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BACKGROUND: Cough is a defense mechanism that protects the airways and lungs in response to airway irritation. The sensory neurons involved in detecting airway irritants and the neural pathways mediating cough share similarities with those that encode pain from the body. Painful conditioning stimuli applied to one body site are known to reduce the perception of pain at another. However, whether the neural regulation of cough is influenced by painful stimuli is not known. RESEARCH QUESTION: What are the behavioral and neural outcomes of painful conditioning stimuli on urge-to-cough (UTC) and cough evoked by inhaled capsaicin? STUDY DESIGN AND METHODS: Sixteen healthy participants underwent psychophysical testing and functional MRI while completing a series of capsaicin inhalations to induce UTC and cough. The responses associated with capsaicin inhalation without pain were compared with those after the application of painful conditioning stimuli. RESULTS: Significant decreases were seen behaviorally of 18.7% ± 17.3% (P < .001) and 47.0% ± 30.8% (P < .001) in participants' UTC ratings and cough frequencies, respectively, during the application of pain. UTC ratings were reduced by 24.2% ± 36.5% (P < .005) and increased by 67% ± 40% (P < .001) for capsaicin and saline inhalation, respectively, during the scanning session. Painful conditioning stimuli were associated with widespread decreases in regional brain responses to capsaicin inhalation (P < .001). Several brain regions showed levels of reduced activation attributable to painful conditioning that correlated with related changes in behavioral responses during scanning (R2 = 0.53). INTERPRETATION: Pain-related decreases of cough and UTC are accompanied by widespread changes in brain activity during capsaicin inhalation, suggesting that pain can modify the central processing of inputs arising from the airways. A mechanistic understanding of how cough and pain processing interact within the brain may help develop more effective therapies to reduce unwanted coughing.

Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. Command of such vocabulary and its application is crucial for interventional pulmonologists to successfully establish financially sustainable bronchoscopy programs. Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value.

Background Despite the existing evidence-based smoking cessation interventions, chances of achieving that goal in real life are still low among patients with COPD. We sought to evaluate the clinical consequences of changes in smoking habits in a large cohort of patients with COPD. Methods CHAIN (COPD History Assessment in Spain) is a Spanish multicenter study carried out at pulmonary clinics including active and former smokers with COPD. Smoking status was certified by clinical history and co-oximetry. Clinical presentation and disease impact were recorded via validated questionnaires, including the London Chest Activity of Daily Living (LCADL) and the Hospital Anxiety and Depression Scale (HADS). No specific smoking cessation intervention was carried out. Factors associated with and clinical consequences of smoking cessation were analyzed by multivariate regression and decision tree analyses. Results One thousand and eighty-one patients with COPD were included (male, 80.8%; age, 65.2 [SD 8.9] years; FEV1, 60.2 [20.5]%). During the 2-year follow-up time (visit 2, 906 patients; visit 3, 791 patients), the majority of patients maintained the same smoking habit. Decision tree analysis detected chronic expectoration as the most relevant variable to identify persistent quitters in the future, followed by an LCADL questionnaire (cutoff 9 points). Total anxiety HADS score was the most relevant clinical impact associated with giving up tobacco, followed by the LCADL questionnaire with a cutoff value of 10 points. Conclusions In this real-life prospective COPD cohort with no specific antismoking intervention, the majority of patients did not change their smoking status. Our study also identifies baseline expectoration, anxiety, and dyspnea with daily activities as the major determinants of smoking status in COPD. Trial Registry ClinicalTrials.gov; No. NCT01122758; URL: www.clinicaltrials.gov.

Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. Command of such vocabulary and its application is crucial for interventional pulmonologists to successfully establish financially sustainable bronchoscopy programs. Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value.

OBJECTIVE The COPD Assessment Test (CAT) has been proposed for assessing health status in COPD, but little is known about its longitudinal changes. The objective of this study was to evaluate 1-year CAT variability in patients with stable COPD and to relate its variations to changes in other disease markers. METHODS We evaluated the following variables in smokers with and without COPD at baseline and after 1 year: CAT score, age, sex, smoking status, pack-year history, BMI, modified Medical Research Council (mMRC) scale, 6-min walk distance (6MWD), lung function, BODE (BMI, obstruction, dyspnea, exercise capacity) index, hospital admissions, Hospital and Depression Scale, and the Charlson comorbidity index. In patients with COPD, we explored the association of CAT scores and 1-year changes in the studied parameters. RESULTS A total of 824 smokers with COPD and 126 without COPD were evaluated at baseline and 441 smokers with COPD and 66 without COPD 1 year later. At 1 year, CAT scores for patients with COPD were similar (± 4 points) in 56%, higher in 27%, and lower in 17%. Of note, mMRC scale scores were similar (± 1 point) in 46% of patients, worse in 36%, and better in 18% at 1 year. One-year CAT changes were best predicted by changes in mMRC scale scores (β-coefficient, 0.47; P CONCLUSIONS One-year longitudinal data show variability in CAT scores among patients with stable COPD similar to mMRC scale score, which is the best predictor of 1-year CAT changes. Further longitudinal studies should confirm long-term CAT variability and its clinical applicability. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov

Study objective To establish the prevalence of pulmonary embolism (PE) in autopsy material at a tertiary cardiac referral center and its importance as a cause of death in patients with heart disease (HD). Design Case series. Setting National Heart Institute, Mexico City. Patients One thousand thirty-two patients who died at our institution from 1985 to 1994 in whom an autopsy study was performed. Measurements and results Of the 1,032 autopsies reviewed, 231 cases (24.4%) of PE were found; 100 of these patients had a diagnosis of massive PE. Massive PE (obstruction of either of the main pulmonary arteries or more than two lobar arteries) was found to be the third cause of death in this HD population. By age-group distribution, the global prevalence of massive events was higher in patients Conclusions PE was a frequent cause of morbidity and mortality in patients with HD who underwent autopsies. The incidence of massive PE was high in children.

Objective Lung volume reduction surgery has been shown to be an effective treatment for selected patients with advanced emphysema. Nevertheless, prolonged air leaks are a significant complication that limits the utility of this procedure. This study evaluated the safety and effectiveness of a novel surgical system designed to minimize this complication. Methods In 14 dogs, severe upper lobe emphysema was produced by repeated bronchial instillations of papain administered over an approximate 6-month interval. Pulmonary function testing that included lung volumes and flows was performed at baseline, after emphysema, and at 1 month and 6 months after resection in the surgical group, while at comparable intervals in the nonsurgical group. Seven animals were randomly assigned to a surgical group to test a vacuum-assisted surgical system (VALR Surgical System; Spiration; Redmond, WA) that deploys a compression silicone sleeve over portions of the diseased tissue. The other seven dogs comprised the nonsurgical group. Results In both groups, emphysema increased total lung capacity (TLC) approximately 125% as compared to baseline. In the surgical group, no air leaks were observed after resection, and TLC significantly decreased at the 1-month and 6-month periods as compared with postemphysema measurements. At necropsy, histologic examination revealed fibrosis of the compressed lung contained within the sleeve and fibrotic encapsulation of the device. Two animals had evidence of localized infection. Conclusion We successfully created a model of predominantly upper lobe emphysema. The vacuum-assisted surgical system provided safe and effective lung reduction without air leak complications and with sustained improvement in pulmonary function over 6 months.

SESSION TITLE: Cardiothoracic SurgerySESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PMPURPOSE: There has been an increasing incidence of Obstructive Sleep Apnea (OSA) with increasing obesity. Previous studies shown that OSA increases health c

Background Acute exacerbations of COPD (AE-COPD) are a leading cause of hospitalizations in the United States. To estimate the burden of disease (eg, prevalence and cost), identify opportunities to improve care quality (eg, performance measures), and conduct observational comparative effectiveness research studies, various algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been used to identify patients with COPD. However, the validity of these algorithms remains unclear. Methods We compared the test characteristics (sensitivity, specificity, positive predictive value, and negative predictive value) of four different coding algorithms for identifying patients hospitalized for an exacerbation of COPD with chart review (reference standard) using a stratified probability sample of 200 hospitalizations at two urban academic medical centers. Sampling weights were used when calculating prevalence and test characteristics. Results The prevalence of COPD exacerbations (based on the reference standard) was 7.9% of all hospitalizations. The sensitivity of all ICD-9-CM algorithms was very low and varied by algorithm (12%-25%), but the negative predictive value was similarly high across algorithms (93%-94%). The specificity was > 99% for all algorithms, but the positive predictive value varied by algorithm (81%-97%). Conclusions Algorithms based on ICD-9-CM codes will undercount hospitalizations for AE-COPD, and as many as one in five patients identified by these algorithms may be misidentified as having a COPD exacerbation. These findings suggest that relying on ICD-9-CM codes alone to identify patients hospitalized for AE-COPD may be problematic.

Lung volume reduction surgery has been shown to be an effective treatment for selected patients with advanced emphysema. Nevertheless, prolonged air leaks are a significant complication that limits the utility of this procedure. This study evaluated the safety and effectiveness of a novel surgical system designed to minimize this complication.In 14 dogs, severe upper lobe emphysema was produced by repeated bronchial instillations of papain administered over an approximate 6-month interval. Pulmonary function testing that included lung volumes and flows was performed at baseline, after emphysema, and at 1 month and 6 months after resection in the surgical group, while at comparable intervals in the nonsurgical group. Seven animals were randomly assigned to a surgical group to test a vacuum-assisted surgical system (VALR Surgical System; Spiration; Redmond, WA) that deploys a compression silicone sleeve over portions of the diseased tissue. The other seven dogs comprised the nonsurgical group.In both groups, emphysema increased total lung capacity (TLC) approximately 125% as compared to baseline. In the surgical group, no air leaks were observed after resection, and TLC significantly decreased at the 1-month and 6-month periods as compared with postemphysema measurements. At necropsy, histologic examination revealed fibrosis of the compressed lung contained within the sleeve and fibrotic encapsulation of the device. Two animals had evidence of localized infection.We successfully created a model of predominantly upper lobe emphysema. The vacuum-assisted surgical system provided safe and effective lung reduction without air leak complications and with sustained improvement in pulmonary function over 6 months.