Chest
-
Review Meta Analysis
Intrapleural fibrinolytic therapy for treatment of adult parapneumonic effusions and empyemas: a systematic review and meta-analysis.
The purpose of our study was to conduct a systematic review and meta-analysis of all randomized controlled trials to date comparing fibrinolytics with placebo to clarify their current role in the management of parapneumonic effusions and empyemas. ⋯ This meta-analysis does reveal that fibrinolytic therapy is potentially beneficial in the management of parapneumonic effusions and empyemas in the adult population. Although there is insufficient evidence to support the routine use of this therapy for all parapneumonic effusions/empyemas, fibrinolytic therapy may be considered in patients with loculated pleural effusions, because it may prevent the need for surgical intervention. Further randomized controlled trials with adequate power are needed to definitively address the effect of fibrinolytics and the combination of fibrinolytics and deoxyribonuclease on the clinical outcomes outlined in this analysis in patients with parapneumonic effusions/empyemas.
-
Respiratory distress develops in up to 25% of adults and 40% of children with severe falciparum malaria. Its diverse causes include respiratory compensation of metabolic acidosis, noncardiogenic pulmonary edema, concomitant pneumonia, and severe anemia. Patients with severe falciparum, vivax, and knowlesi malaria may develop acute lung injury (ALI) and ARDS, often several days after antimalarial drug treatment. ⋯ Basic critical care facilities are increasingly available in tropical countries. The use of lung-protective ventilation has helped to reduce mortality from malaria-induced ALI/ARDS, but permissive hypercapnia in unconscious patients is not recommended because increased intracranial pressure and cerebral swelling may occur in cerebral malaria. The best antimalarial treatment of severe malaria is IV artesunate.
-
Patients with a primary diagnosis of obstructive sleep apnea frequently demonstrate central sleep apnea that emerges during treatment with CPAP. Although a number of mechanisms for this finding have been hypothesized, the pathophysiology is not definitively known. ⋯ Herein, we review the proposed mechanisms for obstructive sleep apnea complicated by central sleep apnea. Future research is needed to elucidate the relative importance and susceptibility to intervention of the various pathophysiologic mechanisms responsible for this phenomenon, and whether a treatment approach distinct from that of pure obstructive apnea is justified.
-
The severities of COPD (FEV(1) % predicted) and airflow obstruction (FEV(1)/FVC) are considered to be due to both emphysema and small airways disease. To our knowledge, this has not been previously confirmed by combined measurements of emphysema and of small airway function. We hypothesized that small airways disease and emphysema extent contribute independently to the severity of both COPD and airflow obstruction. ⋯ The severities of COPD and airflow obstruction are independently predicted by both small airways disease and emphysema extent.
-
The Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management (REVEAL Registry) was established to characterize the clinical course, treatment, and predictors of outcomes in patients with pulmonary arterial hypertension (PAH) in the United States. To date, estimated survival based on time of patient enrollment has been established and reported. To determine whether the survival of patients with PAH has improved over recent decades, we assessed survival from time of diagnosis for the REVEAL Registry cohort and compared these results to the estimated survival using the National Institutes of Health (NIH) prognostic equation. ⋯ Comprehensive analysis of survival from time of diagnosis in a large cohort of patients with PAH suggests considerable improvements in survival in the past 2 decades since the establishment of the NIH registry, the effects of which most likely reflect a combination of changes in treatments, improved patient support strategies, and possibly a PAH population at variance with other cohorts