Current opinion in pulmonary medicine
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Exacerbations of bronchiectasis have a major impact on quality of life, healthcare costs, and long-term risk of complications. Preventing exacerbations is one of the major goals of treatment. Bronchiectasis is increasingly recognized and the impact of bronchiectasis exacerbations on daily clinical practice is also increasing. ⋯ Treatment of acute exacerbations involves prompt administration of antibiotic therapy with usually 14 days of oral, or for severe exacerbations, intravenous antibiotics. The role of corticosteroids is not established and there is little data on the optimal management approach for acute exacerbations. Home intravenous therapy can reduce healthcare costs and improve patient satisfaction with care. A number of large randomized controlled trials are currently enrolling or have recently completed raising the possibility that the treatment paradigm may change in the near future.
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Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remain important causes of morbidity and mortality in hospitalized patients. New evidence-based guidelines for the diagnosis and treatment of these entities were released by the Infectious Diseases Society of America and the American Thoracic Society in 2016. This review summarizes the recommendations contained within these guidelines and their supporting rationale. ⋯ New guidelines for the diagnosis and treatment of HAP and VAP contain several novel recommendations regarding the diagnosis and treatment of these entities.
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Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and is expected to increase as the population ages. Patients have a high symptom burden, low healthcare quality of life, and unmet needs at the end of life. This review highlights specific palliative care needs of patients with advanced COPD and opportunities to integrate palliative care into standard practice. ⋯ Palliative care is appropriate for patients with COPD and should be integrated with disease-specific therapies. The line between life prolonging and palliative care undoubtedly overlaps and maximizing quality of life throughout the continuum of care should be prioritized for patients with this progressive illness.
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Review
Role of biologics targeting type 2 airway inflammation in asthma: what have we learned so far?
Severe asthma is a heterogeneous syndrome that can be classified into distinct phenotypes and endotypes. In the type 2 (T2)-high endotype, multiple cytokines are produced that lead to eosinophilic inflammation. These cytokines and their receptors are targets for biologic therapies in patients with severe asthma who do not respond well to standard therapy with inhaled corticosteroids. ⋯ Biologics are emerging as a key component of severe asthma management. In patients with T2-high severe asthma, the addition of treatments targeting immunoglobulin E and IL-5 to standard therapy may lead to improvement in clinical outcomes. Other biologic therapies have shown promising preliminary results and need to be studied in further clinical trials. These biologic therapies in conjunction with biomarkers will lead to tailored therapy for asthma.
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Asthma is a heterogeneous disease not only on a clinical but also on a mechanistic level. For a long time, the molecular mechanisms of asthma were considered to be driven by type 2 helper T cells (Th2) and eosinophilic airway inflammation; however, extensive research has revealed that T2-low subtypes that differ from the dominant T2 paradigm are also common. ⋯ Asthma pathogenesis is characterized by two major endotypes, a T2-high featuring increased eosinophilic airway inflammation, and a T2-low endotype presenting with either neutrophilic or paucigranulocytic airway inflammation and showing greater resistance to steroids. This clearly presents an unmet therapeutic challenge. A precise definition and characterization of the mechanisms that drive this T2-low inflammatory response in each patient phenotype is necessary to help identify novel drug targets and design more effective and targeted treatments.