Podcasts about dlco

Lung cancer is one of the most commonly diagnosed type of cancer and so it is fitting that we start the first of our disease-specific oncology series with this diagnosis. This week, we sit down with Thoracic Surgeon, Dr. Jane Yanagawa to discuss surgical considerations in treatment of NSCLC. * How do you choose what type of surgical resection to do?- Considerations: --Lung anatomy --Location of the nodule within lung--Lymph node involvement-Options: --Pneumonectomy: removal of whole lung --Lobectomy: remove a whole lobe--Segmentectomy/sublobar resection: part of a lobe* What does “adequate margins” mean? And how do you know if it's enough?- If you're removing the whole lobe, it does not matter as much - If you're doing a segmentectomy, you want to have samples evaluated while in the OR because if there is signs of more disease that initially thought, you would take this one step further and do a lobectomy. - Need to consider the patient's situation - how good is their status * Why does preoperative workup matter?- Pulmonary function tests: Surgeons are looking at the %FEV1 and %DLCO to then predict what their function would be AFTER surgery. After surgery, they want to ensure patient has %FEV1 or %DLCO >40%. - Lung anatomy: In patients with COPD and endobronchial lesions, sometimes they also get V/Q scans to evaluate ratio- Cardiac echo: Important in pneumonectomy where removal of lung tissue will also remove a significant amount of blood vessels. Want to rule out pulmonary hypertension pre-operatively. - Pulmonary hypertension can also affect someone's survival while they're ventilating with only one lung during the procedure (“single lung ventilation”). - Smoking status: Smoking can increase complications by ~60%. - Pre-habilitation: Encouraging patients to be fit prior to surgery with walking, nutrition, +/- pulmonary rehabilitation* What is “VATS”?- VATS stands for video-assisted thoracoscopic surgery; it is not, in itself, a procedure. But a VATS allows for minimally invasive surgery through the use of a camera. - It involves three incisions (axilla, lowest part of mid-axillary line, one posterior)* In what scenario is a mediastinoscopy warranted? - Needed after EBUS if there is still high index of suspicion for cancer involvement in lymph nodes, even if lymph nodes are negative from EBUS* What is “systematic lymph node sampling”?- An organized way to sample lymph nodes, including all lymph nodes that are along the way, not just the ones that may be involved * As a surgeon, how do you determine if a patient is okay for surgery if the mass is invading another structure?- Need to take the anatomy into consideration - are there major blood vessels or nerves there, for instance, which can impact outcome and recovery.* When should we consider induction chemotherapy from a surgeon's perspective?- Lots of changes in this sphere coming; lots of discrepancy between institutions when there is N2 disease - In Dr. Yanagawa's opinion, anyone with N2 disease should get neoadjuvant therapy * If there is neoadjuvant chemoradiation given, how does that effect your surgery?- Radiation increases scar tissue in the lung tissue. But what is worse is that radiation neoadjuvantly may make wound healing more difficult. She does not prefer radiation pre-operatively- Chemotherapy also adds scar tissue*How does neoadjuvant IO therapy affect scar tissue formation?- The hilum and lymph nodes are more swollen, but does not translate to more complications - She has even seen patients who had gotten IO for another cancer and then get lung cancer, she can still appreciate swollen nodes!* How long after surgery is it safe to start adjuvant therapy?- If patient has a complication from surgery, would not start right away. It is important to discuss with the surgeon about when it is okay to proceed with adjuvant therapy. - If patient has good recovery/without complications, okay to start about 4 weeks after- There is no good guidance yet about when it is safe to start IO after surgery About our guest: Jane Yanagawa, MD is an Assistant Professor of Thoracic Surgery at the UCLA David Geffen School of Medicine and the UCLA Jonsson Comprehensive Cancer Center. She completed medical school at Baylor College of Medicine, after which she went to UCLA for her surgical residency. She went onto Memorial Sloan-Kettering for her Thoracic Surgery Fellowship. In addition to her practice as a thoracic surgeon at UCLA, Dr. Yanagawa also sits on the NCCN NSCLC guidelines committee! We are so grateful she was able to join us despite her very busy schedule! Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

An interview with Dr. Jarushka Naidoo from Johns Hopkins University, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She discusses the identification, evaluation, and management of lung toxicities in patients receiving ICPis, focusing on pneumonitis in Part 5 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines   TRANSCRIPT [MUSIC PLAYING]   SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING]   BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network-- a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcast. My name is Brittany Harvey, and today we're continuing our series on the management of immune-related adverse events. I am joined by Dr. Jarushka Naidoo from Johns Hopkins University in Baltimore, Maryland. Author on management of immune related adverse events in patients treated with immune checkpoint inhibitor therapy, ASCO Guideline update, and management of immune-related adverse events in patients treated with chimeric antigen receptor T-cell therapy ASCO guideline. And, today, we're focusing on lung toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Naidoo. JARUSHKA NAIDOO: Thank you. It's my pleasure to share updates on this guideline. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO Conflict of Interest policy is followed for each guideline. The full Conflict of Interest information for this guideline panel is available online with a publication of the guidelines in the Journal of Clinical Oncology. Dr. Naidoo, do you have any relevant disclosures that are directly related to these guidelines? JARUSHKA NAIDOO: Yes. So I have research funding in the last two years from Merck, AstraZeneca, and Bristol Myers Squibb. And I also have served in a consulting role-- or an advisory board capacity-- for Merck, AstraZeneca, Bristol Myers. And not specifically related to this work, but also Pfizer, Takeda, Daiichi Sankyo, and Kaleido Biosciences. BRITTANY HARVEY: OK. Thank you for those disclosures. Then-- getting into the content of this guideline-- what are the immune-related lung toxicities addressed in this guideline? JARUSHKA NAIDOO: Thanks, Brittany. So the main lung toxicity that is addressed in this guideline is immune checkpoint inhibitor pneumonitis, which-- as this audience knows-- is an uncommon, but potentially fatal toxicity particularly associated with anti-PD-1 or PD-L1 monotherapy, but can also occur with combination immunotherapy approaches. In the guideline, we go through what is known about the natural history, risk factors, and then, of course, our comprehensive approach to identifying, evaluating, and managing this toxicity, which is defined as a focal or diffuse inflammation of the lung parenchyma. We also identify that, while pneumonitis is the quintessential lung toxicity that can occur with immune checkpoint inhibitors, we also note that there are some other lung toxicities that have been reported on, but for which we relatively little. And this includes sarcoid-like granulomatous reactions, including subpleural micronodular opacities and hilar lymphadenopathy, as well as pleural effusions. And these have been associated with both CTLA-4 and the PD-1, PD-L1 immune checkpoint inhibitor therapies. BRITTANY HARVEY: I appreciate that overview. So then, you mentioned the main toxicity here is pneumonitis. What are the key recommendations for identification, evaluation, and management of pneumonitis? JARUSHKA NAIDOO: Thanks, Brittany. So yeah, this is a key focus of the guideline. So, as we're aware, pneumonitis is defined as a focal or diffused inflammation of the lung parenchyma and is a toxicity that was identified as one of the early toxicities in the early clinical trials of the PD-1 inhibitors. The incidence of this toxicity is estimated at anywhere between 0% and 10%, and in large meta analysis, looks to be around 2% to 3% in terms of incidents. In terms of how to evaluate patients with suspected immune-related pneumonitis, the common symptoms would be cough, shortness of breath, fever, and chest pain. And in a patient who has suspected pneumonitis, some of the first tests to be done would be to take a pulse oximetry and to do some chest imaging. Chest imaging is preferable with a CT scan with contrast in order to rule out alternative etiology, such as pulmonary embolus For patients who are symptomatic-- which means CTCAE grade 2 or greater-- we also recommend a standard infectious workup, which is guided by institutional guidelines. But based on our ASCO guideline, we outline that this should include, at a minimum, a nasal swab, sputum culture and sensitivity, blood culture and sensitivity, and urine culture and sensitivity, as well as a standard COVID-19 evaluation. When we come to the diagnosis of pneumonitis, we then evaluate that in terms of CTCAE grade. Where the grade of pneumonitis refers, firstly, to whether a patient has symptoms, and the proportion of the lung parenchyma that may be involved with pneumonitis on chest imaging. Broadly speaking, patients with grade 1 pneumonitis are asymptomatic and usually identified on radiographic imaging almost incidentally. For these patients, we would recommend either holding immunotherapy or proceeding with close monitoring. And we recommend that patients should have weekly physical exams and pulse oximetry offered, and consideration of further chest imaging if the diagnosis is uncertain, or to follow progress-- usually around every three to four weeks-- or, if a patient becomes symptomatic, it may be more often than this. We also recommend that we may consider doing spirometry or DLCO evaluation as a repeat in these patients. Broadly, again, in terms of the evaluation of patients-- if patients are symptomatic from pneumonitis, which means they have a symptom related to radiographic features, then this would be called grade 2. And usually, radiographically, patients have more of the lung parenchyma involved-- greater than 25%-- and require a medical intervention. And the management would be prednisone, 1 to 2 milligrams per kilogram per day, that is then tapered over 4 to six weeks, and immunotherapy is held during that time. Importantly, in order to knuckle down the diagnosis of pneumonitis, we recommend consideration of doing a bronchoscopy with bronchoalveolar lavage sampling in order to truly rule out alternative infectious diagnoses or lymphangitis carcinomatosis. And for this reason, a transbronchial biopsy can also be considered. In some cases, we also consider treating with empiric antibiotics to cover infection if we feel that this remains in the differential diagnosis. If patients do not clinically improve after 48 to 72 hours on prednisone, then we recommend treating at a higher grade, meaning grade 3, where patients have severe symptoms, hospitalization is required, and a larger proportion of the lung parenchyma is involved. For these patients who have grade 3 or greater pneumonitis, we recommend permanently discontinuing immunotherapy, administering a higher dose of steroids at methylprednisolone, 1 to 2 milligrams per kilogram per day. And, once again-- if there is no improvement after 48 hours, we recommend a range of potential additional immunosuppressive approaches, which include either infliximab, mycophenolate mofetil, intravenous immunoglobulin, or cyclophosphamide. And there are currently no recommendations as to which may be the optimum immunosuppressive approach, but there are a number of clinical trials aiming to elucidate the answer to this. Importantly, overall in patients who are symptomatic, it may also be appropriate to consult pulmonary medicine and infectious diseases teams to weigh in on the diagnosis and management going forward. BRITTANY HARVEY: Great. Thank you for that clear, step-wise approach to the evaluation and management of pneumonitis. So then, in your view, Dr. Naidoo-- how will these recommendations for the management of lung toxicities impact both clinicians and patients? JARUSHKA NAIDOO: I think it's very important for both clinicians and patients to be aware of the potential side effects of the treatment that patients are receiving with immune checkpoint inhibitors. We know that some toxicities from immunotherapy tend to be mild and can be managed quite well with corticosteroids or other approaches. What we understand about lung toxicities is that, thankfully-- in the majority of cases-- pneumonitis will be well-controlled with corticosteroids and holding of immunotherapy. However, in a proportion of patients, pneumonitis may become severe and may even lead to treatment-related deaths. And for that reason, both patients and clinicians need to be aware of what to look out for in terms of the symptoms of pneumonitis, and how to diagnose and manage this toxicity quickly and efficiently in order to avoid poor outcomes. BRITTANY HARVEY: Absolutely. Those are excellent points for both clinicians and patients to keep in mind. So I really want to thank you for all of your work on these guidelines and for taking the time to speak with me today, Dr. Naidoo. JARUSHKA NAIDOO: You're very welcome, Brittany. And thank you to the ASCO oncology community for the opportunity to share this important work. BRITTANY HARVEY: And thank you to all of our listeners for tuning into the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune-related adverse events. To read the full guideline, go to www.asco.org/supportive care guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]

In today's episode we discuss: —Epidemiology: A retrospective case series conducted by radiologists from Zucker School of Medicine at Hofstra/Northwell in Manhasset, NY evaluated imaging features of six patients (all >65 years old) who presented to the emergency department with PCR-confirmed moderate-to-severe SARS-CoV-2 infection that was complicated by thromboembolic events. These authors suggest a hyper-inflammatory state secondary to SARS-CoV-2 infection may increase susceptibility to systemic thrombosis and recommend venous thromboembolism (VTE) prophylaxis in severe COVID-19 cases. —Understanding the Pathology: Australian pulmonologists respond to recently published data by Mo et al, 2020 that showed diffusion capacity of carbon monoxide (DLCO) and carbon monoxide transfer coefficient (KCO) in COVID-19 patients reduced by 50% and 25% after recovery, respectively. They caution against interpreting these findings as attributable only to reduced alveolar volume and instead propose that lung fibrosis in COVID-19 associated acute respiratory distress syndrome (ARDS) may lead to loss of alveolar units and disrupt the alveolar-capillary barrier. Since pulmonary vascular abnormalities (i.e. vascular pruning, reduced blood flow) may alter DLCO, authors recommend further studies using more specific measures (i.e. combined DLCO and DLNO measurements or advanced imaging techniques) to clarify the pathophysiology underlying reduced gas exchange. —Management: Emergency Medicine and Critical Care physicians in Saudi Arabia conducted a prospective observational analysis using a point-of-care ultrasound (POCUS) with the Riyadh Residual Lung Injury in COVID-19 (RELIC) scale to predict the evolution of lung injury in 171 severe COVID-19 patients and found that the combination of the two modalities were able to predict evolving interstitial lung disease with a sensitivity of 0.82 (95% CI: 0.76–0.89) and specificity of 0.91 (95% CI: 0.94–0.95). --- Support this podcast: https://anchor.fm/covid19lst/support

Background: Pulmonary alveolar proteinosis (PAP) is a rare disorder characterised by abundant alveolar accumulation of surfactant lipoproteins. Serum levels of KL-6, high molecular weight human MUC1 mucin, are increased in the majority of patients with PAP. The prognostic significance of KL-6 in PAP is still unknown. Aim of the study was to evaluate whether serum KL-6 levels correlate with the outcome of the disease. Patients and methods: From 2006 to 2012, we prospectively studied 33 patients with primary autoimmune PAP. We measured serum KL-6 levels by ELISA (Eisai, Tokyo, Japan), and evaluated the correlation between initial KL-6 levels and clinical variables. Disease progression was defined as deterioration of symptoms, and/or lung function, and/or chest imaging. Main results: The initial serum KL-6 levels were significantly correlated with the baseline PaO2, A-aDO(2), DLCO, VC and TLC (p=0.042, 0.012, 0.012, 0.02 and 0.013, respectively). The change over time of serum KL-6 correlated with the change over time of DLCO (p=0.017). The initial serum KL-6 levels were significantly higher in patients with disease progression than in those with remission (p

In Anbetracht der hohen Prävalenz an Atemwegs- und Lungenerkrankungen gewinnt deren Diagnostik und Therapie zunehmend an Bedeutung. Eine klinisch etablierte Methode zur Lungenfunktionsprüfung stellt die nicht-invasive Messung der Diffusionskapazität für Kohlenmonoxid (DLCO) dar, die Rückschluss auf die Gasaustauschfähigkeit der Lunge gibt. Welche Komponenten der Lunge- die Perfusion bzw. das Parenchym - bei reduzierter Diffusionskapazität konkret von pathologischen Veränderungen betroffen sind, lässt sich mittels des neuen Messverfahrens der kombinierten Diffusionskapazität für Kohlenmonoxid und Stickstoffmonoxid (DLNO) eruieren. Die vorliegende Untersuchung hat sich zum Ziel gesetzt, die Abhängigkeit des viel versprechenden Verfahrens von den Messbedingungen sowie die Aussagekraft der Messergebnisse bezüglich pathologischer Lungenveränderungen unter Hinzunahme bildgebender Verfahren zu prüfen. Bei Variation der Atemanhaltezeit von 4 s, 6 s, 8 s und 10 s differierten bei gesunden (n=10; Mittelwert +/- SD Alter 31 +/- 9 a; FEV(1) 108 +/- 8% Soll) und lungenkranken Probanden (n=10; Alter 33 +/- 9 a; FEV(1) 69 +/- 28% Soll) DLCO und DLNO signifikant (jeweils p < 0.05). Bei 6 s und 8 s waren jedoch für beide Studiengruppen vergleichbare Messwerte zu erheben, so dass eine standardisierte Messung der kombinierten Diffusionskapazität für CO und NO bei 6 s Atemanhaltezeit bzw. bei 8 s entsprechend den derzeit geltenden Empfehlungen zur Messung der Standard DLCO bei 10±2 s Atemanhaltezeit (MacIntyre et al., 2005) durch die Daten aktueller Untersuchung zu empfehlen ist. Der Vergleich der Messungen der kombinierten Diffusionskapazität sowie der Spirometrie und Ganzkörperplethysmographie von lungenkranken Probanden (n=21; Mittelwert +/- SD Alter 34 +/- 8 a; FEV(1) 59 +/- 13% Soll) mit deren hochauflösenden Thorax-Computertomograhien zeigte eine stärkere Korrelation mit DLCO und DLNO als mit den Messgrößen konventioneller Messmethoden, FEV1 als Standardgröße inbegriffen. Die CT Scores korrelierten am engsten mit DLNO (rS = -0.83; p < 0.001). Ferner ließ sich eine signifikante Beziehung zu DLCO (rS = -0.79; p < 0.001) und dem volumenspezifischen Transferkoeffizienten KNO (rS = -0.63; p < 0.01) nachweisen. Demnach erlaubt das neue Messverfahren der kombinierten Diffusionskapazität für CO und NO den Schweregrad struktureller Lungenalterationen nicht-invasiv zu quantifizieren. Um den Zusatznutzen vorgestellter Methode abschließend zu beurteilen, bedarf es weiterer prospektiver Longitudinalstudien.

Background: The randomized placebo-controlled IFIGENIA-trial demonstrated that therapy with high-dose N-acetylcysteine (NAC) given for one year, added to prednisone and azathioprine, significantly ameliorates (i.e. slows down) disease progression in terms of vital capacity (VC) (+9%) and diffusing capacity (DLco) (+24%) in idiopathic pulmonary fibrosis (IPF). To better understand the clinical implications of these findings we performed additional, explorative analyses of the IFGENIA data set. Methods: We analysed effects of NAC on VC, DLco, a composite physiologic index (CPI), and mortality in the 155 study-patients. Results: In trial completers the functional indices did not change significantly with NAC, whereas most indices deteriorated with placebo; in non-completers the majority of indices worsened but decline was generally less pronounced in most indices with NAC than with placebo. Most categorical analyses of VC, DLco and CPI also showed favourable changes with NAC. The effects of NAC on VC, DLco and CPI were significantly better if the baseline CPI was 50 points or lower. Conclusion: This descriptive analysis confirms and extends the favourable effects of NAC on lung function in IPF and emphasizes the usefulness of VC, DLco, and the CPI for the evaluation of a therapeutic effect. Most importantly, less progressed disease as indicated by a CPI of 50 points or lower at baseline was more responsive to therapy in this study.

Background Due to large-scale destruction, changes in membrane diffusion (Dm) may occur in cystic fibrosis (CF), in correspondence to alterations observed by computed tomography (CT). Dm can be easily quantified via the diffusing capacity for nitric oxide (DLNO), as opposed to the conventional diffusing capacity for carbon monoxide (DLCO). We thus studied the relationship between DLNO as well as DLCO and a CF-specific CT score in patients with stable CF. Methods Simultaneous single-breath determinations of DLNO and DLCO were performed in 21 CF patients (mean ± SD age 35 ± 9 y, FEV1 66 ± 28%pred). Patients also underwent spirometry and bodyplethysmography. CT scans were evaluated via the Brody score and rank correlations (rS) with z-scores of functional measures were computed. Results CT scores correlated best with DLNO (rS = -0.83; p < 0.001). Scores were also related to the volume-specific NO transfer coefficient (KNO; rS = -0.63; p < 0.01) and to DLCO (rS = -0.79; p < 0.001) but not KCO. Z-scores for DLNO were significantly lower than for DLCO (p < 0.001). Correlations with spirometric (e.g., FEV1, IVC) or bodyplethysmographic (e.g., SRaw, RV/TLC) indices were weaker than for DLNO or DLCO but most of them were also significant (p < 0.05 each). Conclusion In this cross sectional study in patients with CF, DLNO and DLCO reflected CT-morphological alterations of the lung better than other measures. Thus the combined diffusing capacity for NO and CO may play a future role for the non-invasive, functional assessment of structural alterations of the lung in CF.

In der vorliegenden Arbeit wurde eine Querschnittsanalyse der Lungenfunktion und der gesundheitsbezogenen Lebensqualität bei insgesamt 50 Langzeitüberlebenden nach ARDS untersucht (im Median 5,5 Jahre nach Extubation). Das untersuchte Patientenkollektiv rekrutierte sich aus einer 1995 retrospektiv identifizierten Kohorte von 80 ehemaligen ARDS-Patienten, die zwischen Januar 1985 und Januar 1995 an der Klinik für Anaesthesiologie der Ludwig-Maximilians-Universität München behandelt wurden. Anhand der erhobenen Daten konnte gezeigt werden: 1. Bei der Mehrzahl der ehemaligen ARDS-Patienten persistieren pathologische Lungenfunktionswerte auch noch nach Jahren, wobei sich als häufigste Störung eine Reduktion des exspiratorischen Flows im Sinne einer während des ARDS erworbenen „small airway disease“ bei 32 % aller Patienten zeigte. 2. Es konnte zwischen Schwere der initialen Lungenschädigung und dem späteren Grad der Einschränkung der Lungenfunktion keine direkte Beziehung nachgewiesen werden. 3. Es besteht ein signifikanter Zusammenhang zwischen gesundheitsbezogener Lebensqualität und Zahl der eingeschränkten Lungenfunktionsparameter. 4. Bei den meisten Patienten war die gesundheitsbezogene Lebensqualität in allen Bereichen des SF-36-Scores im Vergleich zu einer alters- und geschlechtsspezifisch identischen Kontrollgruppe reduziert. Hierbei war die größte Reduktion im Bereich der auf somatischer Ebene erfassten Kategorien festzustellen, eine geringere Reduktion zeigte sich bei psychosozialen Kategorien. Erkennbar war durch Heranziehung des SF-36-Scores der Voruntersuchung ein signifikanter Trend der Besserung bei beiden Komplexen im Langzeitverlauf. 5. Lediglich bezüglich der Diffusionskapazität DLCO besteht eine positive Korrelation zwischen Normalisierung dieses Parameters der Lungenfunktion und der gleichzeitigen Verbesserung der HRQL. 6. Leichte somatische und psychosoziale Einschränkungen bei Langzeitüberlebenden nach ARDS sind häufig nach Jahren noch nachweisbar und vermutlich von bleibender Natur. 7. Der Großteil der Patienten erreicht wieder eine generelle körperliche Erholung, einen ausreichenden HRQL- Wert und war wieder in der Lage einer Erwerbstätigkeit nachzugehen. 8. Patienten, die multiple Einschränkungen ihrer Lungenfunktion nach ARDS aufweisen, sind gefährdet eine dauerhafte, schwere Beeinträchtigung ihrer körperlichen und geistigen gesundheitsbezogenen Lebensqualität zu erleiden und benötigen daher eine gründliche körperliche und psychologische Evaluierung.