Revisiting Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome
Synopsis: Despite at least 1 large trial showing benefit, the use of neuromuscular blockade during treatment of acute respiratory distress syndrome has never become routine. This trial evaluates 90-day mortality after randomization to either early neuromuscular blockade or usual low target sedation. Source: National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury (PETAL) Clinical Trials Network, Moss M, Huang DT, Brower RG, et al. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med. 2019;380:1997–2008. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Living in a Poor, Rural Community Is an Independent Risk Factor for Developing Chronic Obstructive Pulmonary Disease
Synopsis: In this nationally representative sample of Americans, the following characteristics were significant risk factors associated with a higher prevalence of COPD: living in a rural area with a high level of poverty in the community. Among nonsmokers, living in a community that uses coal for heating was an additional risk factor. Source: Raju S, Keet CA, Paulin LM, et al. Rural residence and poverty are independent risk factors for chronic obstructive pulmonary disease in the United States. Am J Respir Crit Care Med. 2019;199(8):961–969. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Omadacycline is a Potential New Drug For Treatment in Moderate to Severe Community-acquired Pneumonia
Synopsis: Omadacycline is a new antibiotic, derived from the tetracycline class, which might fill the need for a novel antibiotic that is effective against the common bacterial organisms causing community-acquired pneumonia. This trial showed it to be noninferior to moxifloxacin. Source: Stets R, Popescu M, Gonong JR, et al. Omadacycline for community-acquired bacterial pneumonia. N Engl J Med. 2019;380:517–527. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

A Rare Cause of Spontaneous Pneumothorax
Pulmonary nodules detected at thoracic imaging studies are a frequent occurrence. The management of such nodules largely revolves around comparison with prior imaging studies to document stability, and, in the absence of such priors, serial imaging assessment, as determined by the patient’s age, smoking status, and nodule characteristics, including size, border characteristics, and nodule attenuation. Often such incidentally detected nodules, particularly when small, are ultimately shown to be benign through lack of growth at serial imaging assessment, and therefore a conservative approach to these nodules is general...
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Images in Pulmonary Medicine Source Type: research

Myths and Legends: Do Bronchial Valves Have a Role in the Management of Emphysema?
This article also reviews the potential benefits of EBVs and the associated complications. Although bronchial valves have yielded promising results and are a potentially safer alternative to lung volume reduction surgery, further guidelines are needed to improve patient selection and procedure performance. Myth: In severe emphysema, surgical resection is the only option for lung volume reduction. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Clinical Myths and Evidence-Based Medicine Source Type: research

Biomarkers in Pulmonary Infections
Pneumonia, either community acquired or hospital acquired, is the most frequent severe infection. Despite all new tools and developments, pneumonia is difficult to diagnose clinically, resulting from the lack of a “gold standard” method of diagnosis. This uncertainty is at least in part responsible for the overuse and misuse of antibiotics in the community and in the hospital, and this practice is probably a main drive for antibiotic resistance. Biomarkers may improve the clinical evaluation of a patient with a clinical suspicion of pneumonia. Among all the potential biomarkers, C-reactive protein and procalcit...
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Respiratory Infections Source Type: research

Fatal Sepsis and Septic Shock Secondary to Aeromonas hydrophila Pneumonia: Report of a Case and Review of the Literature
We report a case of a 40-year-old immunocompetent woman who presented with pneumonia and septic shock secondary to A. hydrophila infection. Her clinical course was complicated by acute respiratory distress syndrome, metabolic acidosis, and multiorgan failure resulting in mortality. The isolate was susceptible to third-generation and fourth-generation cephalosporins, piperacillin-tazobactam, fluoroquinolones, and trimotheprim/sulfamethoxazole. Review of the literature for previous reports of infection with Aeromonas species infection in previously healthy individuals suggests that pneumonia and bacteremia due to A. hydrophi...
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Respiratory Infections Source Type: research

Etiologies and Outcomes of Acute Respiratory Distress Syndrome With No Identified Common Risk Factor
Almost 10% of patients with acute respiratory distress syndrome (ARDS) have no identified ARDS risk factor at ARDS diagnosis. A prompt identification of the cause of ARDS is required to initiate a targeted treatment. The purpose of this review is to delineate the main rare causes of ARDS and to provide clinicians with a pragmatic diagnostic workup. Recent epidemiological data have proposed the identification of a subgroup of ARDS patients lacking exposure to common risk factors. These can be categorized as having immune-mediated, drug-induced, malignant, and idiopathic diseases. A standardized diagnostic workup including c...
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Critical Care/Respiratory Care Source Type: research

Relapsing Plastic Bronchitis: A Brief Review of Currently Available Management Strategies
We describe one such case, wherein all the traditionally described medical therapies did not provide sustained amelioration of symptoms and required transfer for thoracic duct ligation. The patient’s clinical and radiographic features, management strategies, and clinical course are reviewed, alongside a brief review of the currently available management strategies for the clinical practitioner in dealing with plastic bronchitis. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - July 1, 2019 Category: Respiratory Medicine Tags: Topics in Pulmonary Medicine Source Type: research

Can Quadrupling Inhaled Glucocorticoid Dose During Early Asthma Exacerbation Reduce the Need For Systemic Steroids or Hospital Admission?
Synopsis: In this unblinded, multicenter, randomized control trial, patients with mild asthma who quadrupled the dose of their inhaled glucocorticoids upon initial signs of asthma control deterioration experienced fewer severe asthma exacerbations than patients who did not quadruple their inhaled glucocorticoid dose. Source: McKeever T, Mortimer K, Wilson A, et al. Quadrupling inhaled glucocorticoid dose to abort asthma exacerbations. N Engl J Med. 2018;378:902–910. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Palliative Care For Patients With Advanced Chronic Obstructive Pulmonary Disease (COPD) Remains Underutilized
Synopsis: COPD patients experience distressing symptoms and a poor quality of life. This population-based, repeated cross-sectional study suggests that palliative strategies in advanced disease remain underutilized. Source: Gershon AS, Maclagan LC, Luo J, et al. End-of-life strategies among patients with advanced chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2018;198:1389–1396. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Unilateral Multicystic Pulmonary Disease in a Young Adult: An Unusual Diagnosis
We present a case of a 20-year-old woman diagnosed with unilateral entire lung CPAM on the basis of radiologic findings that was surgically resected via video-assisted thoracoscopic surgery. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Images in Pulmonary Medicine Source Type: research

Lung Ultrasound for Daily Monitoring and Management of ARDS Patients
Lung ultrasound has greatly developed in the last decade, becoming increasingly important both for the diagnosis and for the monitoring of acute respiratory failure; it can be used on a daily basis at the bedside to improve the clinical assessment of the critically ill. This review describes how lung ultrasound can be used to assess patients with acute respiratory distress syndrome (ARDS), from the initial diagnosis to the daily management and monitoring. Quantification of lung aeration can be performed at the bedside with the lung ultrasound score; it is reliable when compared with computed tomography scan, easy to learn,...
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Critical Care/Respiratory Care Source Type: research

Noninvasive Oxygenation Strategies For Acute Exacerbation of Interstitial Lung Disease: A Retrospective Single-center Study and a Review of the Literature
Acute exacerbation of interstitial lung disease (AE-ILD) causes severe respiratory failure so that the patients would often require mechanical ventilation. Mechanical ventilation may improve survival in selected patients with AE-ILD; however, in-hospital mortality rate is so high in patients who need mechanical ventilation that the use of mechanical ventilation is weakly recommended. Although there is no fixed strategy with regard to selection of oxygen devices, a palliative approach to how to spend the end-of-life periods is often needed. Although noninvasive ventilation may be used to avoid intubation, high-flow nasal ca...
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Interstitial, Inflammatory & Occupational Lung Disease Source Type: research

A Novel Therapeutic Approach Using the Combination of Vacuum-assisted Closure System and 1-Way Valve After Open-Window Thoracostomy in Treating Chronic Empyema Complicated by Multiple Bronchopleural Fistulae
Empyema thoracis may be an ancient disease, but it still occurs in present-day thoracic practice. Despite medical and technical progression, pleural infection remains a major health care concern. When empyema thoracis is complicated by bronchopleural fistulae or repeated infections, it becomes a clinical challenge to physicians and can substantially lengthen and complicate a patient’s course of treatment. This case report presents a 48-year-old male patient with chronic empyema and multiple bronchopleural fistulae who was effectively treated by a combination of a 1-way valve and vacuum-assisted closure system through...
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Interventional Pulmonary Medicine Source Type: research

The Clinical and Research Utility of Bronchoscopy in Cystic Fibrosis
Bronchoscopy is used in the management of cystic fibrosis (CF) for multiple reasons, of which sampling respiratory secretions has been the most frequent. The evidence behind the role of bronchoscopy for routine sampling of respiratory secretions to determine clinical management is lacking, although there remain well-accepted indications for bronchoscopy in research and follow-up of advanced therapies in the CF population. We review the clinical and research utility of bronchoscopy in patients with CF and outline promising research uses of this tool that can contribute to recent advances in understanding and treating CF. (S...
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Topics in Pulmonary Medicine Source Type: research

Subtle But Clinically Significant: A Review of Antibody Deficiencies in Adults
Primary immunodeficiency diseases are becoming more frequently diagnosed in the adult population. Although infections are the most common symptoms, patients can also present with sequelae of autoimmune and noninfectious pulmonary diseases, such as interstitial lung disease and granulomatous disease. Pulmonologists are likely to encounter patients with various and, at times, subtle symptoms suggestive of immunodeficiency. In this review article, we discuss the presentation, evaluation, and management of 4 antibody deficiencies: common variable immunodeficiency, selective immunoglobulin A deficiency, specific antibody defici...
Source: Clinical Pulmonary Medicine - May 1, 2019 Category: Respiratory Medicine Tags: Respiratory Infections Source Type: research

Myth: For Bronchoscopy Training in the 21st Century, there is a Standard Curriculum or Metrics for EBUS-TBNA Bronchoscopy Education With Good Supporting Evidence: Erratum
No abstract available (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Erratum Source Type: research

Zephyr Endobronchial Valves Improve FEV1 and Quality of Life in Heterogenous Emphysema
Synopsis: In patients with severe heterogenous emphysema and little or no collateral ventilation in target lobes, Zephyr Endobronchial Valve treatment provides statistical and clinical benefits in lung function and quality of life compared with current standard of care therapies over a 12-month period. Source: Criner GJ, Sue R, Wright S, et al. LIBERATE Study Group. A multicenter randomized controlled trial of Zephyr endobronchial valve treatment in heterogenous emphysema (LIBERATE). Am J Respir Crit Care Med 2018;198:1151–1164. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Efficacy of Dupilumab for Treatment of Moderate-to-Severe Asthma
Synopsis: Dupilumab is a novel biologic agent that targets the shared interleukin 4/13 receptor. It is safe and efficacious in patients with moderate-to-severe asthma; however, subgroup analysis suggests that patients with elevated markers of type-2 inflammation benefit most from this drug. Source: Castro M, Corren J, Pavord ID, et al. Dupilumab efficacy and safety in moderate-to-severe uncontrolled asthma. NEJM 2018;378:2486–2496. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Cough and Nasal Pain: Putting Together an Uncommon Diagnosis
The pulmonary vasculitides include a wide spectrum of disorders that have in common inflammation and destruction of pulmonary blood vessels. Granulomatosis with polyangiitis (GPA), formerly known as Wegener granulomatosis, is the most common of the antineutrophil cytoplasmic antibody–associated small-vessel vasculitides, and affects a number of organ systems. GPA affects a wide age range, although it typically presents in middle adulthood. The classic triad of GPA—upper airway involvement (sinusitis, otitis media, mucosal ulcerations, airway inflammation), lower respiratory tract disease, and glomerulonephritis...
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Images In Pulmonary Medicine Source Type: research

Bronchoscopy in the Immunosuppressed Patient
Bronchoscopy in the immunosuppressed patient is routinely undertaken, as mortality of immunosuppressed hosts with pulmonary infiltrates is high. Generally, complications from bronchoscopy are rare, with pneumothorax and respiratory failure being the most serious. Immunosuppressed hosts do not have a higher complication rate than the general patient. In patients with HIV, bronchoscopy should be undertaken even if sputum samples are negative when suspicion is high for Pneumocystis jirovecii or tuberculosis. Patients with a hematologic malignancy have a high incidence of pulmonary infiltrates, and delaying bronchoscopy can si...
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Clinical Myths and Evidence-Based Medicine Source Type: research

Neurological Emergencies in the Intensive Care Unit
Neurological emergencies present a unique challenge in the intensive care unit, requiring rapid evaluation and treatment. There is a complex interplay in critically ill patients, wherein illness affects the brain and the brain can, in turn, affect the illness, making diagnosis and management challenging. In this review, we discuss the diagnosis and management of common neurological issues that may be encountered in the intensive care unit, including elevated intracranial pressure, traumatic brain injury, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, status epilepticus, neurological complications of cr...
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Colleagues in Respiratory Medicine Source Type: research

Management of Pulmonary Vasculitis: A Concise Review
The pulmonary vasculitides are an uncommon group of disorders that are characterized by inflammation and necrosis of the blood vessel wall, usually involving the small and medium-sized blood vessels in the lung. Management has traditionally involved the use of immunosuppressive agents and newer adjunctive therapies such as plasmapheresis. Recent trials over the last decade have highlighted the successful use of these agents in treating this life-threatening illness; however, much remains unknown in terms of exact dosing of these agents and duration of treatment. Adverse events from these therapies remain a serious concern ...
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Interstitial, Inflammatory & Occupational Lung Disease Source Type: research

Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: The Doctors are In, but the Jury is Still Out
Despite attempts to optimize outcomes in acute respiratory distress syndrome (ARDS) using mechanical ventilation and medical management, the mortality associated with this syndrome remains very high. The use of extracorporeal membrane oxygenation (ECMO), particularly veno-venous ECMO (VV-ECMO), as a rescue therapy has grown significantly in recent decades. This review outlines the risks and benefits of ECMO for the treatment of ARDS, examines the body of evidence behind this practice, including 4 randomized controlled trials and 2 case-controlled studies, and discusses the remaining questions and directions for future rese...
Source: Clinical Pulmonary Medicine - March 1, 2019 Category: Respiratory Medicine Tags: Critical Care/Respiratory Care Source Type: research

Acute Respiratory Distress Syndrome as a Precursor to Post–Intensive Care Syndrome
More than 6 million patients are cared for in an intensive care unit annually in the United States, and millions more internationally. Acute respiratory failure (ARF) is a common indication for intensive care unit admission, one that afflicts more than half of critically ill patients. Acute respiratory distress syndrome (ARDS) is a severe, life-threatening form of ARF. With advances in care over the last 50 years, the majority of ARF and ARDS patients survive. The survivorship literature is largely one that describes functional impairments and reduced quality of life after critical illness. In this review article, we put f...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Critical Care/Respiratory Care Source Type: research

Pulmonary Vasculitides: A Review
Vasculitides are uncommon diseases that target multiple sites of the respiratory tract. Their manifestations vary widely, ranging from the banal (cough, rash) to life threatening (renal failure, diffuse alveolar hemorrhage). Small-vessel, antineutrophil cytoplasmic antibody–associated vasculitides are the principal forms affecting the lungs. Less often, larger vessel and immune-complex vasculitides afflict the respiratory tract, although the management of these conditions often mirrors that of the antineutrophil cytoplasmic antibody–associated vasculitides with immunosuppression and supplemental modalities such...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Interstitial, Inflammatory & Occupational Lung Disease Source Type: research

Rituximab in Connective Tissue Disease–associated Interstitial Lung Disease: A Community-based Experience and Review of Literature
Interstitial lung disease (ILD) is an important manifestation of the connective tissue disorders (CTD), which can lead to significant morbidity and mortality. Conventional therapy involves immunosuppression. Rituximab (RTX), a chimeric monoclonal antibody leading to B-cell depletion, appears to have some benefit in different forms of CTD-ILD. Our community-based, university-affiliated ILD clinic receives referrals from various medical practitioners in the community, including non-university based rheumatologists. The approach to the assessment and management of these patients is multidisciplinary and involves discussions w...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Interstitial, Inflammatory & Occupational Lung Disease Source Type: research

Does Therapy With Adjuvant Corticosteroids Change Outcomes in Pneumocystis Pneumonia in Patients Without HIV?
Synopsis: Corticosteroids in Pneumocystis pneumonia without associated human immunodeficiency virus have long been controversial. However, recent literature is demonstrating that they may have no benefit, but rather cause an increase in morbidity. Source: Wieruszewski PM, Barreto JN, Frazee E, et al. Early corticosteroids for Pneumocystis pneumonia in adults without human immunodeficiency virus are not associated with better outcome. Chest 2018;154(3):636–644. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Does Dose Matter in Intravenous Thrombolysis for Acute Pulmonary Embolism?
Synopsis: In a retrospective analysis of intensive care unit patients using voluntarily reported national data, half-dose intravenous tissue plasminogen activator (tPA) for acute pulmonary embolism increased the need for escalation of care when compared with full-dose intravenous tPA. There was a lower risk of bleeding for half-dose tPA. Source: Kiser TH, Burnham EL, Clark B, et al. Half-dose versus full-dose alteplase for treatment of pulmonary embolism. Crit Care Med. 2018;46(10). (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Pulmonary Fat Embolism Syndrome After Liposuction Surgery
We present the case of a 52-year-old woman who developed FES as a complication of liposuction of the axilla, pectoris, and back. This case presents the typical radiologic findings in a patient with liposuction-induced FES. With the growing number of liposuction procedures, it is important for physicians to become aware of the fact that liposuction is not a risk-free procedure. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Images in Pulmonary Medicine Source Type: research

Primary Tracheal Lymphoma as a Rare Cause of Focal Tracheal Stenosis in an HIV-negative Patient
A human immunodeficiency virus negative, 71-year-old man who presented with a stridorous cough was found to have a focal tracheal stenosis associated with regional lymphadenopathy on chest computed tomography. On direct inspection, tracheal lesions were noted and biopsied with a 2.4 mm cryoprobe, establishing the diagnosis of primary tracheal lymphoma. The patient subsequently received chemotherapy, with clinical and imaging improvement of the tracheal stenosis. This case highlights a very rare cause for tracheal lesions and the use of cryoprobe over forceps biopsy as a tool to facilitate optimal tissue acquisition ...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Images in Pulmonary Medicine Source Type: research

Myth: For Bronchoscopy Training in the 21st Century, there is a Standard Curriculum or Metrics for EBUS-TBNA Bronchoscopy Education With Good Supporting Evidence
Lung cancer-related deaths in the United States in 2015 totaled 153,718, which is equivalent to a major catastrophe such as a Boeing 777 aircraft crashing and killing 550 passengers every 1.5 days per year. Lung cancer is the third most common cancer after breast cancer (for women) and prostate cancer (for men). In 2015, there were 218,527 new cases of lung cancer diagnosed in the United States. The large incidence and mortality of this malignancy makes it essential for efficient, accurate, and timely diagnosis via minimally invasive methods for lung cancer as well as staging. It is, therefore, of utmost importance to adeq...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Clinical Myths And Evidence-based Medicine Source Type: research

Septic Pulmonary Embolism: A Case Series, Proposed Set of Diagnostic Criteria, and Review of the Literature
We report on 4 cases of septic pulmonary embolism and provide a comprehensive review of this important entity. We also propose a modified set of diagnostic criteria in order to evaluate suspected cases clinically and confirm this diagnosis. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Respiratory Infections Source Type: research

Acute Respiratory Distress Syndrome as a Precursor to Post–Intensive Care Syndrome
More than 6 million patients are cared for in an intensive care unit annually in the United States, and millions more internationally. Acute respiratory failure (ARF) is a common indication for intensive care unit admission, one that afflicts more than half of critically ill patients. Acute respiratory distress syndrome (ARDS) is a severe, life-threatening form of ARF. With advances in care over the last 50 years, the majority of ARF and ARDS patients survive. The survivorship literature is largely one that describes functional impairments and reduced quality of life after critical illness. In this review article, we put f...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Critical Care/Respiratory Care Source Type: research

Pulmonary Vasculitides: A Review
Vasculitides are uncommon diseases that target multiple sites of the respiratory tract. Their manifestations vary widely, ranging from the banal (cough, rash) to life threatening (renal failure, diffuse alveolar hemorrhage). Small-vessel, antineutrophil cytoplasmic antibody–associated vasculitides are the principal forms affecting the lungs. Less often, larger vessel and immune-complex vasculitides afflict the respiratory tract, although the management of these conditions often mirrors that of the antineutrophil cytoplasmic antibody–associated vasculitides with immunosuppression and supplemental modalities such...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Interstitial, Inflammatory & Occupational Lung Disease Source Type: research

Rituximab in Connective Tissue Disease–associated Interstitial Lung Disease: A Community-based Experience and Review of Literature
Interstitial lung disease (ILD) is an important manifestation of the connective tissue disorders (CTD), which can lead to significant morbidity and mortality. Conventional therapy involves immunosuppression. Rituximab (RTX), a chimeric monoclonal antibody leading to B-cell depletion, appears to have some benefit in different forms of CTD-ILD. Our community-based, university-affiliated ILD clinic receives referrals from various medical practitioners in the community, including non-university based rheumatologists. The approach to the assessment and management of these patients is multidisciplinary and involves discussions w...
Source: Clinical Pulmonary Medicine - January 1, 2019 Category: Respiratory Medicine Tags: Interstitial, Inflammatory & Occupational Lung Disease Source Type: research

Is Procalcitonin No Longer Relevant for Guiding Antibiotic Use for Lower Respiratory Tract Infections?
Synopsis: In this multicenter randomized trial, the utility of procalcitonin assay results for decreasing antibiotic use in lower respiratory tract infections was investigated. Emergency department and hospital-based clinicians were provided with procalcitonin assay results and instructions on their interpretation for a group of patients presenting with lower respiratory tract infections whose need for antibiotics was still uncertain. The provision of these results and the instruction on their utility did not result in less antibiotic use compared with usual care. Source: Huang DT, Yealy DM, Filbin MR et al. Procalcitonin...
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

What’s the Risk? Varenicline May Increase Cardiovascular Complications in Users
Synopsis: Data are mixed and controversial with regard to the literature on varenicline causing increased cardiovascular complications. The authors of this study determined that there may be a 34% higher risk of cardiovascular complications associated with the use of varenicline, compared with no use. Source: Gershon AS, Campitelli MA, Hawken S, et al. Cardiovascular and neuropsychiatric events after varenicline use for smoking cessation. Am J Respir Crit Care Med. 2018;197:913–922. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

A Rare Etiology for an Endobronchial Lesion
Solitary pulmonary nodules are a frequent finding at thoracic imaging studies. Most solitary pulmonary nodules are the result of malignancy—either primary lung malignancies or solitary metastases—or infections, particularly granulomatous infections. Lesions arising from a bronchus are less common causes of solitary pulmonary nodules at thoracic imaging studies; most such lesions represent malignancies arising from the airways, such as carcinoid tumors and minor salivary gland tumors. Primary endobronchial neoplasms, both benign and malignant, often have a similar appearance at imaging studies, particularly thor...
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Images in Pulmonary Medicine Source Type: research

Immunosuppressive Treatment Regimens in Connective Tissue Disease–associated Interstitial Lung Disease
The management of interstitial lung disease due to connective tissue disease presents a challenge for clinicians, as this is a heterogeneous group of diseases, and there are no clear guidelines to follow, with only sparse randomized controlled trials available to guide therapy. Multiple different medications have been used for the treatment of interstitial lung disease due to connective tissue disease, with mostly retrospective studies or small case series documenting their efficacy. Ultimately, the choice of medication, the dosage, and the duration of therapy should be individualized for each patient after weighing the ri...
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Interstitial, Inflammatory and Occupational Lung Disease Source Type: research

Management of Malignant Pleural Effusion
Malignant pleural effusion is a common clinical problem with an increasing incidence that may be seen to complicate the management of almost all forms of cancer. It is associated with a very poor median survival leading to a palliative management approach. Several methods are available in the management of malignant pleural effusion including simple pleural aspiration, talc pleurodesis, or indwelling pleural catheters. Patient selection, however, remains difficult. The role for each management option, their indications, predictors of success, and factors influencing patient selection are all crucial considerations and are ...
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Topics in Pulmonary Medicine Source Type: research

Screening of Obstructive Sleep Apnea: A Review of Questionnaire-based Tools
Obstructive sleep apnea (OSA) is a significant problem resulting from the obstruction of the upper airway. It leads to cardiovascular disorders, cognitive impairment, epilepsy, fatigue, sleepiness, diabetes, and perioperative complications. It is important to identify and treat OSA before it leads to other comorbidities. Thus, reliable questionnaire-based methods have been developed for screening this disease. This review article elaborates the most common questionnaires used for the screening of OSA: the STOP questionnaire, STOP-Bang questionnaire, Berlin questionnaire, Epworth Sleepiness Scale, Fatigue Severity Scale, an...
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Topics in Pulmonary Medicine Source Type: research

Evidence of Efficacy of Intrabronchial Valves for Persistent Air leak
The management of persistent air leaks remains a common and challenging clinical problem. The introduction of intrabronchial valves has offered an alternative intervention for air-leak management; however, the efficacy of these valves remains unclear. Numerous case reports and case series currently exist as well as some larger trials; however, many remained plagued with shortcomings of retrospective, often single-center descriptions. Within this review, we attempt to describe the history of intrabronchial valves, the current intrabronchial valve systems available for use, and the current literature available evaluating int...
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Interventional Pulmonary Medicine Source Type: research

Respiratory Tract Colonization by Candida Species Portends Worse Outcomes in Immunocompromised Patients
The significance and clinical management of Candida colonization of the respiratory tract are ill-defined. We now report the frequency of Candida species from the lower respiratory tract in hematopoietic stem cell transplant recipients (HSCT) undergoing bronchoscopy with broncheoalveolar lavage for pneumonitis after HSCT. The University of Michigan Clinical Microbiology Laboratory Database was queried for all respiratory cultures positive for Candida species between 2000 and 2012. We concurrently performed a retrospective analysis of 515 HSCT recipients with pneumonitis at our institution between 2001 and 2012. During this...
Source: Clinical Pulmonary Medicine - November 1, 2018 Category: Respiratory Medicine Tags: Respiratory Infections Source Type: research

IMPACT Trial: Triple Versus Dual Therapy for COPD Results in Decreased Rate of Exacerbations
Synopsis: Despite clinical guidelines recommending triple therapy with an inhaled corticosteroid (ICS), long-acting muscarinic receptor antagonist (LAMA), and long-acting beta-agonist (LABA) for individuals with GOLD D chronic obstructive pulmonary disease, the evidence supporting this is weak. The IMPACT study was a randomized controlled trial that provided evidence that exacerbation risk is decreased in patients using triple therapy compared with an ICS/LABA or LAMA/LABA. Source: Lipson DA, Barnhart F, Brealey N, et al. Once-daily single-inhaler triple versus dual therapy in patients with chronic obstructive pulmonary d...
Source: Clinical Pulmonary Medicine - September 1, 2018 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Pembrolizumab Plus Chemotherapy in Patients With Previously Untreated Metastatic Non–small Cell Lung Cancer Without EGFR or ALK Mutations is Superior to Chemotherapy Alone
Synopsis: In this double-blind, phase 3 trial, the addition of pembrolizumab to standard chemotherapy with a platinum-based drug and pemetrexed resulted in better overall survival, progression-free survival, as well as tumor response rate among patients with previously untreated metastatic nonsquamous, non–small cell lung cancer without sensitizing epidermal growth factor receptor or anaplastic lymphoma kinase mutations. Source: Leena Gandhi, Delvys Rodriguez-Abreu, Shirish Gadgeel, et al. Pembrolizumab plus chemotherapy in metastatic non–small cell lung cancer. New England Journal of Medicine. 2018. Doi:10.10...
Source: Clinical Pulmonary Medicine - September 1, 2018 Category: Respiratory Medicine Tags: Pulmonary Trends Source Type: research

Thin-walled Cystic Pulmonary Lesions: Rare Considerations
A pulmonary cyst may be defined as an abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired in etiology, typically with a circumscribed interface with adjacent normal lung, and a wall thickness>1 mm. Pulmonary cysts are not infrequent abnormalities at thoracic computed tomography. Occasionally, pulmonary cysts are incidentally encountered at thoracic imaging studies and, when limited in number, may even be regarded as a consequence of normal age-related pulmonary changes. The causes of cysts within the lung parenchyma are numerous, and pulmonary cysts s...
Source: Clinical Pulmonary Medicine - September 1, 2018 Category: Respiratory Medicine Tags: Images in Pulmonary Medicine Source Type: research

RNA Acquisition From Transbronchial Needle Aspiration in Non–Small Cell Lung Cancer
The current complexity of non–small cell lung lies in multiple histologies, targetable mutations, and gene expression, all of which are necessary information for structuring treatment and formulating prognosis. Obtaining this information from small-volume biopsies can present unique challenges, and researchers are exploring RNA analysis to elicit this. RNA analysis is already being used in other malignancies such as those of the breast and thyroid. We performed a review of the literature, demonstrating that sufficient material can be obtained through RNA specimens collected during endobronchial ultrasound-guided tran...
Source: Clinical Pulmonary Medicine - September 1, 2018 Category: Respiratory Medicine Tags: Clinical Myths and Evidence-Based Medicine Source Type: research

Role for Sampling Nonpalpable Supraclavicular Lymph Nodes Found by Ultrasound at the Time of EBUS-TBNA: A Single-center Pilot Study
In conclusion, we propose that ultrasound fine-needle aspiration of SCLN is feasible and can be highly diagnostic in these high-risk patients. (Source: Clinical Pulmonary Medicine)
Source: Clinical Pulmonary Medicine - September 1, 2018 Category: Respiratory Medicine Tags: Interventional Pulmonary Medicine Source Type: research