Long-Term Patient-Reported Symptom Improvement and Quality of Life after Transthoracic Diaphragm Plication in Adults.

BACKGROUND: Open and robotic-assisted transthoracic approaches for diaphragm plication are accepted surgical interventions for diaphragm paralysis and eventration. However, long-term patient-reported symptom improvement and quality of life (QOL) remains unclear. STUDY DESIGN: A telephone-based survey was developed focusing on postoperative symptom improvement and QOL. Patients who underwent open or robotic-assisted transthoracic diaphragm plication (2008-2020) across three institutions were invited to participate. Patients who responded and provided consent were surveyed. Likert responses on symptom severity were dichotomized and rates before and after surgery were compared using McNemar's test. RESULTS: Forty-one percent of patients participated (43 of 105 responded, mean age 61.0 years, 67.4% male, 37.2% robotic-assisted surgery), with an average time between surgery and survey of 4.1 ± 3.2 years. Patients reported significant improvement in dyspnea while lying flat (67.4% pre- vs 27.9% postoperative, p < 0.001), dyspnea at rest (55.8% pre- vs 11.6% postoperative, p < 0.001), dyspnea with activity (90.7% pre- vs 55.8% postoperative, p < 0.001), dyspnea while bending over (79.1% pre- vs 34.9% postoperative, p < 0.001), and fatigue (67.4% pre- vs 41.9% postoperative, p = 0.008). There was no statistical improvement in chronic cough. 86% of patients reported improved overall QOL, 79% had increased exercise capacity, and 86% would recommend surgery to a friend with a similar problem. Analysis comparing open and robotic-assisted approaches found no statistically significant differences in symptom improvement or QOL responses between the groups. CONCLUSIONS: Patients report significantly improved dyspneic and fatigue symptoms after transthoracic diaphragm plication, regardless of open or robotic-assisted approach. The majority of patients report improved QOL and exercise capacity.

Management of Severe Asthma Beyond the Guidelines.

PURPOSE OF REVIEW: Asthma is one of the most common chronic respiratory diseases worldwide, yet only a small percentage of patients are categorized as having severe disease. Severe asthmatics, however, are responsible for the largest burden of healthcare costs and lost productivity. Several recent guidelines have addressed disease pathogenesis and treatment modalities for these complex patients. Herein, we review the severe asthma guidelines, compare the existing guidelines, address key areas that are yet to be addressed in the guidelines, and discuss future directions for severe asthma research. RECENT FINDINGS: This is a narrative review of the 2019 European Respiratory Society/American Thoracic Society (ERS/ATS) and Global Initiative for Asthma (GINA) guidelines that specifically address the diagnosis and management of severe asthma. The pathophysiological mechanisms that underlie severe asthma are reviewed, and novel therapies that target specific pathophysiological pathways in severe asthma are discussed in detail. Although the guidelines address the use of novel biological therapies for patients with T2-mediated disease, data comparing these agents remain sparse. This review addresses several areas that are topics beyond the guidelines and highlight key areas where future research is warranted. This review provides a comprehensive overview of the current state of severe asthma treatment and discusses potential avenues for future research for this patient population.