Chest
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A 44-year-old woman with Child-Pugh class C cirrhosis due to primary biliary cirrhosis and mild portopulmonary syndrome received a liver transplant. Her basal catheterization showed a mean pulmonary arterial pressure (mPAP) of 28 mm Hg, pulmonary artery occlusion pressure (PAOP) of 8 mm Hg, pulmonary vascular resistance (PVR) of 307 dynes.s.cm-5, and a cardiac output of 5.2 L/min. The echocardiogram did not reveal right ventricular dilatation (mid-diameter of 34 mm). ⋯ At the end of surgery, the brain natriuretic peptide level was 66 pg/mL (< 100 pg/mL). One day following transplantation, the patient remained hemodynamically stable and was therefore weaned from mechanical ventilation. However, 6 h following extubation, she reported breathlessness and tightness in chest, and developed sudden arterial hypotension, oxygen desaturation, and oliguria.
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An outsized proportion of asthma-related morbidity and mortality is borne by the 5% to 15% of affected patients who have severe forms of the disease. These patients experience poorly controlled symptoms and frequent exacerbations despite daily treatment with high-dose inhaled corticosteroids and other long-acting controller medications. Ongoing research has elucidated key pathophysiologic processes and other clinical parameters related to asthma severity and persistence. ⋯ During this web-based Clinical Issues program (available online at https://courses.elseviercme.com/asthma18/761e), a panel of expert faculty discuss a series of topics related to the pathophysiology and heterogeneity of severe asthma, including the following: characterizing severe asthma phenotypes and endotypes; identification of patients with severe asthma; and the role of biomarkers in asthma phenotyping. The faculty also highlight the identification and management of comorbid conditions commonly associated with asthma. An overview of new and emerging biologic therapies for severe asthma is provided, followed by a detailed discussion on personalizing treatment for patients with severe asthma.