Clinics in chest medicine
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Clinics in chest medicine · Sep 2011
ReviewOptimizing antibiotic pharmacodynamics in hospital-acquired and ventilator-acquired bacterial pneumonia.
Nosocomial pneumonia carries a high morbidity and mortality and creates a large burden on health care use. As resistance to currently available antibiotics continues to increase, the role of pharmacodynamics in drug regimen optimization becomes pivotal to the clinical success of patient therapy. This article reviews the evidence behind pharmacodynamic optimization including the use of Monte Carlo simulations, changes in pharmacokinetic parameters of critically ill patients, and differing strategies to optimize drug regimens. Emphasis is placed on drugs used to treat hospital-acquired and ventilator-acquired pneumonia, and programs implementing pharmacodynamic optimization are highlighted.
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This review summarizes recent clinical data examining the use of aerosolized antimicrobial therapy for the treatment of respiratory tract infections in mechanically ventilated patients in the intensive care unit. Aerosolized antibiotics provide high concentrations of drug in the lung without the systemic toxicity associated with the intravenous antibiotics. First introduced in the 1960s as a treatment of tracheobronchitis and bronchopneumonia caused by Pseudomonas aeruginosa, now, more than 40 years later, there is a resurgence of interest in using this mode of delivery as a primary therapy for ventilator-associated tracheobronchitis and an adjunctive therapy for ventilator-associated pneumonia.
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Pneumonia is an important clinical and public health problem. Identification and prediction of severe pneumonia are significant concerns. Attempts to define severe pneumonia should recognize that different purposes are served by different definitions; no single definition meets all needs. ⋯ Biomarkers are not yet ready for routine use. The authors recommend careful consideration of the implications of any given definition of pneumonia severity. Outcome studies are needed to integrate human and health care system factors with the application of pneumonia severity definitions.
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Lung allocation in the United States has changed significantly with the introduction of the Lung Allocation Score (LAS) system in May 2005. Since then, organ allocation is no longer based on waiting time but on a measure of transplant benefit (the difference between survival with vs without a transplant). The LAS system has met its primary goal of reducing time and mortality on the waiting list. Better understanding of pretransplant factors that influence long-term posttransplant outcomes of the individual patient will be instrumental in improving the LAS system in the future.
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Clinics in chest medicine · Jun 2011
ReviewAlternatives to lung transplantation: treatment of pulmonary arterial hypertension.
The development of targeted therapies for pulmonary arterial hypertension currently based on prostaglandin, nitric oxide, and endothelin pathways has resulted in major advances in the treatment of patients with pulmonary arterial hypertension. This article reviews the current evidence that supports both the use of mono- and combination therapy. The article also considers the role of atrial septostomy in the treatment of pulmonary arterial hypertension, particularly as a bridge to transplantation. Finally, the article provides a review of the role and outcomes of pulmonary thromboendartertectomy for patients with chronic thromboembolic pulmonary hypertension.