Seminars in respiratory and critical care medicine
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Central airway obstruction (CAO) is seen in malignant and nonmalignant airway disorders and can lead to significant morbidity and mortality. Endobronchial ablative therapies are used in conjunction with mechanical debridement to achieve hemostasis and restore airway patency. These therapies can be classified into modalities with immediate or delayed effect. ⋯ Therapies with delayed effect include cryotherapy, brachytherapy, and photodynamic therapy. These modalities should not be used for acutely symptomatic CAO, and typically require follow-up bronchoscopy for removal of debris from the airway. Multimodality approach typically leads to better outcomes.
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The purpose of this article is to provide an introduction to rigid bronchoscopy (RB). We will briefly discuss its history, evolution, and resurgence while we highlight its versatility and usefulness for today's interventional pulmonologist and thoracic surgeon. Despite being one of the earliest pulmonary procedures described, RB is still an important technique. ⋯ Performing RB requires proper preprocedure preparation, exceptional understanding of upper airway anatomy, specific hand-eye coordination, and open communication between the bronchoscopist and the anesthesiologist. These skills can be primarily learned and maintained with repetition. This article will review information relevant to this technique and lay a foundation to be built upon for years to come.
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Pleural infection remains a common and serious respiratory condition with important implications for patients and health-care services. This review will cover the management of pleural infection including medical treatment, the role of intrapleural agents and surgical treatment. We discuss the directions that future research in this important area might take. ⋯ Despite advances in microbiology, medical management, and surgery, the mortality of pleural infection at one year remains approximately 20% for the last two decades. Future studies are required to validate predictive scores for patients' stratification (RAPID score) and the role of fibrinolytics (combination of tPA plus DNase). Surgical drainage remains a vital treatment option, but ongoing research is required to define the group of patients who would benefit most and when, in the disease course, this treatment should be offered.
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Ultrasonography of the thorax has become a more recognized tool in pulmonary medicine, thanks to continuing clinical research that has proven its many valuable roles in the day-to-day management of pulmonary and pleural diseases. Ultrasound examination is a cost-effective imaging modality that permits the pulmonologist to obtain information about the pathologies in the thorax without the risk of exposure to ionizing radiation, providing the examiner with real-time and immediate results. Its ease of use and training along with its portability to the patient's bedside and accurate examination of the pleural space has allowed for safer pleural procedures such as thoracentesis, chest tube placement, tunneled pleural catheter placement, and medical thoracoscopy. In this review, we summarize the technique of chest ultrasonography, compare ultrasound to other frequently used thoracic imaging modalities, and focus on its use in obtaining pleural access while performing invasive pleural procedures.
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The field of interventional pulmonology (IP) is a rapidly growing subspecialty of pulmonary and critical care medicine (PCCM), primarily focused on the evaluation and management of patients with lung nodules, masses, mediastinal and hilar adenopathy, central airway obstruction, and pleural disease. Traditionally passed on in the apprenticeship model, dedicated fellowships began in the early 2000s and there are currently approximately 24 IP fellowships throughout the United States. In addition to the evaluation and management of patients with the above diseases, the additional year provides training in advanced diagnostic and minimally invasive therapeutic procedures that are not specifically taught during a standard PCCM fellowship. This article will review the evolution of the field of IP as well as the pathways to learn advanced procedural techniques.