Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2007
ReviewOptimizing use of beta-lactam antibiotics in the critically ill.
The escalation of serious infections in critically ill patients over the past 25 years has continued despite advances in contemporary medicine. Ongoing research to reduce the high morbidity and mortality rates is mandated. beta-lactam antibiotics are often used empirically in serious infections. The efficacy of these time-dependent antibiotics is correlated with the time that concentrations are maintained above the minimum inhibitory concentration of the infective pathogen. ⋯ Likewise antibiotic resistance continues to grow. Recent data suggest that poor dosing strategies may be contributing to this problem, which is exacerbated by a lack of development of alternate antibiotics. Suffice to say clinicians must use antibiotic regimens that optimally treat the individual patient and reduce the development of antibiotic resistance.
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Semin Respir Crit Care Med · Oct 2007
ReviewBronchoalveolar lavage in idiopathic interstitial lung diseases.
Bronchoalveolar lavage (BAL) is useful for diagnosing various interstitial lung diseases (ILDs) and monitoring ILD during treatment. The ability to detect specific agents or substances by using BAL is especially helpful in determining whether idiopathic ILD has a background causality. BAL in combination with other intensive examinations may enable the definitive diagnosis of an idiopathic ILD. ⋯ On the other hand, these rules cannot be applied to IP associated with collagen vascular disease (CVD). Furthermore, some IIP patients may manifest features of CVD during the clinical course after the detection of IP (interstitial pneumonia). Thus the definite role of BAL cell profiles remains to be determined.
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Bronchoalveolar lavage is a useful diagnostic tool in diffuse or disseminated lung malignancies that do not involve the bronchial structures visible by endoscopy. The neoplastic histotype and the intraparenchymal neoplastic growth pattern are good predictors for diagnostic yield; adenocarcinoma, and tumors with lymphangitic or lepidic growth patterns are more easily diagnosed by bronchoalveolar lavage; in these cases the diagnostic yield reported is higher than 80%. ⋯ Morphological analysis may be implemented by immunocytochemical or molecular tests to identify the cell lineage and the presence of monoclonality. Disorders in which bronchioloalveolar cell hyperplasia/dysplasia is a significant morphological component may have cytological features in bronchoalveolar lavage fluid that mimic lung neoplasms: acute respiratory distress syndrome (ARDS), acute interstitial pneumonitis (AIP), and acute exacerbation of idiopathic pulmonary fibrosis are the most important clinical entities in this group.
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Bronchoalveolar lavage (BAL) provides an important diagnostic tool that can facilitate the diagnosis of various diffuse lung diseases. BAL fluid can be analyzed to determine white blood cell (WBC) profiles and to detect respiratory pathogens. ⋯ Additionally, BAL can play a very important role in the diagnosis of respiratory infection, and it is useful in monitoring the lung allograft and in evaluating pediatric lung disease. Examination of BAL cells or acellular components of BAL via gene microarray technology or proteomic analyses may allow BAL to assume a more prominent role in diagnosis and management of lung disease in the near future.
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Semin Respir Crit Care Med · Oct 2007
ReviewBronchoalveolar lavage in other interstitial lung diseases.
This article reviews the changes in bronchoalveolar lavage (BAL) cytology and cell differentials in some of the rarer interstitial lung diseases. In a few of these diseases BAL has a diagnostic value and can replace lung biopsy. In pulmonary Langerhans cell histiocytosis the characteristic diagnostic finding is an increase in CD1 + Langerhans cells greater than 4% of total cells. ⋯ In collagen vascular disease-associated lung fibrosis, the precise role of BAL in assessment and monitoring disease remains unclear. In drug-induced interstitial lung disease BAL may support a certain clinical/pathological pattern of lung involvement and is helpful for exclusion of other diseases, such as malignancies with pulmonary metastasis, heart disease with pulmonary congestion, or infections. The same is true for radiation-induced lung injury.