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Adnan Majid, MD; Armin Ernst, MD
Author and Funding Information

Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA

Correspondence to: Adnan Majid, MD, Beth Israel Deaconess Medical Center, One Deaconess Rd, Boston, MA 02215; e-mail: amajid@bidmc.harvard.edu


No conflicts of interest exist for either of these authors.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(5):1404. doi:10.1378/chest.09-0216
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To the Editor:

We thank Drs. Murgu and Colt1 for their insightful commentary on our recent article (October 2008) in CHEST.2 It is stated that the clinical improvements noted in the quality-of-life questionnaires, dyspnea scores, and 6-min walk distance in our population are not paralleled by a significant change in the predicted FEV1. They suggest that physiologic measurements intended to quantify the degree of hyperinflation may be a better marker in these patients.

We concur with these suggestions and believe that the quantification of resting and dynamic measurements on lung hyperinflation (inspiratory capacity [IC], inspiratory reserve volume [IRV], IC/minute volume ratio, residual volume, total lung capacity and residual volume/total lung capacity ratio) should be measured before and after surgical central airway stabilization, since there is strong evidence that their decrease correlates with improvement in symptoms and exercise endurance in the COPD population.3

We do want to clarify some of the observations of Drs. Murgu and Colt.1 They quote a previous study by Wright et al,4 where they found an improvement in the mean percent predicted FEV1 after the operation. In this study, the mean preoperative FEV1 was 51.2% predicted and increased to 73.5% predicted after the operation (p = 0.0009). It is important to note that this study was much smaller that the one we reported,2 with only 14 patients, and of those only 5 patients (35%) had an improvement of > 200 mL in FEV.

We think that spirometric measurements (FEV1) may not only reflect the collapse of the central airways, but may also relate to peripheral airway obstruction. For this reason, since the operation only stabilizes the central airways, improvement in FEV1 is expected to be variable.

Although we agree with their observations, we know that dyspnea on exertion is not the only symptom that interferes with the quality of life of these patients. As shown in previous studies,35 orthopnea, choking sensation, intractable cough, inability to clear secretions, and recurrent infections are important symptoms in this patient population. We believe that these symptoms may be related directly to central airway collapse or indirectly from secondary complications. We hypothesize that when secretions are not cleared effectively, these patients are predisposed to superinfection. This will trigger local inflammatory mediators resulting in frequent bouts of bronchospasm, bronchitis, and pneumonia. Future studies need to address the underlying pathophysiology of this process.

Murgu S, Colt H. Trancheoplasty for severe tracheobronchomalacia. Chest. 2009;135:1403-1404. [PubMed] [CrossRef]
 
Majid A, Guerrero J, Gangadharan S, et al. Tracheoplasty for severe tracheomalacia: a prospective outcome analysis. Chest. 2008;134:801-807. [PubMed]
 
O'Donnell D, Sciurba F, Celli B, et al. Effect of fluticasone propionate/ salmeterol on lung hyperinflation and exercise endurance in COPD. Chest. 2006;130:647-654. [PubMed]
 
Wright CD, Grillo HC, Hammoud ZT, et al. Tracheoplasty for expiratory collapse of central airways. Ann Thorac Surg. 2005;80:259-266. [PubMed]
 
Ernst A, Majid A, Feller-Kopman D, et al. Airway stabilization with silicone stents for treating adult tracheobronchomalacia. Chest. 2007;132:609-616. [PubMed]
 

Figures

Tables

References

Murgu S, Colt H. Trancheoplasty for severe tracheobronchomalacia. Chest. 2009;135:1403-1404. [PubMed] [CrossRef]
 
Majid A, Guerrero J, Gangadharan S, et al. Tracheoplasty for severe tracheomalacia: a prospective outcome analysis. Chest. 2008;134:801-807. [PubMed]
 
O'Donnell D, Sciurba F, Celli B, et al. Effect of fluticasone propionate/ salmeterol on lung hyperinflation and exercise endurance in COPD. Chest. 2006;130:647-654. [PubMed]
 
Wright CD, Grillo HC, Hammoud ZT, et al. Tracheoplasty for expiratory collapse of central airways. Ann Thorac Surg. 2005;80:259-266. [PubMed]
 
Ernst A, Majid A, Feller-Kopman D, et al. Airway stabilization with silicone stents for treating adult tracheobronchomalacia. Chest. 2007;132:609-616. [PubMed]
 
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