Annals of the American Thoracic Society
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Recent trends have necessitated a renewed focus on how we deliver formal didactic and simulation experiences to pulmonary and critical care medicine (PCCM) fellows. To address the changing demands of training PCCM fellows, as well as the variability in the clinical training, fund of knowledge, and procedural competence of incoming fellows, we designed a PCCM curriculum that is delivered regionally in the Baltimore/Washington, DC area in the summer and winter. ⋯ The educational consortium has helped build a local community of educators to share ideas, support each other's career development, and collaborate on other endeavors. In this article, we describe how we developed and deliver this curriculum and report on lessons learned.
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The Accreditation Council for Graduate Medical Education has mandated that pulmonary fellows practice evidence-based medicine "across multiple care settings." Currently, most clinical fellowship training is inpatient based, suggesting that more robust fellowship training in outpatient pulmonology is needed. No standardized ambulatory pulmonary curriculum is currently available. ⋯ We created a standardized outpatient pulmonary curriculum and demonstrated its feasibility in positively influencing fellows' perceived competency in ambulatory pulmonology. Additional assessment of knowledge, performance outcomes, and applicability at other institutions is needed.
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Cystic fibrosis is predominantly an airway disease with marked bronchiectatic changes associated with inflammation, chronic colonization, and progressive airflow obstruction. The condition can be identified in childhood and monitored with detectable airway changes early in life while conventional spirometry remains in the normal range. Alpha-1 antitrypsin deficiency can also be detected early in life through blood spot and genetic testing and leads (in some) to the development of airflow obstruction and a predominant emphysema phenotype with bronchiectatic changes in about 30%. ⋯ Chronic obstructive pulmonary disease is usually detected late in the disease process when significant damage has occurred. The condition consists of varying combinations of airway disease, bronchiectasis, colonization, and emphysema. Lessons learned from the physiological evolution of airway disease in cystic fibrosis and the emphysema of alpha-1 antitrypsin deficiency provide strategies to enable early detection of chronic obstructive pulmonary disease in general and its phenotypes.
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Computed tomography (CT) is an obvious modality for subclassification of COPD. Traditionally, the pulmonary involvement of chronic obstructive pulmonary disease (COPD) in smokers is understood as a combination of deleterious effects of smoking on small airways (chronic bronchitis and small airways disease) and distal to the airways with destruction and loss of lung parenchyma (emphysema). However, segmentation of airways is still experimental; with contemporary high-resolution CT (HRCT) we can just see the "entrance" of small airways, and until now changes in airway morphology that have been observed in COPD are subtle. ⋯ Both chest radiologists and pulmonary physicians are quite familiar with the appearance of various patterns of emphysema on HRCT, such as centrilobular, panlobular, and paraseptal emphysema. However, it has not yet been possible to develop operational definitions of these patterns that can be used by computer software to automatically classify CT scans into distinct patterns. In conclusion, even though various emphysema patterns can be recognized visually, CT has not yet demonstrated a great potential for automated subclassification of COPD, and it is an open question whether it will ever be possible to achieve success equivalent to that obtained by HRCT in the area of interstitial lung diseases.
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Randomized Controlled Trial Multicenter Study
A Novel Quantitative Computed Tomographic Analysis Suggests How Sirolimus Stabilizes Progressive Air Trapping in Lymphangioleiomyomatosis.
The Multicenter International Lymphangioleiomyomatosis Efficacy and Safety of Sirolimus (MILES) trial demonstrated that sirolimus stabilized lung function and improved measures of functional performance and quality of life in patients with lymphangioleiomyomatosis. The physiologic mechanisms of these beneficial actions of sirolimus are incompletely understood. ⋯ Collectively, these data suggest that sirolimus attenuates progressive gas trapping in lymphangioleiomyomatosis, consistent with a beneficial effect of the drug on airflow obstruction. We speculate that a reduction in lymphangioleiomyomatosis cell burden around small airways and cyst walls alleviates progressive airflow limitation and facilitates cyst emptying.