Journal of thoracic disease最新文献

Background: Acute respiratory distress syndrome (ARDS) is associated with severe hypoxemia, and awake prone positioning (APP) with high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) is increasingly used to delay intubation. However, airway clearance and patient tolerance remain major challenges. This study aimed to assess whether an electrical impedance tomography (EIT)-guided chest physiotherapy (CPT) protocol could improve oxygenation, comfort, and prone tolerance compared with standard CPT in non-intubated ARDS patients.

Methods: Ninety-two adults with primary ARDS, defined by the Berlin criteria and ratio of arterial oxygen tension to the fraction of inspired oxygen (PaO₂/FiO₂) <150 mmHg on HFNC or NIV, were randomized to EIT-guided CPT or standard CPT. Interventions included repositioning, vibration-assisted clearance, and nebulization, applied with or without EIT guidance. The pre-specified primary endpoint was the change in PaO₂/FiO₂ ratio from day 1 to day 5. Secondary endpoints included the change from day 1 to day 3, patient comfort, prone duration, intensive care unit (ICU) length of stay, and treatment failure (progression to intubation and invasive mechanical ventilation). Analyses were performed in a modified intention-to-treat population, defined as all randomized patients with at least one post-baseline assessment. Outcome assessors were blinded to group allocation.

Results: Eighty-seven patients were included in the final analysis (44 EIT, 43 control). The EIT group showed a significantly greater improvement in PaO₂/FiO₂ from baseline to day 5 (mean between-group difference 31.5 mmHg, P<0.05). Secondary outcomes favored the EIT group, with longer prone duration (13.2 vs. 9.0 hours/day), higher comfort scores (7.0 vs. 5.9), and lower failure rates (4.5% vs. 9.1%). ICU length of stay was similar between groups (13-14 days), reflecting local practice. No serious adverse events were observed.

Conclusions: In patients with ARDS supported by HFNC or NIV, an EIT-guided CPT protocol improved oxygenation, enhanced comfort, and prolonged tolerance of APP. These findings support the clinical utility of EIT in optimizing noninvasive respiratory strategies, though multicenter studies are needed to confirm long-term benefits.

Background: Biomass smoke exposure (BME) is an independent risk factor for chronic obstructive pulmonary disease (COPD), particularly among women and children in developing countries. Existing animal models of biomass smoke-related COPD are limited due to prolonged modeling periods. This study aimed to develop a novel composite protocol for constructing a biomass smoke-related COPD mouse model using porcine pancreatic elastase nebulization.

Methods: Six-week-old female C57BL/6 mice (n=6 per group) were exposed to porcine pancreatic elastase nebulization on the first day and biomass smoke for the remaining 6 days of each week over a 4-month period. Pulmonary function, histopathology, and inflammatory markers were assessed via pulmonary function tests, Hematoxylin & eosin (H&E) staining, enzyme-linked immunosorbent assay (ELISA) and multiplexed liquid chip analysis respectively.

Results: BME induced significant pulmonary function impairment, characterized by increased functional residual capacity (FRC), quasi-static compliance, and static compliance, alongside reduced a ratio of forced expiratory volume at 100 ms and forced vital capacity (FEV100/FVC), dynamic pulmonary compliance as well. Histopathological analysis revealed emphysema and bronchiectasis in lung tissue. Elevated levels of interleukin-1β (IL-1β) and interleukin-10 (IL-10) were observed in the BME group, with a concurrent increase in plasma interleukin-2 (IL-2). In the BME group, mitogen-activated protein kinase 1 (MAPK1) expression increased, whilst expression of signal transducer and activator of transcription 3 (STAT3) decreased. Additionally, matrix metalloproteinase-9 (MMP9) expression decreased.

Conclusions: The results of this study indicate that BME significantly induced pulmonary function injury leading to emphysema and bronchiectasis changes, as well as systemic inflammation. IL-10 may play a significant role in the pro-inflammatory/anti-inflammatory mechanisms of COPD by regulating the expression of key signalling pathway proteins. A novel COPD modeling method incorporating elastase was constructed.

Background: Transthoracic esophagectomy (TTE) is the preferred approach for curative esophageal cancer. However, concomitant single-lung ventilation limits its use in patients with compromised cardio-pulmonary function. Transhiatal esophagectomy (THE) grants two-lung ventilation yet offers a limited mediastinal lymphadenectomy and is only suitable for distal tumors. A promising alternative is robot-assisted cervical esophagectomy (RACE). Initial studies show its feasibility, yet, the mediastinal lymph node yield (LNY) is unknown. The aim of this study is to describe the accessibility of the lymph node stations (LNS) and to analyze to which extent the mediastinal LNS can be resected during the cervical phase of RACE.

Methods: Experienced robotic upper-gastrointestinal (GI) surgeons performed cervical esophagectomy and mediastinal lymphadenectomy on 4 cadavers using a "da Vinci Xi" surgical system through a left cervical approach. Target LNS were 4R, 4L, 5 and 7, as defined by Naruke. Resected tissues were categorized as primary-esophagus and lymph nodes (LNs) resected through RACE- or secondary-residual LNs post-RACE- resected tissue and were analyzed by experienced pathologists. LNs were counted for every station.

Results: Station 4R yielded a median of 16 LNs primarily and 12 secondarily; station 4L: 17 primarily, 0 secondarily; station 5: 4 primarily, 7 secondarily; and for station 7: 9 primarily and 5 secondarily.

Conclusions: This study shows that the RACE procedure delivers a limited mediastinal lymphadenectomy. LNS 4L can be fully resected. Stations 4R, 5 and 7 could be partially resected. The RACE procedure may, however, be a viable alternative for patients who cannot undergo a TTE.

Background: Advances in multimodal therapy have reshaped treatment paradigms for clinical stage II (cII) non-small cell lung cancer (NSCLC), yet optimal treatment sequencing remains controversial. We sought to investigate predictors of adjuvant uptake, accuracy of clinical staging, and oncologic outcomes in patients undergoing upfront surgical resection.

Methods: The retrospective analysis was completed of the National Cancer Database (NCDB) for patients with cII disease from 2015 to 2019 who underwent surgical resection. Patients were stratified by receipt of adjuvant therapy (AT). Rates of uptake, pathologic staging, and survival outcomes were analyzed. Cox regression and Kaplan-Meier curves were used to evaluate overall survival (OS) in propensity-score matched cohorts.

Results: A total of 17,674 patients with cII NSCLC underwent surgical resection between 2015 and 2019, with 728 (4.1%) receiving neoadjuvant therapy, while the remainder (n=16,946, 95.9%) underwent upfront surgery. Of those undergoing upfront surgical resection, 8,620 (50.9%) were treated with AT and pathologic upstaging occurred in 23.3% (n=3,941) of the cohort. In patients that were pathologic stage II-IV, only 58.4% (n=8,240/14,116) received AT (P<0.001). Factors associated with lower uptake included older age, more comorbidities, and public insurance. In propensity-score matched cohorts, receipt of AT improved 5-year OS (62.2% vs. 52.2%, log-rank P value <0.001).

Conclusions: Despite over 80% of cII patients meeting indications for adjuvant treatment consideration, less than 60% of eligible patients receive it. Failure is associated with worse survival, particularly in upstaged patients; thus, processes should be put in place to help ensure return to intended oncologic therapy or implement practice patterns incorporating neoadjuvant protocols.

Background and objective: Minimally invasive and sublobar anatomical lung resection has become the gold standard for stage I non-small cell lung cancer (NSCLC) under 2 cm. Preoperative surgical planning with three-dimensional computed tomography (3DCT) reconstruction has become more common to improve safety and accuracy of resection. The aim of this review is to evaluate the evidence for 3DCT reconstruction in improving perioperative outcomes in patients undergoing anatomical lung resection.

Methods: A targeted literature review of evidence for 3DCT reconstruction in the perioperative period, focusing on quantitative data. Studies were included if they offered comparative data between two-dimensional computed tomography (2DCT) and 3DCT, or if they reported outcomes directly influenced using 3D imaging. Articles were excluded if they did not address preoperative imaging strategies, lacked peer review, or failed to provide sufficient data for analysis.

Key content and findings: Forty papers were identified for this review. Seventeen only described bronchovascular patterns and anatomical variations with no surgical procedure performed and were excluded. Twenty-three described 3DCT reconstruction in relation to surgical resection. Nine studies assessed resection margins, with one reporting a change from segmentectomy to lobectomy due to 3DCT findings (10.5%). Two showed improved margin adequacy with 3DCT, though overall evidence remains limited. Across six comparative studies, two reported reduced blood loss with 3DCT, while others showed no difference. Operative time showed mixed results: three retrospective studies reported shorter durations, though the single randomised controlled trial, the DRIVATS study, found no difference. There was also no difference in clinical outcomes such as chest tube drainage, postoperative complications and postoperative hospital stay. However, this may be due to segmentectomy being a heterogeneous group of operations, as well as underpowered studies.

Conclusions: Although randomized evidence demonstrating the superiority of 3DCT reconstruction over conventional computed tomography (CT) is lacking, 3DCT remains a valuable adjunct for visualising complex anatomical structures and guiding operative planning.

Background: Lung resections and stereotactic body radiation therapy (SBRT) are primary treatments for clinical stage I non-small cell lung cancer (NSCLC). The aim of this network meta-analysis is to compare the differences in effectiveness between SBRT and specific lung resections, including lobectomy, segmentectomy, and wedge resection for clinical stage I NSCLC.

Methods: PubMed, EMBASE, Cochrane Library, and the ClinicalTrials.gov registry were searched. Random-effects model was conducted to assess differences in survival outcomes and treatment-related complication incidence between SBRT and three specific lung resections (lobectomy, segmentectomy, wedge resection). Subgroup analyses were performed according to clinical stages, regions, and publication years.

Results: A total of 30 studies were enrolled for network meta-analysis. All three lung resections demonstrated superior overall survival (OS) compared with SBRT [lobectomy: hazard ratio (HR) 0.65, 95% confidence interval: 0.53-0.79; segmentectomy: HR 0.64, 95% confidence interval: 0.50-0.82); wedge resection: HR 0.72, 95% confidence interval: 0.55-0.93]. The recurrence-free survival (RFS) of patients in lobectomy and segmentectomy groups was significantly better than that of patients in the SBRT group, with no significant difference between the wedge resection and SBRT groups. Patients with clinical stage IA NSCLC showed no significant difference in OS between SBRT and three lung resections (lobectomy: HR 0.99, 95% confidence interval: 0.85-1.16; segmentectomy: HR 0.98, 95% confidence interval: 0.83-1.16; wedge resection: HR 1.71, 95% confidence interval: 0.91-3.26).

Conclusions: For clinical stage I NSCLC patients, lobectomy and segmentectomy are superior to SBRT. Wedge resection is associated with similar RFS but better OS to SBRT. In clinical stage IA NSCLC, SBRT may provide comparable OS to lung resections.

Background: Patients experiencing acute exacerbation of chronic obstructive pulmonary disease (AECOPD) often face poor prognoses and high readmission rates. While corticosteroids play a central role in the management of AECOPD by reducing airway inflammation, improving lung function, and accelerating symptom resolution, their impact on subsequent readmission risk in AECOPD patients remains unclear. This study aimed to explore the relationship between corticosteroid use prior to intensive care unit (ICU) admission and the 90-day all-cause readmission risk in AECOPD patients.

Methods: We included 1,219 AECOPD patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. To balance baseline characteristics between groups, we employed inverse probability of treatment weighting (IPTW) based on propensity scores. A multivariate logistic regression model was utilized to assess the association between corticosteroid use and 90-day readmission risk. Subgroup analyses evaluated heterogeneity across different populations, along with a mediation analysis to investigate the role of elevated blood glucose levels.

Results: After adjusting for all confounding factors, corticosteroid use before ICU admission was associated with a significantly heightened risk of 90-day readmission in both the original and IPTW-weighted cohorts, with odds ratios of 1.933 [95% confidence interval (CI): 1.400-2.664] and 1.970 (95% CI: 1.417-2.738), respectively. This association remained robust across subgroup analyses. Mediation analysis indicated that elevated blood glucose levels mediated the readmission risk, accounting for 29.7% and 17.4% of the total effect in the original and IPTW cohorts, respectively.

Conclusions: Corticosteroid usage before ICU admission is significantly associated with a heightened risk of 90-day readmission in AECOPD patients, partially mediated by elevated blood glucose levels.