Current opinion in pulmonary medicine
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Pleurodesis is intended to prevent the accumulation of fluid or air in the pleural space by creating symphysis between the visceral and parietal pleura. The main indications for this procedure are malignant effusions and pneumothorax. A reexpandable lung and reasonably long expected survival are criteria that must be met before pleurodesis is attempted in a patient with malignant pleural effusion. ⋯ Talc appears to be the sclerosing agent of choice in cases of cancer, whereas video-assisted thoracic surgery techniques are preferable for the treatment of pneumothorax, especially in young patients. To improve results and prevent complications, application of the right technique is crucial, especially with regard to size of drainage and rate of suction. In addition, recent research suggests that prevention of a systemic activation of coagulation with prophylactic heparin should be taken into account in patients who are undergoing pleurodesis for palliative treatment of malignant effusion.
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Many individuals are now surviving their injuries to face the consequences of an activated immunoinflammatory system and the complications of supportive therapy. The pulmonary system bears the force of this insult. ⋯ The purpose of this review is to discuss the etiology and pathophysiology of acute respiratory failure following severe injury and the novel therapeutic approaches. A combination of immunomodulating and mechanical ventilation strategies will likely provide the most successful approach to reducing the morbidity and mortality associated with acute respiratory failure following injury.
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The prevalence of antibiotic resistance in respiratory pathogens is increasing rapidly. In the community, resistance to beta-lactam antibiotics has escalated dramatically among Moraxella catarrhalis, Haemophilus influenzae, and Streptococcus pneumoniae. Resistance to penicillin among S. pneumoniae has developed at an alarming rate over the past two decades. ⋯ Fluoroquinolone resistance has increased in P. aeruginosa and Staphylococcus aureus and has now been identified in Escherichia coli isolated from hematology wards. Excessive use of antibiotics may promote the emergence and spread of resistant microorganisms. Rigorous infection control measures and modification of antibiotic use patterns may limit or reduce the prevalence of resistant organisms.
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Many traditional drugs and techniques are gaining popularity in the treatment of asthma, although scientific proof of their value is usually inadequate. Alternative remedies, including herbs and nonmedication management techniques, have not been shown to be useful primary measures, but they still appeal to patients who feel unsatisfied with orthodox medicines. ⋯ The evidence on the role of steroid-sparing agents is not encouraging, but administering steroids once a day in the mid-afternoon may provide benefit. New aerosol techniques are appearing, but judgement is needed to select the best device for each medication as well as for each patient.
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Airway inflammation is now recognized as a major factor in the pathogenesis of cystic fibrosis (CF) lung disease. Therapies aimed at decreasing the inflammatory response represent a new strategy for treatment, and attention has focused primarily on the therapeutic potential of corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Alternate-day prednisone (1 mg/kg) may be beneficial; however, unacceptable adverse effects limit long-term use. ⋯ Because of the large burden and deleterious effects of uninhibited neutrophil elastase and oxidants in the CF airway, antiproteases and antioxidants are also being studied. To optimize anti-inflammatory therapy, it is necessary to understand the mechanism of action of these agents in the CF lung, to determine which of these agents would provide the most benefit to patients with CF, and to determine which therapies should be initiated at what age or stage of lung disease. It is hoped that adding anti-inflammatory therapy to an already comprehensive treatment program will decrease morbidity and improve the quality of life for patients with CF.