Clinics in chest medicine
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Pediatric lung transplantation is becoming more common, and with increasing experience there is increasing success. The most common indications for considering lung transplantation are cystic fibrosis, pulmonary vascular disease (usually due to congenital heart disease), and fibrotic lung disease. ⋯ The patients with cystic fibrosis face additional obstacles to the success of transplantation: airway colonization with Gram-negative organisms, pancreatic insufficiency, glucose intolerance, and osteoporosis. The survival for children is comparable to adults, reaching about 65% at 1 year, and 69% at 2 years.
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Despite the multitude of potential complications that may be encountered during the early post-transplant period, the majority of transplant recipients experience a smooth transition from postoperative intensive care, to step-down unit, to the regular medical floor, and, ultimately, to their home within 10 to 14 days without any significant unexpected events. The likelihood of serious complications can be greatly reduced through careful recipient selection, impeccable donor management, and the cooperative efforts of surgeons, pulmonologists, nurse specialists, and the numerous experienced consultants required for a successful transplant program. Although many unique facets contribute to the complexity of lung transplant patient care, attention to the details of high-quality general postsurgical care will yield excellent results.
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With AIDS has come a new level of T-cell immunosuppression, beyond that previously seen. The impact of the HIV pandemic on the field of fungal infections includes a major increase in the number of serious fungal infections, an increase in the severity of those infections, and even some entirely new manifestations of fungal illness. ⋯ T-cell opportunists including Cryptococcus neoformans and the endemic mycoses are the most important pathogens. Phagocyte opportunists, including Aspergillus species and agents of mucormycosis, are less important.
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This article covers a selected group of topics dealing with the contribution of lung immunocompetent cells in the host defense mechanisms against HIV. These include recent findings suggesting that bidirectional signals between alveolar macrophages and pulmonary cytotoxic T lymphocytes define regulatory networks, which contribute to the accumulation of HIV-specific effector cells in the lung microenvironment. The authors also emphasize the cell pattern of HIV infection in the lung, highlighting the role of the retrovirus in weakening pulmonary host defenses and its spreading into the lower respiratory tract.
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Clinics in chest medicine · Sep 1996
ReviewEvolving concepts in the ventilatory management of acute respiratory distress syndrome.
With few modifications, a high tidal volume, normoxic, normocapnic ventilation paradigm developed as the standard approach to supporting most critically ill patients. Large tidal volumes, high end-tidal (plateau) alveolar pressures, and low levels of positive end-expiratory pressure are still common in many ICUs during ventilation of acute respiratory distress syndrome (ARDS). ⋯ A relatively small but growing number of practitioners are shifting their first priority from optimizing oxygen exchange, oxygen delivery, or respiratory system compliance to ensuring adequate lung protection. This article reviews the basis for concern about traditional ventilatory support in ARDS and develops an approach based on current evidence and newer options for management.