Veno-Venous Extracorporeal Lung Support as a Bridge to or Through Lung Volume Reduction Surgery in Patients with Severe Hypercapnia.

Extracorporeal lung support (ECLS) represents an essential support tool especially for critically ill patients undergoing thoracic surgical procedures. Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we report the efficacy of veno-venous ECLS (VV ECLS) as a bridge to or through LVRS in patients with end-stage lung emphysema and severe hypercapnia. Between January 2016 and May 2017, 125 patients with end-stage lung emphysema undergoing LVRS were prospectively enrolled into this study. Patients with severe hypercapnia caused by chronic respiratory failure were bridged to or through LVRS with low-flow VV ECLS (65 patients, group 1). Patients with preoperative normocapnia served as a control group (60 patients, group 2). In group 1, VV ECLS was implemented preoperatively in five patients and in 60 patients intraoperatively. Extracorporeal lung support was continued postoperatively in all 65 patients. Mean length of postoperative VV ECLS support was 3 ± 1 day. The 90 day mortality rate was 7.8% in group 1 compared with 5% in group 2 (p = 0.5). Postoperatively, a significant improvement was observed in quality of life, exercise capacity, and dyspnea symptoms in both groups. VV ECLS in patients with severe hypercapnia undergoing LVRS is an effective and well-tolerated treatment option. In particular, it increases the intraoperative safety, supports de-escalation of ventilatory strategies, and reduces the rate of postoperative complications in a cohort of patients considered "high risk" for LVRS in the current literature.

Single-Site Cannulation Venovenous Extracorporeal CO2 Removal as Bridge to Lung Volume Reduction Surgery in End-Stage Lung Emphysema.

Lung volume reduction surgery (LVRS) is an important treatment option for end-stage lung emphysema in carefully selected patients. Here, we first describe the application of low-flow venovenous extracorporeal CO2 removal (LFVV-ECCO2R) as bridge to LVRS in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute failure of the breathing pump. Between March and October 2015, n = 4 patients received single-site LFVV-ECCO2R as bridge to LVRS. Indication for extracorporeal lung support was severe hypercapnia with respiratory acidosis and acute breathing pump failure. Two patients required continuous mechanical ventilation over a temporary tracheostomy and were bed ridden. The other two patients were nearly immobile because of severe dyspnea at rest. Length of preoperative ECCO2R was 14 (1-42) days. All patients underwent unilateral LVRS. Anatomical resection of the right (n = 3) or left (n = 1) upper lobe was performed. Postoperatively, both patients with previous mechanical ventilatory support were successfully weaned. ECCO2R in patients with end-stage lung emphysema experiencing severe hypercapnia caused by acute breathing pump failure is a safe and effective bridging tool to LVRS. In such patients, radical surgery leads to a significant improvement of the performance status and furthermore facilitates respiratory weaning from mechanical ventilation.

Management of adult patients with Langerhans cell histiocytosis: recommendations from an expert panel on behalf of Euro-Histio-Net.

Langerhans Cell Histiocytosis (LCH) is an orphan disease of clonal dendritic cells which may affect any organ of the body. Most of the knowledge about the diagnosis and therapy is based on pedriatic studies. Adult LCH patients are often evaluated by physicians who focus on only the most obviously affected organ without sufficient evaluation of other systems, resulting in patients being underdiagnosed and/or incompletely staged. Furthermore they may be treated with pediatric-based therapies which are less effective and sometimes more toxic for adults. The published literature on adult LCH cases lacks a comprehensive discussion on the differences between pediatric and adult patients and there are no recommendations for evaluation and comparative therapies. In order to fill this void, a number of experts in this field cooperated to develop the first recommendations for management of adult patients with LCH. Key questions were selected according to the clinical relevance focusing on diagnostic work up, therapy, and follow up. Based on the available literature up to December 2012, recommendations were established, drafts were commented by the entire group, and redrafted by the executive editor. The quality of evidence of the recommendations is predominantly attributed to the level of expert opinion. Final agreement was by consensus.

Comparison of two demand oxygen delivery devices for administration of oxygen in COPD.

AIM: Demand oxygen delivery systems (DODSs) were developed to secure the mobility of patients requiring oxygen therapy. The aim of the present study was to compare the efficacy of two currently available DODS with continuous oxygen administration (CONT). PATIENTS: Thirteen patients with COPD (mean [+/- SD] FEV1, 28 +/- 5.2% predicted; mean P(O2), 56.4 +/- 8.1 mm Hg [breathing room air]). INTERVENTION: Treatment for 30 min with CONT at a flow rate of 2 L/min, with the DODSs Oxytron 3 (Weinmann; Hamburg, Germany) or DeVilbiss EX 3000 (Somerset, PA) in random sequence. Arterialized blood samples were obtained from a hyperaemized ear lobe after 15 and 30 min. RESULTS: After 15 min, no significant differences in P(O2) or arterial oxygen saturation (Sa(O2)) were observed. In comparison with CONT (mean P(O2), 70.5 +/- 10.4 mm Hg; mean Sa(O2), 94.8 +/- 2.13%), oxygenation with the Oxytron 3 (mean P(O2), 66.3 +/- 10.3 mm Hg; mean Sa(O2), 93.5 +/- 2.6%) was significantly less after 30 min when measured independently by blood gas analysis and pulse oximetry. The DeVilbiss EX 3000 (mean P(O2), 69.1 +/- 12.0 mm Hg; mean Sa(O2), 94.5 +/- 3.2%) and CONT showed no differences. CONCLUSIONS: P(O2) did not reach equilibrium after 15 min of treatment with the DODSs. The titration of a patient to a DODS is recommended, since simply accepting the manufacturer's information on oxygen equivalent does not guarantee an adequate supply of oxygen.

Sleep-related breathing disorders are associated with ventricular arrhythmias in patients with an implantable cardioverter-defibrillator.

STUDY OBJECTIVES: The aim of this study was to examine the influence of sleep-related breathing disorders (SBDs) on the occurrence of ventricular arrhythmias in patients with reduced left ventricular ejection fraction (LVEF), and life-threatening ventricular tachyarrhythmias treated with an implantable cardioverter-defibrillator. PATIENTS: Thirty-eight patients with LVEF of 36 +/- 13% (mean +/- SD) underwent a sleep study. When an apnea-hypopnea index (AHI) > 10/h occurred, SBD was diagnosed. MEASUREMENTS AND RESULTS: In patients with SBDs, ventricular arrhythmias (couplets, triplets, short runs) were recorded simultaneously by Holter ECG and differentiated in episodes with and without disordered breathing. An apnea-associated arrhythmia index (AI) was defined as the number of ventricular arrhythmias occurring simultaneous to disordered breathing. Accordingly, a nonapnea-associated arrhythmia index (NAI) was calculated as the number of ventricular arrhythmias during normal breathing. SBDs were diagnosed in 14 patients: Cheyne-Stokes respiration (CSR) [n = 8; AHI, 32.1 +/- 25.0/h], and obstructive sleep apnea (OSA) [n = 6; AHI, 34.1 +/- 14.6/h]. Four patients in the OSA group and four patients in the CSR group had ventricular arrhythmias during sleep, revealed by Holter ECG. In these eight patients, the AI was significantly higher than the NAI (20.9 +/- 18.8/h vs 4.9 +/- 3.3/h, respectively). CONCLUSIONS: These data show that ventricular arrhythmias occurred significantly more often in association with disordered breathing in patients at high risk for arrhythmias and reduced LVEF.