Chemoembolization of the lung improves tumor control in a rat model.
PURPOSE: The novel method of organ-specific drug application we present here is unilateral chemoembolization of the lung by injecting the pulmonary artery with degradable starch microspheres and cytotoxic drugs to improve tumor control in lung metastases. EXPERIMENTAL DESIGN: In a solitary metastasis rat model (CC531 adenocarcinoma), we studied the clinical and histological tumor response as well as subacute toxicity of the lung. Fourteen days after tumor induction, animals were randomized into five groups. Groups I and II served as controls. Group III received carboplatin i.v. (45 mg/kg). Isolated lung perfusion with buffered starch solution and carboplatin (15 mg/kg) was installed in group IV. Chemoembolization with carboplatin (15 mg/kg) was performed in group V. RESULTS: Seven days later, the difference in the tumor volume before and after treatment was +422 mm(3) (+/-226) in group I, +697 mm(3) (+/-423) in group II, +70 mm(3) (+/-31) in group III, -8 mm(3) (+/-17) in group IV, and -17 mm(3) (+/-16) in group V (P < 0.05 groups IV and V versus groups I, II, and III). No pleural spread was observed in groups IV and V. Histologically, the area of tumor necrosis was largest in group IV. Mild alveolar cell hyperplasia, pulmonary edema, and hemorrhage without subacute fibrotic changes were noted in all groups. CONCLUSION: This is the first study to perform chemoembolization of the lung. Compared with i.v. therapy, chemoembolization was more effective without serious toxicity. Its efficacy was comparable with that of isolated lung perfusion but less stressful for a possible clinical application. (+info)
Noninvasive ventilation for chest wall and neuromuscular disorders.
Neuromuscular and chest wall disorders are individually uncommon but together form an important group of conditions that can lead to chronic ventilatory failure. This is best recognised in scoliosis, kyphosis, following a thoracoplasty, in muscular dystrophies, such as Duchenne muscular dystrophy (DMD), and myotonic dystrophy, after poliomyelitis and with motor neurone disease (amyotrophic lateral sclerosis). If bulbar function is impaired, tracheostomy ventilation may be required, but in other situations, noninvasive ventilation is preferable. Positive pressure techniques using nasal and face masks are usually the first choice, but negative pressure ventilation is an alternative. There are no randomised-controlled trials regarding the indications for initiating noninvasive ventilation, but this is usually provided if there are symptoms due to nocturnal hypoventilation or right heart failure in the presence of a raised carbon dioxide tension in arterial blood (Pa,CO2) either at night or, more usually, in the daytime as well. There is no evidence that "prophylactic" ventilatory support is of benefit if this is provided before ventilatory failure has appeared. Careful selection of patients is required, especially in the presence of progressive neuromuscular disorders such as DMD and motor neurone disease. There are no randomised-controlled trials concerning the outcome of noninvasive ventilation in these conditions, but studies have shown an improved quality of life, physical activity and haemodynamics, normalisation of blood gases and slight improvement in other physiological measures, such as the vital capacity and maximal mouth pressures. Survival in chest wall disorders is approximately 90% at 1 yr and 80% at 5 yrs, and similar figures have been obtained in nonprogressive neuromuscular conditions. If, however, the underlying disorder is deteriorating, particularly if it involves the bulbar muscles, it may limit survival despite the provision of adequate noninvasive ventilatory support. (+info)
Physiological characterization of variability in response to lung volume reduction surgery.
This paper examines potential physiological mechanisms responsible for improvement after lung volume reduction surgery (LVRS). In 25 patients (63 +/- 9 yr; 11 men, 14 women), spirometry [forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC)], lung volumes [residual volume (RV) and total lung capacity (TLC)], small airway resistance, recoil pressures, and respiratory muscle contractility (RMC) were measured before and 4-6 mo after LVRS. Data were interpreted to assess how changes in each component of lung mechanics affect overall function. Among responders (DeltaFEV(1) > or = 12%; 150 ml), improvement was primarily due to an increase in FVC, not to FEV(1)-to-FVC ratio. Among nonresponders, FEV(1), FVC, and RV/TLC did not change after surgery, although recoil pressure increased in both groups. Both groups experienced a reduction in RMC after LVRS. In conclusion, LVRS improves function in emphysema by resizing the lung relative to the chest wall by reducing RV. LVRS does not change airway resistance but decreases RMC, which attenuates the potential benefits of LVRS that are generated by reducing RV/TLC. Among nonresponders, recoil pressure increased out of proportion to reduced volume, such that no increase in vital capacity or improvement in FEV(1) occurred. (+info)
Effect of gravity and posture on lung mechanics.
The volume-pressure relationship of the lung was studied in six subjects on changing the gravity vector during parabolic flights and body posture. Lung recoil pressure decreased by approximately 2.7 cmH(2)O going from 1 to 0 vertical acceleration (G(z)), whereas it increased by approximately 3.5 cmH(2)O in 30 degrees tilted head-up and supine postures. No substantial change was found going from 1 to 1.8 G(z). Matching the changes in volume-pressure relationships of the lung and chest wall (previous data), results in a decrease in functional respiratory capacity of approximately 580 ml at 0 G(z) relative to 1 G(z) and of approximately 1,200 ml going to supine posture. Microgravity causes a decrease in lung and chest wall recoil pressures as it removes most of the distortion of lung parenchyma and thorax induced by changing gravity field and/or posture. Hypergravity does not greatly affect respiratory mechanics, suggesting that mechanical distortion is close to maximum already at 1 G(z). The end-expiratory volume during quiet breathing corresponds to the mechanical functional residual capacity in each condition. (+info)
Chest wall kinematic determinants of diaphragm length by optoelectronic plethysmography and ultrasonography.
To estimate diaphragm fiber length from thoracoabdominal configuration, we measured axial motion of the right-sided area of apposition by ultrasonography and volumes displaced by chest wall compartments [pulmonary, abdominal rib cage, and abdomen (Vab)] by optoelectronic plethysmography in four normal men during quiet breathing and incremental exercise without and with expiratory flow limitation. Points at the cephalic area of apposition border were digitized from echo images and mapped into three-dimensional space, and the axial distance from the xyphoidal transverse plane (D(ap)) was measured simultaneously with the volumes. Linear regression analysis between changes (Delta) in D(ap) and the measured volume changes under all conditions showed that 1) DeltaD(ap) was linearly related more to DeltaVab than to changes in pulmonary and abdominal rib cage volumes; and 2) this was highly repeatable between measures. Multiple stepwise regression analysis showed that DeltaVab accounted for 89-96% of the variability of DeltaD(ap), whereas the rib cage compartments added <1%. We conclude that, under conditions of quiet breathing and exercise, with and without expiratory flow limitation, instantaneous DeltaD(ap) can be estimated from DeltaVab. (+info)
Comparison of proportional assist ventilation and pressure support ventilation in chronic respiratory failure due to neuromuscular and chest wall deformity.
BACKGROUND: The physiological and symptomatic effects of proportional assist ventilation (PAV) and pressure support ventilation (PSV) were compared in stable awake patients with neuromuscular and chest wall deformity (NMCWD). METHODS: Oxygen saturation (SaO(2)), transcutaneous carbon dioxide (TcCO(2)), minute ventilation (VE), tidal volume (VT), respiratory rate (RR), and diaphragm electromyography (EMGdi) were measured in 15 patients during both modes. Subjective effort of breathing and synchrony with the ventilator were assessed using visual analogue scales. RESULTS: Three of 15 patients failed to trigger the ventilator in either mode and were excluded. In the 12 remaining patients there were similar improvements in SaO(2), TcCO(2), VE, VT, and RR during both modes. The mean (SD) percentage fall in EMGdi was greater during PSV (-80.5 (10.7)%) than during PAV (-41.3 (35.2)%; p= 0.01). Effort of breathing (p=0.004) and synchrony with the ventilator (p=0.004) were enhanced more with PSV than with PAV. CONCLUSION: Both PSV and PAV produced similar improvements in physiological parameters. However, greater diaphragm unloading was observed with PSV than with PAV, associated with greater symptomatic benefit. These findings suggest that tolerance to PAV may be compromised in patients with NMCWD. (+info)
Giant cell tumor originating from the anterior arc of the rib.
We report a case of giant cell tumor originating from the anterior arc of the rib. The tumor and the surrounding chest wall were completely resected, and the chest wall defect was covered with Marlex mesh. Giant cell tumor of the bone usually originates from the epiphysis of long bones. Even when the tumor occur in ribs, it usually occur in the posterior aspect. However, giant cell tumor should be included in the differential diagnosis of a tumor originating from the anterior arc of the ribs. (+info)
Spectral characteristics of airway opening and chest wall tidal flows in spontaneously breathing preterm infants.
We compared the harmonic content of tidal flows measured simultaneously at the mouth and chest wall in spontaneously breathing very low birth weight infants (n = 16, 1,114 +/- 230 g, gestation age: 28 +/- 2 wk). Airway opening flows were measured via face mask-pneumotachograph (P-tach), whereas chest wall flows were derived from respiratory inductance plethysmography (RIP) excursions. Next, for each, we computed two spectral shape indexes: 1) harmonic distortion (k(d); k(d,P-tach) and k(d,RIP), respectively) defines the extent to which flows deviated from a single sine wave, and 2) the exponent of the power law (s; s(P-tach) and s(RIP), respectively), describing the spectral energy vs. frequency. P-tach and RIP flow spectra exhibited similar power law functional forms consistently in all infants. Also, mouth [s(P-tach) = 3.73 +/- 0.23% (95% confidence interval), k(d,P-tach) = 38.8 +/- 4.6%] and chest wall (s(RIP) = 3.51 +/- 0.30%, k(d,RIP) = 42.8 +/- 4.8%) indexes were similar and highly correlated (s(RIP) = 1.17 x s(P-tach) + 0.85; r(2) = 0.81; k(d,RIP) = 0.90 x k(d,P-tach) + 8.0; r(2) = 0.76). The corresponding time to peak tidal expiratory flow-to-expiratory time ratio (0.62 +/- 0.08) was higher than reported in older infants. The obtained s and k(d) values are similar to those reported in older and/or larger chronic lung disease infants, yet appreciably lower than for 1-mo-old healthy infants of closer age and/or size; this indicated increased complexity of tidal flows in very low birth weight babies. Importantly, we found equivalent flow spectral data from mouth and chest wall tidal flows. The latter are desirable because they avoid face mask artificial effects, including leaks around it, they do not interfere with ventilatory support delivery, and they may facilitate longer measurements that are useful in control of breathing assessment. (+info)