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J Thorac Cardiovasc Surg 2008;135:1210-1219
© 2008 The American Association for Thoracic Surgery

General Thoracic Surgery

Postpneumonectomy syndrome: Surgical management and long-term results

General Thoracic Surgery Unit, Massachusetts General Hospital, Boston, Massachusetts

Received for publication June 13, 2007; revisions received November 1, 2007; accepted for publication November 15, 2007.

^_* Address for reprints: Douglas J. Mathisen, MD, Chief, General Thoracic Surgery Unit, Hermes C. Grillo Professor of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street, Blake 1570, Boston, MA 02114. (Email: dmathisen{at}partners.org).

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Figure E1 Figure E2 Figure E3 Figure E4 Table E1 Table E2 References

 
Objective: Postpneumonectomy syndrome is a rare syndrome of dynamic airway obstruction caused by extreme rotation and shift of the mediastinum after pneumonectomy, resulting in symptomatic central airway compression. We have treated this syndrome by mediastinal repositioning and placement of saline-filled prostheses into the pneumonectomy space. There is a paucity of outcome data for patients treated surgically, with only a single series of 11 patients previously reported. We analyzed our recent experience with treatment of this syndrome and report on the short and long-term outcomes and quality of life assessment of the largest series ever reported of patients treated by mediastinal repositioning.

Methods: Records were reviewed of all patients who underwent mediastinal repositioning for postpneumonectomy syndrome between January of 1992 and June of 2006. Long-term health-related quality of life was assessed by administration of the Saint George's Respiratory Questionnaire.

Results: There were 18 patients (15 women and 3 men) with a median age of 44 years (range 14–67 years). Thirteen patients had undergone right pneumonectomy, and 5 patients had undergone left pneumonectomy. None of the patients in whom postpneumonectomy syndrome developed after left pneumonectomy had a right-sided aortic arch. Five patients had undergone pneumonectomy in childhood (age < 13 years). The median interval between pneumonectomy and mediastinal repositioning was 7.5 years (range 1.1–54.8 years). The median follow-up was 32 months (range 4–143 months). The operative mortality was 5.6% (1/18). Complications occurred in 5 patients (27.8%): pneumonia in 3 patients and acute respiratory distress syndrome in 2 patients. The median hospitalization was 6 days (range 3–155 days). Some 77% (10/13) of patients reported significant improvement in their breathing and overall state of health after surgery; 15.4% of patients (2/13) were somewhat better, and 7.7% of patients (1/13) had no improvement. No patients' condition was worse after surgery. All patients who reported improvement in their symptoms after surgery remained symptomatically improved at the time of the quality of life assessment. Some 92.3% (12/13) were not at all or only slightly limited in their social activities because of breathing problems, and 84.6% (11/13) were not at all or only slightly limited in their ability to work as a result of their physical health.

Conclusion: Repositioning of the mediastinum with placement of prostheses for postpneumonectomy syndrome can be performed with low mortality and morbidity. Surgical repositioning provides immediate and lasting symptomatic relief to patients in whom postpneumonectomy syndrome develops.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Figure E1 Figure E2 Figure E3 Figure E4 Table E1 Table E2 References

 
Postpneumonectomy syndrome is a rare condition that occurs in children or adults after a pneumonectomy. For reasons that remain poorly understood, in certain patients, the heart and mediastinum shift excessively toward the side of the pneumonectomy and the great vessels also rotate significantly. Herniation of the remaining lung with overdistension accompanies this shift and rotation. After either right or left pneumonectomy, the remaining distal trachea and/or main bronchus can become compressed against the vertebral column or aorta by the pulmonary artery. This results in severely symptomatic central airway compression and dynamic airway obstruction ( Figure 1).

View larger version (118K): [in this window] [in a new window]   Figure 1. Representative preoperative bronchoscopic appearance of the trachea and left main bronchus in postpneumonectomy syndrome after a right pneumonectomy.

There remains a paucity of outcome data on patients with postpneumonectomy syndrome treated surgically. Since our original report, only a collection of small case reports have been reported. The purpose of this study was to evaluate and analyze our recent experience with treatment of this syndrome and report on the short and long-term outcomes and quality of life (QOL) assessment of patients treated with mediastinal repositioning.

	Materials and Methods

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All patients who were evaluated and treated surgically for postpneumonectomy syndrome at our institution between January of 1992 and June of 2006 were identified from a prospectively maintained surgical database. The institutional review board at Partners Healthcare and Massachusetts General Hospital approved this study, and all patients were contacted and agreed to participate in the QOL assessment. The medical records of these patients were reviewed for patient demographics, presenting signs and symptoms, surgical approach, date of surgery, interval between the pneumonectomy and the development of postpneumonectomy syndrome, preoperative and postoperative radiographic and pulmonary function studies, postoperative morbidity and mortality, length of hospitalization, and last follow-up visit or date of death. Because patients came from a wide geographic referral area, follow-up was necessarily carried out by patient questionnaire and with the cooperation of the referring physicians. Long-term QOL was assessed by a self-administered questionnaire on general QOL, the short-form health survey [12 items] (SF-12), and a health-related QOL questionnaire, the Saint George's Respiratory Questionnaire (SGRQ). The SF-12 is a comprehensive general QOL assessment tool based on the short-form health survey [36 items], which has been validated in more than 2000 publications to be useful in monitoring general and specific populations, comparing the burden of different diseases, and differentiating the health benefits produced by different treatments. The SGRQ is the most widely used disease-specific health status questionnaire used to measure health impairment in patients with chronic obstructive respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD). It is a self-administered 51-item survey encompassing 3 components: symptoms, activity, and social or psychologic impacts. Scores range from 0 (best score) to 100 (worst score), and a change of 4 units has been shown to be clinically significant.

	Results

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Figure E1 Figure E2 Figure E3 Figure E4 Table E1 Table E2 References

 
Patient details are listed in Table 1. Eighteen patients were evaluated and treated surgically for postpneumonectomy syndrome. Fifteen patients were female (83.3%), and 3 patients were male (16.7%). The syndrome developed after right pneumonectomy in 13 patients and after left pneumonectomy in 5 patients. None of the patients in whom the syndrome developed after left pneumonectomy had a right aortic arch. All patients had symptoms of progressive and incapacitating dyspnea that occurred with minimal effort and that occurred at rest in the most severely affected patients. Other presenting symptoms were audible stridor or wheezing (56%), recurrent infections (33%), cough (22%), gastroesophageal reflux (11%), hemoptysis (11%), chest pain (5%), and dysphagia (5.6%). The median age at the time of attempted correction was 44 years, with a range of 14 to 67 years. The median interval between the original pneumonectomy and the time of attempted correction was 7.5 years, with a range from 1.1 to 54.8 years. Five patients had undergone pneumonectomy in childhood (age < 13 years). Two patients had undergone prior operative procedures to reposition the mediastinum and required redo surgery. One patient had developed recurrent symptoms 4 years after her original repositioning operation, which had included placement of a breast prosthesis in the pneumonectomy space. Two subsequent attempts to reposition her mediastinum had failed to resolve her airway obstruction, and she had become ventilator dependent. In an attempt to liberate her from mechanical ventilation, she underwent aortic division with bypass from the ascending aorta to the descending aorta with a graft. She developed hemodynamic instability postoperatively and died of multisystem organ failure on postoperative day 2. The second patient was a 20-year-old woman who developed recurrent postpneumonectomy syndrome 1 year after her original mediastinal repositioning operation when one of her saline-filled breast implants spontaneously ruptured. She subsequently had Lucite balls placed into the pneumonectomy space, which did not relieve the symptoms (Figures E1 and E2). She was then referred to our institution, and at her third operation, we removed all of the Lucite balls and repositioned her mediastinum with saline-filled breast implants (Figures E3 and E4). She remains well and fully active 4 years after this procedure and recently gave birth to a child. The indication for pneumonectomy was neoplastic disease in 9 patients, chronic infection in 4 patients, congential lung disease in 2 patients, broncholithiasis in 2 patients, and trauma in 1 patient.

The pneumonectomy space was filled with saline-filled breast prostheses in all 18 patients. The number and volume of prostheses were selected, which was sufficient to fill the pneumonectomy space returning the heart and mediastinum to a central position without compressing the heart and remaining lung. The volume necessary to reposition the mediastinum is determined by instilling a measured amount of saline into the pneumonectomy space. The median number of implants used was 2 (range 1–4). The median volume of prostheses placed was 805 mL (range 225–1610 mL). Intraoperative flexible bronchoscopy to assess the patency and stability of the airway was performed after repositioning the mediastinum and after prosthetic placement ( Figure 2). It was also performed once the patients were placed supine after the completion of the operation. Pulse, blood pressure, and central venous pressure were carefully monitored during mediastinal repositioning and prosthetic placement, and once the patient was placed supine after the chest had been closed to detect tamponade physiology. An intraoperative chest radiograph was obtained in all patients to assess the mediastinal position and rule out any significant atelectasis. Sometimes after the thoracic incision is closed, the prosthetic volume instilled is too great, producing atelectasis and/or hemodynamic compromise. This was the case in 4 patients who had their partially closed incision reopened and the prosthetic volume reduced. Other than the first patient in the series who underwent aortic division, none of the subsequent 17 patients had any significant tracheobronchial malacia after repositioning, and none required placement of airway stents after surgery.

View larger version (74K): [in this window] [in a new window]   Figure 2. A, Preoperative bronchoscopy in a 39-year-old woman (patient 11) who developed postpneumonectomy syndrome after right pneumonectomy 1 year earlier. The left lower lobe bronchus (arrows) has been almost completely compressed. B, Postoperative bronchoscopy showing widely patent lobar orifices.

Hospital Course
There were no intraoperative deaths. One patient died after surgery, and the operative mortality for the series was 5.6% (1/18). The cause of death was multisystem organ failure after aortic division and bypass in a 45-year-old woman who developed recurrent postpneumonectomy syndrome 4 years after successful mediastinal repositioning with breast prostheses. The median hospitalization was 6 days (range 3–155 days). Complications occurred in 5 patients (27.8%). Pneumonia developed in 3 patients, and acute respiratory distress syndrome developed in 2 patients.

Long-term Outcomes
Follow-up was complete in all 17 operative survivors. The median follow-up was 32 months (range 4–143 months). One patient underwent reoperation to have his implants removed 1 year after placement because his dyspnea symptoms and pulmonary function studies had worsened after mediastinal repositioning with implants; it was thought that lobar compression developed as a result of the implants. His symptoms improved after removal of his implants.

Pulmonary Function Studies
Eleven patients had pulmonary function studies with spirometry performed before and after surgical correction ( Table 2). The vital capacity decreased in all patients from a mean of 2.28 to 1.64 L (P < .05). The forced expiratory volume in 1 second (FEV₁) decreased in 9 patients and improved in 2 patients. The mean decreased from 1.33 to 1.11 L (P < .05). The FEV₁/forced vital capacity (FVC) ratio improved in 8 patients, was unchanged in 1 patient, and decreased in 2 patients. The mean increased from 0.61 to 0.71 (P < .05). Peak expiratory flow rates (PEFRs) improved in 7 patients and decreased in 4 patients. Postoperative PEFR was not significantly different from preoperative values.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Figure E1 Figure E2 Figure E3 Figure E4 Table E1 Table E2 References

 
For reasons that remain unknown, in a small subset of patients who undergo pneumonectomy, excessive mediastinal shift and rotation toward the empty hemithorax can occur. This mediastinal displacement results in airway obstruction that causes progressive and disabling symptoms. After right pneumonectomy, the mediastinum shifts to the right and posteriorly with counterclockwise rotation of the heart and great vessels, as seen on computed tomography scan. After left pneumonectomy, the mediastinum rotates clockwise. Mediastinal shift and rotation are accompanied by herniation and hyperinflation of the remaining lung. The trachea and mainstem bronchus are displaced toward the pneumonectomy space, and the main bronchus becomes compressed between the left pulmonary artery and vertebral column or descending aorta in the case of a right pneumonectomy, or between the right pulmonary artery and vertebral column or aorta in the case of a left pneumonectomy.

There have been many case reports in the literature describing postpneumonectomy syndrome in both children and adults. Although the incidence in adults in unknown, the syndrome is thought to be more likely to develop in infants and young children than in adults.^2-4 In children, the incidence has been estimated to be 1 case per 640 pneumonectomies.⁴ Factors that have been proposed to explain the higher incidence in the younger age group include increased elasticity and compliance of the remaining lung and mediastinal tissues and anatomic changes as a result of somatic growth. In our original report, only 2 of 11 patients had undergone pneumonectomy in childhood. In the present series, 5 of 18 patients had undergone pneumonectomy in childhood.

Postpneumonectomy syndrome seems to be more common after right pneumonectomy.⁵ Of the 29 patients we have treated at our institution, 20 developed the syndrome after right pneumonectomy and 9 developed the syndrome after left pneumonectomy. We do not have an explanation for this observation. Given the natural leftward position of the heart, it is possible that rightward mediastinal shift after right pneumonectomy produces more severe anatomic derangement and is therefore more likely to cause symptoms. Although we originally believed that the presence of a right aortic arch was a prerequisite for developing postpneumonectomy syndrome after left pneumonectomy, it has been shown that postpneumonectomy syndrome can occur with a left-sided aortic arch after left pneumonectomy.^6-10 In contrast with our original report, none of the 5 patients who developed postpneumonectomy syndrome after left pneumonectomy had a right aortic arch.

A variety of methods to attempt surgical correction of postpneumonectomy syndrome have been reported. Most consist of single case reports. Division of the ligamentum arteriosum⁶, fixation of the aorta or pulmonary artery to the sternum,^11,12 and placement of expandable metallic stents¹³ have been reported with varying results. Given the young age of many of these patients and the future possibility of stent migration, erosion into the pulmonary artery or aorta, and development of granulation tissue, long-term results with stenting confirming its safety and efficacy are needed before it can be recommended as primary treatment for this syndrome.

As our experience with this syndrome has grown, we believe that surgical correction is best achieved by restoration of the normal mediastinal position to allow the compressed airway to return to its normal position and patency. Several methods for repositioning the mediastinum have also been described. These include suture fixation of the pericardium to the back of the sternum,¹ surgical and chemical phrenectomy,⁵ and placement of prostheses to fill the empty hemithorax. Lucite plastic balls,¹² silastic implants,^3,14,15 injection of sulfur hexafluoride into the pneumonectomy space,¹⁶ and saline-filled breast prostheses^1,7,9,10 have been used prophylactically and therapeutically. Since our original report, we have treated all patients with postpneumonectomy syndrome with mediastinal repositioning and placement of saline-filled breast prostheses. This method of correction has also been widely adopted by other groups with success.^7,9,10

In our original report, 4 patients were found to have significant malacic changes in their airways in addition to shift and rotation of the mediastinum. Mediastinal repositioning and fixation by placement of prostheses are insufficient, and the other procedures we have tried to address the malacic airway have not been successful. The only operative death in the current series was 1 patient who developed severe airway malacia and recurrent symptoms 4 years after mediastinal repositioning. Three subsequent attempts to reposition her mediastinum were unsuccessful, and she died of complications after an attempt to relieve her airway compression with aortic division and bypass. We did not encounter severely malacic airways in the 17 patients who underwent operation after this patient. We would recommend that patients who have malacic airways in addition to mediastinal shift undergo mediastinal repositioning and stenting of the airway with a completely covered stent. Kelly and colleagues¹⁷ reported successful management of such a patient using this strategy.

The benefit of repositioning the mediastinum is the result of relief of the compression of the bronchial tree and correction of the hyperinflation of the herniated lung. Pulmonary function studies in the 11 patients who had spirometry available before and after repositioning showed improvements in flow rates and a decrease in hyperinflation. All patients showed a decrease in FVC due to relief of hyperinflation. In most patients, the decrease in FVC was also greater in absolute amount than the decrease in FEV₁, resulting in an improvement in the FEV₁/FVC ratio. However, in contrast with the findings of our original report, which showed a consistent improvement in PEFR and an improvement in the FEV₁/FVC ratio in every patient, in this series, PEFR improved in 7 patients and decreased in 4 patients. The improvement in PEFR was not statistically significant. In the only other report in the literature that has reported on pulmonary function tests before and after mediastinal repositioning for postpneumonectomy syndrome, Valzi and colleagues⁹ reported a significant increase in the PEFR for all 5 patients in their series with a mean improvement of 44.2%. The FEV₁/FVC ratio in their patients improved in 3 patients, decreased in 1 patient, and was unchanged in 1 patient. The mean improvement was 13.2%. One possible explanation for the difference in PEFR findings is that perhaps there was less tracheal compression in the patients who did not have an improvement in PEFR after surgery. Hyperexpansion of the remaining lung may have been a more significant factor for these patients, and relief of dyspnea symptoms may have been due to a decrease in hyperinflation. In the 4 patients who had a decline in PEFR, the FEV₁/FVC ratio improved in 3. The 1 patient who showed decline in both the FEV₁/FVC ratio and PEFR also had worse symptoms after repositioning and underwent removal of his implants 1 year later. His symptoms improved somewhat after removal of the implants.

Studies in patients with COPD have demonstrated that evaluation of the effectiveness of treatments for COPD requires the assessment of both clinical and physiologic variables. In patients with obstructive lung disease with dyspnea as the primary symptom, spirometric parameters such as FEV₁, FEV₁/FVC, and PEFR are well established in providing an objective measure of improvements in airflow after a therapeutic intervention. However, assessments of dyspnea, functional status, and overall heath status are required to characterize response to treatment. The most widely used disease-specific health status questionnaire for patients with obstructive lung disease is the SGRQ. This standardized measure was designed to quantify the impact of disease of chronic airflow limitation on health and well-being.¹⁸ SGRQ scores have been shown to have good repeatability and correlate with a range of established measures of disease activity, such as spirometry, 6-minute walking distance, mortality, and the incidence of COPD exacerbations.^18,19 The total mean SGRQ score of patients who underwent mediastinal repositioning and who completed the questionnaire was 25.9 ± 4.9 (Table E2). In a recent study evaluating the association between health-related QOL and disease severity using the Global Initiative for Chronic Obstructive Lung Disease guidelines, a total SGRQ score of 25 corresponded to a Global Initiative for Chronic Obstructive Lung Disease stage I, which was characteristic of patients with mild COPD.²⁰ An SGRQ total score of 25.9 also compares favorably to patients in the National Emphysema Treatment Trial. The baseline SGRQ total score was 52.5 ± 12.6 for patients in the surgical arm of the National Emphysema Treatment Trial and 53.6 ± 12.7 for patients randomized to medical therapy.²¹ The results of the QOL assessment suggest that the clinical symptomatic improvement in patients with postpneumonectomy syndrome who undergo mediastinal repositioning is more significant than can be quantified by pulmonary function studies alone. Mediastinal repositioning provides significant improvement in relief of symptoms and enables patients to return to a high level of activity and good functional status. Moreover, these improvements in overall and disease-specific health-related QOL appear to be durable.

	Conclusions

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Figure E1 Figure E2 Figure E3 Figure E4 Table E1 Table E2 References

 
Although we still have no explanation from this study or other reports why extreme mediastinal displacement and rotation occur in a small subset of patients who undergo pneumonectomy, once postpneumonectomy syndrome is identified and becomes symptomatic, patients should undergo prompt surgical correction. Mediastinal repositioning and placement of saline-filled breast implants can be performed with low morbidity and mortality, and provide significant and durable symptomatic relief to patients with postpneumonectomy syndrome.

	Figure E1

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Postpneumonectomy syndrome in a 20-year-old woman (patient 16) who underwent right pneumonectomy for carcinoid 4 years earlier. She developed postpneumonectomy syndrome within 1 year of pneumonectomy and had mediastinal repositioning with breast implants. Recurrent symptoms developed after one of the implants ruptured. The patient underwent reoperation with placement of Lucite balls. A, Chest roentgenogram shows heart and mediastinum displaced to the right with obliteration of the right pleural space. The lung is hyperexpanded and herniated, and numerous plombage balls can be seen. B, Lateral view demonstrates posterior displacement of mediastinal contents.

	Figure E2

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A, Computed tomography scan of the same patient shows shift of the mediastinum to the right and posteriorly with compression of the left mainstem bronchus between the pulmonary artery and the aorta. B, Despite the presence of numerous prostheses, the mediastinum is shifted into the pneumonectomy space.

	Figure E3

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At the time of the third corrective operation, numerous Lucite plombage balls were removed from the pneumonectomy space and replaced with saline-filled breast implants.

	Figure E4

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Computed tomography scan after third corrective operation. Lung herniation has been corrected, and the mediastinum is in the central position with the left main bronchus to the left of the spine.

	Table E1

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Selected responses to Short Form-12 and St George's Respiratory Questionnaire: Total respondents = 13

1. In general, would you say your health at present is:  Excellent 7.7%  Very good 46.2%  Good 38.5%  Fair 7.7%  Poor 0% 2. Compared with your condition before your operation, how would you rate your health in general now?  Much better than before surgery 76.9%  Somewhat better 15.4%  About the same 7.7%  Somewhat worse 0%  Much worse 0% 3. Compared with your condition before surgery, was your breathing better after operation?  Much better 76.9%  Somewhat better 15.4%  About the same 7.7%  Somewhat worse 0%  Much worse 0% 4. If your breathing was improved after your operation, has it remained so?  Yes 100%  No 0% 5. During the past 4 weeks, to what extent have your physical or emotional problems related to your breathing problems interfered with your normal social activities with family, friends, neighbors, or groups?  Extremely 0%  Quite a bit 0%  Moderately 8.3%  Slightly 25%  Not at all 67% 6. During the past 4 weeks, have you had to cut down on the amount of time you spend on work or other activities as a result of your physical health?  All of the time 0%  Most of the time 15.4%  Some of the time 0%  A little of the time 23.1%  None of the time 61.5% 7. During the past 4 weeks, have you accomplished less than you would like as a result of your physical health?  All of the time 0%  Most of the time 23.1%  Some of the time 15.4%  A little of the time 7.7%  None of the time 53.9% 8. During the past 4 weeks, have been limited in the kind of work or other activities as a result of your physical health?  All of the time 0%  Most of the time 7.7%  Some of the time 23.1%  A little of the time 30.8%  None of the time 38.5% 9. During the past 4 weeks I have coughed  Almost every day 7.7%  Several days per week 0%  A few days per month 30.8%  Only with lung/respiratory infections 30.8%  Not at all 30.8% 10. During the past 4 weeks, I have brought up phlegm  Almost every day 0%  Several days per week 7.7%  A few days per month 23.1%  Only with lung/respiratory infections 7.7%  Not at all 61.5% 11. During the past 4 weeks, I have had shortness of breath  Almost every day 15.4%  Several days per week 15.4%  A few days per month 23.1%  Only with lung/respiratory infections 23.1%  Not at all 23.1% 12. During the past 4 weeks, I have had episodes of wheezing  Almost every day 0%  Several days per week 0%  A few days per month 15.4%  Only with lung/respiratory infections 38.5%  Not at all 46.2% 13. During the last 4 weeks how many severe or very unpleasant episodes of lung/respiratory problems have you had?  More than 3 episodes 7.7%  3 episodes 7.7%  2 episodes 7.7%  1 episode 46.2%  No episodes 38.5% 14. During the last 4 weeks, in an average week, how many good days (with few lung/respiratory problems) have you had?  None 0%  1 or 2 0%  3 or 47.7%  nearly every day 84.6%  all 7.7% 15. How would you describe your lung/respiratory condition?  The most important problem I have 7.7%  Causes me a lot of problems 0%  Causes me a few problems 69.2%  Causes me no problems 15.4% 16. Do you still have an audible wheeze?  Yes 23.1%  No 76.9% 17. Which of the following best describes how your breathing problem affects you  It does not stop me from doing anything I would like to do 30.8%  It stops me from doing one or two things I would like to do 69.2%  It stops me from doing most of the things I would like to do 7.7%  It stops me from doing everything I would like to do 0%

	Table E2

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St George's Respiratory Questionnaire scores

Patient No. Symptoms score Activity score Impacts score Total score 2 53.98 35.79 29.34 35.87 3 16.33 0.00 4.20 5.00 5 47.26 29.70 18.88 27.72 7 34.90 49.13 16.57 30.50 9 36.60 31.72 5.85 19.59 10 9.63 35.79 6.53 16.66 11 11.56 0.00 0.00 2.07 13 33.43 73.83 25.53 42.75 14 53.96 86.59 64.94 70.05 15 33.28 23.72 12.36 19.82 16 59.35 23.72 21.20 28.86 17 37.48 29.63 25.39 28.94 18 8.92 18.81 4.56 10.00 Mean + SE 25.9 + 4.9

SE, Standard error.

	Footnotes

 
Presented at the 87th Annual Meeting of the American Association for Thoracic Surgery in Washington, DC, May 5–9, 2007.

^_* Dr Grillo died on October 14, 2006.

	References

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