Day 1 :
Keynote Forum
Vickie R Shannon
The University of Texas MD Anderson Cancer Center, USA
Keynote: Pulmonary rehabilitation and the cancer setting: Is it beneficial? Is it safe?
Time : 9:50-10:20
Biography:
Vickie R Shannon holds MD from Washington University and is triple certified by the American Board of Internal Medicine in Internal Medicine, Pulmonology and Critical Care. Her research and clinical works in the area of pulmonary rehabilitation in cancer patients has made her a much-sought-after speaker and mentor to students interested in pursuing careers in medicine. In 2006, she launched an innovative pulmonary rehabilitation program at MD Anderson Cancer Center for cancer patients who suffer from compromised pulmonary function and performance status. Her primary clinical interests include chemotherapy and radiation-induced lung injury, lung injury in the immunocompromised host and pulmonary rehabilitation.
Abstract:
Statement of the Problem: Evidence-based support for pulmonary rehabilitation (PR) in the management of patients with chronic lung disease has grown tremendously. A beneficial role has been largely shown among patients with chronic obstructive pulmonary disease (COPD) and patients with pulmonary emphysema enlisted for lung volume reduction surgery. In these settings, significant reductions in dyspnea and improvements in exercise performance and health-related quality of life have been demonstrated following a program of PR. PR is often advocated as an adjunctive intervention in patients with cancer. Recent small studies suggest that PR may favorably impact lung cancer management by improving a variety of clinically meaningful outcomes, such as performance status, chemotherapy-related fatigue, oxygen consumption, exercise tolerance, and health-related quality of life. However, the true benefits and safety of this intervention in the cancer setting remain in question.
Purpose of the Study: To determine the role and safety of PR in improving chronic symptoms of dyspnea, fatigue and/or exercise intolerance in patients with hematologic and solid malignancies.
Methods: Patients with active hematologic or solid malignancies who were referred to the pulmonary service for evaluation of chronic dyspnea and/or decreased functional status were placed in our outpatient PR program and prospectively studied. Baseline clinical evaluation and functional status, including 6-minute walk distance (6 MWD), cardiopulmonary exercise testing (CPET) and self-reports of perceived exertion and dyspnea were used to develop an individualized exercise prescription and PR program for each patient. All studies were repeated upon program completion. The 12-week program encompassed thrice weekly progressive aerobic and resistance training sessions and weekly didactic educational and psychosocial components.
Results: PR program participation significantly increased the mean 6MWD distance (23%, P<.05) and oxygen consumption, as assessed by VO2 (18.6%, P<0.05). Dyspnea and perceived exertion scores were similar at pre- and post-rehabilitation despite greater post-rehabilitation physiologic work. Significant improvements were seen among patients with liquid and solid malignancies. No adverse events occurred during the study.
Conclusion: Pulmonary rehabilitation appears safe and shows promise as a therapeutic intervention in the management of a heterogeneous population of oncology patients with debilitating pulmonary symptoms.
Keynote Forum
Keith J Robinson
Florida International University, USA
Keynote: The use of surrogate end points in pulmonary arterial hypertension: Enhancing clinical decision making by improving time to clinical worsening observations
Time : 10:20-10:50
Biography:
Keith J Robinson is an Associate Clinical Professor with Florida International University practicing with Pulmonary Physicians of South Florida, LLC. He has completed his Medical training from Indiana University, his Residency in Internal Medicine from The University of Florida, Jacksonville, FL, and his Fellowship in Pulmonary/Critical Care Medicine from the University of California, CA.
Abstract:
Pulmonary Arterial Hypertension (PAH) is defined as a mean pulmonary artery pressure (mPAP)>25 mmHg at rest and >30 mmHg during exercise. Available pharmacologic therapies target pre-capillary disease by reducing pulmonary artery (PA) pressures. The effects of relaxing the PA, mitigates right heart failure caused by prolonged elevation in PA pressures. Early recognition and intervention in clinical deterioration is paramount towards maintaining exercise capacity, quality of life (QOL) and survival in PAH, but current clinical end points are limited in their predictive ability to reduce the latency in time to clinical worsening (TTCW). Field tests such as the 6 minute walk test (6 mwt), cardiopulmonary exercise testing (CPET) and the incremental shuttle walk test (ISWT) are simple to perform, validated means to measure response to intervention and correlate with invasive right heart catheterization data, which is the gold standard measure of PAH. However, clinically significant changes in these field tests, after intervention, have not demonstrated improved morbidity, hospitalization or need for the initiation of rescue therapy. Newer surrogate markers of disease, such as the tricuspid annular plane systolic excursion (TAPSE) and cardiac MRI, allow noninvasive measurement right ventricular (RV) function and demonstrate prognostic ability in PAH. However, imaging studies lack the ability to predict time to worsening heart function, due to lack of correlation with exercise capacity information. Physical activity, assessed by steps taken per day, is a cost effective therapy improving QOL and correlates with exercise capacity measurements obtained during field testing. Unfortunately, measuring physical activity is limited due to concerns exercise training may increase the risk of adverse clinical events. Optimum management of PAH, centers on preservation of RV function by early treatment of PA elevation and early detection of changes to PA pressure, prior to patient report. This goal requires movement away from outdated clinical trial designs and combining surrogate end points that detect changes in physical activity, which may predate loss of RV function.
Keynote Forum
Shahid Sheikh
Ohio State University College of Medicine, USA
Keynote: Wheezing in Infancy. When to treat and why?
Time : 10:50-11:20
Biography:
Shahid Sheikh is currently working as an Associate Professor of Pediatrics at Ohio State University College of Medicine in the Divisions of Pulmonary Medicine and Allergy and Immunology. He is also working in the Department of Pediatrics in the Nationwide Children’s Hospital, USA.
Abstract:
Asthma is a common chronic disease of childhood. In the United States alone, asthma affects about 5 million children, with an estimated annual cost of more than $4 billion and prevalence of asthma is rising. Adoption and adherence to asthma guidelines is still less than optimal. Strategies to improve clinical outcomes depend heavily on educating primary care physicians. In busy primary care practices, physicians lack time educate parents on preventive asthma management plans. Thus it is important that, in addition to physicians, other medical personnel such as nurses and nurse practitioners be a part of patient/family education to improve self-management of asthma. Once trained, they can help implement preventive clinical management plans, educate patients and families, and ensure that patients are on appropriate therapies to achieve adequate asthma control. We are working on this model for last four years at our Institution and I can share results and outcomes.
- Pulmonary Diseases and Disorders | Symptoms and Comorbid | Pulmonary Function Testing and Diagnosis | Acute Bronchitis | Asthma and Related Disorders | COPD and Related Disorders | Pulmonary Vascular Diseases | Critical Care Medicine
Location: Bora Salon
Chair
Vickie R Shannon
The University of Texas MD Anderson Cancer Center, USA
Co-Chair
Bradley J Phillips
Creighton University School of Medicine, USA
Session Introduction
Joanne Baerg
Loma Linda University Medical Center, USA
Title: Respiratory management of the newborn with an Omphalocele
Biography:
Joanne Baerg is currently working as a Pediatric Surgeon at Loma Linda University Children’s Hospital, Loma Linda, CA, USA.
Abstract:
An omphalocele is a congenital defect of the umbilical ring with herniation of the viscera. Despite of advances in neonatal care, for live-born infants, the mortality rate remains between five and 25%. Respiratory failure at birth is an independent predictor of mortality for omphalocele infants, but the causes are diverse. In this presentation, giant and non-giant omphalocele are compared, as giant omphalocele have more respiratory difficulties. Prenatal predictors of post-natal respiratory failure and care strategies are discussed. Pulmonary hypoplasia is defined. Historically, fetuses and infants with omphalocele are reported to have markedly reduced chest capacities. Recently, fetal magnetic resonance imaging (MRI) has expanded the understanding of decreased congenital lung volume in infants with omphalocele. Clinical-radiologic correlation studies support the use of prenatal MRI to predict the degree of respiratory insufficiency observed in the postnatal period. The contribution of major anomalies to respiratory difficulties is discussed. Infants with omphalocele may have increased pulmonary vascular reactivity and pulmonary hypertension that increases the post-natal mortality risk. In this presentation, pulmonary hypoplasia and pulmonary hypertension are defined as distinct entities. The two diagnoses must be distinguished from each other in the clinical setting. The implications of congenital heart defects are explained. The role and goals of assisted ventilation for respiratory failure are expanded. Since 2011, infants with omphalocele and respiratory failure have required the extra-corporeal membrane oxygenator. The first review of the Extra-Corporeal Life Support (ELSO, Ann Arbor, MI USA) database for the causes of respiratory failure and outcomes in omphalocele infants place will be presented. The timing of surgical repair, post-operative complications such as compartment syndrome, delayed surgical closure techniques and the implications of a ruptured omphalocele are explained. Pulmonary function abnormalities, chronic lung disease, the role of tracheostomy, the influence of gastroesophageal reflux disease (GERD), prematurity, and improved outcome strategies are discussed.
Zhilong Jiang
Fudan University, PR China
Title: The distinct roles of circulating monocytes and alveolar macrophages in mouse model with acute lung injury
Biography:
Abstract:
Acute lung injury and acute respiratory distress syndrome (ALI/ARDS) are characterized with acute diffuse alveolar damage, influx of neutrophils and protein-rich exudates in the alveolar spaces. Circulating monocytes are activated and infiltrated into alveolar space to form alveolar macrophages, provide home defense against pathogen invasion and induce lung inflammation under the physiological and pathological conditions. Alveolar macrophages are heterogeneous types of cells. To clarify the distinct roles of circulating monocytes and alveolar macrophages, in this study we depleted circulating monocytes and alveolar macrophages respectively via intravenous and intratracheal administration of liposome clodronate into C57/B6 mice. Two days after cell depletion, the mice were intratracheal treated with LPS to establish ALI/ARDS mouse model. BAL and lung tissues were collected 2 days after LPS treatment for analysis of lung inflammation and cellular responses. We observed an elevated lung neutrophilia in BAL and lung tissues of mice treated with LPS alone as compared to the naïve control mice. However, the lung inflammation was significantly suppressed by pre-depletion of circulating monocytes in ALI/ARDS mouse model as compared to the mice treated with LPS alone. In contrast, the lung inflammation was significantly enhanced in the mice pre-depleted with alveolar macrophages as compared to the mice treated with LPS alone. The lung severity was positively correlated to the levels of MCP-1, IL-17, surfactant protein D (SP-D) and HMGB1. The results indicated the pro-inflammatory role of circulating monocytes, but anti-inflammatory role of alveolar macrophages in the LPS-induced ALI/ARDS mouse model. Blocking circulating monocyte homing into lung during LPS treatment via intraperitoneal administration of MCP-1 neutralizing antibody significantly suppressed the lung inflammation as compared to the IgG isotype antibody treated controls. In addition, we observed that resveratrol, an anti-oxidant as well as SIRT1 activator can suppress MCP-1 expression in bone marrow-derived macrophages (BMMs). Intraperitoneal adoptive transfer of the resveratrol-treated BMMs into LPS-treated mice significantly suppressed BMMs migration into lung and induction of lung inflammation in the mouse model. The immune suppressive effects were also achieved by intraperitoneally injection of resveratrol in mice with ALI/ARDS. In SOCS3 knock-out mice, we observed that SOCS3 deficiency up-regulated MCP-1 expression in the SOCS3 knock-out BMMs and lung tissues, the results were correlated to the enhanced lung inflammation as compared to the wild-type mice with ALI/ARDS. Thereby, molecular intervention of circulating monocyte function would be beneficial in the treatment of ALI/ARDS.
Bradley J Phillips,
Creighton University School of Medicine, USA
Title: The Role of Traumatic Pneumonectomy
Biography:
Bradley J. Phillips is an Associate Professor of surgery, currently working as a vice chair for Surgery Surgical Research at Department of Surgery with Creighton University School of Medicine, USA. His area of expertise is in “Trauma-Burn-ICU Coverage, adult & pediatric injury”. He did his education from Michigan State University College of Human Medicine, M.D., 1991-1995. Dr. Bradley published various articles in multiple journals.
Abstract:
Introduction: Thoracic injuries are common in both blunt and penetrating trauma. While most of these injuries are managed non-operatively, approximately 7-20% undergo a thoracotomy and of these, 1-6% ultimately require pulmonary resection. Wedge resection and lobectomies are well-studied in the literature; however, there is a paucity of reports on total pneumonectomy in the setting of trauma injury. The objective of this study was to characterize injuries requiring a traumatic pneumonectomy in the National Trauma Data Bank (NTDB) from 2002 to 2012.
Methods: Using ICD-9 procedure codes 32.50 and 32.59, we identified 42 patients who underwent a traumatic pneumonectomy from the NTDB that occurred between 2002 and 2012. We collected data on gender, age, mechanism of injury, injury severity score (ISS), Glasgow Coma Scale (GCS), time to procedure, hospital length of stay, complications, and mortality. We used univariate statistical analysis with statistical significant set as p<0.05.
Results: Forty-two patients (33 males, 10 females) underwent pneumonectomy for traumatic injuries over the 11-year period with an overall mortality rate of 81%. Twenty-six patients had an ISS greater than or equal to 25 and an associated 96% mortality rate. 23 patients (55%) had penetrating injuries and 19 (45%) had blunt with mortality rates of 74% and 89%, respectively. The most common mechanisms of injury were motor vehicle accident (MVA; 38%) and firearms (50%). MVAs had considerably higher mortality (94%) than firearm injuries (71%). Time to procedure was 3.6 hours in survivors and 6 hours in nonsurvivors.
Conclusion: In this study, we characterized 42 patients undergoing a traumatic pneumonectomy for blunt or penetrating injuries. Although total pneumonectomy in trauma is relatively rare, this procedure was associated with a very high mortality rate of 81%. The lethality of these injuries was related to several factors including ISS and mechanism of injury. The difference in time to procedure between survivors and nonsurvivors suggests that
Emmanuel OUEDRAGOO
ONG Solthis, Niger
Title: Evaluation of the benefit of different complementary exams in the search for a TB diagnosis algorithm for HIV patients put on ART in Niamey, Niger
Biography:
Emmanuel OUEDRAOGO has expertise in the management of HIV and tuberculosis of adults and adolescents in low-income countries. He has acquired these experiences after years of clinical practice, program management and operational research both in hospitals and in health programs. He is a Doctoral graduate in General Medicine and he is also a Medical Specialist, Public Health Technician. He holds a Master of Science degree in the control of tropical diseases including HIV, tuberculosis, malaria and neglected tropical diseases. He also holds a Master’s degree of Sciences, Technologies and Health.
Abstract:
Statement of the Problem: In Niger, the tuberculosis (TB) screening among people living with human immunodeficiency virus (HIV) (PLHIV) is nonsystematic and the use of additional tests is very often limited. The objective of this research is to evaluate the performance and the cost-effectiveness of various paraclinical testing strategies of TB among adult patients with HIV, using available tests in routine for patients cared in Niamey.
Methodology & Theoretical Orientation: This is a multicentric prospective intervention study performed in Niamey between 2010 and 2013. TB screening has been sought in newly diagnosed PLHIV, before ART treatment, performing consistently: A sputum examination by MZN (Ziehl-Nielsen staining) and microscopy fluorescence (MIF), chest radiography (CR) and abdominal ultrasound. The performance of these different tests was calculated using sputum culture as a gold standard. The various examinations were then combined in different algorithms. The cost-effectiveness of different algorithms was assessed by calculating the money needed to prevent a patient, put on ART, dying of TB.
Findings: Between November 2010 and November 2012, 509 PLHIV were included. TB was diagnosed in 78 patients (15.3%), including 35 pulmonary forms, 24 ganglion and 19 multifocal. The sensitivity of the evaluated algorithms varied between 0.35 and 0.85. The specificity ranged from 0.85 to 0.97. The most cost effective algorithm was the one involving MIF and CR.
Conclusion: We recommend implementing a systematic and free direct examination of sputum by MIF and a CR for the detection
Shahid Sheikh
Ohio State University College of Medicine, USA
Title: Cystic Fibrosis. A success story
Biography:
Dr. Shahid Sheikh is currently working as an Associate Professor of Pediatrics at Ohio State University College of Medicine in the Divisions of Pulmonary Medicine and Allergy and Immunology. He is also working in the Department of Pediatrics in the Nationwide Children’s Hospital, USA.
Abstract:
Cystic fibrosis (CF) is an autosomal recessive progressive disease involving many organ systems but primary morbidity and mortality is with the involvement of lung disease. Because of genetic defects, inadequate hydration of pulmonary secretions leads to thick mucus causing airway obstruction which predispose to colonization, chronic infection and inflammation leading to irreversible bronchiectasis and ultimately resulting in end stage lung disease and respiratory failure. Current therapies for pulmonary disease in patients with CF decrease disease progression by improving secretion mobility and decreasing pulmonary infection and inflammation. These therapies have improved median predicted survival among patients with cystic fibrosis to more than 40 years. Now new disease modifying therapies are becoming a reality. We will discuss how life expectancy have improved over time and how it will be keep on getting better as CF now is not considered a pediatric disease. We will also discuss CF care model and its implications on other chronic illnesses.
Marc Jimenez
Papworth Hospital, UK
Title: Extracorporeal respiratory support ilts with severe respiratory failure
Biography:
Dr Marc Giménez-Milà undertook his postgraduate training in Anaesthesiology in Hospital Clínic of Barcelona (Spain) and his senior clinical fellowship in Cardiothoracic Anaesthesia and Intensive Care at Papworth Hospital in Cambridge (UK). Currently he is working as a Consultant in Anaesthesia and Intensive Care at Papworth providing Anaesthesia care for cardiothoracic procedures including heart and lung transplantation and also forms part of the Papworth Veno-venous ECMO service. He published in peer-reviewed journals and is a member of editorial board of both ARC Journal of Anesthesiology and Current Updates in Anesthetics and Anesthesiology. He was awarded with the 2016 Fernando Vidal award from the Catalan Society of Pain (Barcelona, Spain). He holds the European Diploma of Anaesthesia and Intensive Care (EDAIC), European Society of Cardiology accreditation for Transoesophageal echocardiography and is a Focused intensive care echocardiography (FICE) mentor
Abstract:
Aims:
1. Review of current evidence of VV-ECMO for severe respiratory failure.
2. Assessment of patient with severe respiratory failure
3. Indications and contraindications
4. Different clinical settings: Traumatic brain injury, asthma, ARDS
5. Outcomes
Donald Davidson
University of Edinburgh, UK
Title: Cathelicidins have direct antiviral activity against respiratory syncytial virus in vitro and protective function in vivo
Biography:
Donald J Davidson has completed his PhD at the MRC Human Genetics Unit and undertook Postdoctoral training in Innate Immunity research at the University of British Columbia, Vancouver as a Welcome Trust Fellow. In 2004, he has joined the University of Edinburgh/MRC Centre for Inflammation Research, where he established an independent research group as a Welcome Trust funded Fellow
Abstract:
Respiratory syncytial virus (RSV) is a leading cause of respiratory tract infection in infants, causing significant morbidity and mortality. No vaccine or specific, effective treatment is currently available. A more complete understanding of the key components of effective host response to RSV and novel preventative and therapeutic interventions are urgently required. Cathelicidins are host defence peptides, expressed in the inflamed lung with key microbicides and modulatory roles in innate host defence against infection. Here we demonstrate that the human cathelicidin LL-37 mediates an antiviral effect on RSV via direct damage to the viral envelope, disrupting viral particles and decreasing virus binding to, and infection of, epithelial cells. Delivery of exogenous LL-37 is protective in vivo in a murine model of pulmonary RSV infection, demonstrating maximal efficacy when applied concomitantly with virus. Furthermore, endogenous murine cathelicidin, induced by infection, has a fundamental role in protection against disease following infection with RSV. Finally, higher nasal levels of LL-37 are associated with protection in a healthy human adult RSV infection model. These data lead us to propose that cathelicidins are a key, non-redundant component of host defence against airway infection with RSV; functioning as a first point of contact antiviral shield, and having additional later phase roles in minimizing the severity of disease outcome. Consequently, cathelicidins represent an inducible target for preventative strategies against RSV infection and may inform the design of novel therapeutic analogues for use in established infection
Rui Hou
Peking Union Medical College Hospital, China
Title: Surgical treatment of pulmonary artery aneurysm: An institutional experience
Biography:
Rui Hou has completed his MD from Tongji Medical College, Huazhong University of Science of Technology. He is currently an Attending Surgeon at Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, China. He has published more than 10 papers in reputed journals and has expertise in the field of surgical treatment and management of cardiac/vascular diseases
Abstract:
Objectives: Pulmonary artery aneurysm (PAA) is extremely rare in clinic. It should be treated carefully because of the possibility of fatal complications including rupture, dissection, pulmonary embolism and heart failure. Our goal is to contribute a better understanding of this disease and its treatment.
Methods: Patients diagnosed with PAA were retrieved from the institute’s database. The detailed information including etiology, clinical presentation, diagnostic methods, operation methods and long-term outcomes of those surgical cases were outlined and analyzed.
Results: There are overall 21 patients diagnosed with PAA in PUMCH from 1980 to 2015, among which five patients received surgical treatment, including two giant PAA. The complete remission rate of surgical cases was 80% and the post-operative hospital stay was 8.5±1.29 days. There is one post-operative death due to distributive shock.
Conclusion: PAA must be seriously classified by etiology so as to be treated appropriately. PAA of giant size and those with pulmonary hypertension, anatomical anomalies, rapid growth and compression of neighboring critical structures are proper candidates for surgery. The surgical options include aneurysm repair and replacement with allogeneic/synthetic grafts, adopted specifically in different situations. Also, the correction of associated abnormalities should be done simultaneously at surgery. The surgical outcomes are effective and the long-term prognoses are satisfactory
Mandeep K Garg
Postgraduate Institute of Medical Education and Research, India
Title: Radiological findings in allergic bronchopulmonary aspergillosis (ABPA)
Biography:
Mandeep K Garg is a board certified Radiologist and is currently working as an Additional Professor at Postgraduate Institute of Medical Education and Research, Chandigarh, India. His main area of interest is thoracic radiology. He is a Member of International working group on ABPA complicating asthma and also a Member of National Faculty who formulated National guidelines for diagnosis and management of Community and Hospital acquired pneumonia (CAP and HAP), COPD and Bronchial Asthma in adults in India. He is actively involved in research and teaching of postgraduate students in radiology and pulmonary medicine. He has published more than 40 papers in journals of repute apart from contributing many chapters in books
Abstract:
Allergic bronchopulmonary aspergillosis (ABPA) is an immunological lung disorder occurring due to hypersensitivity reactions against the fungus Aspergillus fumigatus. Diagnosis of ABPA is based upon a set of clinical, immunological and radiological criteria. Imaging plays an important role in diagnosis of ABPA. However, at times, diagnosis of ABPA can be challenging, despite well-established criteria. Radiologist should be familiar with imaging findings and various diagnostic criteria of ABPA, so as to give a more confident diagnosis. Role of imaging in ABPA is not only limited to diagnosis of central bronchiectasis. In recent years, imaging has been used for classification and prognostication of the disease. Certain imaging features like high attenuation mucus (HAM) are helpful in determining the immunological severity and disease relapse. ABPA has non-specific features on chest radiography. High resolution computed tomography (HRCT) is the imaging modality of choice for diagnosis of bronchiectasis in ABPA. Magnetic resonance imaging (MRI) appears to have a promising role in evaluation of ABPA. Based upon presence of central bronchiectasis (CB) and HAM, ABPA can be classified based as ABPA-S (mild), ABPA-CB (moderate), and ABPA-CB-HAM (severe). This classification not only reflects immunological severity but also predicts the risk of recurrent relapses. In recent years, the role of radiology in ABPA has evolved. Radiology plays an important role not only in diagnosis but also in the classification and prognostication of the disease