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The new lung allocation policy has led to an increase in distant donors and consequently enhanced logistical burden of procuring organs. Though early single-center studies noted similar outcomes between same-team transplantation (ST, procuring team from transplanting center) and different-team transplantation (DT, procuring team from different center), the efficacy of DT in the contemporary era remains unclear. In this study, we evaluated the trend of DT, rate of transplanting both donor lungs, 1-year graft survival, and risk of Grade 3 primary graft dysfunction (PGD) using the Scientific Registry of Transplant Recipient (SRTR) database from 2006 to 2018. A total of 21619 patients (DT 2085, 9.7%) with 19837 donors were included. Utilization of DT decreased from 15.9% in 2006 to 8.5% in 2018. Proportion of two-lung donors was similar between the groups, and DT had similar 1-year graft survival as ST for both double (DT, HR 1.108, 95% CI 0.894 – 1.374) and single lung transplants (DT, HR 1.094, 95% CI 0.931 – 1.286). Risk of Grade 3 PGD was also similar between ST and DT. Given our results, expanding DT may be a feasible option for improving lung procurement efficiency in the current era, particularly in light of the COVID-19 pandemic.

In November 2017, the donation service area (DSA) was removed as the primary unit of US donor lung allocation. Our primary objective was to evaluate the effect of this change on recipient characteristics, the use of pretransplant extracorporeal membrane oxygenation (ECMO), and on index hospitalization length of stay (LOS) and early posttransplant complications. We also assessed whether these outcomes differed in high and low competition centers, as defined by the Herfindahl-Hirschman Index. Following DSA removal, there was a 9-day decrease in median waitlist time (P = .001) and an increase in median lung allocation score (40 vs 42, P

The Lung Screen Uptake Trial tested a novel invitation strategy to improve uptake and reduce socioeconomic and smoking-related inequalities in lung cancer screening (LCS) participation. It provides one of the first UK-based ‘real-world’ LCS cohorts. Of 2012 invited, 1058 (52.6%) attended a ‘lung health check’. 768/996 (77.1%) in the present analysis underwent a low-dose CT scan. 92 (11.9%) and 33 (4.3%) participants had indeterminate pulmonary nodules requiring 3-month and 12-month surveillance, respectively; 36 lung cancers (4.7%) were diagnosed (median follow-up: 1044 days). 72.2% of lung cancers were stage I/II and 79.4% of non-small cell lung cancer had curative-intent treatment.

THE OBJECTIVE of our study was to increase the efficiency of treatment of tuberculosis postoperative reactivations in a previously operated lung, by clarifying the medical indications, improving surgical techniques and tactics when removing a previously resected lung.METHODS AND MATERIALS. We analyzed the results of treatment of 220 patients who, in the 2004–2017 timeframe in our institution, had pneumonectomies (76 cases) and pleuropneumonectomies (144 cases) for tuberculosis relapse in a previously operated lung. For more objective planning of surgical treatment and evaluation of its results, we identified three degrees of treatment radicalism: radical, conditionally radical, and palliative.RESULTS. 32 patients, who had carried a radical surgery, were diagnosed as having a complete clinical effect at the time of discharge (absence of destruction cavities in a single lung, bacterial excretion and illiquid complications) in 100 % of cases; in the group of patients operated conditionally radical, there were diagnosed 161 out of 168 (95.8 %) and in the group of patients operated palliative, there were distinguished only 3 cases out of 20 (15.0 %).CONCLUSION. The implementation of the completion pneumonectomy and pleurapneumonectomy is accompanied by high technical complexity and more frequent development of intraoperative and postoperative complications. At the same time, the high efficiency of treatment of tuberculosis relapses in a previously operated lung can be achieved using the recommended tactics and techniques of surgical treatment when performing radical and conditionally radical interventions.

To investigate the chest CT imaging characteristics and clinical manifestations of patients with COVID-19 pneumonia.This study included 150 patients with COVID-19 pneumonia diagnosed from January 10 to February 12, 2020 to analyze their clinical and CT imaging characteristics.The period between symptom onset and initial CT examination ranged from 1 to 8 days. There were 83 cases (55.33%) involving both lungs, 67 cases (44.67%) involving a single lung (left 25 cases and right 42 cases). There were 49 cases (32.67%) of single intrapulmonary lesion, 33 cases (22.00%) of multiple intrapulmonary lesions, 68 cases (44.00%) of diffused intrapulmonary lesions, 67 cases (44.67%) of subpleural lesions, 24 cases (16.00%) of lesions localizing along the bronchovascular bundles, and 59 cases (39.33%) with lesions in both locations. There were 18 cases (12.00%) exhibiting ground-glass nodules of 10 mm, 124 cases (82.67%) of patchy ground-glass opacities with or without consolidation, 8 cases (5.33%) of cord-like lesions, 6 cases (4.00%) of pleural effusion, and 2 cases (1.33%) of enlarged lymph nodes.The main manifestations of initial chest CT in COVID-19 pneumonia patients was ground-glass opacities, commonly involving single site in patients 35 years old and multiple sites and extensive area in patients 60 years old. The common lesion sites were the subpleural region and the posterior basal segments of the lower lobes, mostly showing thickening of the interlobular septum and mixed with consolidation.

Background We investigated the clinical value of accurate sublobectomy of pulmonary nodules using video‐assisted thoracoscopy (VATS). In June 2017 to June 2019, single lung nodule patients who accepted thoracoscopic resection were included. Palpation and intraoperative ultrasound (IU) were used to localize lung nodules, and the success rate, location time and safety compared. Performance of lung nodule ultrasound was assessed. The success rate of IU localization of pulmonary nodules with different properties was studied. Results A total of 33 cases with single pulmonary nodules were included in the study, and 32 cases (97%) were successfully located by IU as opposed to 16 cases (48.5%) located by palpation (P

INTRODUCTION: The ability to perform endotracheal intubation is one of the basic skills that paramedics should demonstrate. However, in some cases where lung or bronchial injuries have occurred, it may be necessary to separate the lung by attaching a bronchial blocker and ventilating single lung. The aim of the study was to evaluate the effectiveness of bronchial protection with VivaSight-EB bronchial blocker tube and one-lung ventilation by paramedics in conditions of simulated lung injury. MATERIAL AND METHODS: The study was a prospective randomized cross-over simulation trial in which 27 paramedics took part. In the study, paramedics performed endotracheal intubation with ETView SL and then introduced a VivaSight-EB bronchial blocker and one-lung ventilation. The bronchial protection procedure took place in two scenarios: (A) normal airway; (B) difficult airway. VivaSight-EB bronchial blocker introduction time (T1) and one-lung ventilation time (T2) and the efficacy of the procedure were analysed. RESULTS: The efficacy of endotracheal intubation with ETView SL tube was 100% during both Scenario A and Scenario B. The efficacy of endotracheal intubation with ETView SL tube was 100%. The effectiveness of the first attempt to protect the bronchi with a bronchial blocker was 26% for both scenarios and the total effectiveness of bronchial protection was 100% in both cases. Time T1 for endotracheal intubation was 18sec for Scenario A (IQR; 16.5–25) and 20 sec for Scenario B (IQR; 17–25). The time to perform one-lung ventilation (Time T2) in scenarios A and B was 43 sec (IQR; 38–62.5) vs. 43.5 sec (38–65). CONCLUSIONS: The simulation study confirmed the research hypothesis that the paramedics were able to perform one-lung ventilation using the ETView-Blocker® bronchial blocker tube after a short training.

OBJECTIVES Typically, single-lung ex vivo lung perfusion (SL-EVLP) is preferred when there is concern of contamination from the opposite lung. However, a comprehensive assessment of the SL-EVLP has not been completed. The purpose of this study is to compare the physiological parameters of SL-EVLP and double-lung EVLP (DL-EVLP) in the assessment of transplant suitability. METHODS Seven pairs of rejected donor lungs were perfused in cellular EVLP, with a tidal volume of 6 ml/kg ideal body weight and a perfusion flow of 70 ml/kg/min. The transplant suitability of each side was judged in the DL-EVLP. Subsequently, the tidal volume and flow were reduced by half. The right SL-EVLP was maintained for 10 min by clamping the left main pulmonary artery and the bronchus. Similarly, left SL-EVLP was performed. The physiological parameters were compared between SL-EVLP and DL-EVLP. RESULTS PO2/FiO2 ratio was significantly lower in SL-EVLP than in DL-EVLP [182.5 (127.5-309.5) vs 311.5 (257.5-377.0) mmHg, P

We present a novel case of a patient with nephrotic syndrome and previous left pneumonectomy who had a massive pulmonary embolism of his remnant right pulmonary artery. He underwent surgical embolectomy and veno-arterial extracorporeal membrane oxygenation (ECMO). Early embolectomy using retrograde pulmonary perfusion and post-operative ECMO helped the patient survive this catastrophic event.

Considering the insufficient understanding of pulmonary cryptococcosis (PC) with consolidation, 22 patients were evaluated based on the chest computed tomography (CT) images and clinical manifestation. The clinical symptoms were mild, mainly manifesting as cough and sputum. Pulmonary lesions mostly involved a single lobe in a single lung with multiple lesions. Specifically, single lung involvement was observed in 17 cases, single lobe in 16 cases and multiple lesions in 14 case. Fifteen cases were mainly distributed in the periphery and 17 cases in the long axis in parallel to the pleura. Nineteen cases had air bronchograms. Eight cases displayed cavitation inside the lesions and 18 cases had surrounding halo signs. Seventeen cases had pleural thickening, of which 10 cases had "pasting wall" signs. The clinical symptoms of PC with consolidation were relatively mild. Comprehensive clinical and imaging performance could improve the diagnosis of the disease.

Background The cold ischemia time (CIT) is a period of time between harvesting an organ for transplant and its reperfusion just after implantation. CIT may have an impact on frequency of complications after lung transplant that can be treated by means of bronchoscopic intervention. The aim of the study was to investigate the correlation between CIT and frequency of bronchoscopic intervention. Methods The retrospective study consists of 91 patients: 22 single lung recipients (24%) and 69 double lung recipients (76%) who underwent lung transplant from March 2012 to June 2019. All statistical analyses were performed in SPSS 25.0 and R 3.5.3. The P levels less than .05 were deemed statistically significant. Results The average CIT in single lung transplant was 5.91 hours, and in double lung transplant it was 8.61 hours. For the 4- to 8-hour CIT the percentages were 80.95% for single lung recipients and 46.38% for double lung recipients. For CIT longer than 8 hours, the following percentages were observed: 9.53% in single lung transplant and 53.62% in double lung transplant. Each subsequent hour of CIT exponentially increases the risk of intervention 1505 times (50.05%). Conclusions Prolonged CIT seems to be a risk factor for airway complication, especially in the double lung recipient group.

International audience; The first successful single-lung and double-lung transplantations were performed in the eighties. Since then both surgical and anesthesiological management have improved. The aim of this paper is to describe the surgical technique of lung transplantation: from the anesthesiological preparation, to the explantation and implantation of the lung grafts, and the preparation of the donor lungs. We will also describe the main surgical complications after lung transplantation and their management. Each step of the surgical procedure will be illustrated with photos and videos.

Background The study was conducted to retrospectively evaluate the safety and effectiveness of computed tomography (CT)‐guided percutaneous microwave ablation (MWA) for peripheral non‐small cell lung cancer (NSCLC) in 11 patients with a single lung after pneumonectomy. Methods From May 2011 to March 2015, 11 single‐lung patients (8 men and 3 women; mean age 60.3 years, range 46–71) with peripheral NSCLC underwent 12 sessions of MWA. Eleven tumors measuring 13–52 mm (mean 30.2 mm) were treated. Follow‐up was performed via CT scan at 1, 3, 6, 12, 18, and 24 months after the procedure and annually thereafter. Clinical outcomes were evaluated and complications after MWA were summarized. Results At a median follow‐up period of 20 months (range 6–38), four patients showed evidence of local recurrence at a rate of 36.4% (4/11). Median overall survival was 20 months. The overall survival rates at one, two, and three years after MWA were 88.7%, 63.6%, and 42.3%, respectively. Complications after MWA included pneumothorax (33.3%), hemoptysis (33.3%), intrapulmonary bleeding (25%), pleural effusion (16.7%), and pulmonary infection (8.3%). None of the patients died during the procedure or in the 30 days after MWA. Conclusion CT‐guided percutaneous MWA is safe and effective for the treatment of peripheral NSCLC in patients with a single lung after prior pneumonectomy.

Background: The thoracoscopic approach has become a standard procedure in the field of lung resections. However, its advantage in single-lung patients has not yet been well studied. We describe a series of successful thoracoscopic wedge resections in patients presenting with lung cancer after contralateral pneumonectomy. Methods: Eight patients, with a previous pneumonectomy (5 right and 3 left) for lung cancer, underwent resection for a suspicious neoplasm on the remaining lung. All lesions were detected in the asymptomatic phase during regular follow-up after pneumonectomy based on repeated computer tomography (CT). Only single peripheral lesions less than 2 cm were eligible for wedge resection were eligible for surgery. Videoassisted thoracoscopic, margin-free tumor wedge resections, were performed during apnea windows with the lung in a deflated position. Results: All patients were treated by a wedge resections smaller than a single segment. Only one patient needed a mini-thoracotomy conversion to accomplish a safe margin-free resection. Median total surgical operative time was 37 minutes. There were no postoperative deaths, while morbidity was 12.5%. Conclusions: Thoracoscopic surgery represents a feasible surgical option in selected patients after contralateral pneumonectomy, with careful preoperative assessment and using short apnea windows in good collaboration with anesthesiologists. Histological definition, made possible by the surgical-procedure, gives patients the possibility to eventually undergo further targeted therapies. Randomized prospective trials are necessary to assess the best management of peripheral small lung nodules in single-lung patients, in particular to define which patients can benefit from a surgical approach.

The number of patients who need cardiac support with a left ventricular assist device (LVAD) has increased over the last decade. However, the number of reports of organ retrieval from donors with an LVAD is still small. Successful lung retrieval for single lung transplantation was performed from a donor on LVAD support. This required special care not to injure the heart, great vessels, and the device, particularly the outflow conduit, because of significant conglutination around the device. A right single lung transplantation was performed successfully, with no postoperative complications. This means that patients on an LVAD could be potential donors for lung transplantation.

Glenn followed by Fontan are still the main two procedures for the treatment of patients with single ventricle. Some patients may be challenging due to unfavorable cardiopulmonary anatomy. In this report, we present Glenn shunt procedure in a patient with single pulmonary artery and congenitally agenetic lung.

Purpose Single lung transplantation (SLT) is an option for certain lung transplant recipients and allows for maximal utility of a limited donor pool. However, whether a single lung should be transplanted when the contralateral donor lung is too injured for transplant is a challenging clinical scenario. The introduction of ex vivo lung perfusion (EVLP) has improved donor lung assessment and we hypothesize that it has improved SLT outcomes in this setting. We examined outcomes in SLT recipients with and without the use of EVLP. Methods A retrospective single-centre review of all SLT performed between 2000 and 2017 was performed. To account for the introduction of EVLP in our program in 2008, we considered the years 2000-2008 the “pre-EVLP era” and 2009-2017 the “EVLP era”. SLT recipients were classified as Group 1 (Control) when both donor lungs were transplanted, Group 2 (Pre-EVLP era) when one lung was declined at the donor site and the other transplanted directly, Group 3a (EVLP era; non-EVLP) when one lung was declined at the donor site and the other transplanted directly, and Group 3b (EVLP era; EVLP utilized) when one lung was declined but the transplanted lung deemed acceptable using EVLP. The outcomes of interest were survival, time-to-extubation, and ICU and hospital stay. Results A total of 244 SLT were performed between 2000 and 2017. There were 143 SLT in Group 1, 21 in Group 2, 33 in Group 3a, and 47 in Group 3b. There was a significantly better 30-day mortality in the EVLP era (Table 1). Use of SLT increased from 12.7% of lung transplants pre-EVLP era to 16.8% in the EVLP era. Conclusion Though not every SLT with rejected contralateral lung necessitated evaluation by EVLP, the availability of EVLP allowed for additional evaluation of questionable single lungs. This has led to increased utilization rates and improved outcomes of SLT with a rejected contralateral lung in the EVLP era.

To improve the treatment of destructive tuberculosis of a single lung by using of collapse surgery.The authors analyzed an experience of collapse surgery for destructive tuberculosis of a single lung.Collapse surgery was effective in 77.5% of patients.Endoscopic surgical collapse improves the outcomes in patients with destructive tuberculosis of a single lung and expands the possibilities for surgery in these patients when resection is not applicable.Повышение эффективности лечения пациентов с деструктивным туберкулезом единственного легкого путем совершенствования коллапсохирургических операций.Проанализирован опыт применения коллапсохирургических операций по поводу деструктивного туберкулеза единственного легкого.У 77,5% пациентов операции коллапса были эффективны.Коллапсохирургические вмешательства при использовании рекомендуемых ВАТС-методик улучшают результаты лечения деструктивного туберкулеза единственного легкого и расширяют операбельность больных этой тяжелейшей категории в тех случаях, когда резекционная хирургия неприменима.

Purpose Patients with end-stage heart failure and one functioning (Fx) lung are often referred for combined heart-lung transplantations (HLTx). However, this strategy carries significant waitlist & post-transplant mortality. Between 1987 and 2018, only 37% of the pediatric patients listed for HLTx were actually transplanted. This study aims to evaluate if heart transplant alone (HTx) remains a viable option for this patient population. Methods Using both the Pediatric Health Information System (PHIS) and United Network for Organ Sharing (UNOS) databases, HTx recipients with one Fx lung and congenital heart disease between 2006 and 2015 (n=19) were identified. All other HTx recipients in a merged PHIS-UNOS database during the same period were classified as two Fx lungs (n=2,625). Post-transplantation survival rates for recipients with one and two Fx lungs were compared using Kaplan-Meier analysis. Results HTx recipients with one Fx lung had lower post-transplantation survival rates than recipients with two Fx lungs (p=0.03) but comparable conditional 60-day survival rates (p=0.56). Recipients with one Fx lung had one- and five-year survival rates of 71% and 40% with 60-day conditional one- and five-year survival rates of 100% and 90%, respectively. Five out of the six deceased HTx recipients with one Fx lung died within 60 post-operative days and before being discharged. Renal dysfunction (GFR Conclusion HTx recipients with one Fx lung can do well but seem to have a high early post-operative mortality that usually indicates high-risk recipients with multiple risk factors. Patient selection and timing of transplantation referral will be key to improving these outcomes. Keeping in mind the low percentage of waitlisted patients who actually make it to HLTx, HTx appears to be the best option for patients with end-stage heart failure and one Fx lung.

Purpose The purpose of this study was to examine outcomes and survival with extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LT) stratified by recipient age. Methods The United Network for Organ Sharing database was analyzed for patients aged ≥18 years who were bridged to a lung transplant with an ECMO between 2005 to 2018. Recipients were categorized into 3 age groups based on age at the time of listing. Baseline clinical characteristics and post-transplant in-hospital outcomes were compared among 3 age groups. The Kaplan Meier survival curves and the log rank test were used to estimate and compare survival among patient groups. Results During the study period, a total of 275 patients were bridged to LT with an ECMO. There were 154 (56%) patients aged 60 years. Mean wait-list time was comparable among patient groups (17 vs.18. vs.18 days, p =0.981). Compared to the younger patients, patients > 60 years had a higher incidence of tobacco usage, history of cardiac surgery and more likely to be transplanted for IPF, with a single lung. Mean LAS scores were lower in the >60year group than the other two patient groups. ( 60yrs. 73; p = 0.011). There was no difference in post-transplant in-hospital outcomes. Post-transplant survival at 1-year was significantly lower in the older age groups. ( 60yrs. 61%; Log rank test: p = 0.021). Conclusion Post-transplant survival after ECMO as a bridge to LT is significantly reduced in patients older than 60. Age should be strongly considered in the deciding whether to bridge patients to LT with ECMO.

We report for the first time in literature an exceptional case of a third-time lung transplantations (LTx) done on a single lung because of previous pneumonectomy in a cystic fibrosis 22-year-old female. Several hypotheses were advocate to explain the need of persistent continuous noninvasive ventilation occurred after left pneumectomy. Finally, chronic lung allograft dysfunction (CLAD) associated with near- diaphragmatic palsy secondary to lung distension was the retained diagnosis. Twenty-three months after third-time single lung retransplantation she is still alive, in good condition, with a Forced Expiratory Volume in 1 second (FEV1) measured at 47%, justifying the accepted risk and the technical difficulties of an exceptional procedure.

Background and Objective: Identifying abnormalities in chest CT scans is an important and challenging task, demanding time and effort from specialists. Different parts of a single lung image may present both normal and abnormal characteristics. Thus, detecting a single lung as healthy (normal) or not is inaccurate. Methods: In this work we propose dp-BREATH, a method capable of detecting abnormalities in pulmonary tissue regions and directing the specialist’s attention to the lung region containing them. It starts by highlighting regions that may indicate pulmonary abnormalities based on the healthy pulmonary tissue behavior using a superpixel-based approach and a heat map visualization. This is achieved by modeling regions of healthy tissue using a statistical model. All regions considered abnormal are modeled and classified according to their probability of containing each of the studied abnormalities. Further, dp-BREATH provides a better recognition of radiological patterns, with the likelihood of a selected lung region to contain abnormalities. Results: We validate the statistical model of healthy and abnormal detection using a representative dataset of chest CT scans. The model has shown almost no overlap between healthy and abnormal regions, and the detection of abnormalities presented precision higher than 86%, for all recall values. Additionally, the fitted models describing pulmonary radiological patterns present precision of up to 87%, with a high separation for three of five radiological patterns. Conclusions: dp-BREATH’s heat map representation and its list of radiological patterns probabilities provided are intuitive methods to assist physicians during diagnosis.

This chapter presents a historical milestone of lung transplantation from the early experimental studies and clinical attempts to the advances of the Toronto Group and Stanford Group to the most recent developments.

Objectives Treatment of central and ultra-central lung tumors with stereotactic ablative radiotherapy (SABR) remains controversial due to risks of treatment-related toxicities compared with peripheral tumors. Here we report our institution's experience in treating central and ultra-central lung tumor patients with SABR. Materials and Methods We retrospectively reviewed outcomes in 68 patients with single lung tumors, 34 central and 34 peripheral, all treated with SABR consisting of 50Gy in 4–5 fractions. Tumor centrality was defined per the RTOG 0813 protocol. We defined "ultra-central" tumors as those with GTV directly abutting the central airway. Results Median follow-up time was 18.4months and median overall survival was 38.1 months. Two-year overall survival was similar between ultra-central, central, and peripheral NSCLC (80.0% vs. 63.2% vs. 86.6%, P =0.62), as was 2-year local failure (0% vs. 10.0% vs. 16.3%, P =0.64). Toxicity rates were low and comparable between the three groups, with only two cases of grade 3 toxicity (chest wall pain), and one case of grade 4 toxicity (pneumonitis) observed. Patients with ultra-central tumors experienced no symptomatic toxicities over a median follow-up time of 23.6 months. Dosimetric analysis revealed that RTOG 0813 central airway dose constraints were frequently not achieved in central tumor treatment plans, but this did not correlate with increased toxicity rate. Conclusion Patients with central and ultra-central lung tumors treated with SABR (50Gy in 4–5 fractions) experienced few toxicities and good outcomes, similar to patients with peripheral lung tumors.

During lung development many internal and external factors can influence normal lung maturation. Mechanical ventilation and oxygen supplementation of preterm infants triggers bronchopulmonary dysplasia, a chronic lung disease characterised by enlarged septa thickness and less alveoli. Recently, several new methods for lung morphological analysis have been established, such as the stereological analysis of lungs embedded in plastic. A comparative, quantitative analysis of the structure of individual lung lobes has never been undertaken. In the present study, single lung lobes isolated from C57Bl/6 mice exposed to normoxia (21% O2) or hyperoxia (85% O2) from the day of birth for 14 days, were embedded in plastic, and analysed by stereology. For the whole-lung, the mean septal wall thickness was significantly increased from 10.2 μm in 21% O2 to 15.3 μm in 85% O2. In the single lobe study, the septa thickness was increased only in the caudal and left lobe from 11.4 μm in 21% O2 to 15.2 μm in 85% O2 and 11.6 μm in 21% O2 to 14.2 μm in 85% O2, respectively. The alveolar density in the whole-lung was decreased from 1.6 × 107 cm−3 in 21% O2 to 0.7 × 107 cm−3 in 85% O2. In contrast, the single lobe analysis revealed a higher alveolar density in the cranial lobe 2.2 × 107 cm−3 and in the middle lobe 2.0 × 107 cm−3 in 21% O2, which was also noted in the in 85% O2, at 1.3 × 107 cm−3 and 1.4 × 107 cm−3, respectively. The stereological study of each single lung lobe individually was more accurate and precise compared with the whole-lung analysis. Moreover, individual lung lobes in mice might follow a different development patterns, and this should be further investigated.

Computed Tomography (CT) scans are often employed to diagnose lung diseases, as abnormal tissue regions may indicate whether proper treatment is required. However, detecting specific regions containing abnormalities in a CT scan demands time and effort of specialists. Moreover, different parts of a single lung image may present both normal and abnormal characteristics, what makes inaccurate the classification of a single lung as healthy (normal) or not. In this paper we propose the BREATH method, capable of detecting abnormalities in lung tissue regions, highlighting them by means of a heat map visualization. The method starts by segmenting lung tissues using a superpixel-based approach, followed by the training of a statistical model to represent normal tissues and, finally, the generation of a heat map showing abnormal regions that require attention from the physicians. We validated our statistical model using a dataset with 246 lung CT scans, where 40 are healthy and the remaining present varying diseases. Experimental results show that BREATH is accurate for lung segmentation with F-Measure of up to 0.99. The statistical modeling of healthy and abnormal lung regions has shown almost no overlap, and the detection of superpixels containing abnormalities presented precision values higher than 86%, for all values of recall. These values support our claim that the heat map representation of BREATH for the abnormal detection can be used as an intuitive method to assist physicians during the diagnosis.

Single lung transplants (SLTs) leave in place a diseased lung, a potential source of complications. Native lung pneumonectomy is occasionally indicated. We present 2 cases of native lung complications (NLCs) managed with video-assisted thoracoscopic surgery (VATS) pneumonectomy at our institution, a procedure never reported in this context before. Case 1 involves a 59-year old gentleman with refractory, invasive pulmonary aspergillosis of the native lung, 5 years after SLT for idiopathic pulmonary fibrosis. Case 2 involves a 66-year old gentleman with α-1 antitrypsin deficiency who developed severe haemoptysis and intraparenchymal haemorrhage in the native lung 12 years after SLT. A VATS pneumonectomy was performed in both cases because we believed it would facilitate wound healing and hasten recovery in immunosuppressed patients. Our short-term results align with this hypothesis. We conclude that VATS pneumonectomy is a feasible, adequate and safe procedure in this patient population; larger series are needed to draw definitive conclusions.

Introduction To commission the Monte Carlo (MC) algorithm based model of CyberKnife robotic stereotactic system (CK) and evaluate the feasibility of patient specific QA using the ArcCHECK cylindrical 3D-array (AC) with Multiplug inserts (MP). Results Four configurations were used for simple beam setup and two for patient QA, replacing water equivalent inserts by lung. For twelve collimators (5–60 mm) in simple setup, mean (SD) differences between MC and RayTracing algorithm (RT) of the number of points failing the 3%/1 mm gamma criteria were 1(1), 1(3), 1(2) and 1(2) for the four MP configurations. Tracking fiducials were placed within AC for patient QA. Single lung insert setup resulted in mean gamma-index 2%/2 mm of 90.5% (range [74.3–95.9]) and 82.3% ([66.8–94.5]) for MC and RT respectively, while 93.5% ([86.8–98.2]) and 86.2% ([68.7–95.4]) in presence of largest inhomogeneities, showing significant differences (p Discussion After evaluating the potential effects, 1.12 g/cc PMMA and 0.09 g/cc lung material assignment showed the best results. Overall, MC-based model showed superior results compared to RT for simple and patient specific testing, using a 2%/2 mm criteria. Results are comparable with other reported commissionings for flattening filter free (FFF) delivery. Further improvement of MC calculation might be challenging as Multiplan has limited material library. Conclusions The AC with Multiplug allowed for comprehensive commissioning of CyberKnife MC algorithm and is useful for patient specific QA for stereotactic body radiation therapy. MC calculation accuracy might be limited due to Multiplan’s insufficient material library; still results are comparable with other reported commissioning measurements using FFF beams.

Single-lung transplantation (SLT) in patients with emphysema leads to a cranial displacement of the diaphragm on the transplanted side and a shift of the mediastinum toward the transplanted lung. The objective of the present study was to assess the effect of unilateral lung inflation on the mechanics of the diaphragm. Two endotracheal tubes were inserted in the two main stem bronchi of six anesthetized dogs, and radiopaque markers were attached along muscle fibers in the midcostal region of the two halves of the diaphragm. The animals were then placed in a computed tomographic scanner, the left or the right lung was passively inflated, and the phrenic nerves were stimulated while the two endobronchial tubes were occluded. As lung volume increased, the fall in airway opening pressure (ΔPao) in the inflated lung during stimulation decreased markedly, whereas ΔPao in the noninflated lung decreased only moderately ( P < 0.001). Also, the two hemidiaphragms shortened both during relaxation and during phrenic stimulation, but the ipsilateral hemidiaphragm was consistently shorter than the contralateral hemidiaphragm. In addition, the radius of curvature of the ipsilateral hemidiaphragm during stimulation increased, whereas the radius of the contralateral hemidiaphragm remained unchanged. These observations indicate that 1) in the presence of unilateral lung inflation, the respiratory action of the diaphragm is asymmetric; and 2) this asymmetry is primarily determined by the differential effect of inflation on the length and curvature of the two halves of the muscle. These observations also imply that in patients with emphysema, SLT improves the action of the diaphragm on the transplanted side.

Here we describe a case of a biologically indolent renal cell carcinoma. A single lung metastasis was found 1 yr after resection of a pT2bNxM0 Fuhrmann grade 2 tumor. After a further 1 yr, the patient was treated with IFN-alpha and bevacuzimab. Treatment for renal cell carcinoma should be tailored individually for each patient.

This brief review is meant to serve as a refresher for faculty teaching respiratory physiology to medical students. The concepts of ventilation and perfusion matching are some of the most challenging ideas to learn and teach. Some strategies to consider in teaching these concepts are, first, to build from simple to more complex by starting with a single lung unit and then adding additional units representing shunting, mismatch, and deadspace. Second, use simplified analogies, such as a bathtub, to help students conceptualize new ideas. Third, introduce the concept of alveolar to arterial O2 differences and the mechanisms for increasing differences as additional lung units are added. Fourth, use the consistent thread of causes of hypoxemia through the lecture to maintain continuity and provide clinical relevance. Finally, use clinically relevant examples at each step and solidify new concepts by discussing differential diagnoses at the end of the lecture(s).

Objective: Ischemia-reperfusion (I/R) injury of the lungs is still a critical problem and a challenge in the field of thoracic and cardiovascular surgery. This study will evaluate effects of Ulinastatin(UTI) on the Intercellular Adhesion Molecule-1(ICAM-1) in the lung ischemia-reperfusion injury of rats. Methods: Single lung in suit warm I/R animal model was used. The rats were subjected to 90 min left lung ischemia followed by 30 min and 120 min of reperfusion separately. The animals were divided into 6 groups. The lungs were removed before ischemia (group pre-I, n=6), before reperfusion (group pre-R, n=6), 30 min (group NU-30, n=6) and 120 min (group NU-120, n=6) after reperfusion began. The UTI (50000 U/kg) was administered just before reperfusion began and the lungs were removed 30 min (group U-30, n=6) and 120 min (group U-120, n=6) after reperfusion began. For ELISA assay of ICAM-1, the supernatants from left lung tissue homogenates were used. Results: The level of ICAM-1 was increasing as ischemia and reperfusion lasted from Group Pre-R to Group Nu- 120. When UTI was admitted before reperfusion, the ICAM-1 was down-regulated as seen in the Group U-30 and the group U-120, but in the group U-30 the ICAM-1 was down-regulated significantly(P

Background After pneumonectomy, the development of a new lung cancer or a recurrence in the residual lung is a challenge. Surgery often is considered contraindicated. The goal of our study is to assess the morbidity and mortality of lung resection on a single lung. Methods All patients who underwent lung resection after pneumonectomy from January 1996 through December 2012 were reviewed. Results There were 12 patients (10 men and 2 women). Mean age was 71 years (range, 54–81 years). Mean preoperative FEV 1 was 1470 mL (52%) and preoperative FVC 2153 mL (61.5%). Subsequent pulmonary resection was performed after a median follow-up of 34.5 months. Wedge resection was performed in all patients. Diagnosis was pulmonary metastatic lung cancer in 2 patients, metachronous lung cancer in 6, metastatic extrathoracic cancer in 3 and benign nodule in 1. Complications occurred in 4 patients (33.4%) while operative mortality was nil. Conclusions Lung resection on a single lung is a safe procedure associated with acceptable morbidity and mortality. Careful patient selection is very important.

Pulmonary artery slings are rare congenital anomalies seen only on the left side. The presence of right pulmonary artery (RPA) sling is extremely rare. We report a case of a RPA sling with a single lung associated with tracheal stenosis and its management.

This retrospective study was conducted to compare the clinical outcomes of radiofrequency ablation (RFA) with those of stereotactic body radiotherapy (SBRT) in patients with lung tumors. Local tumor progression, adverse events, and overall survival were compared in patients who underwent either RFA or SBRT for a single lung tumor measuring 5 cm or smaller. This study was approved by the institutional review boards of two institutions. Informed consent was waived. During September 2009 to June 2012, 48 patients [30 males and 18 females, with a mean age ± standard deviation (SD) of 75.0 ± 7.5 years] underwent RFA at one institution and 47 patients (21 males and 26 females, with a mean age ± SD of 77.0 ± 7.5 years) underwent SBRT in another. The mean maximum tumor diameter ± SD was 2.0 ± 0.8 cm (range 0.6−3.9 cm) in the RFA group, and 2.1 ± 0.9 cm (range 0.8–4.7 cm, p = 0.539) in the SBRT group. The RFA and SBRT groups showed similar 3-year local tumor progression [9.6 %, 95 % confidence interval (CI) 3.6–23.9 % vs. 7.0 %, 95 % CI 0.2–20.2 %, p = 0.746] and overall survival rates (86.4 %, 95 % CI 69.2–94.3 % vs. 79.6 %, 95 % CI 60.6–90.1 %, p = 0.738). No factor significantly affected local tumor progression. A maximum tumor size of 2 cm was identified as a prognostic factor in both univariate and multivariate analyses. No death was related to treatment procedures. Major complication rates (Grade 3 adverse events) of the RFA (10.4 %, 5/48) and SBRT (8.5 %, 4/47, p > 0.999) groups were similar. For lung tumor patients, lung RFA provided local tumor control and survival that were similar to those achieved using SBRT, with equal safety.

Pulmonary bipartitioning or split lung transplantation, which was first described in 1997, presently represents the most efficient use of donor lungs. With this technique, a left donor lung can be separated into an upper and lower lobe and used for bilateral transplantation in a smaller recipient. The right donor lung remains for use as a single lung graft in another patient. In 2001, a similar technique for splitting a right lung was described. The technique of harvesting and procurement of the donor organ for split lung transplantation is identical to the standard lung transplantation technique. The final separation of the donor lung is performed at the level of the interlobar fissure immediately prior to implantation. The lower lobe is implanted in the left recipient hemithorax, whereas the upper lobe, after closing of the central end of the left main pulmonary artery, and a 180° rotation along the vertical axis, is grafted into the right hilus. The use of extracorporeal membrane oxygenation (ECMO) provides intraoperative hemodynamic stability and protects the first implanted lobe from overflow and resulting reperfusion injury. This report discusses the technique developed at the department of cardiothoracic surgery of the Medical University of Vienna.

By enhancing gaseous uptake from the non-ventilated lung during procedures performed thoracoscopically, the rapid diffusion properties of nitrous oxide would be expected to speed lung collapse and so facilitate surgery. To assess the effect of nitrous oxide on the speed of absorptive lung collapse, a study was conducted using 11 anaesthetised sheep. Speed of collapse was assessed in an indirect manner by recording the time required in a closed-chest situation for the airway pressure distal to a single lung airway occlusion to decrease to - 1.0 kPa. The influence of nitrous oxide was assessed by comparing the time taken for this decrease in airway pressure when the animal was being mechanically ventilated with 50% nitrous oxide in oxygen with the time taken when using 100% oxygen. In all assessments, it was found that the decrease in airway pressure to - 1.0 kPa occurred in a shorter time when nitrous oxide was used. The findings lend support to the hypothesis that during thoracoscopic surgery, mechanical lung ventilation with an oxygen/nitrous oxide mixture will increase the rate of gaseous uptake from the non-ventilated lung and so hasten its absorptive collapse.

Whole organ decellularization of complex organs, such as lungs, presents a unique opportunity for use of acellular scaffolds for ex vivo tissue engineering or for studying cell-extracellular matrix interactions ex vivo. A growing body of literature investigating decellularizing and recellularizing rodent lungs has provided important proof of concept models and rodent lungs are readily available for high throughput studies. In contrast, comparable progress in large animal and human lungs has been impeded owing to more limited availability and difficulties in handling larger tissue. While the use of smaller segments of acellular large animal or human lungs would maximize usage from a single lung, excision of small acellular segments compromises the integrity of the pleural layer, leaving the terminal ends of blood vessels and airways exposed. We have developed a novel pleural coating using non-toxic ionically crosslinked alginate or photocrosslinked methacrylated alginate which can be applied to excised acellular lung segments, permits inflation of small segments, and significantly enhances retention of cells inoculated through cannulated airways or blood vessels. Further, photocrosslinking methacrylated alginate, using eosin Y and triethanolamine (TEOA) at 530nm wavelength, results in a mechanically stable pleural coating that permits effective cyclic 3-dimensional stretch, i.e. mechanical ventilation, of individual segments.

The "low-probability" interpretation of ventilation-perfusion lung scans has been characterized as misleading or even dangerous because of the high prevalence of pulmonary embolism associated with such an interpretation. Since the completion of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study, analyses of the PIOPED database have allowed identification of several abnormalities seen on ventilation-perfusion scans that have a positive predictive value (PPV) for pulmonary embolism of less than 10%. These include nonsegmental perfusion abnormalities (PPV = 8%), perfusion defects smaller than the corresponding areas of increased opacity at chest radiography (PPV = 8%), matched ventilation-perfusion abnormalities in two or three zones of a single lung (PPV = 3%), one to three small segmental perfusion defects (PPV = 1%), triple matched defects in the upper or middle lung zone (PPV = 4%), and the stripe sign (PPV = 7%). Use of these abnormalities as interpretative criteria constitutes "very low probability" interpretation and will reduce the number of low-probability interpretations of ventilation-perfusion lung scans, which may be considered nondiagnostic because of the unacceptably high rate of false-negative results. This will enhance the utility of the ventilation-perfusion lung scan for screening patients with suspected pulmonary embolism.

Introduction The major limiting factor for lung transplantation (LT), both worldwide and in Spain, is the number of suitable lung donors. This, together with the increased demand for LT, led us to propose the performance of 2 single lung transplantations simultaneously using the same donor (the “twinning procedure”). Objective The objective of this study was to analyze the outcome of patients who underwent transplantation with this procedure, assessing differences between the first and the second transplant. Patients and Methods From November 2001 to August 2008, 46 single lung transplantations (SLTs) were performed with 23 donors. Results The mean ischemia time was 258 minutes (median, 265) for the first transplantation and 312 minutes (median, 320) for the second transplantation. Primary graft dysfunction occurred in 5 patients (24%) in the first group and 9 in the second group (39%; P = .27). The median intubation time was 8 hours for the first and 6.5 hours for the second group. The mean hospital stay was 39 and 31 days, respectively. Postoperative mortality was 2 (8.7%) and 3 (13%) patient, respectively ( P = .99). There was no significant difference in the incidence of acute rejection episodes, infections, or chronic rejections. Five-year survival rates were 67.9% for the first and 61.5% for the second (Kaplan-Meier). Conclusions The performance of 2 SLTs using the same donor and in the same hospital was feasible with adequate planning, permitting better use of donors and reducing waiting list time and mortality. Our results showed no increased risk for recipients of the second transplant in the early postoperative and long-term periods.

The purpose of this study was to determine the chest radiographic findings of acute rejection and the accuracy of chest radiography in making this diagnosis in patients undergoing lung transplantation. For each of 100 transbronchial biopsies performed on 25 lung transplant recipients (single lung in three, double lung in 22), chest radiographs obtained within 24 hours before the biopsy were reviewed retrospectively without knowledge of clinical or biopsy information. Transbronchial biopsy revealed 42 instances of acute rejection in 17 patients and 58 instances of no acute rejection (normal, n = 43; other processes, n = 15). All pulmonary parenchymal radiographic abnormalities were assessed. Acute rejection was associated with the presence of middle or lower lung reticular interstitial or airspace disease in 21 lungs (sensitivity = 0.50 [21/42]). This pattern was seen in 18 lungs without acute rejection (specificity = 0.69 [40/58]). There was no difference in the appearance of the lungs between grades 1 and 2 acute rejection. Normal lungs were noted in 20 instances of acute rejection (48%). The authors conclude that chest radiograph findings are abnormal in about 50% of instances of biopsy-proven acute rejection. Because the appearance of acute rejection is similar to that of other conditions, the diagnosis cannot be made accurately by chest radiography.

The hemodynamic effect and degree of damage in grafts of single lung transplants for pulmonary hypertension were studied in rats with monocrotaline-induced pulmonary hypertension. Inbred male Lewis rats (weight 200-230 g) were divided into two groups. Group 1 (control group, n = 16) underwent isogenic left lung transplantation, while group 2 (n = 15) received an intravenous administration of monocrotaline (80 mg/kg i.v.) and underwent isogenic left single lung transplantation 3 week later. Hemodynamic evaluations were performed prior to transplantation, at 1 h postoperatively, and on days 3 and 7 after transplantation. Mean pulmonary arterial pressure (mPAP) rapidly declined after transplantation in group 2, from 39.3 +/- 8.7 mmHg to 18.5 +/- 3.0 mmHg 1 h after transplantation, and remained stable on day 7 after transplantation. No significant difference in the mPAP between the two groups was observed after transplantation. The extravascular lung water volume (ELWV: dry/wet ratio) in the right lung of group 2 significantly increased on day 3 (0.86 +/- 0.02) (P0.01), and subsequently decreased to control levels on day 7 (0.83 +/- 0.02). There was no significant difference in the ELWV in the grafted lungs between the two groups (0.84 +/- 0.03 vs 0.86 +/- 0.04), but there was tendency toward an increase in ELWV in group 2 on days 3 and 7. These data thus demonstrated that a hemodynamic improvement was obtained by single lung transplantation; however the degree of graft damage was remarkable in the pulmonary hypertension group.