Time-trend analysis of the pulmonary function after surgical treatment for esophageal cancer.

OBJECTIVE: To evaluate, in function of time, the modification of pulmonary function after radical esophagectomy with the aim of identifying clinical and/or surgical predictors of functional worsening. PATIENTS AND METHODS: Data of 57 patients operated from 01/06 to 06/11 were retrospectively reviewed. Thirty-eight patients (67%) underwent transhiatal cervico-laparotomic (CL-Group) and 19 (33%) a Mc-Keown cervico-thoraco-laparotomic esophagectomy (CTL-Group). The pulmonary function has been evaluated before and one month after surgery. The outcome has been benchmarked with demographic/clinical characteristics, the type of operation and the presence of post-operative pulmonary complications (POPCs). RESULTS: Mean age and male/female distribution were 66.6±10.6 yrs and 39/18, respectively. A total of 14 (24% of total sample) POPCs occurred with a significantly higher occurrence in the CTL-Group (71% vs 28%, p < 0.001) and in those patients with a pre-operative concurrent pathological condition (64% in COPD patients vs 36% in patients without COPD, p = 0.021). A global worsening of the spirometric parameters (expressed as the baseline percentage change, Δ) emerged, but this decrease was significantly higher in the CTL-Group in terms of Δ-FVC (p = 0.005) and Δ-FEV1 (p = 0.005). Similarly, those patients who have experienced a POPC, showed a higher reduction of the pulmonary function regardless of the surgical approach when compared with those who did not (Δ-FVC: p = 0.053 and Δ-FEV1%: p = 0.015). CONCLUSIONS: In the context of a global reduction of pulmonary function, patients who underwent trans-thoracic esophagectomy or experienced a POPC showed a significantly worse pattern. These patients could be the "best target" for therapeutic rehabilitative strategies in the pre-operative and/or post-operative setting. This assumption is to be proven through prospective clinical trials.

The clinical and integrated management of COPD.

COPD is a chronic pathological condition of the respiratory system characterized by persistent and partially reversible airflow obstruction, to which variably contribute remodeling of bronchi (chronic bronchitis), bronchioles (small airway disease) and lung parenchyma (pulmonary emphysema). COPD can cause important systemic effects and be associated with complications and comorbidities. The diagnosis of COPD is based on the presence of respiratory symptoms and/or a history of exposure to risk factors, and the demonstration of airflow obstruction by spirometry. GARD of WHO has defined COPD "a preventable and treatable disease". The integration among general practitioner, chest physician as well as other specialists, whenever required, assures the best management of the COPD person, when specific targets to be achieved are well defined in a diagnostic and therapeutic route, previously designed and shared with appropriateness. The first-line pharmacologic treatment of COPD is represented by inhaled long-acting bronchodilators. In symptomatic patients, with pre-bronchodilator FEV1 < 60%predicted and ≥ 2 exacerbations/year, ICS may be added to LABA. The use of fixed-dose, single-inhaler combination may improve the adherence to treatment. Long term oxygen therapy (LTOT) is indicated in stable patients, at rest while receiving the best possible treatment, and exhibiting a PaO2 ≤ 55 mmHg (SO2<88%) or PaO2 values between 56 and 59 mmHg (SO2 < 89%) associated with pulmonary arterial hypertension, cor pulmonale, or edema of the lower limbs or hematocrit > 55%. Respiratory rehabilitation is addressed to patients with chronic respiratory disease in all stages of severity who report symptoms and limitation of their daily activity. It must be integrated in an individual patient tailored treatment as it improves dyspnea, exercise performance, and quality of life. Acute exacerbation of COPD is a sudden worsening of usual symptoms in a person with COPD, over and beyond normal daily variability that requires treatment modification. The pharmacologic therapy can be applied at home and includes the administration of drugs used during the stable phase by increasing the dose or modifying the route, and adding, whenever required, drugs as antibiotics or systemic corticosteroids. In case of patients who because of COPD severity and/or of exacerbations do not respond promptly to treatment at home hospital admission should be considered. Patients with "severe or "very severe COPD who experience exacerbations should be carried out in respiratory unit, based on the severity of acute respiratory failure. An integrated system is required in the community in order to ensure adequate treatments also outside acute care hospital settings and rehabilitation centers. This article is being simultaneusly published in Multidisciplinary Respiratory Medicine 2014; 9:25.

Pulmonary rehabilitation in lung cancer.

Non-small-cell lung cancer (NSCLC) represents a very severe disease, being its incidence increasingly reported and, nowadays, successfully treatable only when surgery is deemed to be feasible. Furthermore, the disease and the clinical effects related to the complementary therapies (radio and/or chemotherapy) may strongly affect, frequently with dramatic clinical side effects, the patient's ability to endure physical exercise. In such context, the PR(PR), which has already been proved to be useful and effective in other diseases such as COPD, could play a pivotal role. The aim of this review article is, therefore, to analyze the pertinent data recently reported in English literature in order to highlight the role of rehabilitation as complementary therapy in the management of patients with NSCLC. The evidence currently available suggests that, when surgery is indicated, PR is a safe and feasible option, both during pre-operative and post-operative timing.The safety and feasibility of rehabilitation are proven even in inoperable patients, although to date, little evidence has been reported on its role in the overall management of such complex diseases.

Is pulmonary function damaged by neoadjuvant lung cancer therapy? A comprehensive serial time-trend analysis of pulmonary function after induction radiochemotherapy plus surgery.

OBJECTIVE: We have analyzed short- and long-term variations of pulmonary function in locally advanced non-small cell lung cancer after induction chemoradiotherapy. METHODS: Twenty-seven patients with stage IIIA (N2) non-small cell lung cancer underwent resection with radical intent after induction chemoradiotherapy in the period 2003 to 2006. Pulmonary function has been evaluated by spirometry, diffusing capacity of the lung for carbon monoxide, and blood gas analysis before induction chemoradiotherapy (T0), 4 weeks after induction chemoradiotherapy and before surgery (T1), and 1 (T2), 3 (T3), 6 (T4), and 12 months (T5) after surgery. RESULTS: A 22.80% decrease of diffusing capacity of the lung for carbon monoxide (P < .001) was observed at T1. At T2 significant decreases in the following were present: vital capacity, -20.50% (P < .001); forced vital capacity, -22.50% (P < .001); forced expiratory volume in 1 second, -23.00% (P < .001); peak expiratory flow, -29.0 (P < .001); forced expiratory flow 25% to 75%, -13.7% (P = .005); and diffusing capacity of the lung for carbon monoxide, 43.6% (P < .001). However, in the interval between T2 and T5, a progressive improvement of lung function in most parameters was observed, but only diffusing capacity of the lung for carbon monoxide presented a significant increase (P < .001). Within the same time gap (T2 to T5), subjects 65 years of age or younger showed an increasing trend for vital capacity, forced expiratory volume in 1 second, total lung capacity, and residual volume significantly different from that of elderly patients, in whom a decrease in these parameters is reported. CONCLUSIONS: An impairment of respiratory function is evident in the immediate postoperative setting in patients with non-small cell lung cancer receiving induction chemoradiotherapy. In the long-term period, a general recovery in diffusing capacity of the lung for carbon monoxide was found, whereas an improvement of forced expiratory volume in 1 second, vital capacity, total lung capacity, and residual volume was detected in the younger population only.

[Evaluation of the flow/volume curve in normal subjects. Study of the flow fall index]. / La valutazione della curva flusso/volume nei soggetti normali. Studio dell'indice di caduta del flusso (I.C.F.).

Variations in the flow/volume curve have been examined in normal subjects in relation to age. It was noted that although flow varies in absolute terms, its fall is constant in both men and women, at equal age. On the other hand, a flow reduction first of 25% and then 50% of CVF was noted in relation to age.

[Intravenous salbutamol in the treatment of bronchial spasm]. / Il salbutamolo per via venosa nella terapia del broncospasmo.

Personal experience with slow venous drip salbutamol is reported. The VC, MEVS and FEP values showed that the drug possessed a good bronchodilatatory action, though the presence of side-effects meant that doses had to be restricted.

[Asthma as a psychosomatic disease and its treatment with tranquilizing agents]. / A proposito dell'asma come malattia psicosomatica e del suo trattamento con psicofarmaci

On the basis of personal research and experience, it is concluded that the majority of asthmatics also suffer from psychoneurosis and that psychological alterations are primary and not secondary to dyspnoea. Some hypotheses are put forward relating the onset of asthma and psychoneurosis.

[The neurovegetative system in the pathogenesis of bronchial spasm]. / Il sistema neurovegetativo nella patogenesi del broncospasmo

The therapeutic efficacy of atropine and salbutamol sprays alone or in association was experimented in patients with atopic bronchial asthma as part of an investigation of the bronchodilatatory drugs and the pathogenesis of bronchospasm. As personally observed in other situations, combination of these drugs does not allow their maximum effect to be obtained.

[Critical analysis of the diagnostic value of the flow-volume curve]. / Analisi critica del significato diagnostico della curva flusso-volume

Changes in the flow-volume curve after administration of a bronchodilator were studied in reversible bronchial obstruction. The concept of isovolume is used in analysis of the curve indices, i.e. it is felt that the index (75, 60, 50, 25% FVC) after administration should be fixed on the curve at the same volume as on the basic curve to enable an indirect account to be taken of changes in flow in function of time, since, if resistance is reduced, the emitted volume varies in the same period even though the conditions promoting the flow are unchanged.

[Current evaluation of beta-adrenergic agents in the treatment of bronchial spasm]. / Valutazione attuale dei beta-adrenergici nella terapia del broncospasmo

The current status of beta-adrenergics in the treatment of bronchospasm is discussed. Personal experience is reviewed with special attention being paid to associations of the drugs on aminophylline, atropine and bechlomethasone dipropionate.

[Prognostic evaluation of cardiorespiratory insufficiency in chronic bronchitis]. / Valutazione prognostica della insufficienza cardiorespiratoria nella bronchite cronica

The course of chronic bronchitis is examined with particular stress on the most important clinical and functional factors for the purposes of the prognostic judgment on the disease. Phenomena of reoccurrence of cardiorespiratory insufficiency are also examined.