U.S. Center for the Alpha One International Registry

AIR Research

Semin Thorac Cardiovasc Surg 2002 Oct;14(4):371-80

Patient selection for lung volume reduction surgery: Is outcome predictable?

Bloch KE, Russi EW, Weder W.

Pulmonary and Thoracic Surgery Divisions, University Hospital of Zurich,
Switzerland.

Patient selection for lung volume reduction surgery (LVRS) relies on sound
physiologic concepts and experience from large case series. LVRS should be
considered in severely symptomatic emphysema with marked airflow obstruction and
hyperinflation despite optimal medical management, and in the absence of major
comorbidities associated with excessive perioperative risks. Qualitative
estimation of functional benefit from LVRS in suitable candidates has been based
on functional criteria (e.g., high inspiratory conductance, high residual
volume/total lung capacity ratio), on heterogeneity of emphysema assessed by
computed tomography (CT) or perfusion scans, and on severity of emphysema
assessed by CT or impaired diffusing capacity. Selection strategies relying on
such criteria have provided favorable functional results at a low mortality, but
further validation of potential outcome predictors in prospective trials is
needed. Copyright 2002, Elsevier Science (USA). All rights reserved.

Chest 2003 Mar;123(3):845-53

Long-term assessment of lung function in survivors of severe ARDS.

Neff TA, Stocker R, Frey HR, Stein S, Russi EW.

Institute of Anesthesiology, University Hospital Zurich, Switzerland.

STUDY OBJECTIVES: To investigate the long-term outcome of lung function in
survivors of severe ARDS after modern treatment strategies including lung
protective mechanical ventilation and prone positioning maneuvers. DESIGN:
Follow-up cohort study. SETTING: University hospital pulmonary division and
level 1 trauma center. PATIENTS: Sixteen survivors of severe ARDS (from 1992 to
1994) with a lung injury score > or = 2.5. MEASUREMENTS: The follow-up study
(from 1995 to 1996) included interview, physical examination, chest radiographs,
static and dynamic lung volumes, diffusion capacity of the lung for carbon
monoxide (DLCO), blood gas analysis, and cardiopulmonary exercise testing
(CPET). RESULTS: The mean +/- SD interval between hospital discharge and
functional assessment was 29.5 +/- 8.7 months (range, 15.0 to 40.7 months). In
approximately one half of the patients, mild abnormalities in static and dynamic
lung volumes were found. In 25% (4 of 16 patients), lung function was
obstructive; in 25% (4 of 16 patients), lung function was restrictive; and in
6.3% (1 of 16 patients), a combined obstructive-restrictive pattern was
revealed. DLCO was impaired in 12.5% (2 of 16 patients); gas exchange during
exercise was impaired in 45.5% (5 of 11 patients). CONCLUSIONS: Residual
obstructive and restrictive defects as well as impaired pulmonary gas exchange
remain common after severe ARDS. CPET is a very sensitive measure to evaluate
residual impairment of lung function after ARDS. Using CPET, reduced pulmonary
gas exchange can be detected in many patients with normal DLCO.

Swiss Med Wkly 2002 Nov 2;132(39-40):557-61

News on lung volume reduction surgery.

Russi EW, Weder W.

Pulmonary Division, University Hospital of Zurich, CH-8091 Zurich, Switzerland.
erich.russi@dim.usz.ch

Lung volume reduction surgery (LVRS) is an established therapeutic option for
patients with advanced pulmonary emphysema after all conservative measures,
including comprehensive pulmonary rehabilitation, have been exhausted. LVRS
improves pulmonary function, shortness of breath, exercise capacity and hence
quality of life in some 80% of cases for up to four years. Even patients with
homogeneous types of pulmonary emphysema improve if those with extremely low
FEV1 and/or very low diffusion capacity are excluded. At experienced centres
perioperative mortality is less than 2% in appropriately selected patients, and
current results suggest that the five-year survival in COPD patients may even be
improved by this palliative surgical intervention. In patients under 60 LVRS may
serve as a bridging procedure to lung transplantation. Bronchoscopic creation of
extraanatomic bronchopulmonary passages--endoscopic LVRS--is a novel approach
now under investigation.

Swiss Med Wkly 2002 Aug 10;132(31-32):455-8
Tolerability, safety and efficacy of conventional amphotericin B administered by
24-hour infusion to lung transplant recipients.

Speich R, Dutly A, Naef R, Russi EW, Weder W, Boehler A.

Medical Clinic A, Zurich University Hospital, Switzerland. klinspr@usz.unizh.ch

BACKGROUND: Fungal infections cause serious morbidity and mortality in lung
transplant recipients. Expensive lipid formulations of amphotericin B (AmB) are
generally used because of fear of adverse effects due to concomitant
cyclosporine A and other nephrotoxic drugs. However, a 24-hour dosing regimen of
AmB may be well tolerated even in these patients. METHODS: In an open pilot
study 6 out of 94 lung transplant recipients with invasive or semi-invasive
bronchopulmonary azole-resistant candidal infections (3 paraspilosis, 2
glabrata, 1 krusei) were treated for 40 (17-73) days by 24-hour continuous
infusions of AmB 1 mg/kg. Additionally, patients received at least 1000 ml of
0.9% saline intravenously per day. Beside cyclosporine A at serum trough levels
of 240 (195-273) microg/l, five patients additionally received aminoglycosides
for at least 2 weeks, and 4 were treated with ganciclovir. RESULTS: Calculated
creatinine clearance decreased from 57 (43-73) ml/min to a nadir of 35 (28-39)
and recovered to 52 (33-60) after cessation of therapy. One patient needed
temporary haemofiltration for 7 days after 30 days of AmB, most probably because
of the use of contrast media in conjunction with furosemide and hypovolaemia.
Besides three episodes of mild hypokalaemia no other side effects attributable
to AmB were recorded. While in one case an asymptomatic candidal colonisation
persisted for 10 months, the other 5 were cured from their infection.
CONCLUSION: These preliminary data show that conventional AmB administered by
24-hour infusion is well tolerated, safe, and efficacious in lung transplant
recipients receiving cyclosporine A and other nephrotoxic substances.

Swiss Med Wkly 2002 Jun 29;132(25-26):338-44

Complementary and alternative medicine in asthma: do they work?

Steurer-Stey C, Russi EW, Steurer J.

Department of Internal Medicine, Medical Policlinic, University Hospital Zurich,
Switzerland. claudia.stey@dim.usz.ch

OBJECTIVE: An increasing number of patients with asthma are attracted by
complementary and alternative medicine (CAM). Therefore, it is of importance
that scientific evidence about the efficacy of this type of therapy is regarded.
METHOD: We searched the electronic databases Medline, Embase and the Cochrane
Library for controlled trials and systematic reviews to evaluate the evidence of
the most popular alternative therapies, i.e. acupuncture, homeopathy, breathing
techniques, herbal and nutritional therapies. RESULTS: Claims that acupuncture
is effective for the treatment of asthma are not based on well-performed
clinical trials. The role of homeopathy in the treatment of asthma needs further
evaluation. Breathing techniques, e.g. improved control of breathing by yoga,
may contribute to the control of asthma symptoms, but due to the small number of
controlled trials and due to the small number of patients it is not possible to
make firm judgments. Herbal remedies cannot be recommended based on the
available evidence. Recommendations for a diet high in vitamin C and marine
fatty acids are not harmful, but evidence for clinically meaningful effects are
scant. CONCLUSION: Up to now evidence is lacking that alternative forms of
medicine are more effective than placebo in asthma. However, lack of evidence
does not always mean that treatment is ineffective, but it could mean that
effectiveness has not been adequately investigated. High quality research as in
conventional therapy should be fostered in complementary medicine.

Psychother Psychosom 2002 Nov-Dec;71(6):333-41

Preliminary validation of PRISM (Pictorial Representation of Illness and Self
Measure) - a brief method to assess suffering.

Buchi S, Buddeberg C, Klaghofer R, Russi EW, Brandli O, Schlosser C, Stoll T,
Villiger PM, Sensky T.

Psychiatric Department, University Hospital Zurich, Switzerland.
sbuechi@psyp.unizh.ch

BACKGROUND: Alleviation of suffering is widely acknowledged as one of the main
goals of medicine. However, no measure to assess this crucial aspect of illness
has been developed to date. AIMS: To validate PRISM (Pictorial Representation of
Illness and Self-Measure) as a simple quantitative method of assessing the
perceived burden of suffering due to illness. METHODS: Validity and reliability
studies to date have involved over 700 patients with a variety of chronic
physical illnesses. RESULTS: Reliability of PRISM is good (test-retest
reliability r = 0.95; p < or = 0.001, interrater reliability r = 0.79; p < or =
0.001). Qualitative data indicate that the interpretation of the PRISM task is
not only consistent among patients, but also consistent with that expected from
existing literature on suffering. As expected, PRISM shows strong correlations
with psychological variables (notably depression and coping resilience) and also
correlates with SF-36 subscale scores. Prospective longitudinal data demonstrate
that PRISM is sensitive to therapeutic change. It is very acceptable to patients
and takes less than 5 min to administer. CONCLUSION: In the absence of a 'gold
standard' measure of suffering, our validation data must be interpreted with
caution. However, the performance of PRISM is entirely consistent with what
would be expected of a measure of suffering, based on current published work.
Copyright 2002 S. Karger AG, Basel

Chest 2002 Aug;122(2):747-50

Successful lung volume reduction surgery in a child with severe airflow
obstruction and hyperinflation due to constrictive bronchiolitis.

Bloch KE, Weder W, Boehler A, Zalunardo MP, Russi EW.

Pulmonary Division, University Hospital of Zurich, Switzerland.
pneubloc@usz.unizh.ch

Lung volume reduction surgery (LVRS) may improve pulmonary function in patients
with severe emphysema. However, its effects in other types of obstructive lung
disease are unknown. To delay the need for lung transplantation, we performed
LVRS in a 14-year-old boy with disabling airflow obstruction/hyperinflation
secondary to postinfectious bronchiolitis nonresponsive to medical therapy.
Within days after LVRS, a major improvement of symptoms and lung function
occurred and persisted for > 1 year. Our observation suggests that LVRS may be a
novel treatment option in selected patients with extreme hyperinflation even if
the underlying disease is not emphysema.

Am J Transplant 2002 Feb;2(2):167-72

Osteoporosis before lung transplantation: association with low body mass index,
but not with underlying disease.

Tschopp O, Boehler A, Speich R, Weder W, Seifert B, Russi EW, Schmid C.

Division of Pulmonary Medicine, University Hospital, Zurich, Switzerland.

Due to progress in lung transplantation, post-transplantation osteoporosis
becomes an important problem. We determined bone mineral density (BMD) in 74
lung transplantation candidates, among them 24 patients with cysticfibrosis, 16
with chronic obstructive pulmonary disease, 14 with pulmonary fibrosis, and 11
with pulmonary hypertension. The mean T score (+/- SD) was -2.6 +/- 1.3 at
femoral neck (FN), -2.2 +/- 1.6 at Ward's triangle (WT) and -2.3 +/- 1.5 at
lumbar spine (LS). Osteoporosis was found in 61% of the patients at FN, 45% at
WT and 50% at LS. Patients with different underlying lung diseases were
similarly affected, not only those with cystic fibrosis but also others,
including patients with pulmonary hypertension. No association was found between
BMD and age, gender, menstrual condition in women and testosterone level in men.
A negative correlation was found between chronic glucocorticoid use and T
scores. Body mass index correlated positively (p < 0.01) with T scores at any
site and the correlation was also significant for the 2 largest subgroups. Loss
of lung function (FEV1) also was associated with lower T scores. No correlation
was found between BMD and biochemical indices of bone turnover. Multivariate
analysis revealed BMI and glucocorticoid use as independent risk factors. We
conclude that osteoporosis is a very common condition in patients with end-stage
pulmonary disease, independent of the underlying diagnosis. In view of
additional bone loss under immunosuppressive treatment after lung
transplantation, early diagnosis and prevention of osteoporosis in the
pretransplant period should receive high priority.

J Thorac Cardiovasc Surg 2002 May;123(5):845-54

Gain and subsequent loss of lung function after lung volume reduction surgery in
cases of severe emphysema with different morphologic patterns.

Bloch KE, Georgescu CL, Russi EW, Weder W.

Pulmonary and Thoracic Surgery Division, University Hospital of Zurich,
Switzerland.

OBJECTIVE: Surgical lung volume reduction improves lung function and dyspnea in
advanced emphysema to a variable degree. Because long-term results with this
procedure are scant, we prospectively investigated lung function over several
years after lung volume reduction surgery with regard to emphysema morphology.
METHODS: Bilateral video-assisted thoracoscopic lung volume reduction surgery
was performed in severely symptomatic patients with marked hyperinflation caused
by advanced nonbullous emphysema. Emphysema heterogeneity was visually graded on
chest computed tomography. Symptoms and lung function were assessed before the
operation and 3, 6, and then every 6 months after the operation. RESULTS: A
total of 115 patients with a median forced expiratory volume in 1 second of 0.73
L (27% of predicted value) underwent lung volume reduction surgery. Follow-up
extended over a median of 37 months. Median forced expiratory volume in 1 second
significantly increased within 6 months after the operation by 37% in
homogeneous (n = 27), by 38% in intermediately heterogeneous (n = 37), and by
63% in markedly heterogeneous emphysema (n = 51, P <.05 vs. other morphologies).
Maximal forced expiratory volume in 1 second was reached within 6 months after
lung volume reduction surgery and decreased in the first postoperative year by
0.16 L per year in homogeneous, by 0.19 L per year in intermediately
heterogenous, and by 0.32 L per year in markedly heterogeneous emphysema (P <.01
vs. other morphologies). The decline in forced expiratory volume in 1 second
over subsequent years decelerated according to an exponential decay and was
similar for all morphologic types (median annual decrease of 0.09 L [9%]).
CONCLUSIONS: Lung volume reduction surgery improves lung function in severe
homogeneous and, to an even greater extent, heterogeneous emphysema. Forced
expiratory volume in 1 second peaks within 6 months postoperatively. The
subsequent decline is most rapid in the first year and slows down in succeeding
years according to an exponential decay. Therefore, long-term functional results
of lung volume reduction surgery may be more favorable than expected from linear
extrapolations of short-term observations.

Swiss Med Wkly 2002 Feb 9;132(5-6):67-78

Management of chronic obstructive pulmonary disease: the Swiss guidelines.
Official Guidelines of the Swiss Respiratory Society.

Russi EW, Leuenberger P, Brandli O, Frey JG, Grebski E, Gugger M, Paky A, Pons
M, Karrer W, Kuhn M, Rochat T, Schibli R, Soler M, Wacker J.

Pulmonary Division, University Hospital of Zurich. erich.russi@dim.usz.ch

Thorax 2002 Mar;57(3):277-80

BAL findings in a patient with pulmonary alveolar proteinosis successfully
treated with GM-CSF.

Schoch OD, Schanz U, Koller M, Nakata K, Seymour JF, Russi EW, Boehler A.

Division of Pulmonary Medicine, University Hospital, Zurich, Switzerland.

BACKGROUND: Idiopathic pulmonary alveolar proteinosis (PAP) has recently been
recognised as a disease of impaired alveolar macrophage function caused by
neutralising anti-granulocyte-macrophage colony-stimulating (anti-GM-CSF)
autoantibodies. Subcutaneous recombinant human GM-CSF is a novel treatment for
PAP, but its mechanism of action is unclear. METHODS: Clinical, functional, and
bronchoalveolar lavage (BAL) findings were prospectively evaluated in a patient
with PAP treated with daily subcutaneous GM-CSF 8 microg/kg for 12 weeks.
RESULTS: Treatment resulted in improvements in dyspnoea, lung function, and peak
cycle ergometry performance. In serum and BAL fluid the titre of anti-GM-CSF
autoantibodies was raised at baseline and markedly reduced on treatment. At
baseline the BAL fluid cellular profile showed a decrease in the absolute number
and the percentage of macrophages (50%) and an increase in lymphocytes (45%),
predominantly CD4+. This cellular distribution remained unchanged after 6 and 12
weeks of treatment while macrophages became morphologically normal and
functionally improved. Extracellular proteinaceous material completely
disappeared. CONCLUSIONS: Clinically successful treatment of PAP with GM-CSF was
associated with a profound reduction in GM-CSF neutralising autoantibodies,
improvement in alveolar macrophage morphology and function, but persistent BAL
lymphocytosis.

Eur Respir J 2002 Jan;19(1):54-60

Improved quality of life after lung volume reduction surgery.

Hamacher J, Buchi S, Georgescu CL, Stammberger U, Thurnheer R, Bloch KE, Weder
W, Russi EW.

Dept of Internal Medicine, University Hospital, Zurich, Switzerland.

Lung volume reduction surgery (LVRS) improves dyspnoea, pulmonary function, and
physical performance in patients with severe pulmonary emphysema. This study
investigated the impact of LVRS on health-related quality of life (HRQL) over a
2-yr period following surgery. Thirty-nine consecutive patients were
prospectively assessed before LVRS, and followed over 24 months postoperatively.
The assessments included pulmonary function, dyspnoea (Medical Research Council
(MRC) dyspnoea score), 6-min walking distance (6MWD) and HRQL using the Short
Form 36-item questionnaire (SF-36). Several domains of SF-36 improved
considerably over 2 yrs after surgery: Physical Functioning: 39 +/- 4 (mean +/-
SEM) versus 16 +/- 2 (p<0.01); Vitality: 51 +/- 3 versus 32 +/- 3 (p<0.01);
Social Functioning: 72 +/- 4 versus 51 +/- 5 (p<0.01). Also, improvements in
pulmonary function (forced expiratory volume in one second (FEV1): 27 +/- 1%
predicted, residual volume (RV)/total lung capacity (TLC): 0.65 +/- 0.01), 6 MWD
(274 +/- 16 m) and dyspnoea (MRC: 3.9 +/- 01) were sustained for up to 2 yrs
after LVRS (FEV1 36 +/- 2% pred, RV/TLC: 0.58 +/- 0.02; 6 MWD: 342 +/- 19 m;
MRC: 2.0 +/- 0.2; p<0.05). In patients with severe emphysema, lung volume
reduction surgery had positive effects on health-related quality of life and
pulmonary function over 2 yrs.

Pneumologie 2002 Feb;56(2):132-7

Difficult to manage asthma: clinical phenotypes and principles of therapy

[Article in German]

Menz G, Buhl R, Gillissen A, Kardos P, Matthys H, Pfister R, Russi EW, Simon HU,
Vogelmeier C, Wettengel R, Worth H, Rabe KF.

Hochgebirgsklinik Davos-Wolfgang, CH. guenter.menz@hgk.ch

Am J Respir Crit Care Med 2001 Sep 1;164(5):813-8

Side effects of mandibular advancement devices for sleep apnea treatment.

Fritsch KM, Iseli A, Russi EW, Bloch KE.

Pulmonary Division, Department of Internal Medicine, University Hospital of
Zurich, Zurich, Switzerland.

Our purpose was to investigate side effects of sleep apnea treatment by
removable oral appliances (OA) that advance the mandible. In 22 patients
suffering from obstructive sleep apnea (OSA), questionnaire evaluations,
polysomnographies, cephalographies, and dental plaster casts were obtained
before initiation of treatment with OA that fully covered both dental arches.
Patients were reevaluated after 3 to 12 mo (questionnaires, polysomnographies)
and 12 to 30 mo (questionnaires, cephalographies, plaster casts) during
continuous treatment. Polysomnographies confirmed improved breathing by OA. All
patients experienced persistent alleviation of symptoms after 12 to 30 mo and
wished to continue treatment. Side effects were common but only mildly
disturbing: mucosal dryness (86% of patients), tooth discomfort (59%), and
hypersalivation (55%). Cephalographies revealed a decrease in the mean (+/- SE)
upper incisors to maxillary plane angle from 102 +/- 2 degrees at baseline, to
101 +/- 2 degrees after 12 to 30 mo (p < 0.05). Overbite and overjet were also
slightly (mean reduction < 1 mm) but significantly reduced. None of these side
effects required discontinuation of treatment. OA are an effective therapy of
obstructive sleep apnea. Mild side effects are common but rarely require
intervention. Nevertheless, close follow-up during long-term therapy by OA is
advisable in order to timely detect potentially relevant orthodontic changes.

Swiss Med Wkly 2001 May 5;131(17-18):238-45

Improved results after lung transplantation--analysis of factors.

Speich R, Boehler A, Zalunardo MP, Stocker R, Russi EW, Weder W.

Department of Internal Medicine, University Hospital, Zurich, Switzerland.
klinspr@usz.unizh.ch

Better recipient selection, sophisticated postoperative surveillance and new
immunosuppressive and anti-infective regimens can improve the results of lung
transplantation. We compared the results of lung transplants performed between
1992 and 1996 (early period; 47) and between 1997 and 2000 (recent period; 46)
in a cohort study to assess which factors influenced survival. Estimates of
relative hazards were adjusted for possible confounding effects with the use of
Cox regression analysis. Overall 2-year survival was 70%. Survival by this time
was significantly better in the recent period (82% vs. 60%; p = 0.0093). Acute
rejection episodes and death due to BOS were less frequent in the recent period.
There were no technical failures, and the cumulative incidence of BOS was low
(34% at 5 years). The beneficial effect of the transplantation date 1997 or
later at a hazard ratio of 0.33 (95% CI, 0.13-0.84) was materially changed only
by the adjustment for ganciclovir prophylaxis (0.50; 95% CI, 0.09-2.91) and
immunosuppression with mycophenolate mofetil (0.80; 95% CI, 0.27-2.36). After
adjustment for both ganciclovir and mycophenolate mofetil, the beneficial time
period effect was completely removed (1.24; 95% CI, 0.14-11.39).
Immunosuppressive therapy with mycophenolate mofetil and use of ganciclovir
prophylaxis in addition to careful postoperative surveillance and surgical
expertise can lead to improved results after lung transplantation.

Ther Umsch 2001 May;58(5):315-20

Therapy of allergic bronchial asthma

[Article in German]

Bucher C, Russi EW.

Allergiestation, Dermatologische Klinik und Abteilung fur Pneumologie,
Departement fur Innere Medizin, Universitatsspital, Zurich.

Asthma and atopy are strongly related conditions. The presence of specific IgE
to perennial (arthropods, animal dander and other), seasonal (pollens, certain
fungal spores) and occupational allergens is associated with the occurrence of
asthmatic symptoms. Current therapy is based on combining three principles:
Avoidance of trigger factors and of allergen exposure, drug therapy, and
specific immunotherapy. Feasability and effectiveness of allergen avoidance
(particularly of perennial allergens) have been proven. However, these measures
must often be supplemented with drug therapy. Several classes of drugs are
nowadays available for treatment of asthmatic symptoms and, most importantly,
for control of the bronchial inflammatory process which underlies atopic asthma.
Specific immunotherapy is a good treatment option in allergy to pollens, but its
use is controversial in allergy to house dust mites and other perennial
allergens. Finally, it should be kept in mind that the successful longterm
management of patients with atopic asthma depends highly on the compliance of
patients.

Am J Respir Crit Care Med 2001 Apr;163(5):1171-5

Effects of lung volume reduction surgery for emphysema on diaphragm dimensions
and configuration.

Cassart M, Hamacher J, Verbandt Y, Wildermuth S, Ritscher D, Russi EW, de
Francquen P, Cappello M, Weder W, Estenne M.

Department of Radiology, University Hospital, Zurich, Switzerland.

Part of the functional benefit provided by lung volume reduction surgery (LVRS)
may be related to improvement in respiratory muscle function resulting from
changes in diaphragm dimension and configuration. To study these changes, we
obtained 3D reconstructions of the muscle using spiral computed tomography in 11
patients with severe emphysema before and 3 mo after surgery, and in 11 normal
subjects matched for sex, age, height, and weight. Bilateral LVRS was performed
by thoracoscopy in eight patients and by sternotomy in three patients.
Acquisitions were made in the supine posture at relaxed FRC, midinspiratory
capacity, and TLC. On average, LVRS produced a 51 +/- 11% increase in FEV(1) and
a 30 +/- 4% decrease in FRC. The total surface area of the diaphragm (A(di)) and
of the zone of apposition (A(ap)) at FRC increased by 17 +/- 4% and 43 +/- 8%,
respectively, but the surface area of the dome did not change. Compared with the
values recorded in the normal subjects, postoperative values of A(di) and A(ap)
at FRC were reduced by 11% (p < 0.05) and 24% (p < 0.005), respectively. The
curvature of the dome increased at TLC in the left sagittal plane, but was
otherwise unaffected by the procedure. We conclude that LVRS substantially
increases A(di) and A(ap), but does not significantly improve diaphragm
configuration at FRC.

Pneumologie 2000 Jun;54(6):256-62

Inhalable corticosteroids in long-term COPD treatment. Opinions of an expert
panel

[Article in German]

Gillissen A, Barczok M, Buhl R, Kardos P, Magnussen H, Matthys H, Rabe KF, Rothe
T, Russi EW, Schauer J, Schmitz M, Vogelmeier C, Wettengel R, Worth H, Menz G.

Med. Universitatsklinik und Poliklinik II, Bonn.
adrian.gillissen@mailer.meb.uni-bonn.de

Chest 2000 Jun;117(6):1560-7

Lung volume reduction surgery: a survey on the European experience.

Hamacher J, Russi EW, Weder W.

Department of Surgery, University Hospital, Zurich, Switzerland.

STUDY OBJECTIVE: To evaluate the activity and evolution in the field of lung
volume reduction surgery (LVRS) performed at surgical centers in Europe.
BACKGROUND: LVRS is a novel surgical therapy with the potential to improve lung
function, exercise performance, and quality of life in selected patients
suffering from severe pulmonary emphysema. METHODS: Questionnaire addressed to
75 European thoracic surgical centers presumed to perform LVRS, and review of
the literature. RESULTS: Of 45 responding centers, 42 centers in 17 countries
covering a population of 423 million reported performing LVRS. Until the end of
1998, 1,120 patients were reported to have undergone LVRS, corresponding to 2.6
patients/million inhabitants. Thirty-one of 40 centers (78%) perform the
operation bilaterally. Most centers (83%) evaluate their activity prospectively.
The average perioperative mortality rate of 4.1% is moderate. The most commonly
utilized technique is video-assisted thoracoscopy, which is most frequently
performed bilaterally. Two thirds of the centers treat patients with
alpha(1)-antitrypsin deficiency, and half of the centers will consider patients
with homogenous morphology of emphysema on CT scan for LVRS. Half of the centers
also perform lung transplantation. The five largest centers have operated on 49%
of all LVRS patients assessed by this survey. CONCLUSIONS: LVRS is performed at
few thoracic surgical centers throughout Europe, with a large variation in the
operative activity between different regions. Half of the centers also perform
lung transplantation. Between 1995 and 1997, the number of LVRS procedures
performed per year nearly tripled but has reached a plateau since then. As five
centers perform nearly half the total number of operations, an optimal exchange
of knowledge with smaller centers seems important.

Transplantation 2000 Apr 27;69(8):1629-32

Osteonecrosis after lung transplantation: cystic fibrosis as a potential risk
factor.

Schoch OD, Speich R, Schmid C, Tschopp O, Russi EW, Weder W, Boehler A.

Division of Respiratory Medicine, University Hospital, Zurich, Switzerland.

BACKGROUND: Osteonecrosis is a known complication after transplantation of solid
organs. The incidence of osteonecrosis after lung transplantation is not well
documented. METHODS: We investigated the incidence of symptomatic osteonecrosis
in lung transplant recipients, transplanted between November 1992 and June 1998
at our institution. For the detection of osteonecrosis, all patients complaining
of musculoskeletal pain underwent magnetic resonance imaging. Demographic
characteristics, time after transplantation, etiology of underlying lung
disease, and the number of steroid pulses for rejection episodes were compared
for patients with and without osteonecrosis. RESULTS: Of 63 transplant
recipients, all 49 with a follow-up of >3 months were included for analysis. Of
seven symptomatic transplant recipients, five cases of osteonecrosis (10%) were
detected at a median duration of 216 days (range 44-600) after transplantation.
Patients with osteonecrosis have been treated with the same immunosuppressive
regimen and with an equal number of steroid pulses for acute rejection episodes
(1.4+/-1.1 vs. 1.4+/-1.5, P=0.69), but were younger (26+/-8 vs. 40+/-11 years,
P<0.01) than other transplant recipients. Symptomatic osteonecrosis was detected
in four of 14 patients (29%) with cystic fibrosis (CF), compared with one
osteonecrosis among 35 patients (3%) with other underlying diseases (P<0.02).
Within the group of CF patients, specific clinical and demographic
characteristics correlating with the risk for subsequent osteonecrosis could not
be found. CONCLUSION: In lung transplant recipients, CF may be a risk factor for
the development of symptomatic osteonecrosis.

Eur Respir J 2000 Mar;15(3):570-8

Detection of inspiratory flow limitation during sleep by computer assisted
respiratory inductive plethysmography.

Kaplan V, Zhang JN, Russi EW, Bloch KE.

Dept of Internal Medicine, University Hospital of Zurich, Switzerland.

The potential of respiratory inductive plethysmography (RIP) to detect
inspiratory flow limitation during sleep was investigated. Sixteen sleep apnoea
patients underwent polysomnography. Airflow by a flowmeter attached to a nasal
mask, oesophageal and mask pressure were recorded along with calibrated RIP.
Presence of inspiratory flow limitation was defined by constant or decreasing
flow without pressure dependence throughout significant portions of inspiration,
its absence by a linear or mildly alinear pressure:airflow relationship. Based
on this standard, three of various computerized RIP derived parameters, with
highest performance to detect flow limitation, were identified. They were
combined to an inspiratory flow limitation, (IFL)-Index(RIP), which was
validated prospectively in another 10 sleep apnoea patients. RIP derived
fractional inspiratory time, peak to mean inspiratory flow ratio, and ribcage
contribution to tidal volume had the highest accuracy to detect flow limitation
(area under the receiver operating characteristic (ROC) curves 0.81, 0.76, 0.76,
respectively, 160 comparisons). Prospective validation revealed an area under
the ROC curve for the IFL-Index(RIP) to detect flow limitation of 0.89 (95%
confidence interval 0.85 to 0.93, 200 comparisons) with sensitivity and
specificity at the point of equality of 80%. It is concluded that inspiratory
flow limitation may be assessed by computer assisted analysis of respiratory
inductive plethysmography derived breathing patterns with clinically acceptable
accuracy.

Ann Thorac Surg 2000 Feb;69(2):632-3

Redo lung volume reduction surgery in a patient with alpha1-antitrypsin
deficiency.

Stammberger U, Thurnheer R, Schmid RA, Russi EW, Weder W.

Department of Surgery, University Hospital Zurich, Switzerland.

Lung volume reduction surgery is a palliative procedure that improves dyspnea
and pulmonary function in selected patients with advanced emphysema.
Postoperative benefit is sustained for an individual period and depends on the
emphysema morphology, the surgical technique, and other not yet well-defined
factors. The question whether lung volume reduction surgery can be performed a
second time on the same thoracic cavity is often raised but experience in this
regard is lacking. We describe a patient who has undergone a successful redo
operation 2 years after the initial lung volume reduction surgery.

Ann Thorac Surg 1999 Nov;68(5):1792-8

Two years' outcome of lung volume reduction surgery in different morphologic
emphysema types.

Hamacher J, Bloch KE, Stammberger U, Schmid RA, Laube I, Russi EW, Weder W.

Department of Internal Medicine, University Hospital, Zurich, Switzerland.

BACKGROUND: Lung volume reduction surgery (LVRS) improves dyspnea, pulmonary
function, and quality of life in selected patients with severe emphysema. We
investigated the role of emphysema morphology in 37 patients as an outcome
predictor for up to 2 years after operation. METHODS: Patients selected for
bilateral thoracoscopic LVRS were divided, according to a simplified emphysema
morphology classification, into three groups (homogeneous, moderately
heterogeneous, and markedly heterogeneous) based on a preoperative chest
computed tomogram. Pulmonary function, walking distance, and dyspnea were
assessed. RESULTS: Functional improvement after LVRS was best in markedly
heterogeneous emphysema with an increase from preoperative forced expiratory
volume in 1 second of 31% +/- 2% (mean +/- standard error of the mean) to 52%
+/- 4% of predicted postoperatively. It was significantly higher than in
homogeneous emphysema (from 26% +/- 1% to 38% +/- 2% predicted) and in
intermediately heterogeneous emphysema (from 29% +/- 2% to 44% +/- 45%
predicted). At 24 months postoperatively, forced expiratory volume in 1 second
and dyspnea score continued to be significantly better than preoperative levels
in all three morphologic groups. The survival rate was highest in patients with
markedly heterogeneous emphysema. CONCLUSIONS: Functional and subjective
improvements were maintained after LVRS for at least 24 months in patients with
heterogeneous or homogeneous emphysema type.

Technol Health Care 1999;7(5):331-42

Peripheral database module for clinical management and research in sleep
medicine.

Matthews F, Blaser J, Russi EW, Bloch KE.

Department of Medicine, University Hospital of Zurich, Switzerland.

Hospital-wide information systems may provide economical solutions for
communication processes or for documentation by means of centralized digital
medical records. Within a large university hospital, however, there may be too
many diverse subspecialties and too many special medical procedures to be
supported comprehensively by a single database information system. A peripheral
modular system has been tailored to the specific needs of a sleep disorder
clinic as an adjunct to the main clinical information system. The client server
application allows for automatic data acquisition by on-line devices and by a
graphical user interface. It supports administrative tasks for patient
management, specific encounter interactions and data retrieval for research.
Performance and acceptance of the system was assessed during clinical use,
revealing positive response by the users, also with respect to significant time
savings. Our experience suggests that the concept of peripheral database modules
as "satellites" to a main clinical system provides flexibility in design and
implementation of the specialized databases while providing access to data of
more general relevance via the main database.

Respiration 1999;66(5):440-7

German version of the Epworth Sleepiness Scale.

Bloch KE, Schoch OD, Zhang JN, Russi EW.

Pulmonary Division, Department of Internal Medicine, University Hospital,
Zurich, Switzerland.

BACKGROUND: The Epworth Sleepiness Scale (ESS) is a questionnaire widely used in
English speaking countries for assessment of subjective daytime sleepiness.
OBJECTIVE: Our purpose was to translate and validate the ESS for use in
German-speaking countries. METHODS: A German translation of the ESS was
administered to 159 healthy German-speaking Swiss and to 174 patients with
various sleep disorders. RESULTS: The mean +/- SD of ESS scores in normals was
5.7+/-3.0, in patients it was 13.0+/-5.1 (p<0.001). Scores were not correlated
with age or gender but with the percentage of time spent at an oxygen saturation
<90% (R = 0.35, p<0.001), and the respiratory disturbance index (R = 0.26,
p<0.001) in primary snorers and sleep apnea patients. Item analysis confirmed
internal consistency of the scale (Cronbach alpha = 0.60 in normals, and 0.83 in
patients). Follow-up scores in 25 sleep apnea patients on treatment showed a
reduction by 7+/-5 points (p<0.05). CONCLUSIONS: Our data validate the ESS for
application in German-speaking populations. The simplicity, reliability and the
apparent lack of relevant influences of language and cultural background on
performance of the ESS makes it a valuable tool for clinical management and
research.

Eur Respir J 1999 Jul;14(1):230-6

Functional and morphological heterogeneity of emphysema and its implication for
selection of patients for lung volume reduction surgery.

Russi EW, Bloch KE, Weder W.

Pulmonary Division, University Hospital, Zurich, Switzerland.

Lung volume reduction surgery (LVRS) in patients with advanced pulmonary
emphysema aims to alleviate symptoms and enhance quality of life by improving
respiratory mechanics. The theoretical concepts of the operation predict the
greatest functional benefit in patients with marked hyperinflation, and with
airflow obstruction due to loss of elastic recoil. Consistent observations in
several centres, have confirmed these expectations. To achieve maximal reduction
in lung volume at the least cost of functional tissue, resection is targeted to
the lung zones with the most severe destruction by emphysema, leaving zones with
relatively well-preserved tissue intact. Heterogeneity in emphysema distribution
as assessed by visual scoring of the chest computed tomography scan according to
a simple grading system has been shown to correlate with LVRS outcome variables.
Therefore, evaluation of lung volume reduction surgery candidates has to include
the functional and morphological characteristics of the emphysema as well as a
general assessment of perioperative risk. However, the knowledge of potential
predictive factors of lung volume reduction surgery outcome is so far based on
retrospective analysis of highly selected patients. Therefore, many questions in
respect of the selection of ideal candidates for this procedure remain
unanswered at the present time.

Internist (Berl) 1999 Aug;40(8):825-9

Clinical diagnosis of bronchial asthma

[Article in German]

Russi EW.

Abteilung fur Pneumologie, Universitatsspital Zurich.

Eur J Nucl Med 1999 Aug;26(8):812-7

Practicability and safety of dipyridamole cardiac imaging in patients with
severe chronic obstructive pulmonary disease.

Thurnheer R, Laube I, Kaufmann PA, Stumpe KD, Stammberger U, Bloch KE, Weder W,
Russi EW.

Pulmonary Division, Department of Internal Medicine, University Hospital of
Switzerland, CH-8091 Zurich, Switzerland.

We tested the practicability of dipyridamole myocardial nitrogen-13 ammonia
positron emission tomography (dipyridamole (13)NH(3 )PET) for the perioperative
risk assessment of coronary artery disease (CAD) in a cohort of patients with
severe chronic obstructive pulmonary disease (COPD) undergoing lung volume
reduction surgery (LVRS). Twenty consecutive LVRS candidates, 13 men and 7 women
(mean age 57+/-2 years), without symptoms of CAD were prospectively studied by
dipyridamole (13)NH(3 )PET. Side-effects and overall tolerance were assessed by
a questionnaire and visual analogue scale. Repeated pulmonary function tests
were performed before and 4, 12, 16 and 30 minutes after dipyridamole injection.
All dipyridamole (13)NH(3 )PET studies were negative for CAD. Seventeen patients
underwent LVRS without cardiac complications; three patients did not undergo
LVRS for other reasons. Nine patients suffered intolerable dyspnoea requiring
i.v. aminophylline. Mean FEV(1) decreased significantly after dipyridamole
infusion: in nine patients the reduction in FEV(1)exceeded 15% from baseline. We
found that dipyridamole is not well tolerated and causes significant
bronchoconstriction in patients with severe COPD. Although all
dipyridamole-induced side effects can be promptly reversed by aminophylline,
dipyridamole cannot be recommended as a pharmacological stress in this setting.

Eur J Cardiothorac Surg 1999 May;15(5):585-91

Lung volume reduction surgery combined with cardiac interventions.

Schmid RA, Stammberger U, Hillinger S, Vogt PR, Amman FW, Russi EW, Weder W.

Department of Surgery, University Hospital, Zurich, Switzerland.

OBJECTIVE: Postoperative course and functional outcome were evaluated in
patients who underwent lung volume reduction surgery (LVRS) or in combination
with valve replacement (VR), percutaneous transluminal coronary angioplasty
(PTCA), placement of a stent, or coronary artery bypass grafting (CABG).
METHODS: Patients with severe bronchial obstruction and hyperinflation due to
pulmonary emphysema were evaluated for lung volume reduction surgery. Cardiac
disorders were screened by history and physical examination and assessed by
coronary angiography. Nine patients were accepted for LVRS in combination with
an intervention for coronary artery disease (CAD). In addition, three patients
with valve disease and severe emphysema were accepted for valve replacement (two
aortic-, one mitral valve) only in combination with LVRS. Functional results
over the first 6 months were analysed. RESULTS: Pulmonary function testing
demonstrates a significant improvement in postoperative FEV1 in patients who
underwent LVRS combined with an intervention for CAD. This was reflected in
reduction of overinflation (residual volume/total lung capacity (RV/TLC)), and
improvement in the 12-min walking distance and dyspnea. Median hospital stay was
15 days (10-33). One patient in the CAD group died due to pulmonary edema on day
2 postoperatively. One of the three patients who underwent valve replacement and
LVRS died on day 14 postoperatively following intestinal infarction. Both
survivors improved in pulmonary function, dyspnea score and exercise capacity.
Complications in all 12 patients included pneumothorax (n = 2), hematothorax (n
= 1) and urosepsis (n = 1). CONCLUSION: Functional improvement after LVRS in
patients with CAD is equal to patients without CAD. Mortality in patients who
underwent LVRS after PTCA or CABG was comparable to patients without CAD. LVRS
enables valve replacement in selected patients with severe emphysema otherwise
inoperable.

Ther Umsch 2001 May;58(5):315-20

Therapy of allergic bronchial asthma

[Article in German]

Bucher C, Russi EW.

Allergiestation, Dermatologische Klinik und Abteilung fur Pneumologie,
Departement fur Innere Medizin, Universitatsspital, Zurich.

Am J Respir Crit Care Med 2001 Apr;163(5):1171-5

Comment in:
Am J Respir Crit Care Med. 2001 Apr;163(5):1042-3.

Effects of lung volume reduction surgery for emphysema on diaphragm dimensions
and configuration.

Cassart M, Hamacher J, Verbandt Y, Wildermuth S, Ritscher D, Russi EW, de
Francquen P, Cappello M, Weder W, Estenne M.

Department of Radiology, University Hospital, Zurich, Switzerland.

Pneumologie 2000 Jun;54(6):256-62

Inhalable corticosteroids in long-term COPD treatment. Opinions of an expert
panel

[Article in German]

Gillissen A, Barczok M, Buhl R, Kardos P, Magnussen H, Matthys H, Rabe KF, Rothe
T, Russi EW, Schauer J, Schmitz M, Vogelmeier C, Wettengel R, Worth H, Menz G.

Med. Universitatsklinik und Poliklinik II, Bonn.
adrian.gillissen@mailer.meb.uni-bonn.de

Am J Respir Crit Care Med 2000 Jul;162(1):246-51

A randomized, controlled crossover trial of two oral appliances for sleep apnea
treatment.

Bloch KE, Iseli A, Zhang JN, Xie X, Kaplan V, Stoeckli PW, Russi EW.

Department of Internal Medicine, University Hospital of Zurich, Zurich,
Switzerland. pneubloc@usz.unizh.ch

Our purpose was to compare the effectiveness and side effects of a novel,
single-piece mandibular advancement device (OSA-Monobloc) for sleep apnea
therapy with those of a two-piece appliance with lateral Herbst attachments
(OSA-Herbst) as used in previous studies. An OSA-Monobloc and an OSA-Herbst with
equal protrusion were fitted in 24 obstructive sleep apnea patients unable to
use continuous positive airway pressure (CPAP) therapy. After an adaptation
period of 156 +/- 14 d (mean +/- SE), patients used the OSA-Monobloc, the
OSA-Herbst, and no appliance in random order, using each appliance for 1 wk.
Symptom scores were recorded and sleep studies were done at the end of each
week. Several symptom scores were significantly improved with both appliances,
but to a greater degree with the OSA-Monobloc. Epworth Sleepiness Scale scores
were 8.8 +/- 0.7 with the OSA-Herbst, and 8.6 +/- 0.8 with the OSA-Monobloc
devices, and 13.1 +/- 0.9 without therapy (p < 0.05 versus both appliances). The
apnea/hypopnea index was 8.7 +/- 1.5/h with the OSA-Herbst and 7.9 +/- 1.6/h
with the OSA-Monobloc device, and 22.6 +/- 3.1/h without therapy (p < 0.05
versus both appliances). Side effects were mild and of equal prevalence with
both appliances. Fifteen patients preferred the OSA-Monobloc, eight patients had
no preference, and one patient preferred the OSA-Herbst device (p < 0.008 versus
OSA-Monobloc). We conclude that both the OSA-Herbst and the OSA-Monobloc are
effective therapeutic devices for sleep apnea. The OSA-Monobloc relieved
symptoms to a greater extent than the OSA-Herbst, and was preferred by the
majority of patients on the basis of its simple application.

Chest 2000 Jun;117(6):1560-7

Lung volume reduction surgery: a survey on the European experience.

Hamacher J, Russi EW, Weder W.

Department of Surgery, University Hospital, Zurich, Switzerland.

Transplantation 2000 Apr 27;69(8):1629-32

Osteonecrosis after lung transplantation: cystic fibrosis as a potential risk
factor.

Schoch OD, Speich R, Schmid C, Tschopp O, Russi EW, Weder W, Boehler A.

Division of Respiratory Medicine, University Hospital, Zurich, Switzerland.

Eur Respir J 2000 Mar;15(3):570-8

Detection of inspiratory flow limitation during sleep by computer assisted
respiratory inductive plethysmography.

Kaplan V, Zhang JN, Russi EW, Bloch KE.

Dept of Internal Medicine, University Hospital of Zurich, Switzerland.

Ann Thorac Surg 2000 Feb;69(2):632-3

Redo lung volume reduction surgery in a patient with alpha1-antitrypsin
deficiency.

Stammberger U, Thurnheer R, Schmid RA, Russi EW, Weder W.

Department of Surgery, University Hospital Zurich, Switzerland.

Ann Thorac Surg 1999 Nov;68(5):1792-8

Two years' outcome of lung volume reduction surgery in different morphologic
emphysema types.

Hamacher J, Bloch KE, Stammberger U, Schmid RA, Laube I, Russi EW, Weder W.

Department of Internal Medicine, University Hospital, Zurich, Switzerland.

Eur Respir J 1999 Mar;13(3):480-1

Surgical lung volume reduction for severe pulmonary emphysema--a new review
series.

Russi EW, Weder W.

Ther Umsch 1999 Mar;56(3):157-60

Surgical lung volume reduction--an option for treating severe pulmonary
emphysema

Russi EW, Weder W.

Abteilung fur Pneumologie und Klinik fur Viszeralchirurgie, Universitatsspital
Zurich.

Lung volume reduction surgery is a novel operative concept, which may be applied
in certain patients, who are severely handicapped by advanced pulmonary
emphysema and suffer from dyspnea at minimal exercise despite optimal medical
therapy. The most destroyed lung parts are resected by video-assisted
thoracoscopy. This type of surgery has a surprisingly low morbidity and
mortality at specialized centers. It improves symptoms by ameliorating lung
function and exercise tolerance. Maximal functional improvement is observed and
lung function starts to decline slowly within one to two years thereafter.

Ther Umsch 1999 Mar;56(3):142-6

Alpha 1-antiproteinase deficiency

Ritscher D, Russi EW.

Abteilung Pneumologie, Universitatsspital Zurich.

The dysbalance between proteolytic neutrophil elastase and its endogeneous
inhibitor seems to be a pathogenetic key mechanism in the origin of pulmonary
emphysema (elastase-antielastase hypothesis). This hypothesis is supported by
the observation, that low serum levels of alpha 1-antitrypsin can be observed in
smokers with premature pulmonary emphysema. alpha 1-proteinase inhibitor is an
acute phase protein with known structural and moleculargenetic aspects, which is
synthesized by the liver and reaches the lung by the circulation. Its role is
the inactivation of excessive neutrophil elastase in the pulmonary parenchyma,
which is liberated during inflammation and destroys elastin and other components
of extra-cellular connective tissue matrix. This is an overview on epidemiology,
clinical aspects, genetics and molecular biology of this particular disease
which was described in 1963.

Ther Umsch 1999 Mar;56(3):136-41

Modern long-term oxygen therapy--practical aspects

Anderhub HP, Russi EW.

Abteilung fur Pneumologie des Universitatsspitals, Zurich.

Modern and accurately performed long term oxygen therapy improves quality of
life and life expectancy in patients with chronic obstructive lung disease
suffering from hypoxemia. This type of therapy often fails since the patient is
bothered by the nasal prongs and fears to dwell outside his home. As a
consequence, the major goal of this form of therapy, namely enhanced patients
mobility is not attained. Oxygen can be delivered at a high efficiency by a
transtracheal catheter. This mode of application may considerably improve the
patients comfort and hence his compliance and mobility.

Chest 1999 Feb;115(2):318-20

Surgical lung volume reduction in emphysema: how much for how long?

Russi EW.

Langenbecks Arch Chir Suppl Kongressbd 1998;115:1260-3

Functional results after bilateral thoracoscopic lung volume reduction surgery
in emphysema

Stammberger U, Hamacher J, Bloch KE, Schmid RA, Russi EW, Weder W.

Department Chirurgie, Universitatsspital Zurich.

We investigated functional results, complications and survival of patients
undergoing bilateral video-assisted thoracoscopic (VAT) lung volume reduction
surgery (VRS) for severe, diffuse pulmonary emphysema [FEV1 28 +/- 0.8 (%
pred.), RV/TLC 0.65 +/- 0.01, 12' walking distance 499 +/- 21 (m)]. From January
1994 to March 1998, 106 of 286 candidates were operated, 85 patients (mean age
64, range 38-78 years, 30 females) fulfilled the study criteria and were
included in the prospective study. Hyperinflation decreased to an RV/TLC ratio
of 0.51 +/- 0.01 after 3 months and 0.55 +/- 0.02 after 24 months, FEV1
increased to 43 +/- 1.6 (% pred.) after 3 months and 35 +/- 2.3 (% pred.) after
24 months, and the 12' walking distance was 687 +/- 29 (m) 3 months
postoperative and 626 +/- 44 (m) after 24 months.

Schweiz Med Wochenschr 1998 Oct 3;128(40):1487-99

Accidents related to sleepiness: review of medical causes and prevention with
special reference to Switzerland.

Laube I, Seeger R, Russi EW, Bloch KE.

Department of Internal Medicine, University Hospital-Zurich.

Sleepiness is a major cause of traffic accidents. Our purpose was to review
determinants of accidents related to sleepiness and measures to prevent them. We
performed a systematic literature review on the topic and studied official
accident statistics and legislation regarding medical driving ability in
Switzerland. In 1997, 79,178 road traffic accidents, each causing bodily injury
or property damage in excess of 500 Swiss francs, occurred in Switzerland.
According to official statistics, sleepiness accounted for only 1% of identified
causes. However, scientific studies performed in other countries suggest that
sleepiness is a contributing factor in up to 30% of traffic accidents. Causes of
hypersomnolence are sleep restriction, sleep disturbance by external
environmental factors, inappropriate sleep hygiene, and sleep disorders. Several
reports suggest an increased crash rate in patients with obstructive sleep
apnoea syndrome. At our clinic, every sixth sleep apnoea patient reports
sleepiness-related driving problems which resulted in traffic accidents in one
third of them. Long monotonous motorway drives, late night, early morning and
late afternoon hours are associated with an increased crash rate. Drivers with
excessive sleepiness should not drive until the cause of hypersomnolence is
determined and treated appropriately. Medical assessment of driving ability in
patients with sleep disorders involves a specific history including standardised
questionnaires, sleep studies and vigilance tests. Swiss legislation authorizes
physicians to report sleepy drivers to the authorities if they are thought to
represent an accident risk for themselves or others. We conclude that sleepiness
is a common but under-recognised cause of traffic accidents. Enhancing awareness
of the problem in the public, early recognition and treatment of sleep
disorders, and counselling of drivers with excessive sleepiness may contribute
to prevention.

Am J Respir Crit Care Med 1999 Jan;159(1):301-10

Role of lung perfusion scintigraphy in relation to chest computed tomography and
pulmonary function in the evaluation of candidates for lung volume reduction
surgery.

Thurnheer R, Engel H, Weder W, Stammberger U, Laube I, Russi EW, Bloch KE.

Pulmonary Division, Department of Internal Medicine; Institute of Nuclear
Medicine, Department of Surgery, University Hospital of Zurich, Zurich,
Switzerland.

Lung perfusion scintigraphy is employed to evaluate patients with severe
emphysema who are candidates for lung volume reduction surgery (LVRS). Our
purpose was to investigate the role of scintigraphy in relation to chest
computed tomography (CT) and lung function in this setting. Six observers
blinded to clinical data retrospectively scored preoperative scintigrams of 70
patients undergoing bilateral video-assisted LVRS according to the distribution
of lung perfusion as homogeneous, intermediately heterogeneous, or markedly
heterogeneous. Heterogeneity of emphysema distribution was also assessed by
chest CT. Dyspnea and pulmonary function were measured preoperatively and 3 mo
postoperatively. In 42 patients with markedly heterogeneous, in 18 with
intermediately heterogeneous, and in 10 with homogeneous perfusion, mean (+/-
SE) FEV1 increased by 57 +/- 8% (p < 0.0001), 38 +/- 9% (p < 0.001), and 23 +/-
9% (p = NS) (p = NS for intergroup comparisons). In a multiple regression
analysis, functional improvement after LVRS was more closely correlated with
preoperative hyperinflation and the degree of emphysema heterogeneity estimated
by chest CT than with the degree of perfusion heterogeneity assessed by
scintigraphy. In 16 of 22 patients with homogeneous emphysema distribution in
the chest CT scintigraphy revealed intermediately or markedly heterogeneous
perfusion. We conclude that lung perfusion scintigraphy has a limited role in
prediction of outcome, but it may help to identify target areas for resection in
LVRS candidates with homogeneous CT morphology.

Eur Respir J 1998 Oct;12(4):785-92

Exercise performance and gas exchange after bilateral video-assisted
thoracoscopic lung volume reduction for severe emphysema.

Stammberger U, Bloch KE, Thurnheer R, Bingisser R, Weder W, Russi EW.

Dept of Surgery, University Hospital, Zurich, Switzerland.

Lung volume reduction surgery (LVRS) improves dyspnoea and pulmonary function in
selected patients with severe emphysema. The purpose of this study was to assess
the effects of LVRS on exercise performance and gas exchange in relation to
changes in pulmonary function. In 40 patients (63.2+/-1.4 yrs, mean+/-SE) with
severe emphysema (forced expiratory volume in one second (FEV1) 29+/-1%
predicted, residual volume/total lung capacity (RV/TLC) ratio: 0.63+/-0.01) we
assessed dyspnoea, pulmonary function and exercise performance before and 3
months after bilateral video-assisted thoracoscopic LVRS. The Medical Research
Council dyspnoea score fell from 3.5+/-0.1 to 1.4+/-0.1 (p<0.0005); FEV1
increased by 55+/-9% to 44+/-2% pred (p<0.0005), RV/TLC decreased from
0.63+/-0.01 to 0.51+/-0.02 (p<0.0005). The diffusing capacity remained
unchanged. Maximal work load during bicycle ergometry increased from 34.3+/-2.0
to 48.9+/-2.4 W (p< 0.0005), maximal oxygen uptake (V'O2max) from 10.0+/-0.4 to
12.8+/-0.3 mL x kg(-1) x min(-1) (p<0.0005). The increase in maximal ventilation
during exercise (V'Emax) from 29.5+/-1.5 to 38.6+/-1.8 L x min(-1) (p<0.0005)
was associated with increases in tidal volumes at isowatt and maximal exercise
while corresponding breathing frequencies remained unaltered. The increases in
V'O2max and V'Emax correlated with the increases in FEV1 and the decreases in
RV/TLC. We conclude that the improvement in pulmonary hyperinflation and airflow
obstruction after bilateral thoracoscopic lung volume reduction surgery may
reduce ventilatory limitation, thereby increasing exercise capacity.

Clin Infect Dis 1998 Sep;27(3):649-50

Mycobacterium heidelbergense species nov. infection mimicking a lung tumor.

Pfyffer GE, Weder W, Strassle A, Russi EW.

Swiss National Center for Mycobacteria, Department of Medical Microbiology,
University of Zurich, Switzerland.

Chest 1998 Jun;113(6):1718-9

Whole-lung lavage in alveolar proteinosis by a modified lavage technique.

Bingisser R, Kaplan V, Zollinger A, Russi EW.

Department of Internal Medicine, University Hospital Zurich, Switzerland.

Whole-lung lavage is the only efficient treatment in pulmonary alveolar
proteinosis. A 36-year-old woman with severe pulmonary alveolar proteinosis
confirmed by video-assisted thoracoscopic lung biopsies underwent repetitive
whole-lung lavages without improvement. A modified technique consisting of
manual ventilation between instillation and aspiration of half the amount of
saline used for conventional lavage was applied. Impressive clinical and
functional improvement occurred and persisted for 1 year. We believe that the
amelioration can be attributed to the technique described above.

Eur J Clin Microbiol Infect Dis 1998 Feb;17(2):78-84

Low specificity of the bacterial index for the diagnosis of bacterial pneumonia
by bronchoalveolar lavage.

Speich R, Hauser M, Hess T, Wust J, Grebski E, Kayser FH, Russi EW.

Department of Internal Medicine, Zurich University Hospital, Switzerland.

The bacterial index (BI) as defined by the sum of log10 colony-forming units
(cfu) of microorganisms per milliliter of bronchoalveolar lavage (BAL) fluid,
i.e., a multiplication of the single cfu/ml, has been used to distinguish
between polymicrobial pneumonia (BI> or =5) and colonization (BI<5). Since many
false-positive results are to be expected using this parameter, the diagnostic
value of the BI was studied prospectively by obtaining bacteriologic cultures of
BAL fluid in 165 consecutive unselected patients. In 27 cases the diagnosis of
bacterial pneumonia was established on clinical criteria. In 133 patients
pneumonia could be excluded, and in five patients the diagnosis remained
unclear. Using a cut-off of > or = 10(5) cfu/ml BAL fluid, sensitivity and
specificity for the diagnosis of pneumonia were 33% (9/27) and 99% (132/133),
respectively. Sensitivity was mainly influenced by prior treatment with
antibiotics, being 70% (7/10) in untreated and 12% (2/17) in treated patients.
Applying the BI methodology at a cut-off of > or =5, however, resulted in an
unacceptably high rate of 16 additional false-positive results, thus lowering
the specificity to 87% (116/133; P<0.0001) while increasing the sensitivity to
only 41% (11/27; P = 0.77). In conclusion, given the high rate of false-positive
results, the methodology of the BI is of doubtful value for the diagnosis of
bacterial pneumonia by BAL in an unselected patient group. By applying the
absolute number of cfu/ml BAL fluid, however, positive bacteriologic cultures of
BAL fluid are highly specific for the diagnosis of pneumonia. Their sensitivity
is limited by previous antibiotic therapy.

Eur J Cardiothorac Surg 1998 Mar;13(3):253-8

Effect of lung volume reduction surgery on pulmonary hemodynamics in severe
pulmonary emphysema.

Thurnheer R, Bingisser R, Stammberger U, Muntwyler J, Zollinger A, Bloch KE,
Weder W, Russi EW.

Department of Internal Medicine, University Hospital of Zurich, Switzerland.

OBJECTIVE: The presence of pulmonary hypertension in severe pulmonary emphysema
has been considered a relative contraindication to lung volume reduction surgery
(LVRS). There was concern that resection of lung tissue might further increase
pulmonary artery pressure. To address this point, the prevalence of pulmonary
hypertension in candidates for LVRS was investigated. The changes in pulmonary
artery pressures after bilateral videoassisted thoracoscopic resection was
studied in patients with homo- and heterogeneously destroyed emphysematous
lungs. DESIGN: The pulmonary arterial pressures by right heart catheterization
were prospectively assessed, before and 6 months after LVRS in 21 consecutive
patients (15 males, six females, mean (+/- S.E.) age: 62 +/- 1.9, range 42-74
years). All were former smokers and three had ZZ-AT1 deficiency. The inclusion
criteria were: (a) severe bronchial obstruction (FEV1 < 35% predicted); (b)
pulmonary hyperinflation (RV/TLC > 0.60); and (c) absence of hypercapnia (PaCO2
< 50 mmHg). RESULTS: The FEV1 had increased from 28 +/- 2% to 35 +/- 3% of the
predicted value (P < 0.05) 6 months after surgery. The RV/TLC had declined from
0.65 +/- 0.02 to 0.55 +/- 0.02; PaO2 increased (66 +/- 1 versus 71 +/- 2 mmHg, P
= 0.04), PaCO2 (38 +/- 2 versus 36 +/- 1 mmHg, P = 0.26) did not change. The
pulmonary artery mean pressure (PAPmean) remained unchanged (18 +/- 1 versus 19
+/- 1 mmHg, P = 0.26). In six patients PAPmean was > or = 20 mmHg (up to 24
mmHg) preoperatively. After 6 months, six patients had a PAPmean > or = 20 mmHg
(up to 31 mmHg). CONCLUSIONS: In patients with severe emphysema who are
candidates for LVRS (but have only mild to moderate hypoxemia and a PaCO2 < 50
mmHg) we found no relevant pulmonary hypertension and pulmonary artery pressure
did not change significantly after surgery. Therefore, routine right heart
catheterization is not mandatory for preoperative evaluation.

Am J Respir Crit Care Med 1998 May;157(5 Pt 1):1686-9

Fatal air embolism in an airplane passenger with a giant intrapulmonary
bronchogenic cyst.

Zaugg M, Kaplan V, Widmer U, Baumann PC, Russi EW.

Department of Internal Medicine, University Hospital Zurich, Switzerland.

Considering the large number of airplane passengers with a variety of medical
conditions, the incidence of in-flight emergencies on commercial airline flights
is low. Only few cases of pulmonary barotrauma in airplane passengers with prior
lung pathologies have been reported. We present the unusual case of a female
airplane passenger with a previously diagnosed asymptomatic giant intrapulmonary
bronchogenic cyst who experienced fatal air embolism on a commercial airline
flight. We believe that preventive surgical resection is mandatory in
asymptomatic patients with large intrapulmonary cysts prior to exposure to even
small alterations in ambient pressure as, for instance, prior to airplane flight
or use of mountain cable cars. However, screening for pre-existent lung
pathologies in the growing mass of commercial airline travelers is not
justified.

Langenbecks Arch Chir Suppl Kongressbd 1997;114:1283-6

Bilateral video-assisted thoracoscopic volume reduction surgery for treatment
of advanced pulmonary emphysema

Stammberger U, Thurnheer R, Russi EW, Largiader F, Weder W.

Dep. Chirurgie, Universitatsspital Zurich.

In a prospective study, we investigated the functional results, complications,
and survival of patients who underwent bilateral video-assisted thoracoscopic
(VAT) lung volume reduction surgery (VRS) for severe, diffuse pulmonary
emphysema (FEV1 0.77 +/- 0.03 [1], RV/TLC 0.65, 12' walking distance 482 +/- 26
[m]). From January 94 to March 97, 67 of 179 candidates underwent the operation,
and 58 patients (mean age 64 +/- 1.1, range 42-78 years; 17 women) fulfilled the
study criteria. There was no 30-day mortality; hyperinflation decreased to an
RV/TLC ratio of 0.52 +/- 0.01 after 3 months; FEV1 increased to 1.2 +/- 0.08
[1]; and the 12' walking distance was 687 +/- 29 [m].

Anasthesiol Intensivmed Notfallmed Schmerzther 1997 Dec;32(12):743-6

Restricted respiratory function: anesthesia in advanced pulmonary emphysema

Zollinger A, Weder W, Russi EW, Pasch T.

Institut fur Anasthesiologie, Universitatsspital Zurich.

Eur Respir J 1997 Dec;10(12):2872-5

Bronchial anastomotic complications following lung transplantation: still a
major cause of morbidity?

Schmid RA, Boehler A, Speich R, Frey HR, Russi EW, Weder W.

Dept of Surgery, Pulmonary Division, University Hospital, Zurich, Switzerland.

The frequency of bronchial anastomotic complications following lung
transplantation has decreased in recent years, but continues to be a potential
cause of morbidity and mortality. We have, therefore, reviewed the results of 67
consecutive bronchial anastomoses at risk in 43 patients surviving more than 7
days following lung transplantation. The bronchial anastomoses were performed
using a standardized technique, without direct or indirect revascularization.
Regular triple immunosuppressive therapy was given, including prednisone (0.5 mg
x kg(-1) daily) starting on the day of surgery. Bronchial healing was graded
using the Couraud classification. The median follow-up time was 14 months (range
1-45 months). No major airway complications occurred. On 236 serial
bronchoscopic examinations, no anastomotic stenoses were observed. One
anastomosis showed limited focal necrosis (2 mm) (Couraud 3a), and two
anastomoses had partial primary mucosal healing without necrosis (Couraud 2a).
In all other anastomoses, primary mucosal healing (Couraud 1) was observed.
Carefully performed bronchial anastomosis according to the technique described
enables reliable bronchial healing and yields a low complication rate.
Additional measures, such as direct revascularization, forced telescoping,
omentum wrap and interruption of steroid therapy, are not necessary.

J Thorac Cardiovasc Surg 1998 Jan;115(1):236-7

Lung volume reduction surgery for a patient receiving mechanical ventilation
after a complex cardiac operation.

Schmid RA, Vogt P, Stocker R, Zalunardo M, Russi EW, Weder W.

Department of Surgery, University Hospital, Zurich, Switzerland.

Med Sci Sports Exerc 1997 Nov;29(11):1499-504

Effect of training on repeatability of cardiopulmonary exercise performance in
normal men and women.

Bingisser R, Kaplan V, Scherer T, Russi EW, Bloch KE.

Pulmonary Division, University Hospital of Zurich, Switzerland.

The effect of gender and training on repeatability of cardiopulmonary exercise
performance has not been well defined. Therefore, we performed two bicycle
exercise tests 1 wk apart in each of two groups: In 19 normal subjects (age 24
to 64 yr, 10 females), with a mean maximal oxygen uptake (VO2max) of 42
mL.kg-1.min-1, who had been in an ongoing training program including bicycle
exercise, and in 19 untrained volunteers (23 to 54 yr, 11 females) with a mean
VO2max of 36 mL.kg-1.min-1 (P < 0.05). Mean differences in physiologic variables
measured during tests 1 and 2 were calculated. Repeatability coefficients were
defined as 2 SD in percent of the means. In untrained subjects mean (+/- SD)
maximal heart rate decreased by 4 +/- 5 beats.min-1 from the first to the second
test (P < 0.05). VO2max and maximal work rate (Wmax) remained unchanged. No
significant changes in these or other variables occurred in trained subjects.
Repeatability coefficients for VO2max were 8 and 13% in trained and untrained
subjects, respectively (P = NS). For Wmax the repeatability coefficient in
untrained (11%) exceeded that in trained subjects (4%, P < 0.05). Repeatability
coefficients did not differ among males and females. Our study provides normal
values for repeatability of various parameters assessed during exercise testing
and demonstrates that interpretation of performance during repeated tests has to
account for training of the subjects.

Schweiz Med Wochenschr 1997 Oct 11;127(41):1703-6

Lung diseases in pregnancy.

Russi EW.

Abteilung fur Pneumologie, Universitatsspital Zurich.

When physicians encounter pregnant patients with respiratory complaints, they
face a challenging set of clinical problems. To understand the clinical
cardiopulmonary manifestations of diseases occurring during pregnancy, knowledge
of the basic physiologic changes during pregnancy is necessary. The most
prevalent chest related complaint in pregnant women is shortness of breath,
which is in most cases due to an unpleasant awareness of physiological
gestational hyperventilation. Lung diseases which are frequently seen in young
people, such as bronchial asthma, occur with comparable prevalence in pregnant
women. Clinical symptoms, diagnosis and treatment of most diseases do not differ
from those in the nonpregnant state. However, pharmacotherapy presents unique
aspects, since not only may pharmacokinetics differ, but the fetus must also be
assumed to be a recipient of the drug.

Respiration 1997;64(5):375-80

A case report of a double-blind, randomized trial of inhaled steroids in a
patient with lung transplant bronchiolitis obliterans.

Speich R, Boehler A, Russi EW, Weder W.

Department of Internal Medicine, University Hospital, Zurich, Switzerland.

Lung transplant bronchiolitis obliterans syndrome (BOS) is the most significant
long-term cause of morbidity and mortality after lung transplantation. Although
augmented immunosuppression is used by most centers, reported on treatment to
reverse BOS are largely anecdotal. We performed a double-blind, randomized,
controlled trial (RCT) with ten treatment pairs of 2 weeks duration each
comparing inhaled fluticasone propionate (2 x 1,000 micrograms/day) with placebo
in a patient with BOS grade 2 who previously showed an improvement in lung
function after inhaled steroids. The Baseline Dyspnea Index and the Modified
Medical Research Council Dyspnea Scale showed a significant improvement during
fluticasone treatment compared with the placebo period (2.7 +/- 0.2 vs. 2.0 +/-
0.3; p = 0.043; and 1.7 +/- 0.2 vs. 2.4 +/- 0.2; p = 0.043). The patient
correctly identified fluticasone and placebo, respectively, in eight of ten
trial pairs (p = 0.016). The values of forced expiratory volume in 1 s were
significantly higher during the fluticasone period (1,207 +/- 10 ml; 95%
confidence interval, CI, 1,187-1,227 ml) compared to the placebo period (1,150
+/- 6 ml; 95% CI 1,138-1,162 ml; p = 0.0012). In conclusion, this n-of-1 RCT
suggests the efficacy of high-dose inhaled fluticasone in our patient with lung
transplant BOS. We propose to conduct a multicenter RCT of high-dose inhaled
steroids. Until further data are available, this treatment modality should be
offered to patients with lung transplant BOS.

J Intern Med 1997 Aug;242(2):185-8

Comment in:
J Intern Med. 1998 May;243(5):398-9.

Hyperthyroidism and pulmonary hypertension.

Thurnheer R, Jenni R, Russi EW, Greminger P, Speich R.

Department of Internal Medicine, University Hospital Zurich, Switzerland.

OBJECTIVES: To identify patients with hyperthyroidism and coincidental pulmonary
hypertension and to document reversibility of pulmonary hypertension after
treatment of hyperthyroidism. DESIGN: Patients with hyperthyroidism referred for
transthoracal echocardiography for any reason that showed elevated pulmonary
arterial pressures were collected. After therapy for the thyreotoxic state with
documented normalization of thyroid hormone (IT4), pulmonary arterial pressure
was measured again noninvasively. SETTING: An out-patient tertiary referral
centre. SUBJECTS: The medical records were used to identify, retrospectively,
patients with hyperthyroidism and pulmonary hypertension over a three-year
period (April 1993 to April 1996). INTERVENTIONS AND MAIN OUTCOME MEASURES:
Systolic pulmonary artery pressure (PAPs) was determined by adding up right
ventricular systolic pressure (RVSP) and mean right atrial pressure (RAP)
measured by continuous-wave Doppler echocardiography according to standard
techniques. All patients were treated for hyperthyroidism to normal IT4 levels.
After successful therapy. Doppler echocardiography was repeated. RESULTS: Four
patients with pulmonary hypertension showing elevated PAPs of 40 +/- 11 mmHg
were identified. After therapy. PAPs decreased in all patients to a mean of 25
+/- 6 mmHg. CONCLUSION: The observation of four patients with pulmonary
hypertension and hyperthyroidism is striking and suggests a possible
pathogenetic link of these disorders.

Am J Respir Crit Care Med 1997 Aug;156(2 Pt 1):553-60

Effect of surgical lung volume reduction on breathing patterns in severe
pulmonary emphysema.

Bloch KE, Li Y, Zhang J, Bingisser R, Kaplan V, Weder W, Russi EW.

Department of Internal Medicine, University Hospital of Zurich, Switzerland.

Surgical lung volume reduction may improve pulmonary function and dyspnea in
advanced pulmonary emphysema. To investigate mechanisms of these beneficial
effects we studied breathing patterns before and after surgery. Nineteen
patients with diffuse pulmonary emphysema (FEV1 < 35% of predicted, total lung
capacity > 130% predicted) were studied within 1 mo before, and 1.5 to 7 mo
after thoracoscopic volume reduction. Changes of rib cage and abdominal volumes
were monitored with calibrated respiratory inductive plethysmography for 20 to
60 min during natural breathing at rest. Pulmonary function and dyspnea were
also assessed. Postoperative tidal volumes, respiratory cycle times, and minute
ventilation were not significantly different from preoperative values. The
contribution of abdominal volume changes to tidal volumes increased from a mean
+/- SD of 43 +/- 17% preoperatively to 58 +/- 14% postoperatively (p = 0.03).
The fraction of inspiratory time with abdominal paradoxical motion decreased
from 12.3 +/- 8.3% preoperatively to 5.1 +/- 5.1% postoperatively (p = 0.02).
The phase shift between rib cage and abdominal motion was reduced
postoperatively. Hyperinflation, airway obstruction, and subjective ratings of
dyspnea were significantly improved. The better synchronization of rib
cage-abdominal motion and the greater contribution of abdominal volume changes
to tidal volumes are consistent with a reduction of inspiratory loading and a
greater force-generating capacity of the diaphragm after surgery.

Ann Thorac Surg 1997 Aug;64(2):313-9; discussion 319-20

Radiologic emphysema morphology is associated with outcome after surgical lung
volume reduction.

Weder W, Thurnheer R, Stammberger U, Burge M, Russi EW, Bloch KE.

Department of Surgery, University Hospital, Zurich, Switzerland.

BACKGROUND: Lung volume reduction surgery is known to alleviate dyspnea and to
improve pulmonary function, performance in daily activity, and quality of life
in selected patients with severe pulmonary emphysema. We investigated the role
of radiologically assessed emphysema morphology on functional outcome after a
lung volume reduction operation. METHODS: The preoperative chest computed
tomograms in 50 consecutive patients who had undergone surgical lung volume
reduction were retrospectively reviewed by 6 physicians blinded to the clinical
outcome. Emphysema morphology was determined according to a simplified
classification (ie, homogeneous, moderately heterogeneous, and markedly
heterogeneous; lobe predominance). We studied the impact of these morphologic
aspects on functional outcome at 3 months. RESULTS: We found a fair
interobserver agreement applying our classification system. Functional
improvement after surgical lung volume reduction was best in markedly
heterogeneous emphysema with an increase in forced expiratory volume in 1 second
of 81% +/- 17% (mean +/- standard error, n = 17) compared with 44% +/- 10% (n