Current opinion in pulmonary medicine
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There is growing awareness of the significance of obstructive sleep apnea in the general population and in the medical community and, as a result, there is a growing demand for diagnosis and treatment. Attended, in-laboratory polysomnography is resource intensive and not readily available in some communities. Alternate diagnostic strategies have been proposed including the use of home sleep studies. Although these portable systems have been in use for many years, only in the past few years have a significant number of studies been performed to evaluate these systems in the home setting. The use of actigraphy and peripheral arterial tonometry for diagnostic purposes has also recently been investigated. ⋯ Home polysomnography is a viable option for evaluating patients with moderate or high clinical suspicion for sleep-disordered breathing. However, patients with failed or equivocal home studies and those with negative studies but persistent symptoms should undergo standard polysomnography. Further investigations are needed to compare long-term outcomes in patients evaluated using portable devices versus standard polysomnography.
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It has been an ongoing challenge to translate knowledge pertaining to the molecular basis of cystic fibrosis (CF) into a clear understanding of the development of CF lung disease. Various hypotheses have attempted to explain the apparent breach of innate defenses in CF, although a definitive explanation has been elusive. ⋯ With a better understanding of pathogenic steps leading to CF lung disease, we may now be able to direct the development of therapies that will substantially improve disease outcomes.
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Flexible bronchoscopy has revolutionized the evaluation of patients with suspected sarcoidosis and the treatment of sarcoid patients with significant endobronchial disease. The authors explore the diagnostic and therapeutic utility of flexible bronchoscopy by reviewing the pertinent literature with a special interest in recent studies. Bronchoscopy allows multiple diagnostic modalities in suspected sarcoidosis. ⋯ Transbronchial lung biopsy and endobronchial biopsy should be used routinely, and transbronchial needle aspiration should be considered in cases of significant adenopathy. Bronchoalveolar lavage should be used routinely to exclude alternative diagnoses. Therapeutic bronchoscopy is rarely needed, but when necessary the authors' procedure of choice is bronchoscopic balloon dilatation.
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This review considers the literature on bronchoalveolar lavage in the diagnosis of interstitial lung disease published during the last 12 months with the aim of clarifying the role bronchoalveolar lavage can have in diagnostic work-up on the basis of current knowledge and expert opinion. Recent research findings with possible future clinical applications are presented. Various information, useful for research and clinical applications, can be obtained from performing bronchoalveolar lavage in patients with interstitial lung diseases. ⋯ It may be useful to exclude infections and tumors, may help to decide whether to do surgical biopsy, and may aid in distinguishing different forms of interstitial lung disease. Although it is not diagnostic for idiopathic interstitial pneumonias, in the presence of cell patterns considered "typical" of the various forms, it can support clinical diagnosis in the absence of biopsy. Because further studies following standardized protocols and guidelines will presumably find new parameters for bronchoalveolar lavage in the diagnostics of interstitial lung diseases, it would be a mistake to consider bronchoalveolar lavage an obsolete tool.
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Review
What size chest tube? What drainage system is ideal? And other chest tube management questions.
Chest tubes and their accompanying pleural drainage units continue to present challenging questions regarding their optimal use. Appropriate chest tube size selection to accommodate the clinical situation is key, especially in the setting of large pleural air leaks lest a tension pneumothorax ensue. Connection of an appropriate pleural drainage unit to the chest tube is equally important to obviate impeding airflow after successful evacuation by the chest tube. ⋯ Smaller bore tubes may be adequate in patients with limited production of pleural air or of free-flowing pleural liquid. Chest tubes may be removed successfully at either end expiration or end inspiration, and potentially as soon as