Clinics in chest medicine
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Management of patients with a spontaneous pneumothorax continues to challenge clinicians. Recent guidelines help provide care pathways for these patients and highlight the many areas in need of additional study. ⋯ By contrast, pleural air drainage plays the central role in patients with a secondary spontaneous pneumothorax. Surgically directed recurrence prevention and air leak management are preferred for both primary and secondary spontaneous pneumothorax patients.
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The goals of therapeutic thoracentesis are to remove the maximum amount of pleural fluid to improve dyspnea and to facilitate the diagnostic evaluation of large pleural effusions. Pleural manometry may be useful for immediately detecting an unexpandable lung, which may coexist when any pleural fluid accumulates. ⋯ The basics of pleural space mechanics are discussed as they apply to the normal pleural space and to pleural effusion associated with expandable and unexpandable lung. This article also discusses the instrumentation required to perform bedside manometry, how manometry may decrease the risk of re-expansion pulmonary edema when large amounts of fluid are removed, and the diagnostic capabilities of manometry.
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Clinics in chest medicine · Mar 2006
ReviewTherapeutic management of idiopathic pulmonary fibrosis: an evidence-based approach.
The treatment of idiopathic pulmonary fibrosis (IPF) remains controversial. The benefits of conventional treatment with corticosteroids plus either azathioprine or cyclophosphamide have not been established in randomized, controlled trials. ⋯ Recent clinical and animal studies suggest that modulating the effects of profibrotic growth factors and cytokines holds significant promise. As additional well controlled prospective studies are completed, these trials should provide the clinical evidence necessary for identifying optimal treatment strategies for future patients who have IPF.
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Clinics in chest medicine · Mar 2006
ReviewCorticosteroid therapy in asthma: predictors of responsiveness.
Variable responses to corticosteroids are seen in a multitude of disease states including asthma, a disease in which these anti-inflammatory medications play a central role in both acute and chronic management. Clinical factors associated with steroid insensitivity, strategies for managing patients with steroid insensitivity, and underlying molecular mechanisms responsible for variable responses to corticosteroids are described.
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Acute asthma presentations account for 2 million emergency department visits annually in the United States. The causes for these presentations range from undertreated or unrecognized disease, to exacerbations of stable disease usually caused by recent exposure to triggers of exacerbations, to severe disease states unresponsive to conventional therapy. ⋯ The recognition of these phenotypes of acute asthma can enhance the management of these patients in acute and emergency settings. This article describes these potential phenotypes, reviews current therapies, and addresses the challenges of variability of therapeutic response in acute asthma.