lvrs - LVRS And Bullectomy Dr. AKASHDEEP SINGH DEPARTMENT...

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LVRS And Bullectomy Dr. AKASHDEEP SINGH DEPARTMENT OF PULMONARY AND CRITICAL CARE MEDICINE PGIMER CHANDIGARH
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Outline History of Lung Surgery Lung-Volume-Reduction Surgery Overview of LVRS History Clinical Overview Mechanism National Emphysema Treatment Trial Findings from NETT Bronchoscopic Lung-Volume-Reduction Surgery Bullectomy
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History Transverse sternotomy / Costochondrectomy Stiff chest wall was thought to lead to emphysema so operations designed to increase movement of the thoracic cage VC(500–700 m)L and relief of dyspnea inconsistent results. Thoracoplasty :-Shrink the chest Pleurodesis Nourish the lung Stabilize the airways –tracheal fixation & stents
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History Reduce bronchospasm/mucus secretion Sympathectomy Vagotomy Hilar denervation Shrink the lung Phernectomy Radiation Restore the curvature of diaphragm Pneumoperitonium Abdominal belts
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Pneumoperitonium 22 patients Emphysema, Chronic cough, Dulled mentality 1700-3000 cc air into peritoneal cavity Refill, heliox q 2wks 13/22 subjective improvement VC improved ~ 500 cc{ in 11/22} RV , TLC Carter et al NEJM 1950
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LVRS- History Otto Brantigan 56patients, 1957-61,age16-73(58) Staged thoracotomy+hilar dennervation Subjective improvement in 75% of survivors No physiologic measurements were taken Mortality rate 16% immed. postoperative &10% late Selection criteria poorly described ? 16 yr emphysema Otto Brantigan Am. Surgeon 1957
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Brantigan hypothesized Relieves pressure on normal lung Restore shape of diaphragm Restores more negative pl. pressure distends bronchi venous return Difficult to predict who will benefit from surgery Brantigan Am. Surgeon 1957
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Modern Era of LVRS-1995 B/L, LVRS, MS, 20 patients FEV 1 0.77 to 1.4L(82%, ) FVC 2.2 to 2.8L(27%, ) 14/22 on O 2 to 2/15 at 3 mo Mean TLC (22%), RV (39%) Improvement in dysponea , QOL score No mortality Mean LOS 15d (6-49d) Air leak >7d in 11/20 cooper et al J. Thoracic cardiovasc surg. 1995
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Physiological outcome Reported improv.after LVRS — 15–49% increase — 20–80% increase — 15–20% decrease — 10–30% decrease — 10–24 mm Hg increase — 20–90% increase — 5–30% increase — 50–80% improvement Physiologic measurement Forced vital capacity •F E V 1 Total lung capacity Residual volume •P a O 2 6 minute walk distance Maximum oxygen consumption Dyspnea index
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Suggested mechanism of benefit Improved respiratory function Lung recoil Air way conductance Resizing the lung to fit the chest Relieves "pulmonary tamponade." improved cardiac function increased exercise capacity
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Mechanism of increase VC Lung Volume TLC Emphysema Normal RV Pleural Pressure
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Mechanism of increase VC Lung Volume Pleural Pressure Emphysema Homogenous Normal
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Mechanism of increase VC Lung Volume Emphysema Homogenous Normal VCafter VCbefore Pleural Pressure
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DETERMINENTS OF INCREASE VC Fraction of lung remove Targeted zones RV/TLC Lung compliance Inspiratory muscle function?
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Indications for LVRS HRCT scan evidence of bilateral emphysema Severe nonreversible airflow obstruction FEV 1 15
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This note was uploaded on 12/03/2011 for the course MEDICINE 350 taught by Professor Dr.aslam during the Winter '07 term at Medical College.

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lvrs - LVRS And Bullectomy Dr. AKASHDEEP SINGH DEPARTMENT...

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