Pulmonary pharmacology & therapeutics
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Coughing can be both voluntarily induced and involuntarily initiated by activation of vagal afferent nerves innervating the airways and lungs. Centrally, cough is regulated at the level of the brainstem through integration of vagal afferent nerve input by relay neurones in the nucleus tractus solitarius (nTS). ⋯ Peripherally, both neuronal and non-neuronal elements in the airways regulate the excitability of the vagal afferent nerve terminals regulating cough. These multiple levels of integration and encoding of the cough reflex may render this defensive respiratory response highly susceptible to modulation both by disease processes and through therapeutic intervention.
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The assessment of cough severity solely through consultation with the patient is limited by its subjective nature and variability of physician judgement. The assessment of cough has been hampered by a paucity of objective tools, those available have been poorly validated, non-standardized and are impractical for clinical use. ⋯ These tools can be used to validate the presence of cough and assess response to therapy. They will also have an important role in clinical trials.
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Acid is an important mediator in the pathogenesis of cough. Inhalation of exogenous acid triggers cough and endogenous acid may contribute to cough in respiratory diseases. Acid directly stimulates vagal bronchopulmonary sensory nerves that regulate the cough reflex. ⋯ The receptors underlying acid sensitivity of vagal sensory nerves are incompletely understood. The role of TRPV1 has been established but the roles of acid-sensing ion channels (ASIC) and other receptors await more definitive investigation. Here, we provide a brief overview of the cough-related acid-sensitive sensory pathways and discuss the mechanisms of acid sensitivity.
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Pneumonia with secondary pleural infection causes considerable morbidity and mortality. Intrapleural instillation of fibrinolytic agents to dissolve fibrinous adhesions is intended to improve pleural fluid drainage and prevent pleural loculations. ⋯ Pending future clinical trials, fibrinolytic therapy may be used selectively in patients who fail drainage with appropriately sized, image-guided chest tubes if reasons exist to delay or avoid definitive surgical drainage. The scope of this article is to systematically review evidence for the efficacy of intrapleural fibrinolytic therapy in the treatment of PPE and PE with emphasis on controlled trials and present some of the future perspectives.
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Management guidelines for asthma emphasize a stepwise approach in treating this disease based on daytime symptoms, nighttime symptoms, and lung function assessed by peak expiratory flow or forced expiratory volume at 1s (FEV(1)). Although improvement of lung function is a key goal in managing asthma, clinicians often see patients who may have achieved a normal FEV(1) with guideline-recommended treatment but continue to experience limitations in their daily activities. ⋯ Alternate assessment measures are therefore often needed to assess asthma control and achieve a successful treatment outcome. This review will provide practical guidance relevant to the clinical assessment of asthma control.