Long-Term Adherence and Maintenance of Benefits in Pulmonary Rehabilitation

Pulmonary rehabilitation (PR) is a comprehensive intervention in chronic lung diseases, including personalized special therapies, exercise training, education and behavioral changes to improve the physical and psychological status of the patients, and aims to promote behavior that helps improve health status in the long term. A personalized PR program administered by a multidisciplinary team is recently considered a standard and complementary treatment method in chronic lung diseases. After the PR program, dyspnea of COPD patients decreases and their exercise capacities increase. Their daily life activities and physical activities increase. Their functional dependence decreases and quality of life increases. It presents a perfect opportunity to provide self-management and independence for the patients and improve their quality of life. Studies have shown that, unless there is a structured maintenance program, after an average of 6–12 months following PR programs, the gains that are realized start to decrease. Decrease of gains due to causes like a decrease in compliance to exercises, disease progress, attacks and co-morbidities. Causes such as decreased compliance to exercise, progression of the disease, attacks and comorbidities play a role in reducing gains. Especially in advanced age and in the presence of severe disease, the gain in exercise tolerance is lost more rapidly. The methods used and the results obtained to ensure the continuation of the gains differ.

Advances in Minimally Invasive Surgery for Lung Cancer

Over the last 25 years, improvement in instrumentation and surgical techniques has led to widespread adaptation of thoracoscopic (VATS) surgery in the field of thoracic oncology. What once was a niche operation like VATS wedge resection to now hybrid VATS chest wall resections, and advanced surgeries like bronchoplasty and sleeve resections are done with VATS. This has led to improved surgical outcomes for our patients and increased use of surgery in the treatment of chest disease. We review the history of VATS and its current state with most recent changes and upgrades in the technique in this chapter. We review the advancement in uniportal VATS, robotic assisted resection, complex VATS resection, and awake lung surgery with VATS.

Emphysema

Emphysema (Greek word meaning to inflate/to blow) is an increase in the size of airspace distal to the terminal bronchiolus, that is, hyperinflation of the alveoli due to the destruction of the gas-exchanging structures: alveolar walls, alveolar ducts, and respiratory bronchioles with coalescence of airspaces into the abnormal, much larger airspaces. The main consequences are the reduction of alveolar surface for gas exchange and the chronic obstructive pulmonary disease due to the destruction and disappearance of respiratory bronchioles with decreased total small airway diameter sum. Both decreased alveolar surface for gas exchange and chronic obstructive pulmonary disease lead to difficulty in breathing with dyspnea varying from mild to very severe. Two main pathohistologic types of emphysema are centriacinar and panacinar. Centriacinar emphysema involves the central portion of the acinus, and inflation mainly involves respiratory bronchioles and adjacent alveoli, and not all alveoli inside the acinus are involved. Panacinar (panlobular) emphysema is characterized by uniform enlargement and destruction of alveoli throughout the entire acinus. The panacinar emphysema is rare and its most common cause is hereditary alpha-1 antitrypsin deficiency. The centriacinar emphysema is the most frequent emphysema. It is mainly caused by smoking but also by coal dust exposure and advanced age.

Eosinophils as a Biomarker in Asthma and COPD

Asthma and COPD are two diseases related to eosinophils. But at present, we do not know with certainty how much these cells participate in these diseases, beyond that the treatment of the underlying cause produces the resolution of eosinophilia in a “reactive” way. Eosinophil-related diseases are a spectrum of systemic diseases such as Asthma and COPD in pneumology area. Under inflammatory conditions, the number of circulating eosinophils or tissues can increase dramatically, with rapid development of eosinophilia and we can obtain in a simple laboratory test. In general, the number of eosinophils in the blood can provide useful information and considering the differential diagnosis and for the subsequent test of patients presenting with eosinophilia. The treatment of eosinophilia currently in number of 300 cells in which is the criteria and the target to be treat. The best known and most used of all treatments for diseases related to eosinophils are corticosteroids, which decrease circulating and tissue eosinophils in a few hours, through mechanisms that include the direct activation of eosinophil program death. Targeted treatment against eosinophils could improve airway remodeling through mechanisms that are not fully known, and their effects on lung function are variable and decreasing symptoms in patients.

Thoracic Extrapulmonary Tuberculosis in the Millennial Era

Mycobacterium tuberculosis is one of the most pathogenic infectious organisms, usually known for causing cavitary lung infection. But this mycobacterium is also capable of causing masked involvement in any organ of the body. Its clinical manifestation can mimic other conditions according to the organ affected. Extrapulmonary infection is defined as any manifestation caused by tuberculosis in tissues outside the airway or the pulmonary parenchyma. Despite it being a well-known infectious organism throughout decades, tuberculosis continues to be causing great morbidity and mortality in this millennium. This chapter will discuss the clinical manifestations of extrapulmonary tuberculosis (EPTB), when the mycobacteria invade extrapulmonary tissues inside the thorax. We discuss and review the literature about the clinical manifestations, diagnosis and evaluation, and general treatment.

Smoking and COPD: Endothelium-Related and Neuro-mediated Emphysema Mechanisms

This chapter describes endothelium-related and neuro-mediated mechanisms of emphysema development in chronic obstructive pulmonary disease (COPD) and smoking on the basis of previously completed studies, literature data, and own researches. As components of neurogenic inflammation in the processes of tissue remodeling in emphysema, we describe the distribution and activity of the substance P, neurokinin-1 and its receptor, tissue metalloproteinases and their tissue inhibitors in the lungs during the entire experimental period, the modeling of COPD in rats with a smoking model. We also analyzed the content of neurokinin system markers, the localization, and markers of tissue metalloproteinases in human lung tissue structures. We have confidence that there is a special morphofunctional continuum of development of lower respiratory tract remodeling in response to chronic exposure to tobacco smoke and the development of inflammation in COPD. New data suggest that imbalance of neuro-mediated interactions, alteration of vasomotoric signaling mechanisms, secretion, mucociliary clearance, cytoprotection involving substance P-dependent components with impaired content, and development of dystopia of matrix metalloproteinases and their tissue inhibitors are involved in the initiation of morphological restructuring. Research in this direction should be continued to allow approaches to the development of preventive and therapeutic strategies for emphysema.

Surgical Management of Bronchiectasis

Bronchiectasis is a chronic clinicopathological disease of the lung characterized by chronic cough, sputum production, recurrent pulmonary infection, and persistent bronchial dilatation on computed tomography. For many years, bronchiectasis associated with high mortality and morbidity particularly before the advent of antibiotics. The medical treatment of bronchiectasis includes antibiotic therapy, airway clearance, bronchodilators, and anti-inflammatory agents. Surgery is mainly performed for localized disease after failure of the medical treatment, including: segmentectomy, lobectomy, and pneumonectomy. This chapter highlights the current surgical considerations for treatment of bronchiectasis, regarding indications of surgery, preoperative evaluation and preparation, available operative procedures, postoperative outcomes, and other important surgical issues.

The Realm of Oncological Lung Surgery: From Past to Present and Future Perspectives

In this chapter, a historical overview as well as an overview of state of the art of the surgical techniques for the treatment of lung cancer is outlined. The chapter focuses on the introduction of open surgery, video-assisted thoracic surgery (VATS), uniportal VATS (UVATS), and robotic-assisted thoracic surgery (RATS) techniques for lung resections. A short introduction on upcoming techniques and modalities is given. The currently available tools as three-dimensional (3D) computed tomography (CT), virtual reality, and endo-bronchial surgery will be discussed. Based on the current development, this chapter attempts to delineate the horizon of oncological lung surgery. The information is generated not only from the available literature, but also from the experiences of surgeons and other physicians as well as co-workers involved in lung cancer treatment around the world. This chapter can be seen as a general introduction to several aspects of oncological lung surgery.

Application of Thoracic Ultrasonography for Acute Cor Pulmonale in Acute Respiratory Distress Syndrome Patients

Beneficial therapeutic interventions for acute respiratory distress syndrome (ARDS) include lung protective ventilation; however, ventilator may cause or sometimes worsen acute cor pulmonale (ACP) induced by pulmonary gas exchange disorder and pulmonary vascular dysfunction due to ARDS. The incidence of ACP was 22–50% in mechanically ventilated patients. Currently, point-of-care ultrasound has been widely used in ARDS patients, which becomes much more important in the early detection and management of ARDS and its complications. Application of lung ultrasound combined with echocardiography could monitor respiratory status, hemodynamics, and cardiac function and optimize the ventilation setting in order to protect both lung and right ventricle. This chapter will discuss the pathophysiology of ACP associated with ARDS and the use of point-of-care ultrasound to make protective strategies for lung and right ventricle in detail.

COPD Pharmacological Management Update

Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide. Although it is considered both preventable and treatable, COPD still represents an important public health challenge. The classes of pharmacological agents widely used for the maintenance treatment are bronchodilators (SABA, SAMA, LABA, LAMA) and inhaled corticosteroids (ICS). While it is largely accepted that inhaled bronchodilators, which are effective and well tolerated in patients with stable disease, are the cornerstone of the pharmacological management of COPD, there is an ongoing debate regarding the role of inhaled corticosteroids. This is also reflected in the last versions of the GOLD recommendations, which suffered dramatic changes in the recent years. The trend for personalized medicine led to the search for biomarkers which could guide the therapeutic decisions. Recent studies demonstrated that blood eosinophils can reasonably predict the ICS relative efficacy in preventing COPD exacerbations and thus could inform the disease management.