Paediatric respiratory reviews
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The clinical course of acute lung injury (ALI) is a complex and variable process accompanied by severe lung dysfunction, which persists for a long period of time with variable recovery of pulmonary function. The extent and severity of the lung disease associated with ALI varies with those patients having the most severe manifestations of lung disease being grouped as acute respiratory distress syndrome (ARDS). The pathological injury associated with this disease process, termed diffuse alveolar damage (DAD), has three overlapping phases (exudative, proliferative and fibrotic) which are the consequences of severe injury to the alveolar-capillary unit. ⋯ Those areas that demonstrate the major advances within the field are highlighted because of the diverse and vast nature of the cellular components involved in the process of ALI. We are beginning to identify those processes that contribute to the cellular derangements which are the hallmark of ALI. By expanding our understanding of those factors, we should in the future be able to construct therapeutic interventions that address the aetiology of ALI.
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Paediatr Respir Rev · Mar 2001
ReviewAcute lung injury: pathophysiology, assessment and current therapy.
Acute respiratory distress syndrome (ARDS) is a clinically defined entity describing the severity of diffuse alveolar injury caused by direct or indirect injury to the lung. Pathophysiology, clinical course and outcome of ARDS depend on the underlying cause, the severity of the disease and co-morbidities. ⋯ This includes recruitment manoeuvres and the use of high PEEP to open the atelectatic lung and the use of permissive hypercapnia and the limitation of peak inspiratory pressure below 35 cm H2O to avoid overinflation. The clinical benefit of newer modes of ventilatory support such as inverse ratio ventilation, high frequency oscillatory ventilation, surfactant replacement, prone positioning and inhaled nitric oxide has yet to be determined in children.
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The inability to accurately predict the outcome of infants with recurrent wheezy bronchitis makes the early use of inhaled corticosteroids (ICS) controversial. Data from bronchoalveolar lavages and epidemiological surveys suggest a persistent inflammation of the airways in the more severe cases. ⋯ In infants with episodic viral-associated wheeze with or without interval symptoms, ICS use carries the risk of overtreatment and of adverse effects. Long-term prospective studies are urgently required to assess the efficacy and safety of ICS and their possible effects on the natural history of infantile asthma.
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Evidence-based medicine aims to identify, critically appraise and apply the best available evidence in making decisions about the care of patients. These aims are similar to those which conscientious clinicians have always tried to achieve. An evidence-based approach applies a systematic and rigorous methodology to this process to ensure that the evidence which is applied is relevant and of high quality. ⋯ Meta-analysis, when used appropriately, can provide more precise estimates of the effects of healthcare than those derived from the individual studies included in a review. Systematic reviews also provide summaries of the results of evidence-based healthcare. These are available to all interested individuals, including clinicians, healthcare administrators and patients.
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The lung is continually at risk of exposure to noxious environmental agents and respiratory pathogens. An elaborate series of defence mechanisms have been developed to protect the airways from these insults. The lower respiratory tract is protected by local mucociliary mechanisms that involve the integration of the ciliated epithelium, periciliary fluid and mucus. ⋯ Cilia lining the respiratory tract propel the overlying mucus to the oropharynx where it is either swallowed or expectorated. Regulation of periciliary fluid is thought essential to maintenance of both mucociliary clearance and to produce an environment in which airway antimicrobial peptides and defensins are effective. Disruption of mucociliary clearance may be caused by diseases such as cystic fibrosis, primary ciliary dyskinesia and asthma or may be secondary to pollutant exposure and viral or bacterial infections.