Diapositiva 1 - Pneumologia Veneto

Loris Ceron
SC Pneumologia
ULSS 12 Veneziana
BPCO e chirurgia
• Chirurgia nella BPCO
• Chirurgia per la BPCO
Chirurgia nella BPCO
• Il paziente con BPCO ha un rischio di 2,7-4,7 volte aumentato
di complicanze respiratorie dopo un intervento chirurgico
• La complicazione più comune è la polmonite, associata ad un
rischio significativo di mortalità (20% entro un mese
dall’intervento)
Celli BR et al. Standards for the diagnosis and treatment of patients
with COPD. Eur Respir J 2004; 23: 932–946
Arozullah AM, Khuri SF, Henderson WG, Daley J. Development and validation of a
multifactorial risk index for predicting postoperative pneumonia after major
noncardiac surgery. Ann Intern Med 2001 Nov 20;135(10):847-57
RESULTS:
A total of 2466 patients (1.5%) developed pneumonia, and the 30-day
postoperative mortality rate was 21%. A postoperative pneumonia risk index was
developed that included type of surgery (abdominal aortic aneurysm repair,
thoracic, upper abdominal, neck, vascular, and neurosurgery), age, functional
status, weight loss, chronic obstructive pulmonary disease, general anthesia,
impaired sensorium, cerebral vascular accident, blood urea nitrogen level,
transfusion, emergency surgery, long-term steroid use, smoking, and alcohol use.
Patients were divided into five risk classes by using risk index scores. Pneumonia
rates were 0.2% among those with 0 to 15 risk points, 1.2% for those with 16 to 25
risk points, 4.0% for those with 26 to 40 risk points, 9.4% for those with 41 to 55 risk
points, and 15.3% for those with more than 55 risk points. The C-statistic was 0.805
for the development cohort and 0.817 for the validation cohort.
CONCLUSIONS:
The postoperative pneumonia risk index identifies patients at risk for postoperative
pneumonia and may be useful in guiding perioperative respiratory care
N Engl J Med 1999; 340: 937–944
N Engl J Med 1999; 340: 937–944
N Engl J Med 1999; 340: 937–944
Provvedimenti
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cessazione del fumo 4-8 settimane prima dell'intervento
ottimizzazione della terapia
mobilizzazione precoce
respiri profondi
uso di IPPB e di spirometria incentivante
buona analgesia
L'intervento va rinviato in presenza di riacutizzazione
Celli BR et al. Standards for the diagnosis and treatment of patients
with COPD. Eur Respir J 2004; 23: 932–946
Conclusions
In the present study, the efficacy of isolated conventional physical therapy, incentive
spirometry, EPAP or early mobilization was not evaluated. However, it was possible to
demonstrate that the physiotherapeutic approach based on packages of interventions
resulted in reduced incidence of atelectasis and reduced length of hospital stay among
patients undergoing elective open UAS.
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If the % PPO FEV 1 and % PPO DLCO values are both > 60%, the patient is
considered at low risk of anatomic lung resection, and no further tests are
indicated
If either the % PPO FEV 1 or % PPO DLCO are within 60% and 30% predicted, a
low technology exercise test should be performed as a screening test
If performance on the low technology exercise test is satisfactory (stair climbing
altitude > 22 m or shuttle walk distance > 400 m), patients are regarded as at low
risk of anatomic resection
A cardiopulmonary exercise test is indicated when the PPO FEV 1 or PPO DLCO
(or both) are < 30% or when the performance of the stair-climbing test or the
shuttle walk test is not satisfactory
A peak oxygen consumption ( O2 peak) < 10 mL/kg/min or 35% predicted
indicates a high risk of mortality and long-term disability for major anatomic
resection. Conversely, a O2 peak > 20 mL/kg/min or 75% predicted indicates a
low risk.
Chirurgia per la BPCO
• Bullectomia
• Riduzione polmonare chirurgica (LVRS)
• Trapianto polmonare
• Riduzione polmonare endoscopica (ELVR)
Chirurgia per la BPCO
Bullectomia
• In pazienti molto selezionati, la procedura può essere efficace
nell’alleviare la dispnea e migliorare la funzione respiratoria
(evidenza C).
Celli BR et al. Standards for the diagnosis and treatment of patients with COPD. Eur
Respir J 2004; 23: 932–946
Rabe KF et al. Global Strategy for the Diagnosis, Management, and Prevention of
Chronic Obstructive Pulmonary Disease. GOLD Executive Summary. Am J Respir Crit
Care Med 2007;176:532–555
Chirurgia per la BPCO
Celli BR et al. Standards for the diagnosis and treatment of patients
with COPD. Eur Respir J 2004; 23: 932–946
Mehran RJ, Deslauriers J. Indications for surgery and patient work-up for bullectomy.
Chest Surg Clin N Am 1995;5(4):717-34.
If a patient has a smaller bulla, which is less than 30% of the
volume of the hemithorax, the dyspnea is unlikely to be
related to the bulla and its excision is probably not indicated.
The bulla must occupy at least 50% of the hemithorax and show
definite displacement of adjacent lung tissue.
There must be no vanishing lung syndrome nor chronic purulent
bronchitis.
Radiologic evidence of compressed lung tissue that can be reexpanded by removal of the bulla
Evidence of regional imbalance with poor perfusion on the side
of the bulla and relatively good perfusion on the contralateral
side.
Chirurgia per la BPCO
Riduzione polmonare chirurgica (LVRS)
• Lo studio NETT (National Enphysema Therapy Trial) ha dimostrato che i
pazienti con enfisema non omogeneo, prevalente ai lobi superiori, con
FEV1 o DLCO >20% e con scarsa capacità di esercizio dopo un trattamento
riabilitativo preoperatorio avevano una migliore sopravvivenza e una
migliore qualità di vita.
• Il follow-up a lungo termine conferma un miglioramento della
sopravvivenza a 5 anni.
• La procedura è molto costosa e va valutata con molta attenzione
National Emphysema Treatment Trial Research Group. A Randomized Trial
Comparing Lung-Volume–Reduction Surgery with Medical Therapy for Severe
Emphysema. N Engl J Med 2003;348:2059-73
Naunheim KS et al. Long-term follow-up of patients receiving lung-volumereduction surgery versus medical therapy for severe emphysema by the National
Emphysema Treatment Trial Research Group. Ann Thorac Surg 2006 Aug;82(2):43143
Naunheim KS, Wood DE, Mohsenifar Z, Sternberg AL, Criner GJ, DeCamp MM, Deschamps CC, Martinez
FJ, Sciurba FC, Tonascia J, Fishman AP; National Emphysema Treatment Trial Research Group.
Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for
severe emphysema by the National Emphysema Treatment Trial Research Group.
Ann Thorac Surg 2006 Aug;82(2):431-43
RESULTS:
• The intention-to-treat analysis of 1218 randomized patients demonstrates
an overall survival advantage for LVRS, with a 5-year risk ratio (RR) for
death of 0.86 (p = 0.02). Improvement was more likely in the LVRS than in
the medical group for maximal exercise through 3 years and for healthrelated quality of life (St. George's Respiratory Questionnaire [SGRQ])
through 4 years. Updated comparisons of survival and functional
improvement were consistent with initial results for four clinical
subgroups of non-high-risk patients defined by upper-lobe predominance
and exercise capacity. After LVRS, the upper-lobe patients with low
exercise capacity demonstrated improved survival (5-year RR, 0.67; p =
0.003), exercise throughout 3 years (p < 0.001), and symptoms (SGRQ)
through 5 years (p < 0.001 years 1 to 3, p = 0.01 year 5). Upper-lobepredominant and high-exercise-capacity LVRS patients obtained no
survival advantage but were likely to improve exercise capacity (p < 0.01
years 1 to 3) and SGRQ (p < 0.01 years 1 to 4).
VENT Responder Summary
(Delta Treatment & Control @ 6mons)
30.0%
8
25.6%
7
25.0%
6
20.0%
5
15.2%
15.0%
4
10.6%
10.5%
10.0%
9.6%
8.8%
7.2%
3
2
5.8%
5.0%
1
0.0%
H.H. = High Heterogeneity
Total
H.H. (>10%)
N=179
FEV1 % Change
L.E. = Lobar Exclusion
H.H.+ L.E.
N=91
6MWT % Change
N=74
C.F. = Collateral Flow
H.H.+ L.E.+C.F.
N=30
SGRQ Delta (abs)
0
Soggetti candidabili a intervento (protocollo VENT)
153-344
Nuovi casi di BPCO candidabili a intervento
(protocollo VENT)
12-18/anno
Un solo Centro per l‘intervento
Rete Pneumologica per la selezione dei candidati
Creazione di un registro
Selezione dei candidati
In a prospective study of 625 COPD patients, a BODE index of 7
to 10 (on a scale from 0 to 10) was associated with a median
survival of about 3 years, which is less than would be expected
after transplantation.
Patients with a BODE score of 5 to 6 would likely not derive a
survival benefit from transplantation but may be candidates for
early referral.
Orens JB, et al.International Guidelines for the Selection of Lung Transplant
Candidates: 2006 Update—A Consensus Report From the Pulmonary
Scientific Council of the International Society for Heart and Lung
Transplantation. The Journal of Heart and Lung Transplantation, 2006
Sopravvivenza nel trapianto di polmone
Registro Italiano Trapianti
Absolute contraindications.
● Malignancy in the last 2 years, with the exception of cutaneous squamous and basal cell tumors. In
general, a 5-year disease-free interval is prudent. The role of lung transplantation for localized
bronchioalveolar cell carcinoma remains controversial.
● Untreatable advanced dysfunction of another major organ system (e.g., heart, liver, or kidney). Coronary
artery disease not amenable to percutaneous intervention or bypass grafting, or associated with
significant impairment of left ventricular function, is an absolute contraindication to lung
transplantation, but heart-lung transplantation could be considered in highly selected cases.
● Non-curable chronic extrapulmonary infection including chronic active viral hepatitis B, hepatitis C, and
human immunodeficiency virus.
● Significant chest wall/spinal deformity.
● Documented nonadherence or inability to follow through with medical therapy or office follow-up, or
both.
● Untreatable psychiatric or psychologic condition associated with the inability to cooperate or comply
with medical therapy.
● Absence of a consistent or reliable social support system.
● Substance addiction (e.g., alcohol, tobacco, or narcotics) that is either active or within the last 6 months.
Relative contraindications.
● Age older than 65 years. Older patients have less optimal survival, likely due to comorbidities, and
therefore, recipient age should be a factor in candidate selection. Although there cannot be
endorsement of an upper age limit as an absolute contraindication
● Critical or unstable clinical condition (e.g., shock, mechanical ventilation or extra-corporeal membrane
Oxygenation)
● Severely limited functional status with poor rehabilitation potential.
● Colonization with highly resistant or highly virulent bacteria, fungi, or mycobacteria.
● Severe obesity defined as a body mass index (BMI) exceeding 30 kg/m2.12
● Severe or symptomatic osteoporosis.
● Mechanical ventilation. Carefully selected candidates on mechanical ventilation without other acute or
chronic organ dysfunction, who are able to actively participate in a meaningful rehabilitation
program, may be successfully transplanted.
● Other medical conditions that have not resulted in end-stage organ damage, such as diabetes mellitus,
systemic hypertension, peptic ulcer disease, or gastroesophageal reflux should be optimally treated
before transplantation. Patients with coronary artery disease may undergo percutaneous intervention
before transplantation or coronary artery bypass grafting concurrent with the procedure