Respiratory care
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Emphysema and fibrosis, typically the idiopathic pulmonary fibrosis (IPF) form of usual interstitial pneumonia (UIP), can co-exist as combined pulmonary fibrosis emphysema (CPFE). It is unknown whether there is a pathobiologic basis for CPFE beyond the coexistence of fibrosis and emphysema. The aim of this study was to ascertain radiologic differences in severity of fibrosis and emphysema in smokers with IPF versus other forms of UIP. ⋯ When controlled for confounders, smokers with IPFE have worse radiologic CPFE than other smokers with non-IPF UIP and emphysema, suggesting an interactive synergy among IPF, emphysema, and smoking, with more extensive emphysema due to either inherent susceptibility and/or traction effects. IPFE should be considered separately from other CPFE in future work. It is currently unknown whether CPFE is a distinct pathobiologic entity; therefore, we identified subjects with radiologic UIP (any etiology) who had been similarly exposed to smoke, and asked whether there are differences in the extent/severity of radiologic fibrosis and/or emphysema in those with IPF versus individuals with non-IPF UIP. Although relevant confounders were similar, IPF smokers had greater whole lung fibrosis and reticulation scores than smokers with secondary forms of UIP, and in the CPFE subgroup, smokers with IPF/emphysema had worse radiologic CPFE findings than smokers with non-IPF UIP/emphysema. It is shown for the first time that relevant confounding variables do not explain the observed excess radiologic severity of emphysema and fibrosis in smokers with IPF compared with smokers with non-IPF UIP, lending support to the hypothesis that there is a pathobiologic mechanism or synergy involved in IPF with emphysema that is distinct from the mere co-existence of UIP and emphysematous processes.
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Case Reports
Complications With Utilization of Positive-Pressure Devices in a Young Man With Duchenne Muscular Dystrophy.
Because of the progressive muscle weakness they experience, patients with Duchenne muscular dystrophy frequently utilize positive-pressure devices to maintain adequate bronchial hygiene and ventilation. This case illustrates the course of a 19-y-old male who presented with a perforated right tympanic membrane (TM) following the use of these devices. Perforation of the TM while utilizing positive-pressure devices is a rarely reported event. A challenging aspect in this case was balancing the reduction of pressures and maintaining adequate ventilation while at the same time allowing the TM to heal.
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Inhaled nitric oxide (INO) has been used with heated and humidified high-flow nasal cannula (HFNC), nasal CPAP and several forms of noninvasive ventilation (NIV). This study was designed to evaluate the delivered dose of INO, level of NO2 generation, and effect of net gas delivery (addition of INO to the ventilator circuit--gas removed for sampling) on lung pressure at different NO doses during noninvasive respiratory support. ⋯ Clinicians cannot always assume that the set INO level results in a similar lung dose when using all forms of neonatal noninvasive support. Clinical decisions regarding ways to improve INO delivery may need to include changing settings or placing patients on a different form of noninvasive support. The NO2 level delivered to the patient could be greater than the value recorded by the INO delivery system.