Seminars in respiratory and critical care medicine
-
Semin Respir Crit Care Med · Oct 2013
Inflammatory Mechanisms in HIV-Associated Pulmonary Arterial Hypertension.
Pulmonary arterial hypertension (PAH) is a severe complication of human immunodeficiency virus (HIV) infection and a leading major cause of death when present. HIV-PAH could be the consequence of multiple hits including the direct effects of HIV proteins, use of illicit drugs, and chronic inflammation. Indeed, HIV infection has long been identified as an immunosuppressive disease but, since the advent of highly active antiretroviral treatments (HAART), HIV infection is considered as an inflammatory disease in which vascular complications have become a major cause of morbidity and death. ⋯ Conversely to blood CD4 + T cells, gut CD4 + T cells are only partially restored with HAART, usually slowly after several months or years, with a large heterogeneity from one patient to another. These characteristics may cause chronic inflammation, and we hypothesize that PAH may occur because of this inflammatory component despite HAART, even with apparently good response to therapy (i.e., blood CD4 + T cell normalization and undetectable HIV load). Inflammation theory in HIV-PAH (as in other forms of PAH) could open new treatment options.
-
Semin Respir Crit Care Med · Oct 2013
Pulmonary hypertension complicating connective tissue disease.
Pulmonary hypertension (PH) may complicate connective tissue disease (CTD), particularly systemic sclerosis (SSc, scleroderma), and markedly increases mortality. More than 70% of cases of PH complicating CTD occur in SSc, which is the major focus of this article. ⋯ The role of PH-specific therapy is controversial, as prognosis and responsiveness to therapy are worse in SSc-associated PH compared with idiopathic pulmonary arterial hypertension. We discuss medical therapies for CTD-associated PH and the role of lung transplantation for patients failing medical therapy.
-
Because acute lung injury (ALI) may arise from diverse and heterogeneous clinical insults, monitoring strategies for patients with ALI are heterogeneous as well. This review divides the monitoring strategies for ALI into three distinct phases. The "at-risk phase" is the period in which patients are at risk for ALI, and interventions may be applied to minimize or eliminate this risk. ⋯ The primary goals are to optimize fluid resuscitation to prevent organ dysfunction, including ALI, and if ALI occurs to additional optimize fluid balance vis-à-vis the lung. By judicious application of invasive hemodynamic monitoring, particularly in its more modern iterations, clinicians can optimize the ebb and flow phases common to critically ill patients. This is vitally important given our current and growing understanding of the relationship between fluid balance and important clinical outcomes, multiple organ dysfunction syndrome, and mortality.
-
Semin Respir Crit Care Med · Aug 2013
ReviewEmerging pharmacological therapies for prevention and early treatment of acute lung injury.
Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) are serious complications of acute illness and injury, associated with an inpatient mortality of up to 40%. Despite considerable basic science and clinical research, therapeutic options for established ALI are limited. Survivors of ARDS are often faced with poor health-related quality of life, depressive-anxiety disorders, cognitive deficits, and financial strain. ⋯ In addition to improving recognition of at-risk patients, it is necessary to identify novel treatments targeting the pathways that may prevent or ameliorate lung injury. The rationale and animal and clinical evidence for aspirin, systemic and inhaled steroids, β-agonists, renin-angiotensin axis blockers, statins, peroxisome proliferator agonist receptor ligands, curcumin, and inhaled heparin are included in this narrative review. Randomized, controlled trials are currently being designed and implemented to address their efficacy in populations at risk for ALI.