Protective Effects of BNT162b2 Vaccination on Aerobic Capacity Following Mild to Moderate SARS-CoV-2 Infection: A Cross-Sectional Study Israel.

Patients previously infected with acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may experience post-acute adverse health outcomes, known as long COVID. The most reported symptoms are fatigue, headache and attention/concentration issues, dyspnea and myalgia. In addition, reduced aerobic capacity has been demonstrated in both mild and moderate COVID-19 patients. It is unknown whether COVID-19 vaccination mitigates against reduced aerobic capacity. Our aim was to compare the aerobic capacity of vaccinated and unvaccinated individuals previously infected with SARS-CoV-2. Methods: Individuals aged 18 to 65 years with laboratory-confirmed mild to moderate COVID-19 disease were invited to Ziv Medical Centre, Israel, three months after SARS-CoV-2 infection. We compared individuals unvaccinated at the time of infection to those vaccinated in terms of aerobic capacity, measured using symptom-limited cardiopulmonary exercise test (CPET). Results: We recruited 28 unvaccinated and 22 vaccinated patients. There were no differences in baseline demographic and pulmonary function testing (PFT) parameters. Compared with unvaccinated individuals, those vaccinated had higher V'O2/kg at peak exercise and at the anaerobic threshold. The V'O2/kg peak in the unvaccinated group was 83% of predicted vs. 100% in the vaccinated (p < 0.002). At the anaerobic threshold (AT), vaccinated individuals had a higher V'O2/kg than those unvaccinated. Conclusions: Vaccinated individuals had significantly better exercise performance. Compared with vaccinated individuals, a higher proportion of those unvaccinated performed substantially worse than expected on CPET. These results suggest that vaccination at the time of infection is associated with better aerobic capacity following SARS-CoV-2 infection.

[BRONCHIECTASIS--REVIEW OF LITERATURE AND CLINICAL CHARACTERISTICS OF BRONCHIECTASIS PATIENTS TREATED IN THE BRONCHIECTASIS CLINIC AT THE CARMEL MEDICAL CENTER].

AIMS: Bronchiectasis is a suppurative lung disease characterized by wide and distorted bronchi, with daily cough and sputum production punctuated by infectious exacerbations. Etiologies are diverse, and treatment is multidisciplinary, consisting of lung hygiene with mucolytic agents and physiotherapy, anti-inflammatory agents and antimicrobial agents, as needed. This study aims to review the literature and describe the clinical and radiological characteristics of patients with bronchiectasis treated at the Bronchiectasis clinic at Carmel Medical Center. METHODS: We included patients with Lung bronchiectasis according to chest HRCT treated at the Bronchiectasis clinic. We reviewed retrospective data regarding etiologic work up, age symptoms developed, extension of bronchiectasis, Lung function, microbiology of sputum, number of exacerbations and hospitalizations. RESULTS: Seventy four,patients were included, 39 women, mean age--65.7 years. Average lung involvement was two Lobes. Etiologies were: 42% idiopathic, 19% post-infectious and immune deficiency 5.6%. Cultures were positive for S. aureus in 9.5%, H. influenza in 19%, S pneumonia (4.8%), P aeruginosa (41.3%), non tuberculous mycobacteria (9.5%) and other bacteria in 11%. Patients suffered an average of 2.2 exacerbations per year, with 0.45 hospitalizations per year due to exacerbation of bronchiectasis. Mean predicted FEVI in spirometry was 74.32 ± 25%. Patients colonised with P aeruginosa suffered significantly more exacerbations and hospitalizations than patients without P aeruginosa colonization. CONCLUSIONS: Bronchiectasis led to significant morbidity with infectious complications. We suspect that there is under- diagnosis and under-referral of this condition.

Asymptomatic carriage of Pneumocystis jirovecii and cytomegalovirus in lungs of immunocompetent patients.

PURPOSE: Pneumocystis jirovecii (PCP) and cytomegalovirus (CMV) are opportunistic pathogens which cause lung infection in immunocompromised individuals. However, scarce data are available regarding the carriage of CMV or PCP in immunocompetent, non critically ill patients. The purpose of this study was to evaluate the prevalence of PCP and CMV in broncholaveolar lavage of adult immunocompetent, non critically ill patients. METHODS: BAL fluids from immunocompetent patients who underwent bronchoscopy were analyzed by polymerase chain reaction (PCR) for CMV and PCP DNA. We tested CMV antibodies in serum. In patients with positive CMV DNA in lavage fluid, we further analyzed peripheral blood for the presence of CMV DNA. RESULTS: Ninety three patients were included. We did not detect PCP DNA in BAL in any patient. CMV DNA was found in BAL of 5 of 86 CMV IgG positive patients (5.8 %). Patients who were positive for CMV did not differ from patients with negative PCR for CMV regarding demographic and clinical features. CONCLUSION: We did not find PCP colonization in our cohort of patients. However, we found significant prevalence of CMV DNA in BAL from immunocompetent patients, with no evidence of acute CMV infection. This finding may represent colonization by CMV in immunocompetent, non-critically ill individuals.

Multidrug-resistant Klebsiella pneumoniae acquisition in lung transplant recipients.

BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a pathogen that emerged in the late twentieth century and was associated with significant morbidity and mortality. We report for the first time the outcomes of lung transplant recipients infected with CRKP or extended spectrum-ß lactamases K. pneumoniae (ESBL-KP). METHODS: Retrospective review of 136 lung transplant recipients who underwent transplantation between 2004 and 2007 in Rabin Medical Center, Israel. MAIN RESULTS: There were 52 episodes of positive cultures for K. pneumoniae (KP) in 136 recipients - of them 11 (8.1%) with CRKP, 12 (8.8%) with ESBL-KP, and 29 (21.3%) with carbapenem-sensitive ESBL-negative KP. Isolation of CRKP/ESBL-KP was associated with death in the cohort (p < 0.0001) as well as recipients' age at transplantation (p < 0.005). Time-dependent age-adjusted CRKP or ESBL-KP acquisition was an independent factor for death in patients after lung transplant, compared to patients without KP isolation or carbapenem-sensitive ESBL-negative KP (p < 0.0001). CONCLUSION: CRKP and KP-ESBL acquisition was associated with reduced survival among lung transplant recipients.

Artificial stone silicosis [corrected]: disease resurgence among artificial stone workers.

BACKGROUND: Silicosis is a progressive, fibrotic, occupational lung disease resulting from inhalation of respirable crystalline silica. This disease is preventable through appropriate workplace practices. We systematically assessed an outbreak of silicosis among patients referred to our center for lung transplant. METHODS: This retrospective cohort analysis included all patients with a diagnosis of silicosis who were referred for evaluation to the National Lung Transplantation Program in Israel from January 1997 through December 2010. We also compared the incidence of lung transplantation (LTX) due to silicosis in Israel with that of the International Society for Heart and Lung Transplantation (ISHLT) registry. RESULTS: During the 14-year study period, 25 patients with silicosis were referred for evaluation, including 10 patients who went on to undergo LTX. All patients were exposed by dry cutting a relatively new, artificial, decorative stone product with high crystalline silica content used primarily for kitchen countertops and bathroom fixtures. The patients had moderate-to-severe restrictive lung disease. Two patients developed progressive massive fibrosis; none manifested acute silicosis (silicoproteinosis). Three patients died during follow-up, without LTX. Based on the ISHLT registry incidence, 0.68 silicosis cases would have been expected instead of the 10 observed (incidence ratio, 14.6; 95% CI, 7.02-26.8). CONCLUSIONS: This silicosis outbreak is important because of the worldwide use of this and similar high-silica-content, artificial stone products. Further cases are likely to occur unless effective preventive measures are undertaken and existing safety practices are enforced.

Lung cancer in lung transplant recipients: experience of a tertiary hospital and literature review.

BACKGROUND: Lung transplantation is a viable therapy for patients with end-stage lung disease and is being increasingly performed worldwide. The incidence of lung cancer after lung transplantation has increased concomitantly, although data are still sparse. METHODS: The computerized medical records of the Pulmonary Institute of a tertiary care medical center were searched for patients who underwent lung transplantation from 1997 to 2009 and acquired lung cancer postoperatively. The prevalence, potential contributing factors, and outcome of bronchogenic cancer were determined, and the medical literature was reviewed. RESULTS: Bronchogenic cancer developed in 7 of the 290 lung transplant recipients (2.4%). All had received a single lung transplant and in most cases, the cancer developed in the native lung. These findings were similar to reports in the literature. The indication for transplantation was chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis/interstitial lung disease. All had a history of smoking. The average interval from transplantation to development of lung cancer was 5 years (range 1-9). Five patients had stage 4 cancer at diagnosis and 2 had stage 1. Six patients died from 10 days to 1 year after diagnosis. CONCLUSION: Lung transplantation is associated with a relatively high prevalence of bronchogenic cancer, particularly in the native lung, in patients with primary chronic obstructive pulmonary disease/idiopathic pulmonary fibrosis, and a history of smoking. The cancer is usually diagnosed at an advanced stage with poor outcome. Efforts to improve screening are recommended, as aggressive management and treatment may be beneficial for earlier stage disease.

The lung in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a common inflammatory disease, affecting about 1% of the population. Although a major portion of the disease burden including excess mortality is due to its extra-articular manifestations, the prevalence of RA-associated lung disease is increasing. RA can affect the lung parenchyma, airways, and the pleura; and pulmonary complications are directly responsible for 10 to 20% of all mortality. Even though pulmonary infection and drug toxicity are frequent complications of RA, lung disease directly associated with the underlying RA is more common. The prevalence of a particular complication varies based on the characteristics of the population studied, the definition of lung disease used, and the sensitivity of the clinical investigations employed. An overview of lung disease associated with RA is presented here with an emphasis on parenchymal lung disease, pleural effusion, and airway involvement.

Voriconazole and itraconazole in lung transplant recipients receiving tacrolimus (FK 506): efficacy and drug interaction.

BACKGROUND: The aim of this study was to compare the extent of interaction between tacrolimus and itraconazole vs. voriconazole. PATIENTS AND METHODS: This retrospective study included 60 lung transplant recipients who were treated with a tacrolimus-based regimen; 40 received prophylactic itraconazole for the first six months following lung transplantation (LTX), and 20 were treated with voriconazole. All patients had at least 12 months of follow-up. Tacrolimus levels and dosage requirements were compared during and after azole therapy. We assessed the rejection rate, fungal infection rate, and renal function during the study period. RESULTS: The mean tacrolimus dose during itraconazole treatment was 3.26 ± 2.1 mg/d compared with 5.74 ± 2.9 mg/d after itraconazole was stopped, p < 0.0001. Similarly, the mean tacrolimus dose during voriconazole treatment was 1.75 ± 0.9 mg/d compared with 4.85 ± 0.38 mg/d after voriconazole was stopped (p = 0.002). Thus, the mean increase in the total daily dose of tacrolimus after itraconazole and voriconazole withdrawal was 76% and 64%, respectively. No differences in the rejection or fungal infection rates or renal toxicity were observed during the study period, although an increase in positive fungal isolates was noted during itraconazole therapy. CONCLUSION: The tacrolimus dose was reduced more with itraconazole than with voriconazole, without an increase in the rejection rate and with renal function preservation.

Therapeutic effectiveness of rituximab in a patient with unresponsive autoimmune pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterised by the accumulation of lung surfactant in the alveoli. In most cases it is an autoimmune disease with antibodies directed against the growth factor granulocyte-macrophage colony stimulating factor (GM-CSF). Standard of care consists of whole lung lavages in symptomatic patients. An alternative treatment is GM-CSF injections. The case history is reported of a patient with PAP and severe dyspnoea and hypoxaemia. Whole lung lavages and GM-CSF initially resulted in partial remission. However, the patient's condition deteriorated and her saturation during rest with high-flow oxygen treatment was 85%. The patient was treated with an anti-CD20 antibody rituximab which resulted in dramatic improvement. Room air saturation increased to 98% with exercise and she no longer required supplemental oxygen. The diffusion capacity for carbon monoxide increased from 27% to 48% of predicted and the chest x-rays improved. Rituximab may be useful in the treatment of patients with unresponsive PAP.

Bronchoscopic balloon dilatation of tracheobronchial stenosis: long-term follow-up.

OBJECTIVES: Bronchoscopic balloon dilatation (BBD) has become a valuable tool in the treatment of tracheobronchial stenosis (TBS). The objective of this study was to assess the short- and long-term effects of BBD. METHODS: A retrospective study that included all patients with confirmed, symptomatic stenosis, who underwent BBD between 2002 and 2008. A total of 92 BBD procedures were performed in 35 patients at our institute. Lung function studies were recorded for all patients before, immediately after and 1 month following the BBD. Long-term follow-up was for a mean of 33+/-4 months. RESULTS: All patients had initial success, including increased airway dimensions and symptom relief. No complications were noted related to BBD. Forced expiratory volume after one second (FEV(1)) was significantly increased after BBD (10.5%, p=0.03). These effects persisted for at least 1 month. Long-term follow-up, however, demonstrated the need for stent placement in 25 of 35 patients (71%), 210+/-91 days after BBD. Ten of 35 patients died 456+/-119 days after BBD due to progression of primary disease; all deaths were unrelated to the BBD procedures. CONCLUSIONS: BBD is a safe method that offers immediate symptomatic relief in both tracheal and bronchial stenosis. However, BBD is a temporary measure, as many patients will require definitive or additional treatment with laser or stent placement.

Postcoital hemoptysis: our experience and review of the literature.

Hemoptysis after physical activity is a well-known phenomenon. Hemoptysis following sexual intercourse is rarely reported. We describe three patients with hemoptysis occurring only after sexual activity and not following other types of physical effort. The underlying causes were congestive heart failure, uncontrolled hypertension and Takayasu arteritis. The literature is reviewed. We conclude that hemoptysis can present rarely following sexual activity and is usually associated with cardiovascular decompensation. It is always necessary to search for other underlying diseases. We suggest that patients with unexplained hemoptysis should be specifically asked about postcoital hemoptysis should be included in the differential diagnosis of every patient with unexplained hemoptysis.

The 15-step oximetry test: a reliable tool to identify candidates for lung transplantation among patients with idiopathic pulmonary fibrosis.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a relentlessly progressive disease with a median survival of approximately 3 years. Measurements of lung volumes and diffusion capacity at rest are generally used to monitor the clinical course of IPF. Due to its high mortality, identification of patients at high risk is crucial for treatment strategies such as lung transplantation. This study was design to determine whether the simple 15-step climbing exercise oximetry test accurately characterizes disease severity and survival in patients with IPF. METHODS: The study population consisted of 51 patients with progressive IPF. Findings on the 15-step climbing test, pulmonary function tests, cardiopulmonary exercise test and 6-minute walk distance test were assessed at baseline. Participants were prospectively followed for >or=2 years to determine the relationship between the test parameters and survival. RESULTS: On univariate analysis, there were strong correlations between the 15-stair climbing test parameters and survival. On stepwise linear regression analysis, independent significant predictors of mortality were lowest saturation levels on the 15-step test and the 6-minute walk distance test. CONCLUSIONS: The lowest saturation and desaturation areas on the 15-step oximetry test are significantly associated with long-term outcome in patients with IPF. We suggest that the 15-step test be used as a simple and reliable tool to predict severity and prognosis in IPF and to identify candidates for lung transplantation.

Peripheral arterial stiffness and endothelial dysfunction in idiopathic and scleroderma associated pulmonary arterial hypertension.

OBJECTIVE: Pulmonary endothelial dysfunction and increased reflection of pulmonary pressure waves have been reported in pulmonary arterial hypertension (PAH). However, the systemic vascular involvement is not fully understood. Our study focused on the systemic arterial stiffness and endothelial involvement in idiopathic and scleroderma associated PAH. METHODS: Peripheral arterial stiffness and endothelial function were evaluated in 38 patients with idiopathic (n = 28) and scleroderma associated (n = 10) PAH, and 21 control subjects (13 healthy; 8 with scleroderma and normal pulmonary pressure). All participants underwent clinical and cardiopulmonary evaluation. Arterial stiffness was measured through the fingertip tonometry derived augmentation index (AI), which is the boost increase in the late systolic pressure wave after the initial systolic shoulder. Endothelial function was measured by forearm blood flow dilatation response to brachial artery occlusion by a noninvasive plethysmograph (EndoPAT 2000), which is associated with nitric oxide-dependent vasodilatation and yields a peripheral arterial tone (PAT) ratio. RESULTS: Mean systolic pulmonary pressure was 70.5 +/- 21.6 mm Hg (idiopathic-PAH) and 69.3 +/- 20 mm Hg (scleroderma-PAH). AI was higher in scleroderma patients (10.5% +/- 19.6% in healthy controls, 9.0% +/- 21.5% in idiopathic-PAH, 20.1% +/- 19.1% in scleroderma-PAH, and 24.4% +/- 18.9% in scleroderma-controls; nonsignificant). PAT ratio was significantly lower (p < 0.05) than control values in idiopathic-PAH and scleroderma-PAH (PAT ratio: control 2.20 +/- 0.25; idiopathic 1.84 +/- 0.51; scleroderma 1.66 +/- 0.66). AI was not correlated to endothelial dysfunction. There were no differences between the 2 PAH patient groups in age, body mass index, New York Heart Association classification, or 6-min walk test. CONCLUSION: Our study shows a trend towards increased arterial stiffness in scleroderma (nonsignificant), and also peripheral endothelial dysfunction in idiopathic-PAH and in scleroderma-PAH. These findings suggest involvement of different vessels in scleroderma-PAH compared to idiopathic-PAH.

Lung transplantation in patients with scleroderma: case series, review of the literature, and criteria for transplantation.

BACKGROUND: The use of lung transplantation (LTX) to treat respiratory failure because of scleroderma is controversial. We present our experience, review the current literature, and suggest specific criteria for LTX in scleroderma. Of the 174 patients who underwent LTX at our center, seven (4%) had scleroderma-associated respiratory failure. PATIENTS AND METHODS: A MEDLINE search of the English literature was performed for studies of LTX in patients with scleroderma between 1986 and 2006. A Kaplan-Meier survival curve was calculated over the time of the studies. RESULTS: The MEDLINE search yielded one large review and four small case series. The small case series were included in the review. The review and our series yield a total of 54 patients. Mean patient age was 47.1 yr; 59.3% were female. Pre-operative lung data were available for 24 patients: 22 (92%) had pulmonary fibrosis and 17 (71%) had pulmonary hypertension. Most patients (69%) underwent single-lung transplantation. Mean forced expiratory volume at one s after LTX was 67% (range 56-87%). There was no difference in infection and rejection rates between the patients with scleroderma and other LTX recipients. The two- and five-yr survival rates were 72% and 55%, respectively. CONCLUSIONS: LTX is a valid option in well-selected patients with scleroderma and pulmonary fibrosis, yielding good pulmonary function and acceptable morbidity and mortality.

The role of routine bronchoscopy for early detection of bronchial stump recurrence of lung cancer: 1 year post-surgery.

BACKGROUND: Local recurrence after complete resection (R(0)) occur in approximately 20% of patients with stage I disease and in up to 50% with stage III. This study focuses on early detection of stump recurrence by a routine bronchoscopy. METHODS: Prospective analysis 1 year after surgery between April 2006 and April 2008. RESULTS: 104 NSCLC patients (age 69.1+/-9.6 years) participated in the study; 97 underwent lobectomy and 7 pneumonectomy. 61% were stage I, 25% stage II, 10% IIIA, 5% IIIB and 1% stage IV. 66% had N0, 21% had N1 disease, 9% N2 disease and 4% had N3. Bronchoscopy was performed 12.9+/-3.8 months after surgery. Nine percents had stump polyp, 5 (5%) had a suspicious mucosa. Four of the nine polyps were malignant. Nine other patients had squamous metaplasia and two had squamous dysplasia. Malignant stump recurrence was observed in four cases, all had a stump polyp. All had R(0), but two had short (<1.0 cm) tumor-free bronchial margin, two had N1 disease and two N2 disease. Fisher exact analysis showed short bronchus (p=0.003), N2 vs. N0-1 (p=0.012), and N1 vs. N0 (p=0.011) as significant risk factor for stump recurrence. For stump recurrence, one patient underwent completion pneumonectomy and has no evidence for disease (32.2 months), two patients were treated by chemotherapy and one patient died from pneumonia before therapy. CONCLUSION: Routine bronchoscopy 1 year after thoracic resection for NSCLC is justified in patients who are at high risk for local recurrence, i.e. short free bronchial margins and N2/N1 disease.

Herpes zoster after lung transplantation: incidence, timing, and outcome.

BACKGROUND: Although herpes zoster is a common complication of lung transplantation, the epidemiologic data are limited. The aims of the present study were to determine the incidence and clinical manifestations of herpes zoster in a large cohort of lung transplant recipients and to identify risk factors associated with its development. METHODS: The files of all adult patients who underwent lung transplantation at a major tertiary medical center from January 2001 to December 2007 were reviewed. Data were extracted on background, transplant-related, and posttransplantation factors. The occurrence and clinical characteristics of all episodes of herpes zoster were recorded. RESULTS: Of the 198 lung transplant recipients, 23 had a herpes zoster infection, of whom 18 had herpes in a single dermatome. Disseminated cutaneous infection was documented in 4 cases (17%) and visceral involvement in 1. The median duration of follow-up was 34 months (range, 1 to 85 months). There were no recurrent infections. Postherpetic neuralgia was detected in 26% of cases. Antiviral prophylaxis, primarily for cytomegalovirus, was effective (during treatment) against herpes zoster. The incidence of herpes zoster was higher in patients treated with rabbit antithymocyte globulin. CONCLUSIONS: The occurrence of herpes zoster peaks between 12 and 36 months after lung transplantation. Additional immunosuppression may increase the risk. Further studies on preventive strategies against herpes zoster in this population are warranted.

Long-term follow-up of flexible bronchoscopic treatment for bronchial carcinoids with curative intent.

Background. Typical pulmonary carcinoids represent less than 5% of primary lung tumors. In patients with typical bronchial carcinoid, formal surgical resection still remains the gold-standard treatment. Data regarding long-term outcome in using flexible bronchoscope-based modalities under conscious sedation is very limited. Objectives. We sought to investigate, over extended follow-up period, the effectiveness of endobronchial resection for carcinoid tumors with curative intent using flexible bronchoscopy. Methods. Nd:YAG laser photoresection using flexible bronchoscope under conscious sedation. Follow-up included repeat bronchoscopy every 6 months and chest CT every year. Results. Ten patients aged 24 to 70 years with endobronchial carcinoid were treated. The tumor location was variable: 2 left Main bronchus, 1 left upper lobe bronchus, 2 right main bronchus, 2 right middle lobe bronchus and 3 right lower lobe bronchus. No major complications were observed. The patients required between 2 and 4 procedures. Patients were followed for a median period of 29 months with no evidence of tumor recurrence. Conclusions. Endobronchial laser photoresection of typical bronchial carcinoids using flexible bronchsocopy under conscious sedation is an effective treatment modality for a subgroup of patients that provides excellent long-term results that are similar to outcome obtained by more invasive procedures.

Long-term pulmonary function after recovery from pulmonary contusion due to blunt chest trauma.

BACKGROUND: Blunt chest trauma can cause severe acute pulmonary dysfunction due to hemo/pneumothorax, rib fractures and lung contusion. OBJECTIVES: To study the long-term effects on lung function tests after patients' recovery from severe chest trauma. METHODS: We investigated the outcome and lung function tests in 13 patients with severe blunt chest trauma and lung contusion. RESULTS: The study group comprised 9 men and 4 women with an average age of 44.6 +/- 13 years (median 45 years). Ten had been injured in motor vehicle accidents and 3 had fallen from a height. In addition to lung contusion most of them had fractures of more than three ribs and hemo/pneumothorax. Ten patients were treated with chest drains. Mean intensive care unit stay was 11 days (range 0-90) and mechanical ventilation 19 (0-60) days. Ten patients had other concomitant injuries. Mean forced expiratory volume in the first second was 81.2 +/- 15.3%, mean forced vital capacity was 85 +/- 13%, residual volume was 143 +/- 33.4%, total lung capacity was 101 +/- 14% and carbon monoxide diffusion capacity 87 +/- 24. Post-exercise oxygen saturation was normal in all patients (97 +/- 1.5%), and mean oxygen consumption max/kg was 18 +/- 4.3 ml/kg/min (60.2 +/- 15%). FEV1 was significantly lower among smokers (71.1 +/- 12.2 vs. 89.2 +/- 13.6%, P = 0.017). There was a non-significant tendency towards lower FEV1 among patients who underwent mechanical ventilation. CONCLUSIONS: Late after severe trauma involving lung contusion, substantial recovery was demonstrated with improved pulmonary function tests. These results encourage maximal intensive care in these patients. Further larger studies are required to investigate different factors affecting prognosis.

Surfactant as salvage therapy in life threatening primary graft dysfunction in lung transplantation.

OBJECTIVE: Impaired surfactant activity may contribute to primary graft dysfunction after lung transplantation. We assessed the role of surfactant treatment in lung transplant recipients with severe life threatening primary lung graft dysfunction. PATIENTS AND METHODS: Five patients after lung transplantation: 4 after single-lung transplantation, for emphysema (n=3) or idiopathic pulmonary fibrosis (n=1), and 1 patient after double-lung transplantation for cystic fibrosis. All had severe life threatening primary graft dysfunction that failed to respond to conventional measures. Treatment consisted of bronchoscopic instillation of mammalian surfactant, 20-90cc, at 3 (n=1) or 7 days (n=4) after transplantation. RESULTS: There was a significant improvement in the ratio of partial arterial oxygen tension (PaO(2)) to fractional concentration of oxygen in inspired gas (FIO(2)), from a mean of 98.8+/-21.7 to 236.8+/-52.3 mmHg (p=0.0006), within hours of treatment. All were eventually discharged home and showed a satisfactory FEV(1) (44-67% predicted) at the 6-month follow-up. All patients were still alive 6 months or more after transplantation. CONCLUSION: Surfactant treatment improves oxygenation and may be life saving in patients with primary lung graft dysfunction.

The use of surfactant in lung transplantation.

BACKGROUND: Lung transplantation impairs surfactant activity, which may contribute to primary graft dysfunction (PGD). Prompted by studies in animals and a few reports in humans, this study sought to determine if the administration of surfactant during transplantation serves as an effective preventive measure. METHODS: An open, randomized, controlled prospective design was used. Forty-two patients scheduled for single (n=38) or double (n=4) lung transplantation at a major tertiary medical center were randomly assigned to receive, or not, intraoperative surfactant treatment. In the treated group, bovine surfactant was administered at a dose of 20 mg phospholipids/kg through bronchoscope after the establishment of bronchial anastomosis. The groups were compared for oxygenation (PaO2/FiO2), chest X-ray findings, PGD grade, and outcome. RESULTS: Compared with the untreated group, the patients who received surfactant were characterized by better postoperative oxygenation mean PaO2/FiO2 (418.8+/-123.8 vs. 277.9+/-165 mm Hg, P=0.004), better chest radiograph score, a lower PGD grade (0.66 vs. 1.86, P=0.005), fewer cases of severe PGD (1 patient vs. 12, P<0.05), earlier extubation (by 2.2 hr; 95% CI 1.1-4.3 hr, P=0.027), shorter intensive care unit stay (by 2.3 days; 95% CI 1.47-3.74 days, P=0.001), and better vital capacity at 1 month (61% vs. 50%, P=0.022). One treated and 2 untreated patients died during the first postoperative month. CONCLUSIONS: Surfactant instillation during lung transplantation improves oxygenation, prevents PGD, shortens intubation time, and enhances early posttransplantation recovery. Further, larger studies are needed to assess whether surfactant should be used routinely in lung transplantation.