Chronic anemia after lung transplantation: treatment with human recombinant erythropoietin.
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Adult↗
Biomedical subjects
W Klepetko
Publications and source records attributed to W Klepetko.
[Jet ventilation superimposed on a special jet laryngoscope for endoluminal stent insertion in the tracheobronchial system].
BACKGROUND: Stenotic processes of the tracheobronchial system may lead to dyspnoea that can become lift-threatening. To restore sufficient function of the blocked airway, a silicone stent can be inserted. The anaesthesia techniques used for this intervention so far have been complicated. The object of this study was to determine whether the super-imposed high-frequency jet ventilation (SHFJV) via the jet laryngoscope originally designed for microlaryngeal surgery can be utilized for endoluminal stent insertion. METHODS: In 12 patients with acute respiratory insufficiency (ASA 3-5) due to stenosis of the tracheobronchial system, an endoluminal silicone stent was inserted through the jet laryngoscope while the patient was ventilated using SHFJV: RESULTS: A significant rise in paO2 readings prior to the jet ventilation and subsequent measurements was observed. The CO2 elimination was good (average paCO2 31.5 +/- 7.5-53.1 +/- 14 mmHg). Variably high paCO2 readings during stent insertion were related to the respective surgical phases. At the end of the surgical manipulation, all patients had sufficient spontaneous ventilation. CONCLUSIONS: First clinical applications of the jet laryngoscope combined with superimposed jet ventilation for stent insertion demonstrated satisfactory results. Not only were the patients ventilated throughout the procedure, but CO2 elimination was also satisfactory. Superimposed jet ventilation provides a sufficient tidal volume with low ventilation pressures, and therefore oxygenation and CO2 elimination are unproblematic. SHFJV enables the anaesthetist to ventilate the patient nearly continuously with minimal phases of apnoea. The only apnoea phases, as with any other method, occur during surgical manipulation while inserting the stent and thus blocking the airway. We believe that the jet laryngoscope with SHFJV presents a distinct advantage for both anaesthetist and surgeon when inserting stents in the tracheobronchial system.
Acute Disease↗
Effect of lung transplantation on diaphragmatic function in patients with chronic obstructive pulmonary disease.
BACKGROUND: To date there are no data on the effects of lung transplantation on diaphragmatic function in patients with end stage chronic obstructive pulmonary disease (COPD). It is not known whether the relation between the transdiaphragmatic pressure (PDI) and lung volume is altered in recipients after transplantation as a result of changes in diaphragmatic structure caused by chronic hyperinflation. The effect of lung transplantation on diaphragmatic strength was determined in patients with COPD and the relation between postoperative PDI and lung volume analysed. METHODS: Diaphragmatic strength was assessed in eight double lung transplant recipients, six single lung transplant recipients, and in 14 patients with COPD whose lung function was similar to those of the transplant recipients preoperatively. PDI obtained during unilateral and bilateral phrenic nerve stimulation at 1 Hz (twitch PDI) at functional residual capacity (FRC) and during maximal sniff manoeuvres (sniff PDI) at various levels of inspiratory vital capacity (VCin) served as parameters for diaphragmatic strength. Sniff PDI assessed at the various VCin levels were used to analyse the PDI/lung volume relation. RESULTS: Lung transplantation caused a reduction in lung volume, especially in the double lung transplant recipients. As a consequence sniff PDI was higher in the double lung transplant recipients than in the patients with COPD at all levels of VCin analysed. However, sniff PDI values analysed at comparable intrathoracic gas volumes were not reduced in the patients with COPD when compared with those who underwent lung transplantation. Bilateral twitch PDI values were similar in the patients with COPD and in the lung transplant recipients. In the single lung transplant recipients unilateral twitch PDI values were similar on the transplanted and the non-transplanted side. The relation between PDI and lung volume was similar in the patients with COPD and in the lung transplant recipients. CONCLUSIONS: In patients with COPD lung transplantation leads to an increase the maximal sniff induced PDI values by placing the diaphragm in a more favourable position for pressure generation. Since patients with COPD and postoperative lung transplant recipients showed similar PDI/lung volume relations, this suggests that chronic pulmonary hyperinflation does not cause major functional alterations of the diaphragm.
Adult↗
Effect of lung transplantation on right and left ventricular volumes and function measured by magnetic resonance imaging.
To evaluate the effect of lung transplantation on right ventricular (RV) and left ventricular (LV) volumes and function, magnetic resonance imaging (MRI) was performed in 11 patients before and 6 to 24 months after single (n = 7) or double (n = 4) lung transplantation as well as in 15 healthy control subjects. Prior to transplantation, RV end-diastolic (RVEDVI, ml/m2) and end-systolic (RVESVI, ml/m2) volume indices were significantly increased in patients compared with those in control subjects. RV ejection fraction (RVEF, %), although within the lower normal range, was significantly reduced. In contrast, LV volume indices (ml/m2) were significantly smaller in patients than in control subjects, whereas LV ejection fraction (LVEF, %) was not different from that in normal subjects. After lung transplantation, MRI revealed a significant reduction in RVEDVI from 73 +/- 29 to 54 +/- 14 (p = 0.03) and RVESVI from 38 +/- 23 to 20 +/- 6 (p = 0.01) with a concomitant significant increase in RVEF from 48 +/- 14 to 63 +/- 6 (p = 0.01). Consecutively, the LV expanded to normal (LVEDVI from 49 +/- 12 to 65 +/- 14, p = 0.01; LVESVI from 23 +/- 9 to 28 +/- 7, p = 0.05), whereas LVEF remained unchanged (55 +/- 9 versus 56 +/- 8).
Adult↗
[Cytomegalovirus infection following lung transplantation].
The significance of cytomegalovirus (CMV) infection after lung transplantation was investigated in 20 patients (ten women and ten men; mean age 46 [21-67] years). Indications for transplantation were emphysema (n = 6), cystic fibrosis (n = 2), primary pulmonary hypertension (n = 2), pulmonary fibrosis (n = 5), obliterating bronchiolitis (n = 2), cystic lung (n = 2) and bronchiectasis (n = 1). Incidence, diagnostic parameters (serology, virus isolation and histology) and efficacy of prophylactic and therapeutic measures were recorded. 16 of the 20 patients developed a CMV infection, which in 12 was clinically significant. CMV pneumonia developed in two patients, proving fatal in one. The infection occurred a median of 47 (17-200) days after the transplantation. Administration of Ganciclovir (5 mg/kg twice daily intravenously) brought about remission of symptoms in all but one of the patients and improved the clinical parameters.--This experience demonstrates that regular monitoring of the patients for possible CMV infection and its early therapy can achieve a low death rate.
Adult↗
Successful lung transplantation in a long-term ventilator-dependent patient.
Ventilator dependence has been postulated to be a major contraindication for successful lung transplantation. We describe the case of a 44-year-old female patient mechanically ventilated for 10 months after adult respiratory distress syndrome. After a program of physical training the patient underwent successful bilateral sequential lung transplantation. Six months postoperatively she is in good physical condition and is able to carry out the activities of normal daily living. We conclude that in selected patients long-term mechanical ventilatory support is not a contraindication for lung transplantation.
Activities of Daily Living↗
Closed circuit perfusion of an isolated rabbit lung. A new model for the evaluation of preservation quality of stored lungs.
The comparison of different preservation methods in lung transplantation demands a well standardized and reproducible animal model. The aim of this study was to establish as in vitro model in which the oxygenation capacity of the lung can be investigated over an extended period of time. Heart-lung blocks from 6 New Zealand white rabbits were harvested, the pulmonary artery and the left ventricle cannulated and the lungs perfused with whole rabbit blood by means of a roller pump and ventilated with room air. A dialyser was installed into the closed circuit perfusion for continuous deoxygenation of the oxygen-saturated blood gained from the left ventricle. Throughout the stable perfusion period the average arterial and venous partial oxygen pressure (pO2) levels were 105.8 +/- 15.5 mmHg and 55.2 +/- 6.2, respectively (P < 0.05). The average peak airway pressure steadily increased from 10.7 +/- 1.2 mmHg at the start of reperfusion to 21 +/- 14.4 mmHg after 180 minutes (P = NS). With this experimental setting it is possible to maintain stable conditions (i.e. constant venous and arterial blood gases) for at least 180 minutes. It is therefore feasible to compare the influences of different preservation methods on the quality of lung function.
Animals↗
Six-year follow-up after heart valve replacement with the Edwards Duromedics bileaflet prosthesis.
The Duromedics Edwards valve (DE) was designed with a self-irrigating hinge mechanism to reduce the rate of thromboembolic complications. This report presents a prospective follow-up of patients after valve replacement with this prosthesis in a university hospital. Five hundred seven patients had DE prostheses implanted in the aortic (n = 268), mitral (n = 183) or aortic and mitral positions (n = 56). The perioperative mortality was 6.9%. Follow-up was 98% complete, comprising 2009 patient years for a mean follow-up of 48 months: (range 27-84). The actuarial freedom from complications is calculated as follows (linearized rates in parentheses): late mortality 81.0 +/- 2.3% (3.4%/patient year), thromboembolism 93.5 +/- 1.5% (1.1%/patient year), anticoagulation-related hemorrhage 89.5 +/- 2.0% (1.9%/patient year), prosthetic valve endocarditis 96.0 +/- 1.2% (0.7%/patient year), valve-related mortality 93 +/- 1.8% (1.5%/patient year), valve failure 89 +/- 2.0% (2%/patient year), treatment failure 88.0 +/- 2.0% (2.2%/patient year) and all valve-related morbidity and mortality 74.0 +/- 2.8% (5.3%/patient year). Two events of leaflet escape were observed in the study group (0.09%/patient year). Both patients were reoperated successfully. Mechanical hemolysis was subclinical in all cases. The DE shows a complication rate comparable to other modern mechanical valve prostheses. After solving the problem of durability, reconsideration of this valve is worthwhile due to its low risk of thromboembolic complications.
Aortic Valve↗
Arterial to end-tidal CO2 tension difference after bilateral lung transplantation.
OBJECTIVES: To assess ventilation/perfusion mismatch with high ventilation/perfusion ratios (i.e., alveolar deadspace) and to assess capnography as a noninvasive method of monitoring ventilation after bilateral lung transplantation. DESIGN: Clinical, prospective study. Repeated-measures analysis of variance was done to assess the time course of the arterial to end-tidal CO2 tension difference. SETTING: University hospital operating theater and intensive care unit. PATIENTS: Seven consecutive patients aged 25 to 64 yrs who underwent bilateral lung transplantation for end-stage lung disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The arterial to end-tidal CO2 tension difference was determined using infrared absorption capnography during postoperative day 1. Measurements were done at 10 mins, and at 1, 3, 12, and 24 hrs after bilateral lung transplantation (timing of measurements determined from the time when both lungs were perfused and mechanically ventilated). An arterial to end-tidal CO2 tension difference, ranging from 6 to 21 torr (0.8 to 2.8 kPa), mean 16 +/- 5 torr (2.2 +/- 0.7 kPa), was observed immediately after the transplantation. This difference rapidly decreased to 9 +/- 4 torr (1.2 +/- 0.6 kPa; p < .01) after 3 hrs and to 5 +/- 3 torr (0.6 +/- 0.4 kPa; p < .01) after 24 hrs. CONCLUSIONS: Our data suggest marked alveolar deadspace ventilation immediately after bilateral lung transplantation. The presence and rapid improvement of this ventilation/perfusion mismatch may reflect the presence of ischemia-reperfusion lung injury and its improvement in the first hours of reperfusion. In five of seven patients, capnography was not a good measure of PaCO2 during the first hours after bilateral lung transplantation.
Adult↗
Early bacterial infections in lung transplant recipients.
Early bacterial pulmonary infections within 2 weeks after lung transplantation were studied in 29 patients undergoing surgery between December 1989 and May 1992. Suspected pulmonary infections occurred in 11 patients (38 percent). The most common bacterial organisms isolated were Klebsiella pneumoniae (45 percent; 5/11), Pseudomonas aeruginosa (36 percent; 4/11), Escherichia coli (27 percent; 3/11), Staphylococcus aureus (18 percent; 2/11), and Enterobacter cloacae (18 percent; 2/11). The mortality due to infection was 3 percent (1/29) in the early postoperative period. None of the following variables was found to be of prognostic significance: positive donor cultures, ischemic time of the graft, use of cardiopulmonary bypass, number of courses of methylprednisolone for acute rejection, duration of postoperative intubation, and type of surgical procedure. The presence of infection in the early postoperative period did not influence long-term survival. In the absence of prognostic parameters, prompt adjustment of antibiotic therapy to the results of antibiograms remains the most important therapeutic step in the management of infections in the early postoperative period after lung transplantation.
Adult↗
Postoperative complication rate of thoracotomy in patients with normal and abnormal pulmonary function.
Recent advances in perioperative monitoring, anesthesia, and postoperative care have resulted in a more generous attitude towards performing thoracic surgery in patients with reduced pulmonary function. In our hospital 100 patients admitted for thoracotomy with or without pulmonary resection were classified on the basis of their pulmonary function: group I (n = 33) normal, group II (n = 40) moderate reduction, group III (n = 27) marked reduction. The mean and standard deviation in groups I, II, and III were: FEV 1 in % VC: 78 +/- 6, 72 +/- 7, and 58 +/- 10; RV in % TLC: 24 +/- 7, 35 +/- 8, and 43 +/- 9; Resistance, kPal/1/sec: 0.2 versus 0.3 versus 0.5. After surgery there were three postoperative deaths from cardiovascular complications without respiratory failure; all 3 patients were in group II and younger than 70 years. Only one patient (classified as group III and 59 years old) died from a respiratory complication (respiratory insufficiency) after a palliative operation on a large adenocarcinoma. Our data demonstrate that markedly reduced preoperative lung function is not necessarily associated with high risk in thoracic surgery--even in elderly persons--provided intensive pre- and postoperative care is guaranteed.
Adolescent↗
[High-resolution computed tomography (HR-CT) of the lung following lung transplantation].
We report our high-resolution computed tomography (HRCT) and conventional CT findings after lung transplantation in 20 patients. Sixty-four examinations were performed 7-511 days after transplantation. The radiological observations were then correlated with the clinical results. The pathological findings in the early postoperative phase were pleural effusion, edema, and pulmonary consolidation. The HRCT findings associated with acute rejection were nonspecific. Dilation and thickening of the walls of the peripheral bronchi is a common, but non-specific feature in bronchiolitis obliterans. The manifestations of posttransplant lymphoproliferative disorder are discussed in two patients.
Adult↗
Differential expression of cell surface integrins on human mast cells and human basophils.
Integrins are multifunctional recognition molecules and are expressed on various hematopoietic cells. In the present study expression of integrins on the cell surface of human mast cells and human basophils was investigated by using monoclonal antibodies (mAbs) and indirect immunofluorescence. Human mast cells were obtained from lung (n = 5), uterus (n = 5) and skin (n = 4). Human blood basophils were obtained from normal donors (n = 2). In addition, HMC-1 cells (human mast cell line) and KU-812 cells (a basophil cell line) were analyzed. Primary mast cells were found to react with mAbs directed against the common beta chain of beta 1 integrins (CD 29), the alpha chain of VLA-4 (CD 49 d) and VLA-5 (CD 49 e), the beta chain of beta 3 integrins (CD 61), and the alpha chain of the vitronectin receptor (VNR) (CD 51). Mast cells were not recognized by mAbs to beta 2 integrins (CD 18, CD 11 a, CD 11 b, CD 11 c), the alpha chain of VLA-2 (CD 49 b), and VLA-6 (CD 49 f). No differences in expression of integrins on human mast cells obtained from different organs were found. HMC-1 cells and primary mast cells expressed an almost identical pattern of integrins. Human basophils and KU-812 cells were found to react with mAbs directed against beta 1-integrins (CD 29, CD 49 b, CD 49 d, CD 49 e) and beta 2-integrins (CD 18, CD 11 a, CD 11 b, CD 11 c). Together, mast cells and blood basophils express a unique pattern of integrins. These cell surface structures may be involved in the distribution of basophils and tissue mast cells and their accumulation and function in inflammed tissues.
Antibodies, Monoclonal↗
Management of severe bronchial ischemia after bilateral sequential lung transplantation.
A case of severe diffuse bronchial ischemia after bilateral sequential lung transplantation is presented. A combination of initial conservative treatment with silicone stenting and late bilateral retransplantation under stable conditions resulted in good clinical outcome. Factors in decision making and technical aspects of the stenting procedure are discussed.
Adult↗
[Percutaneous CT-guided catheter drainage of intrathoracic fluid accumulations].
To verify the value of percutaneous CT-guided drainage of thoracic fluid collections we studied the outcome in 39 patients retrospectively. 24 (61.5%) of the fluid collections were located in the pleural space, 10 (25.6%) in the lungs and 5 (12.8%) in the mediastinum. 11 CT-guided drainages after a previous attempt were necessary in 9 patients, because of recurrent (n = 6) or residual (n = 5) fluid collections. 70% of the drainage procedures were done using Seldinger's, 30% using trocar technique, mainly with 8.3-12 F catheters. The mean duration of drainage was 10.7 days. In 28 patients (71.8%) the percutaneous CT-guided drainage was curative. In 9 cases (23.1%) the patient's course was stabilised and surgery could be applied electively. 2 patients (5.1%) died because of their underlying end-stage malignancy. None of the drainage procedures changed the patient's course to the worse. There was only 1 pneumothorax with no need of any treatment; no other complication occurred. Our results suggest that percutaneous CT-guided drainage of thoracic fluid collections is a safe and straightforward alternative to surgical treatment.
Adult↗
Monitoring of mononuclear cells from arterial and central venous blood in lung transplant patients.
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Graft Rejection↗
One and one-half year experience with unilateral and bilateral lung transplantation.
Lung transplantation has now become an established form of treatment for end-stage pulmonary parenchymal and vascular diseases. Despite its wide acceptance, technical aspects are still in discussion. We report on the initiation of our own lung transplant program and the technical changes we have performed during our first 1 1/2-year experience. During that period of time, we have performed 26 lung transplantations (16 single lung [SLTX] and 10 bilateral lung transplantations [BLTX]). Three-month survival for the whole group was 74% (69% for the SLTX group and 77% for the BLTX group). No instance of bronchial dehiscence was observed; however, there were eight cases of bronchial stenosis: six were managed by silicone stent insertion, one by bronchoplastic correction, and one by retransplantation. Changes in the technique of the bronchial anastomosis together with the addition of prednisone to the immediate postoperative immunosuppressive regime resulted in almost complete avoidance of these problems.
Adult↗
Pulmonary alveolar microlithiasis: findings on high-resolution CT.
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Adult↗