Results of the Diaphragmatic Plication Database: 10 Years' Experience.

BACKGROUND: Unilateral diaphragmatic paralysis or paresis (UDP) in adults is an often overlooked disease which relevantly impairs the patient's lung function and quality of life. Particularly in idiopathic UDP, there is no evidence for conservative therapy and only little evidence for surgical therapy. METHODS: The method involves retrospective single-center analysis of patients with UDP persistent for at least 1 year who were operated by diaphragmatic resection, plication, and augmentation with a polypropylene mesh. The patients were tested for lung and diaphragmatic function, six-minute walk test (6MWT), and blood gas analysis before, 3 and 12 months after surgery. RESULTS: In total, 85 patients received surgery for UDP. The most frequent reasons for UDP were idiopathic (67%), iatrogenic (mainly cardiac and cervical spine surgery; 24%), and trauma (9%). The mean operation time was 84 ± 24 minutes, the length of hospital stay 8.4 ± 3.9 days, chest tubes were removed after 11.7 ± 4.1 days. Overall morbidity was 42%, mortality 0%. Forced expiratory volume in one second (FEV1) in supine position improved by 12.4% absolute, vital capacity by 11.8% absolute, and sniff nasal inspiratory pressure by 1.4 kPa 12 months after surgery (p <0.001 each). Total lung capacity increased by 6.8% absolute at 12 months (p = 0.001) The 6MWT distance improved by 45.9 m at 3 months and 50.9 m at 12 months (p = 0.001, each). CONCLUSION: Surgical therapy for UDP is highly effective in the long term. The superiority over conservative treatments needs to be evaluated prospectively with standardized physiotherapeutic protocols. FEV1 in supine position and 6MWT are easy to perform tests and represent statistically and patient-relevant outcomes.

Sarcoidosis involvement of the diaphragm leading to right diaphragmatic elevation: a case report.

A 69-year-old male Caucasian presenting with dyspnea on exertion related to unilateral diaphragmatic dysfunction as caused by sarcoidosis is described. First, right diaphragmatic elevation was unexplained, while the patient presented with a restrictive pattern in lung function testing using bodyplethysmography and with reduced global and diaphragmatic respiratory muscle strength as evidenced by respiratory pressures. Subsequently, surgical diaphragm plication was performed, unfortunately, without any clinical improvement. Microscopic examination of diaphragm sections revealed a lymphocytic myositis with granulomatous pleuritis showing multiple non-caseating epithelioid granulomas. Accordingly, a lymphocytic alveolitis (26% lymphocytes) with an elevated CD4/CD8 T cell ratio of 8.0% and elevated serum parameters (neopterin and sIL-2 receptor) were established. Consequently, the diagnosis of pulmonary sarcoidosis with diaphragm involvement but without extrapulmonary involvement has been established. Therefore, sarcoidosis needs to be considered in any patient presenting with unilateral diaphragmatic dysfunction. The optimal treatment strategy, however, needs to be established in the future.

Guidelines on analgosedation, monitoring, and recovery time for flexible bronchoscopy: a systematic review.

BACKGROUND: Patients undergoing bronchoscopy in spontaneous breathing are prone to hypoxaemia and hypercapnia. Sedation, airway obstruction, and lung diseases impair respiration and gas exchange. The restitution of normal respiration takes place in the recovery room. Nonetheless, there is no evidence on the necessary observation time. We systematically reviewed current guidelines on bronchoscopy regarding sedation, monitoring and recovery. METHODS: This review was registered at the PROSPERO database (CRD42020197476). MEDLINE and awmf.org were double-searched for official guidelines, recommendation or consensus statements on bronchoscopy from 2010 to 2020. The PICO-process focussed on adults (Patients), bronchoscopy with maintained spontaneous breathing (Interventions), and recommendations regarding the intra- and postprocedural monitoring and sedation (O). The guideline quality was graded. A catalogue of 54 questions was answered. Strength of recommendation and evidence levels were recorded for each recommendation. RESULTS: Six guidelines on general bronchoscopy and three expert statements on special bronchoscopic procedures were identified. Four guidelines were evidence-based. Most guidelines recommend sedation to improve the patient's tolerance. Midazolam combined with an opioid is preferred. The standard monitoring consists of non-invasive blood pressure, and pulse oximetry, furthermore electrocardiogram in cardiac patients. Only one guideline discusses hypercapnia and capnometry, but without consensus. Two guidelines discuss a recovery time of two hours, but a recommendation was not given because of lack of evidence. CONCLUSION: Evidence for most issues is low to moderate. Lung-diseased patients are not represented by current guidelines. Capnometry and recovery time lack evidence. More primary research in these fields is needed so that future guidelines may address these issues, too.

Development of the Diaphragmatic Paralysis Questionnaire: a simple tool for patient relevant outcome.

OBJECTIVES: Measurement tools of health-related quality of life (HRQL) that are specific for the underlying disorder are inevitably needed to assess HRQL changes following specific treatment strategies. The aim of the current study was to develop a questionnaire assessing HRQL in patients with unilateral diaphragmatic paresis. METHODS: Firstly, topics of health impairments covering physical, psychological, social and functional aspects were predefined by a physician expert panel to ensure face validity. Secondly, all predefined topics were rated by a patient group with unilateral diaphragmatic paresis (untreated: n = 11; postoperative: n = 9) using a 5-point Likert scale ranging from 'not relevant at all' (-2) to 'absolutely relevant' (+2) to guarantee content validity. Thirdly, only relevant topics (0 to +2) were used for item development, while non-relevant items (<0) were not subject for item development. RESULTS: In total, 20 patients rated a total of 43 topics covering a broad spectrum of health impairment. 21 were considered as relevant for item development. Items are answered on a 5-point Likert scale ranging from 'completely untrue' (-2) to 'always true' (+2). The Diaphragmatic Paralysis Questionnaire (DPQ) Summary Score ranges from 0 (worst HRQL) to 100 (best HRQL). Finally, the German DPQ was professionally translated and transculturally adapted into English, Italian, Dutch, French, Greek and Spanish, using translation/back-translation procedures. CONCLUSIONS: The DPQ is the first diseases-specific HRQL measure developed for patients with diaphragmatic paresis. In addition, the DPQ is available in 7 languages free of charge for non-profit purposes. CLINICAL TRIAL REGISTRATION: German clinical trials register: DRKS00017056.

[Video-assisted Thoracoscopic Surgery in Local Anaesthesia and Analgosedation - a Survey of the Members of the German Society of Thoracic Surgeons]. / Videoassistierte thorakoskopische Chirurgie in Lokalanästhesie und Analgosedierung ­ eine Umfrage unter den Mitgliedern der Deutschen Gesellschaft für Thoraxchirurgie.

INTRODUCTION: There is increasing international interest in the use of video-assisted thoracoscopic procedures (VATS) with spontaneous respiration in the treatment of elderly and multimorbid patients. Data on the application and acceptance in Germany are not yet available. METHOD: Germany-wide, online-based survey among the departments of thoracic surgery registered at the German Society of Thoracic Surgeons (DGT) on the application of VATS in local anaesthesia (LA). RESULTS: 101 of 157 hospitals responded (64%). 42% of the respondents perform non-intubated VATS (NIVATS), 31% VATS in LA. Reasons not to perform VATS in LA are lack of experience (51%), doubts about feasibility (29%) and missing indications (24%). Among the performing clinics, the most frequent procedures are pleural catheterisation (94%), pleural biopsy (87%) and pleurodesis (87%). 42% of the clinics perform wedge resections and 10% also anatomical resections in LA. Main target groups are multimorbid patients (77%), elderly patients (65%), patients with anxiety about general anaesthesia (55%) and patients with pre-existing lung diseases (52%). In 97% of the departments, sedation is performed by anaesthesiologists. The main technical difficulties mentioned are impaired view of the surgical field (39%), hypercapnia (29%) and panic attacks (23%). Pain is of minor importance (3%). DISCUSSION: About one third of the participating departments already perform VATS in LA; others have plans to introduce the method. The majority of respondents regard multimorbid, elderly and lung patients as the main target groups, as fewer inflammatory, respiratory and neurological complications are expected.

Sensitivity of chest ultrasound for postoperative pneumothorax in comparison to chest X-ray after lung resecting surgery.

OBJECTIVES: Thoracic ultrasound is superior to chest X-ray for the detection of a pneumothorax in trauma and intensive care medicine. Data regarding its use in non-cardiac thoracic surgery are scarce and contradictory. Previous studies are heterogeneous regarding sonographic methodology and patient selection. This study aimed to evaluate the accuracy of thoracic ultrasound for pneumothorax assessment after lung resecting surgery in unselected patients. METHODS: SONOR (SONOgraphy vs x-Ray) is a prospective observational trial (registry-ID DRKS00014557). A total of 123 consecutive patients with lung resecting surgery received a standardized thoracic ultrasound the same day and in addition to routine chest X-rays in erect position after removal of the chest tube. The sonographer was blinded to radiological findings and vice versa. RESULTS: Sensitivity, specificity, positive and negative predictive values of ultrasound after removing the chest tube were 0.32, 0.85, 0.54, 0.69 for any pneumothorax and 1.0, 0.82, 0.19, 1.0 for pneumothorax ≥3 cm. No clinically relevant pneumothorax was missed. The agreement between sonography- and routine-based therapeutic decisions was 97%. Lung pulse was the most frequently detected sign to sonographically rule out a pneumothorax. CONCLUSIONS: Postoperative thoracic ultrasound in unselected patients has a low overall sensitivity to detect a residual pneumothorax; however, its sensitivity and negative predictive values regarding clinically relevant pneumothorax are high. Test quality depends on the distinct sonographic methodology and patient selection. Anatomic differences in postsurgical and medical patients may be responsible for the contradictory results of previous trials. Studies with a larger population size are required to validate the accuracy of relevant pneumothoraces and identify appropriate selection criteria. CLINICAL TRIAL REGISTRATION NUMBER: DRKS-German Clinical Trials Register, www.drks.de, registry-ID DRKS00014557.

Rationale and design of PASSAT - patients' satisfaction with local or general anaesthesia in video-assisted thoracoscopic surgery: study protocol for a randomised controlled trial with a non-randomised side arm.

BACKGROUND: Although general anaesthesia (GA) with one-lung ventilation is the current standard of care, minor thoracoscopic surgery, i.e. treatment of pleural effusions, biopsies and small peripheral pulmonary wedge resections, can also be performed using local anaesthesia (LA), analgosedation and spontaneous breathing. Whilst the feasibility and safety of LA have been demonstrated, its impact on patient satisfaction remains unclear. Most studies evaluating patient satisfaction lack control groups or do not meet psychometric criteria. We report the design of the PASSAT trial (PAtientS' SATisfaction in thoracic surgery - general vs. local anaesthesia), a randomised controlled trial with a non-randomised side arm. METHODS: Patients presenting for minor thoracoscopic surgery and physical eligibility for GA and LA are randomised to surgery under GA (control group) or LA (intervention group). Those who refuse to be randomised are asked to attend the study on the basis of their own choice of anaesthesia (preference arm) and will be analysed separately. The primary endpoint is patient satisfaction according to a psychometrically validated questionnaire; secondary endpoints are complication rates, capnometry, actual costs and cost effectiveness. The study ends after inclusion of 54 patients in each of the two randomised study groups. DISCUSSION: The PASSAT study is the first randomised controlled trial to systematically assess patients' satisfaction depending on LA or GA. The study follows an interdisciplinary approach, and its results may also be applicable to other surgical disciplines. It is also the first cost study based on randomised samples. Comparison of the randomised and the non-randomised groups may contribute to satisfaction research. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00013661 . Registered on 23 March 2018.