Current opinion in pulmonary medicine
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The challenge presented by a solitary pulmonary nodule has faced physicians and patients since the advent of the chest radiograph. Is the nodule malignant or benign? When should something be done about it and what should that be? The majority of solitary nodules are benign, but the detection of a nodule may be the first and only chance for cure in the patient with lung cancer. ⋯ Advances in radiographic techniques have improved the ability to noninvasively identify whether a nodule is likely malignant or benign. Application of these techniques may ease the decision making and reduce the incision making.
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Pulmonary disease remains a major problem for the 33 million individuals who are thought to be infected with human immunodeficiency virus (HIV) worldwide. Respiratory infections are responsible for a large number of the 2 million deaths that occur each year in association with HIV disease. In countries where the majority of the population can access highly active antiretroviral therapy, morbidity and mortality rates have been cut by up to 80%. ⋯ Tuberculosis remains a global problem. The complexity of the interactions between specific anti-HIV and anti-tuberculous treatment have been highlighted. In the developing world, the importance of immunization and prophylaxis (against bacteria and mycobacteria) have recently been further defined in a number of studies.
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Despite marked improvements in early survival, long-term outcome after lung transplantation is still threatened by obliterative bronchiolitis (OB). Thought to be a manifestation of chronic allograft rejection, OB affects up to 65% of patients at 5 years after surgery and produces a relentless airflow obstruction. ⋯ Because early diagnosis is associated with better prognosis, every effort should be made to detect OB in a preclinical stage. This may be best achieved by combining several techniques, such as surveillance transbronchial biopsy and bronchoalveolar lavage, measurements of ventilation distribution and exhaled nitric oxide, and expiratory computed tomography.
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An important advance in our understanding of the pathophysiology of asthma has been the discovery that airway inflammation is not confined to severe asthma but also characterizes mild and moderate asthma. Inflammation in asthma may be the result of a peculiar type of lymphocytic inflammation whereby Th2 lymphocytes secrete cytokines that orchestrate cellular inflammation and promote airway hyperresponsiveness. The term "airway remodeling" in asthma refers to structural changes that occur in conjunction with, or because of, chronic airway inflammation. ⋯ The consequences of airway remodeling in asthma may include incompletely reversible airway narrowing, bronchial hyperresponsivenesss, airway edema, and mucus hypersecretion. Airway remodeling in asthma thus may predispose persons with asthma to asthma exacerbations and even death from airway obstruction caused by smooth muscle contraction, airway edema, and mucus plugging. Although much has been learned in the past 25 years about the pathophysiology of airway inflammation and airway remodeling in asthma, important questions remain about the relation between airway inflammation and remodeling, the natural history of airway remodeling, and the effects of current asthma treatments on remodeled airways.
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The goal of management of patients with respiratory failure is to restore them to a state of quiet breathing, without complication. This goal is often achieved by pharmacotherapy alone. ⋯ In intubated patients, a ventilatory strategy that prolongs exhalation time and accepts hypercapnia minimizes lung hyperinflation and generally results in a good outcome. Acute asthma often represents failure of outpatient management; key aspects of the outpatient program should be addressed in the acute care setting to help prevent recurrent attacks.