Treatment of emphysema: procedure planning and follow-up by HRCT

Learning objectives To review surgical or bronchoscopic treatment for severe emphysema. To describe preoperative characterization of emphysema by HRCT and to define the specific abnormalities that guide the choice of optimal procedure. To show the regular morphological changes that follow the procedures and to describe the complications as detected by chest x-ray and HRCT. Background COPD is characterized by incompletely reversible expiratory airflow obstruction, and its severity is rated according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification, which defines four stages of disease, according to the post-bronchodilator airflow limitation. HRCT allows the categorization of COPD patients into subtypes that are distinguished accordingly to different structural and functional alterations [1]. Findings and procedure details 1. Lung volume reduction surgery (LVRS) The surgical removal of emphysematous tissue has the purpose of revert ventilation in residual healthy parenchyma [2], specifically in patients suffering from upper-lobes predominant emphysema (Fig. 1); therefore, the pre-operative assessment of emphysema through visual scoring or by quantitative analysis of CT images is needed; the latter precisely calculates the percentage of emphysematous tissue, thus guiding the correct strategy [3]. Conclusion Radiologists should be familiar with HRCT imaging aspects related to this noninvasive treatment option for pulmonary emphysema, which are being increasingly performed in referral centers

Effects of CPAP on systemic hypertension in OSAH: a monocentric, observational, cohort study

9Obstructive sleep apnea-hypopnea (OSAH) is a risk factor for development of systemic arterial hypertension (SAH) and can worse the control of established SAH. We investigated the effects of long-term continuous positive airway pressure (CPAP) treatment in controlling and preventing SAH in a large cohort of subjects referred for sleep study for suspected OSAH.nonenoneBottini, Paolo; Taranto-Montemurro, Luigi; Novali, Mauro; Bettinzoli, Michela; Roca, Elisa; Andreoli, Chiara; Bentivoglio, Maurizio; Corda, Luciano; Tantucci, ClaudioBottini, Paolo; Taranto-Montemurro, Luigi; Novali, Mauro; Bettinzoli, Michela; Roca, Elisa; Andreoli, Chiara; Bentivoglio, Maurizio; Corda, Luciano; Tantucci, Claudi

Additive effect on pulmonary function and disability of intensive pulmonary rehabilitation following bronchoscopy lung volume reduction (BLVR) for severe emphysema

Background: Pulmonary rehabilitation (PR) is mandatory before bronchoscopy lung volume reduction (BLVR); there is scant information about its efficacy post-BLVR. We retrospectively evaluated pulmonary function (PF) and disability in patients pre/post-BLVR and its additive effect on an intensive PR program post-BLVR vs matched non-BLVR controls. We analyzed changes within BLVR patients according to presence or not of atelectasis.Methods: We compared PF and exercise tolerance (6-min walk test, 6MWT) in 39 BLVR patients (FEV1% pred. 28.9 +/- 1.5; RV % pred. 236.1 +/- 7.7) pre-/post-BLVR, and vs. 32 controls (FEV1 % pred. 32.7 +/- 1.5; RV% pred. 217.8 +/- 8.3) before and after PR.Results: BLVR patients showed a greater improvement than controls in PF (difference between groups: 3.8 for FEV1% pred., p = 0.043; -20.5 for RV % pred., p = 0.02) and 6MWT response rate (12/39 vs. 1/39 subjects, p = 0.003). Both groups further improved significantly 6MWT after PR without a significant difference between groups. Atelectasis after BLVR mainly accounted for the improvement in FEV1% pred, RV% pred. and 6MWT compared to both BLVR without atelectasis and controls.Conclusion: BLVR improves PF (particularly RV) and exercise tolerance, patients with lobar exclusion being the best improvers. PR following BLVR yields a further improvement in exercise tolerance in both (atelectasis and non-atelectasis) subgroups

Bronchial Thermoplasty Global Registry (BTGR): 2-year results

Objectives Bronchial thermoplasty (BT) is a device-based treatment for subjects ≥18 years with severe asthma not well controlled with inhaled corticosteroids and long-acting beta-agonists. The Bronchial Thermoplasty Global Registry (BTGR) collected real-world data on subjects undergoing this procedure. Design The BTGR is an all-comer, prospective, open-label, multicentre study enrolling adult subjects indicated for and treated with BT. Setting Eighteen centres in Spain, Italy, Germany, the UK, the Netherlands, the Czech Republic, South Africa and Australia Participants One hundred fifty-seven subjects aged 18 years and older who were scheduled to undergo BT treatment for asthma. Subjects diagnosed with other medical conditions which, in the investigator's opinion, made them inappropriate for BT treatment were excluded. Primary and secondary outcome measures Baseline characteristics collected included demographics, Asthma Quality of Life Questionnaire (AQLQ), Asthma Control Test (ACT), medication usage, forced expiratory volume in one second and forced vital capacity, medical history, comorbidities and 12-month baseline recall data (severe exacerbations (SE) and healthcare utilisation). SE incidence and healthcare utilisation were summarised at 1 and 2 years post-BT. Results Subjects' baseline characteristics were representative of persons with severe asthma. A comparison of the proportion of subjects experiencing events during the 12 months prior to BT to the 2-year follow-up showed a reduction in SE (90.3% vs 56.1%, p<0.0001), emergency room visits (53.8% vs 25.5%, p<0.0001) and hospitalisations (42.9% vs 23.5 %, p=0.0019). Reductions in asthma maintenance medication dosage were also observed. AQLQ and ACT scores improved from 3.26 and 11.18 at baseline to 4.39 and 15.54 at 2 years, respectively (p<0.0001 for both AQLQ and ACT). Conclusions The BTGR demonstrates sustained improvement in clinical outcomes and reduction in asthma medication usage 2 years after BT in a real-world population. This is consistent with results from other BT randomised controlled trials and registries and further supports improvement in asthma control after BT. Trial registration number NCT02104856

Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: Results of a multicenter study

Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes.Background: Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes. Methods: It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV1); of −8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant. Results: One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those &lt;350 mL (n=43) had a statistically significant higher improvement in FEV1 (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (−10.0%±4.8% vs. −4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (−15.0±2.9 vs. −8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV1 (19.0%±3.9%), RV (−10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (−15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described. Conclusions: Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach

Factors Affecting Patency of In Situ Saphenous Vein Bypass: Two Year Results from LIMBSAVE (Treatment of critical Limb Ischaemia with infragenicular Bypass adopting in situ SAphenous VEin technique) Registry

objective: the aim was to demonstrate contemporary outcomes of in situ saphenous vein bypass using a valvulotome.methods: analysis of two year outcomes of a multicentre registry based on the treatment of critical limb ischaemia with infragenicular bypass adopting in situ SAphenous VEin technique (LIMBSAVE). Between January 2018 and december 2019, 541 patients in 43 centres were enrolled. In all patients an innovative valvulotome was used. early outcomes were assessed. two year outcomes according to KaplaneMeier curves in terms of patency and limb salvage were evaluated. Associations between patient and procedure variables were analysed with univariable and multivariable analyses.results: In all cases, a valvulotome was able to lyse the valves. vein injury due to the in situ technique was 3.5%. Thirty day mortality and major amputation rates were 3% and 0.9%, respectively. Mean follow up was 12.1 months. Two year estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 69.1%, 81.4%, 86.5%, and 94.5%, respectively. multivariable analysis showed an association between pre-operative vein diameter &lt; 3 mm and lower primary patency (hazard ration [HR] 14.3, p &lt;.001), primary assisted patency (HR 9.4, p = .002), secondary patency (HR 7.2, p =. 07), and limb salvage (HR 7.8, p = .005) rates. distal anastomosis to a tibial or foot vessel was also associated with lower primary patency (HR 4.8, p = .033), and primary assisted patency (HR 6, p = .011) rates. Use of a suprafascial tributary collateral as a graft was associated with lower primary patency (HR 6.7, p = .013), and primary assisted patency (HR 4.2, p = .042) rates.conclusion: vein diameter &lt; 3 mm, distal anastomosis on a tibial or foot vessel, and use of a suprafascial tributary collateral as a graft were significantly associated with loss of patency and limb loss during follow up