Diagnostic value of post-bronchodilator pulmonary function testing to distinguish between stable, moderate to severe COPD and asthma

Daphne C Richter1, James R Joubert1, Haylene Nell1, Mace M Schuurmans2, Elvis M Irusen21Tiervlei Trial Centre, Karl Bremer Hospital, Bellville, RSA; 2Respiratory Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of Stellenbosch, RSAObjective: The GOLD guidelines suggest that the presence of a post-bronchodilator forced expiratory volume in one second (FEV1) 80% of the predicted value in combination with a FEV1/forced vital capacity (FVC) < 70% confirms the diagnosis of COPD. Limited data exist regarding the accuracy of these criteria to distinguish between COPD and asthma. The aim of this study therefore was to investigate the diagnostic value of post-bronchodilator lung function parameters in obstructive lung disease.Methods: The pulmonary function tests of 43 (22 = COPD, 21 = asthma) patients with similar baseline characteristics were evaluated (baseline FEV1 were 55.7% + 7.6%, and 59.3% + 8.4% predicted for COPD and asthma, respectively). Bronchodilator responsiveness (BDR) was calculated according to three recognized pulmonary function test criteria.Results: The first criteria, post-bronchodilator FEV1 < 80% of the predicted value in combination with a post-bronchodilator FEV1/FVC ratio of <70%, had an accuracy of 70% to diagnose COPD. This combination was very sensitive (100%) in diagnosing COPD, but it was not specific (38%). The second BDR criteria, defined as an increase of <12% and 200 mL of initial FEV1 and criterion number 3, an increase of <9% of predicted FEV1, were less sensitive (55% and 59%, respectively), but more specific (81% and 76% respectively) to diagnose COPD. Our findings suggest that the current recommended spirometric indices are not optimal in differentiating between COPD and asthma.Keywords: obstructive lung disease, diagnosis, post-bronchodilator pulmonary function tes

Long-term outcomes of bilateral lobar lung transplantation†

OBJECTIVES Lobar lung transplantation is an option that provides the possibility of transplanting an urgent listed recipient of small size with a size-mismatched donor lung by surgically reducing the size of the donor lung. We report our short- and long-term results with bilateral lobar lung transplantation (BLLT) and compare it with the long-term outcomes of our cohort. METHODS Retrospective analyses of 75 lung transplant recipients who received downsized lungs with a special focus on 23 recipients with BLLT performed since January 2000. Postoperative surgical complications, lung function tests, late complications and survival were analyzed. The decision to perform lobar transplantation was considered during allocation and finally decided prior to implantation. RESULTS Cystic fibrosis was the most common indication (43.5%) followed by pulmonary fibrosis (35%). Median age at transplantation was 41 (range 13-66) years. Fifteen were females. Nineteen of the transplantations (83%) were done with extracorporeal membrane oxygenation (ECMO) support; 3 of them were already on ECMO prior to transplantation. There was no 30-day or in-hospital mortality. No bronchial complications occurred. The most common early complication was haematothorax (39%), which required surgical intervention. The rate of postoperative atrial arrhythmias was 30%. Forced expiratory volumes in 1 s (% predicted) at 1 and 2 years were 76 ± 23 and 76 ± 22, respectively (mean ± standard deviation). By 2-year follow-up, bronchiolitis obliterans syndrome was documented in 3 patients with a median follow-up of 1457 days. Overall survivals at 1 and 5 years were 82 ± 8 and 64 ± 11%, respectively and were comparable with those of 219 other recipients who received bilateral lung transplantation during the same period (log rank test, P = 0.56). CONCLUSIONS This study demonstrates that BLLT has short- and long-term outcomes comparable with those of standard bilateral lung transplantation. The limitation of lung transplantation due to size-mismatch, particularly in smaller recipients, could be overcome by utilizing lobar lung transplantatio

Development of allograft cancer after lung transplantation: a case report

INTRODUCTION: In contrast to skin cancer and lymphoproliferative disorders, de-novo lung allograft cancer is seldom reported after lung transplantation. CASE REPORT: A 19-year-old patient with severe pulmonary hypertension listed urgently for lung transplantation underwent successful bilateral lung transplant procedure receiving lungs from a 55-year-old donor with a smoking history of 30 pack years. After 3.5 years of lung transplantation, a locally advanced squamous cell carcinoma in the left lung allograft was diagnosed. Extended (intra-pericardial) left pneumonectomy was successfully performed, but the patient died a few weeks later due to acute respiratory distress syndrome. CONCLUSION: Usage of extended criteria donors seems a successful strategy to overcome shortage of donor lungs by the increasing number of lung transplant candidates. However, this approach might increase the risk of novel development of lung allograft cancer, a potential fatal complication that must be considered during follow-up of lung transplant recipients