30 patients (age: 42; FVC:47.5%; FEV1:30%) on the waiting list for lung transplant. SNIP was measured simultaneously with ABSN. 68 sniff were analysed and classified into 4 groups according to ABSN: 16 with thoracic paradox, 24 predominantly abdominal, 16 predominantly thoracic and 12 with abdominal paradox. By definition ABSN was different (p<0.001) among the 4 groups, whereas ABQB (~75%; p=0.373) and SNIP (~53 cmH2O, p= 0.792) were similar (figure 1). SNIP did not change with the different thoraco-abdominal strategies. The diaphragm was not weak and leaded inspiration, therefore ABSN varied because the patients misperformed the manoeuvre. In order to not misunderstand the clinical significance of a sniff test, care should be paid also in thoraco-abdominal movement because SNIP, per se, cannot differentiate between thoracic or diaphragmatic manoeuvre with the risk to lose its specificity

A valid academic path to promote respiratory physiotherapy

A one- year post- graduate Master in Physiotherapy and Pulmonary Rehabilitation has been offered within the University of Milan Medical School in collaboration with Associaz ione Italiana Riabilitatori dell\u2019Insufficienz a Respiratoria (ARIR). The aim is to cover a gap in Italian Physiotherapy academic curricula offering a course with theoretical and practical teaching that make students capable of using different techniques and procedures in respiratory physiotherapy. After the recognition by the International Education Recognition System (IERS), ARIR wanted to investigate if and how this course has affected students'attitude and their profession. METHODS A structured questionnaire made up of 15 multiple- choices items (8 on perceived quality of education and 7 on professional change) was sent by email to all physiotherapists who graduated in the previous four editions of the Master. One month was given for completion. Age, gender, year of degree and year of Master where considered as background variables. RESULTS We had a 78% response rate with 57 out of 73 physiotherapists sending the questionnaire back. Mean age was 37 years (23- 60) and women were the majority (78%). Forty- two students (74%) worked in the respiratory field at the time of application but only 15 (36%) dealt with respiratory patients only. Expectations were completely met at the end of Master for 71% of physiotherapists. 96% reported greater professional and clinical skills after the master with a 67% saying working team relationship has improved. 28% improved their job position thanks to the master degree and physiotherapy working in the respiratory field increased by 22%. CONCLUSIONS This course seems to meet students expectations and offer a solid knowledge to better work within the field of respiratory physiotherapy. It is also a way to promote the profession of respiratory physiotherapy in Italy

Solitary fibrous tumor of the pleura presenting with syncope episodes when coughing

<p>Abstract</p> <p>Background</p> <p>Solitary fibrous tumor of the pleura is a rarely encountered clinical entity which may have different clinical pictures. Although the majority of these neoplasms have a benign course, the malignant form has also been reported.</p> <p>Case presentation</p> <p>We herein describe a case of 72 year-old man with head, facial, and thoracic traumas caused by neurally-mediated situational syncope when coughing. The diagnostic work-up including chest x-ray, CT and PET, revealed a large solitary mass of the left hemithorax. Radical surgical resection of the mass was performed through a left lateral thoracotomy and completed with a wedge resection of the lingula. Hystological examination of the surgical specimen showed an encapsulated mass measuring 12 × 11.5 × 6 cm consistent with a solitary fibrous tumor of the pleura. It's surgical removal definitively resolved the neurologic manifestations. The patient had no postoperative complications. At two years follow-up the patient is free from recurrence and without clinical manifestations.</p> <p>Conclusion</p> <p>In our case its resection definitively resolved the episodes of situational syncope due, in our opinion, to the large thoracic mass compressing the phrenic nerve</p

Role of autofluorescence bronchoscopy in evaluation of bronchial mucosa after lung transplantation

Airway complications are a significant and persistent source of morbidity and mortality after lung transplantation; the incidence of these complications is around 15% with a mortality rate of 2- 3%. Airway complications arise, typically, the first two years post-transplant, and of these almost half are identified prior to discharge; their pathogenesis, as well as to opportunistic infections, appear to be related to the difficult revascularization of the bronchi resulting in chronic ischemia

Extracellular vesicles as graft biomarkers to address lung transplantation outcome

Lung transplantation is the last therapeutic option for end-stage pulmonary failure. Yet, clinical complications may rise after transplantation, such as primary grafts dysfunction (PGD) or chronic lung allograft dysfunction (CLAD). Current clinical parameters have failed to assess the quality of the graft and to predict transplantation outcome. Extracorporeal photopheresis (ECP) is a treatment for graft-versus-host disease. Peripheral blood white blood cells (WBC) are isolated, exposed to 8-methoxypsoralen photosensitizing agent, and subsequently treated with ultraviolet radiation before reinfusion into the patient, causing massive WBC apoptosis. Our working hypothesis is that extracellular vesicles (EV) produced by either the pre-transplantation organ (donor) or host (recipient) could be non-invasive biomarkers to evaluate tissue damage at the cellular level and to monitor organ engraftment

Multicenter randomized study on the comparison between electronic and traditional chest drainage systems

Background: In patients submitted to major pulmonary resection, the postoperative length of stay is mainly influenced by the duration of air leaks and chest tube removal. The measurement of air leaks largely relies on traditional chest drainage systems which are prone to subjective interpretation. Difficulty in differentiating between active air leaks and bubbles due to a pleural space effect may also lead to tentative drain clamping and prolonged time for chest drain removal. New digital systems allow continuous monitoring of air leaks, identifying subtle leakage that may be not visible during daily patient evaluation. Moreover, an objective assessment of air leaks may lead to a reduced interobserver variability and to an optimized timing for chest tube removal. Methods: This study is a prospective randomized, interventional, multicenter trial designed to compare an electronic chest drainage system (Drentech\u2122 Palm Evo) with a traditional system (Drentech\u2122 Compact) in a cohort of patients undergoing pulmonary lobectomy through a standard three-port video-assisted thoracic surgery approach for both benign and malignant disease. The study will enroll 382 patients in three Italian centers. The duration of chest drainage and the length of hospital stay will be evaluated in the two groups. Moreover, the study will evaluate whether the use of a digital chest system compared with a traditional system reduces the interobserver variability. Finally, it will evaluate whether the digital drain system may help in distinguishing an active air leak from a pleural space effect, by the digital assessment of intrapleural differential pressure, and in identifying potential predictors of prolonged air leaks. Discussion: To date, few studies have been performed to evaluate the clinical impact of digital drainage systems. The proposed prospective randomized trial will provide new knowledge to this research area by investigating and comparing the difference between digital and traditional chest drain systems. In particular, the objectives of this project are to evaluate the feasibility and usefulness of digital chest drainages and to provide new tools to identify patients at higher risk of developing prolonged air leaks. Trial registration: ClinicalTrials.gov, NCT03536130. Retrospectively registered on 24 May 2018