The clinical respiratory journal
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Pirfenidone has been shown in three recently published trials to slow down the progression of the devastating interstitial lung disease, idiopathic pulmonary fibrosis (IPF). The precise mechanisms that initiate and perpetuate the histopathological process leading to lung fibrosis in IPF are still uncertain, but increased concentrations of reactive oxidative species and fibrogenetic factors have been observed in the pulmonary tissue of patients. ⋯ Along with the new ATS/ERS/JRS/ALAT 2011 statement for 'Evidence Based Guidelines for Diagnosis and Management', there is now a more profound basis for offering IPF patients an evidence-based evaluation and treatment. This review summarizes the background to the recommended use of pirfenidone for the treatment of IPF.
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Chronic obstructive pulmonary disease (COPD) is associated with substantial morbidity and mortality and is characterised by persistent airway inflammation, which leads to impaired airway function, quality of life and intermittent exacerbations. In spite of recent advances in the treatment of COPD, new treatment options for COPD are clearly necessary. The oral phosphodiesterase-4 (PDE4) inhibitor roflumilast represents a new class of drugs that has shown efficacy and acceptable tolerability in preclinical and short-term clinical studies in patients with COPD. ⋯ Roflumilast is beneficial for maintenance treatment of patients with severe and symptomatic COPD and with a history of frequent acute exacerbations as an add-on to treatment with long-acting bronchodilators. It may have a role as an alternative to inhaled corticosteroids in more symptomatic COPD patients with frequent exacerbations, although direct comparisons are currently lacking.
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Asthma and chronic obstructive pulmonary disease (COPD) are both inflammatory disorders. Diagnosis of these diseases is based upon limitation of expiratory airflow. The pathophysiological correlates to this impaired lung function are complex but they are associated with the development of structural changes in the airways and lung parenchyma. These remodeling processes differ between the two diseases. In asthma, airways obstruction is predominately located in the large airways, although recent studies indicate that inflammation and structural changes also is present in other compartments of the lungs. In COPD, remodeling of the small airways and lung parenchyma are the main correlates to the limitation of expiratory airflow. However, both asthma and COPD are heterogeneous disorders including various phenotypes and there is a considerable overlap between the two diseases. ⋯ In COPD and severe asthma, current anti-inflammatory pharmacotherapy does not restore lung function impairment fully. It is therefore recognized that research aiming to explore mechanisms of airway remodeling should be encouraged.
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The pattern of granulocyte infiltration can be used to identify different inflammatory phenotypes in asthma. Recognized granulocyte phenotypes using induced sputum are eosinophilic (EA), neutrophilic, mixed granulocytic and paucigranulocytic asthma. ⋯ Clinically useful applications of induced sputum analysis are the detection of non-adherence to corticosteroid therapy, assessment of adequacy of inhaled corticosteroid therapy, long-term therapy management in asthma, oral corticosteroid dose adjustment in refractory asthma and assessment of occupational asthma.
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Requirements for diagnostic tests include high validity and good repeatability. ⋯ When designing a study to examine a diagnostic test, the following principles should be followed. First, the order of performance of the diagnostic test and the gold standard in repeated measurements should be randomised. Second, in repeated measurements, the test situations should be equal. Third, the technicians performing the tests should be blinded to the data obtained in the other test or to the result of the gold standard. A pilot study is recommended before conducting the study to examine the diagnostic test.