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We report a case of gastric emphysema secondary to massive gastric distention. The gas within the gastric wall was seen as lines of bubbles on plain films, echogenic foci with distal reverberation on sonograms, and bubbles on computed tomography scans. Gastric emphysema was due to necrosis, illustrating the importance of recognition of these imaging signs.
BACKGROUND: We present a summary report evaluating the efficacy of lung volume reduction surgery (LVRS) in patients with advanced emphysema in the Canadian setting. METHODS: Quality of Life measures assessed the efficacy of adding LVRS to best medical care including rehabilitation in this blinded randomized multicentered controlled trial with 2 years of follow-up. Health utility and quality-adjusted life years (QALY) were outcomes central to our economic assessment. RESULTS: None of the 32 patients randomized to the LVRS arm or 30 patients in the best medical care (BMC) arm crossed-over and no patients were lost to follow-up. Overall surgical mortality was 16% at 2 years while the overall medical mortality was 13% (p = 0.914). There were no 30-day postoperative deaths but 2 deaths (6%) occurred within 90 days of randomization. Surgery reduced the residual volume measured at 6 months by 23% (5,385 mL to 4,322 mL, p = 0.007). There was an increase in forced expiratory volume in 1 second (FEV1) of 30% (265 mL, p = 0.013) from baseline, an improvement in the six minute walk test (6MWT) of 78 meters (p = 0.045), and an increase in Health Utility Index 3 (HUI3) which peaked at 6 months with a difference of 0.16 (p = 0.129). There was a gain in QALYs of 0.21 (p = 0.19) in the LVRS-arm over the BMC-arm. The LVRS costs an additional 28,119 Canadian dollars (CAD) compared with BMC or 133,900 CAD/QALY gained. CONCLUSIONS: The addition of LVRS to best medical care including pulmonary rehabilitation improves pulmonary function, exercise activity, and quality of life in selected patients with advanced emphysema. Cost is high but in keeping with other treatment modalities currently available.
BACKGROUND: Oxygen consumption volume (VO2) and resting energy expenditure are increased in emphysema because of impaired respiratory function and mechanics, with greater oxygen cost of breathing and altered metabolism. We hypothesized that lung volume reduction surgery may improve energy expenditure and metabolism. METHODS: In this 1-year prospective study, 30 patients with moderate-to-severe emphysema underwent bilateral lung volume reduction surgery; 28 similar patients, who refused operation, followed a standard respiratory rehabilitation program. Oxygen consumption volume and resting energy expenditure, both corrected for fat-free mass, VO2 proportion of respiratory muscles (%VO2Resp), respiratory quotient, and energy substrate oxidation were determined by using a calorimetric chamber with indirect methods. RESULTS: Only after surgery significant improvements resulted in 1-second forced expiratory volume (+20.4%, p = 0.009), residual volume (-24.8%, p = 0.001), diffusion-lung carbon-monoxide (+18.4%, p = 0.008), body mass index (+5.5%, p = 0.01), resting energy expenditure (-8.2%, p = 0.006), and %VO2Resp (-44.1%, p = 0.0008) with increase in respiratory quotient (0.79 versus 0.84, p = 0.03) and conversion from prevalent lipid (44.6% versus 34.3%, p = 0.0007) to prevalent carbohydrate (25.2% versus 42.2%, p = 0.0006) metabolism. Thirteen operated on patients discontinued oral steroids, showing the most significant improvements. The remaining 17 experienced significant changes compared with the rehabilitation group despite oral steroids (resting energy expenditure -7.0% versus +4.1%, and %VO2Resp -34.0% versus +0.7%, p = 0.001). Decrease of resting energy expenditure and %VO2Resp correlated with reduction of residual volume (p = 0.02 and p = 0.001) and increment of body mass index (p = 0.03 and p = 0.004). CONCLUSIONS: Lung volume reduction surgery significantly decreased %VO2Resp and resting energy expenditure over respiratory rehabilitation and despite oral steroid therapy. Substrate oxidation changed from prevalent lipid to prevalent carbohydrate. Correlations with residual volume and nutritional status suggest that restoration of respiratory mechanics reduces energy expenditure and approximates metabolism to normal.
Imaging plays a pivotal role in the selection of patients for the surgical treatment of emphysema. In this article, the imaging features of emphysema are reviewed along with the surgical options for treatment. Particular emphasis is given to lung volume reduction surgery as this technique has gained wide acceptance within the thoracic surgical community in recent years. Radiologists need to have an understanding of which patients may be potentially suitable for this technique.
The major features of chronic obstructive pulmonary disease (COPD) comprise a not fully reversible airflow limitation associated with an abnormal inflammatory response, increased mucus production and development of emphysema-like lesions. Animal models that closely mimic these alterations represent an important issue for the investigation of pathophysiological mechanisms. Since most animal models in this area have focused on specific aspects of the disease, we aimed to investigate whether exposure of C57BL/6 mice to nitrogen dioxide (NO2) may cause a more complex phenotype covering several of the characteristics of the human disease. Therefore, mice were exposed to NO2 for 14h each day for up to 25 days. Initial dose response experiments revealed the induction of a significant inflammatory response at a dose of 20 ppm NO2. Mice developed progressive airway inflammation together with a focal inflammation of the lung parenchyma characterized by a predominant influx of neutrophils and macrophages. In addition, goblet cell hyperplasia was detected in the central airways and increased collagen deposition was found in the lung parenchyma. NO2-exposed mice developed emphysema-like lesions as indicated by a significantly increased mean linear intercept as compared to control mice. Finally, the assessment of lung functional parameters revealed the development of progressive airway obstruction over time. In conclusion, our data provide evidence that the inflammatory response to NO2 exposure is associated with increased mucus production, development of airspace enlargement and progressive airway obstruction. Thus, NO2-exposed mice may serve as a model to investigate pathophysiological mechanisms that contribute to the development of human COPD.
Emphysema is caused by exposure to cigarette smoking as well as alpha(1)-antitrypsin deficiency. It has been estimated to cost the National Health Service (NHS) in excess of 800 million pounds per year in related health care costs. The challenges for Critical Care nurses are those associated with dynamic hyperinflation, Auto-PEEP, malnutrition and the weaning from invasive and non-invasive mechanical ventilation. In this paper we consider the impact of the pathophysiology of emphysema, its effects on other body systems as well as the impact acute exacerbations have when patients are admitted to the Intensive Care Unit.
Biting of the buccal mucosa is very frequent injury, whereas facial emphysema caused by cheek bite is rare. We report a case of facial emphysema causing puffing of the cheek through a self-inflicted bite of the buccal mucosa.
Subcutaneous emphysema in the hand is commonly associated with infection or high-pressure injection injuries, with other non-infectious causes being reported as rarities in the literature. We describe an unusual case of minor injury to the first webspace resulting in significant subcutaneous emphysema.
PURPOSE: The purpose of this report was to review and analyze the epidemiologic features of traumatic subcutaneous emphysema (TSE) originating from frontal, nasoethmoidal, and maxillary facial injuries with sinusal involvement in the emergency room setting. PATIENTS AND METHODS: All patients with a fracture involving the paranasal sinuses were evaluated with regard to TSE occurrence. Data analysis extended to gender, age, etiology, fracture sites, TSE location, sinus involvement, treatment, and complications from April 1999 to December 2003. Evaluation methods included computed tomography scan and clinical evaluation. RESULTS: A total of 390 patients sustaining 458 paranasal sinus fractures were included. TSE was observed in 29 patients (7.43%) patients (male-female ratio of 3.83:1, with a mean age of 36.71 +/- 15.71 years). The main etiologies were vehicle accidents and assaults. Isolated maxillary sinuses fractures were found in 17 cases (58.62%). Ethmoidal and maxillary fractures were associated with 9 cases (31.03%), and 1 (3.45%) case had maxillary and frontal fractures together. Ethmoidal, maxillary, and frontal fractures were found concomitantly in 2 (6.90%) cases. Periorbital emphysema was the most prevalent site of presentation, and edema (86.21%) and bone deformities (79.31%) were the most frequent findings associated with TSE. Conservative treatment was the prevalent treatment choice (55.17%), and 1 complication because of persistent pain was noted. CONCLUSION: The results suggest that TSE of the face associated with paranasal sinus fractures maintained the clinical features of its fractures of origin. The ethmoidal sinuses were considered as the most prevalent etiologic site, and the periorbital region was responsible for addressing the higher incidence of SE following paranasal sinus fractures.
BACKGROUND: The management of congenital lobar emphysema has traditionally been surgical. Because of increased use of imaging, this lesion is frequently found in asymptomatic and mildly symptomatic children, prompting us to adopt a more conservative approach to these children. METHODS: All children with congenital lobar emphysema presenting between 1995 and 2002 were included. Medical records, imaging files, and pathology reports were reviewed. RESULTS: Twenty children (0-17 years) were identified. Eight were diagnosed antenatally. Fourteen were managed without surgery. Of the 11 symptomatic children, 6 showed spontaneous improvement. CONCLUSIONS: The favorable outcome of both asymptomatic and mildly symptomatic children suggests that a nonoperative approach should be considered in these patients.
BACKGROUND: We determined the feasibility, safety, and short-term efficacy of bronchoscopic placement of a one-way endobronchial valve in selected bronchopulmonary segments as an alternative to surgical lung volume reduction. METHODS: A total of 21 patients with incapacitating emphysema who underwent this procedure were studied. All patients had placement of the endobronchial valves into the most emphysematous lung segments. We recorded any major complications or deaths attributed to the procedure and analyzed (1) improvements in the spirometric and functional parameters and quality of life and (2) the radiologic changes compared with the baseline data at 30 and 90 days. RESULTS: A total of 20 patients had complete follow-up data. There was no mortality in the group studied. The forced expiratory volume at 1 second, forced expiratory volume at 1 second (percentage of predicted), forced vital capacity, and forced vital capacity (percentage of predicted) all improved significantly at 90 days (0.73 +/- 0.26 L vs 0.92 +/- 0.34 L [P =.009]; 33.3% +/- 11.9% vs 42.2% +/- 15.0% [P =.006]; 1.94 +/- 0.62 L vs 2.25 +/- 0.61 L [P =.015]; and 63.3% +/- 17.6% vs 73.9% +/- 17.1% [P =.012], respectively). The 6-minute walking distance improved at 30 and 90 days (251.6 +/- 100.2 m vs 306.3 +/- 112.3 m and 322.3 +/- 129.7 m; P =.012 and P =.003). The results of the 36-Item Short-Form Health Survey and the St George Respiratory Questionnaire showed significant improvements at 90 days. The Medical Research Council dyspnea grade also improved significantly at 30 and at 90 days (P =.006 and P =.003, respectively). CONCLUSIONS: Endobronchial valve placement is a safe procedure, with significant short-term improvements in functional status, quality of life, and relief of dyspnea in selected patients with emphysema. A larger study with long-term follow-up is therefore warranted.
We present a case of a 59-year-old man with small cell lung cancer (SCLC) who developed heavy thoracic pain because of spontaneous mediastinal emphysema. Autopsy documented a mucosal lesion in the posterior tracheal wall with air leak towards the mediastinum. The occurrence of spontaneous mediastinal emphysema in patients with small cell lung cancer has rarely been described in the literature.
We have observed that pulmonary rapidly adapting receptor activity is greater in emphysematous rats than in controls. Pulmonary receptor activity, if modified by lung disease, may produce an inappropriate drive to breathe which may be perceived as dyspnoea. To investigate the efferent (drive) component of this hypothesis respiratory drive (phrenic nerve activity) was recorded in a rabbit model of emphysema. Drive was measured as slope and peak height of phrenic nerve activity. Slope and peak height were greater in emphysematous rabbits than controls, by 28% and 34%, respectively. Block of slowly adapting pulmonary stretch receptors by inhaled sulphur dioxide (which left only rapidly adapting and C-fibre receptors active) decreased drive in control (slope: 38.89+/-2.29 to 24.09+/-1.26, P<0.01) but not emphysematous rabbits (slope: 49.92+/-4.11 to 54.51+/-5.28, NS). Subsequent vagotomy decreased drive in emphysematous rabbits (slope: 54.51+/-5.28 to 41.41+/-3.90, P<0.05) but not controls (24.09+/-1.26 to 23.07+/-1.84, NS). Increased rapidly adapting receptor activity may, in part, increase respiratory drive in emphysema. This vagal component is only part of the total increased drive which may be perceived as dyspnoea in man.
The pathologic mechanisms of chronic obstructive pulmonary disease (COPD) most certainly involves neutrophil granulocytes, cytotoxic T-cells, macophages and mast cells. The aim of this study was to investigate the relation between the number of mast cells in different compartments in bronchial biopsies of central proximal airways to structural changes, lung function tests and emphysema detected by high resolution computed tomography (HRCT). Twenty nine asymptomatic smoking and 16 never-smoking men from a population study were recruited. Central bronchial biopsies were stained to identify mast cells by immunohistochemistry. The number of mast cells in the epithelium, lamina propria and smooth muscle as well as epithelial integrity and thickness of the tenascin and laminin layer were determined. Smokers had increased numbers of mast cells in all compartments (P<0.001). Structural changes were correlated to mast cell numbers with the closest associations to mast cell numbers in the smooth muscle [epithelial integrity (R(S)=-0.48, P=0.008), laminin layer (R(S)=0.63, P=0.0002), tenascin layer (R(S)=0.40, P=0.03)]. Similar correlations between mast cells and lung function tests were seen [functional residual capacity (FRC) (R(S)=0.60, P=0.0006), total lung capacity (TLC) (R(S)=0.44, P=0.02) and residual volume (RV) (R(S)=0.41, P=0.03)]. No correlations could be detected between mast cells and FEV1 or to emphysema. Smoking is associated with an increase of mast cells in all compartments of the bronchial mucosa, including smooth muscle, and this is related to altered airway structure and function.
Patients suffering from chronic pulmonary emphysema can benefit from a new surgical technique that offers them relief from chronic dyspnea and declining quality of life. Bilateral lung volume reduction surgery (LVRS) involves an innovative surgical stapling technique for removing emphysematous lung tissue. To prevent persistent air leaks, surgeons use bovine pericardium strips to reinforce surgical staple lines created during bilateral LVRS. Perioperative nurses should understand the disease process of chronic pulmonary emphysema, bilateral LVRS techniques, and possible postoperative complications to provide quality nursing care for patients undergoing LVRS procedures.
Subcutaneous emphysema of the thorax may follow thoracic operations for a number of essentially benign reasons and does not usually cause much concern to the thoracic surgeon. We report subcutaneous emphysema of the thorax heralding a retroperitoneal colonic perforation in a patient who had undergone coronary artery bypass grafting 3 days previously.
Ever since the advent of modern chest surgery, surgical pioneers have attempted operations to alleviate, if not cure, patients with emphysema. From the physiologic standpoint illogical procedures such as costochondrectomy, phrenisectomy, or thoracoplasty lead to disastrous results, whereas the effect of operations on the autonomous nervous system was unpredictable. The only worthwhile procedure was bullectomy for localized bullous emphysema. The concept of volume reduction developed by Brantigan in the 1950s and rediscovered by Cooper is the only successful surgical approach to an essentially incurable pulmonary disease.
BACKGROUND: Unilateral lung volume reduction procedures are used to treat pulmonary emphysema. The most significant technical problem with this operation is an air leak from the pulmonary stump. Bovine pericardium has been used to prevent air leaks but is associated with interstitial pneumonia and a high cost. METHODS: The fold plication method was devised to prevent postoperative air leaks to avoid interstitial pneumonia, and to decrease cost. This technique was applied in 20 consecutive patients with emphysema who underwent a unilateral lung volume reduction operation via a thoracoscopic two windows approach. RESULTS: The operative time was approximately 1 hour. There was minimal postoperative bleeding, no persistent air leaks, and no evidence of pneumonia. Pulmonary function improved in all patients. CONCLUSIONS: The unilateral fold plication method is an economical and safe alternative to bovine pericardial patching after lung volume reduction operation to prevent stump air leaks.