Clinics in chest medicine
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Obliterative bronchiolitis following lung transplantation is common and potentially devastating. Its exact cause is undefined, but multiple immune and nonimmune processes contribute to its pathogenesis. ⋯ As our understanding of the disease evolves, it is hoped that effective interventions targeted at specific pathogenetic steps will emerge. In the meantime, obliterative bronchiolitis remains the most important and sinister long-term complication of lung transplantation.
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Despite the multitude of potential complications that may be encountered during the early post-transplant period, the majority of transplant recipients experience a smooth transition from postoperative intensive care, to step-down unit, to the regular medical floor, and, ultimately, to their home within 10 to 14 days without any significant unexpected events. The likelihood of serious complications can be greatly reduced through careful recipient selection, impeccable donor management, and the cooperative efforts of surgeons, pulmonologists, nurse specialists, and the numerous experienced consultants required for a successful transplant program. Although many unique facets contribute to the complexity of lung transplant patient care, attention to the details of high-quality general postsurgical care will yield excellent results.
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This article covers a selected group of topics dealing with the contribution of lung immunocompetent cells in the host defense mechanisms against HIV. These include recent findings suggesting that bidirectional signals between alveolar macrophages and pulmonary cytotoxic T lymphocytes define regulatory networks, which contribute to the accumulation of HIV-specific effector cells in the lung microenvironment. The authors also emphasize the cell pattern of HIV infection in the lung, highlighting the role of the retrovirus in weakening pulmonary host defenses and its spreading into the lower respiratory tract.
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With AIDS has come a new level of T-cell immunosuppression, beyond that previously seen. The impact of the HIV pandemic on the field of fungal infections includes a major increase in the number of serious fungal infections, an increase in the severity of those infections, and even some entirely new manifestations of fungal illness. ⋯ T-cell opportunists including Cryptococcus neoformans and the endemic mycoses are the most important pathogens. Phagocyte opportunists, including Aspergillus species and agents of mucormycosis, are less important.
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Clinics in chest medicine · Sep 1996
ReviewAuto-positive end-expiratory pressure and dynamic hyperinflation.
PEEP is indicated in patients with COPD only to unload the respiratory muscles from the auto-PEEP resulting from expiratory flow limitation. If auto-PEEP is not caused by flow limitation, application of PEEP will cause further hyperinflation, worsening respiratory mechanics, muscle activity, and hemodynamics. To assess the presence of expiratory flow limitation correctly, to measure auto-PEEP correctly, and to identify the maximal PEEP level to be used, measurements of flow and opening pressure must be obtained during a brief period of suspended respiratory muscle activity (obtained by sedation) with the patient's own breathing pattern reproduced accurately.