Current opinion in pulmonary medicine
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In the past few years, there have been exciting developments in bronchoscopic efforts at attaining lung volume reduction (LVR), given real and perceived risks of surgical LVR. The purpose of this review is to discuss these techniques, with special emphasis on what we have learnt in the past 1-2 years. ⋯ Though the preliminary results are quite encouraging, further trials need to be done before these procedures can be adopted in daily practice.
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Chronic obstructive pulmonary disease (COPD) is caused by a mixture of small airway disease (obstructive bronchitis) and parenchymal lung tissue destruction (emphysema). The relative contributions of these two pathologic states vary from person to person. Having the ability to phenotype patients into predominately small airways disease or emphysema may affect the clinical management. ⋯ The current techniques utilized to assess patients for small airway disease need to be improved, so clinicians can more effectively phenotype patients with COPD and small airways disease. This will allow new therapies that target the small airways to be developed and tested, and positively impact on the natural progression of COPD.
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It is increasingly clear that asthma is not a single disease, but a disorder with vast heterogeneity in pathogenesis, severity, and treatment response. In this review, we discuss the present understanding of different asthma phenotypes and endotypes, and the prospects of personalized medicine for asthma. ⋯ Patients with severe asthma have asthma symptoms that are difficult to control, require high dosages of medication, and continue to experience persistent symptoms, asthma exacerbations or airflow obstruction even with aggressive therapy. Although asthma is traditionally viewed as an eosinophilic inflammatory disorder associated with a T-helper cell type 2 (Th2) immune response, recent studies have identified involvement of other effector cells, nonclassical Th2 cytokines and non-Th2 cytokines in severe asthma pathogenesis. Results of several clinical trials of anticytokine antibodies demonstrated the effectiveness of tailoring asthma treatment on the basis of an individual's biology.
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This review summarizes the phenotyping of refractory asthma with an emphasis on how direct bronchoscopic observation and analysis of bronchoalveolar lavage (BAL), biopsy, and brushings of the airways helps direct specific personalized therapy. Additional testing used in phenotyping asthmatic patients is reviewed. ⋯ By using fiberoptic bronchoscopy, specific asthma phenotypes can be identified: laryngopharyngeal reflux with silent aspiration; subacute bacterial infection; tissue eosinophilia; a combination of two or three of these; and nonspecific. Identifying these phenotypes and personalizing therapy with bronchoscopy leads to improved outcomes.
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Asthma morbidity in children remains high despite comprehensive evidence-based guidelines for evaluation and treatment. The objective of this review is to examine the evidence that obstructive sleep-disordered breathing often co-exists with asthma and is associated with asthma severity, and to discuss the clinical implications of this relationship, focusing particularly on studies published within the past year. ⋯ Clinicians should consider evaluating and treating obstructive sleep-disordered breathing in children with severe or difficult-to-control asthma. Further controlled studies are needed to confirm that treatment of obstructive sleep apnea improves pediatric asthma outcomes, and to extend our understanding of how asthma and sleep-disordered breathing interact.