Current opinion in pulmonary medicine
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Constrictive bronchiolitis (CB), also termed in lung transplant patients obliterative bronchiolitis, is inflammation and fibrosis occurring predominantly in the walls and contiguous tissues of membranous and respiratory bronchioles with resultant narrowing of their lumens. CB is found in a variety of settings, most often as a complication of lung and heart-lung transplantation (affecting 34% to 39% of patients, usually in the first 2 years after transplantation) and bone marrow transplantation, but also in rheumatoid arthritis, after inhalation of toxic agents such as nitrogen dioxide, after ingestion of certain drugs such as penicillamine and ingestion of the East Asian vegetable Sauropus androgynous, and as a rare complication of adenovirus, influenza type A, measles, and Mycoplasma pneumoniae infections in children. In lung transplants, CB is the single most important factor leading to death thereafter. ⋯ Decreases in FEV1 from baseline can be used to clinically support CB in transplant patients; the term bronchiolitis obliterans syndrome is used to denote this clinical dysfunction, and a grading system has been established for it that is now widely used in the literature. Significant risk factors for the development of CB in lung transplants include alloantigen-dependent and -independent mechanisms. In the former group are late acute rejection and HLA mismatches at the A loci; in the latter are ischemia/reperfusion injuries to airways that result from the transplantation surgery and cytomegalovirus infection.
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Idiopathic interstitial pneumonias are currently classified into four categories of disease: usual, desquamative, and acute interstitial pneumonia, and nonspecific interstitial pneumonia and fibrosis. Usual interstitial pneumonia appears on high-resolution CT (HRCT) as patchy subpleural areas of ground-glass opacity, irregular lines, and honeycombing. Desquamative interstitial pneumonia presents as patchy subpleural areas of ground-glass opacity in middle and lower lung zones. ⋯ Additional expiratory HRCT scans and scans with patients prone help to narrow the differential diagnosis among various diseases and help diagnose or exclude subtle disease in the posterior part of the lung, respectively. HRCT provides a reproducible method for evaluating the global extent of disease. It also discriminates between fibrotic and reversible inflammatory diseases.
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Great progress has been made both in understanding the pathophysiology of cystic fibrosis and in providing comprehensive medical care for both children and adults with this illness. Cystic fibrosis is the most common genetic disease affecting white people in the United States. ⋯ Considerable work remains to be done in order to better understand how the defect in the cystic fibrosis transmembrane conductance regulator interacts with other ion channels in the lung to create an environment of chronic infection and inflammation. There is promise in the fact that various treatment modalities are in different stages of investigation and that the improvement of the outcomes for patients with cystic fibrosis, and ultimately a cure for this disease, may be forthcoming.
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Although chronic obstructive pulmonary disease (COPD) has a public health importance similar to asthma, it has received less attention. The first guideline on the management of COPD was released in 1987 by the American Thoracic Society. In 1992 the Canadian Thoracic Society released its guidelines. ⋯ These COPD guidelines show many similarities but also have some interesting differences. The aim of this paper is to review these similarities and discrepancies. Like all guidelines, COPD guidelines suffer from the limited amount of evidence-based medicine supporting them, a limitation that, however, provides a strong stimulus for further research.
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Reports of the characterization and understanding of bronchiolitis obliterans organizing pneumonia (BOOP) have continued at an accelerated rate for several years. The radiographic and high-resolution CT features of BOOP continue to be documented. There have been new insights into the pathogenesis of BOOP. ⋯ Childhood BOOP has been described in several reports. Idiopathic BOOP continues to be the most common type; however, a variety of clinical settings such as inhalation of mold spores and associated disorders such as renal transplantation continue to be described. This paper provides an update of advances in the pathogenesis, radiographic features, clinical course, and categorization of the heterogeneity of BOOP.