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  • There is convincing experimental evidence that active sodium and chloride transporters are expressed in the lung epithelium and are responsible for the ability of the lung to remove alveolar fluid at birth as well as in the normal mature lung and when pathological conditions lead to the development of pulmonary edema. The ion transporters described in the alveolar epithelium are epithelial sodium channels, the cystic fibrosis transmembrane conductance regulator, the Na+, K+-ATPase (sodium pump), and aquaporin water channels. In the recent years many experimental studies have shown that the alveolar epithelium plays an important role in alveolar fluid clearance by active vectorial sodium transport. Sodium enters through the apically located amiloride sensitive Na+ channels and it is extruded by the basolaterally located Na+, K+-ATPase consuming ATP with water following iso-osmotically the Na+ gradients. Several drugs that enhance alveolar edema clearance positively affect this mechanism. These include á-adrenergic agonists (epinephrine, nor epinephrine), â-adrenergic agonists (dobutamine, terbutaline, isoproterenol, salmeterol), dopamine, dexamethasone, aldosterone, and several growth factors. The active vectorial sodium and water transport enhanced by specific pharmacological or gene interventions may have a significant role in the resolution of cardiogenic (hydrostatic) or non cardiogenic (increased permeability) pulmonary edema. However, clinical data are lacking yet concerning the importance of the enhancement of lung liquid clearance on survival in patients with acute hypoxemic respiratory failure due to pulmonary edema. Pneumon 2006, 19(1):14-23.
     
  • Bronchial challenge by eucapnic voluntary hyperventilation is based on the stimulation of inflammatory cells and nerve endings of the airways and for this reason is considered as an indirect challenge test. Hyperventilation is associated with increased loss of water from the bronchial mucosa, causing a rise in the osmolarity of the mast cell microenvironment, which eventually releases numerous mediators, as histamine, prostaglandins and leukotrienes. To a lesser extent this effect is enhanced by the stimulation of the airway nerve endings and by the cooling-rewarming sequence. The test bears a strong association with markers of inflammatory airway disease and allows adjustment of anti-inflammatory treatment and more effective disease follow-up. It is also an extremely specific test for the diagnosis of bronchial asthma and it is considered as the test of choice for the diagnosis of exerciseinduced asthma. During the test the subject is encouraged to hyperventilate, in order to achieve and sustain particular target ventilation, which varies according to protocol employed. Eucapnia is sus tained via the simultaneous administration of CO2, while response is quantified by measuring the drop in FEV1. The test is considered positive when the drop is greater than 10%. Eucapnic hyperventilation challenge is considered an extremely safe test. Pneumon 2006, 19(1):24-35.
     
  • The hepatopulmonary syndrome is characterized by the combination of hypoxemia and endopulmonary vascular dilatations in patients with liver disease. Its prevalence ranges from 4% to 29%. Pathology tissue examination reveals dilated arterioles and capillaries as well as communications between arteries and veins. Evidence exists that endopulmonary dilatations correlate with the presence of portal hypertension. The increased production of nitrogen monoxide (NO) and the activation of endothelin receptors are shown to play an important role in the pathogenesis of the syndrome by causing vascular dilatation and by interrupting the normal mechanism of hypoxic vasoconstriction in the lung. Hypoxemia is found in the majority of patients with hepatopulmonary syndrome. In severe cases the phenomena of orthodeoxia and platypnoea ensue. The documentation of endopulmonary dilatations is based on three methods: a. contrast echocardiography, b. perfusion radionuclide scanning with 99mTc, c. pulmonary angiography. Treatment includes oxygen therapy, correction of portal hypertension and in specific cases liver transplantation. Prognosis is poor and mortality exceeds 40%. Pneumon 2006, 19(1):36-41.
     
  • Pulmonary artery catheterization in small mammals contributes to more precise monitoring of hemodynamic parameters studied in experimental models. In addition, it allows drugs to be administered locally in the lungs through the inserted catheter, thus minimizing systemic adverse reactions. A refined technique for insertion of a Swan-Ganz catheter in the pulmonary artery of New Zealand rabbits through right external jugular artery is described. The catheter is bended before the insertion; when the right ventricle is reached, a minimal inflation of the balloon helps its advancement in the pulmonary artery carried along by the blood flow. Pneumon 2006,19(1):42-45.
     
  • Inflammatory pseudotumor (IPT) is a rare benign lesion of the lung of unknown origin. We retrospec¬tively present our experience in the surgical management of ten such cases. During the period 7/1995¬6/2001, 10patients (8 males, 2 females) were operated on due to undefined pulmonary lesions that were ultimately identified as IPT. Mean patient age was 53.5±8.4years (range: 42-69years). The main clinical manifestations included haemoptysis or bloody sputum (3), and recurrent pulmonary infec¬tions (3); the pulmonary lesion was an incidental finding in 4 cases. The thorough preoperative work¬up was negative for malignancy in all cases. All patients underwent exploratory thoracotomy. Frozen sections obtained from the lesions were negative for malignancy in 2 cases and non-diagnostic in the rest. Seven lobectomies, 1 pneumonectomy and 2 wedge pulmonary resections in disease-free margins were performed. The mean postoperative period was 10.2±4.4 days (range: 6-19 days). Morbidity was 10% (due to prolonged air-leakage in 1 patient), while mortality was nil. The pathology report showed that all cases were IPTs, with a mean tumor size of 3.3±1.3 cm (range: 1-5.5 cm). In follow-up examination, all patients are alive with a mean survival of 63.1±19.7 months (range: 32-102 months), with no evidence of recurrence of the lesion. IPT is mimicking lung cancer in clinical and radiological presentations. Neither preoperative investigation, nor intraoperative frozen section pathology exami¬nation are diagnostic. The treatment of choice is surgical resection, which has both diagnostic and therapeutic value, with excellent results. Pneumon 2006,19(1):49-53.
     
  • We report the case of 66-year-old male, presenting with high fever since twenty days before admission, cough, progressive dyspnea, weakness and weight loss. Computed tomography of the chest showed interstitial fibrosis with distribution and morphology more suggestive of UIP pattern, compatible with the patient's clinical findings. Renal function tests and biopsy of the kidney revealed a segmental necrotizing glomerulonephritis with little or no immunoglobulin deposition (pauci-immune) on immunofluorescence. Finally our diagnosis of microscopic polyangiitis expressed as interstitial lung fi¬brosis, was confirmed by positive perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). Pneumon 2006,19(1):59-64.
     
  • We report a case of pulmonary embolism in a young man 39 years old, without obvious risk factors, who was presented to the hospital with symptoms and clinical findings suggestive of pulmonary embolism, due to deep venous thrombosis of lower extremities. Serial echocardiographic studies revealed a large, long mobile thrombus in the right atrium, which was finally thrown into the pulmonary circulation. Despite this new embolic episode the patient remained at the same clinical status, and hemodynamically stable without a further deterioration in his respiratory function. The contribution of echocardiography in the diagnosis of pulmonary embolism and current treatment options are discussed. Pneumon 2006, 19(1):65-73.
     
  • This is a case of a 53 year old woman, non-smoker, presenting with a history of grade III/IV shortness of breath, gradually aggravated over the last week. The patient reported a history of idiopathic pericarditis, diagnosed 4 months ago, under treatment with methyl-prednisolone (24mg/daily). Her clinical examination was unremarkable, while her laboratory findings were indicative of normochromic normocytic anemia (Hct 35%) and lymphopenia (WBC:9.89: Neu:70.2%, Ly:11.5%, MO:3.5%, Eo:1%, Ba:0.1%). Chest x-ray revealed diffuse non-homogeneous opacities of alveolar type, and confluent nodules especially in the middle and lower lung zones. HRCT revealed a predominantly nodular appearance with nodes and nodules in contact with broncho-vascular structures, as well as greater areas of consolidation (possibly due to confluence of pulmonary nodules). Branched linear and nodular opacities, and a patchy ground glass pattern were also noted. Microbiology, virology and immunology testing turned up negative. Despite provided therapy with conventional antibiotics the patient.s clinical condition rapidly deteriorated. The patient underwent bronchoscopy and bronchoalveolar lavage (BAL), whose culture was positive for Penicillium Marneffei (greater than 106). The patient was thereafter administered Amphotericin B and Itraconazole, resulting to a temporary improvement of her clinical condition and radiological findings. Unfortunately the patient died 20 days following the initiation of the indicated therapy. Pneumonia due to Penicillium Marneffei is an extremely rare condition and few references exist in international medical literature. Pneumon 2006, 19(1):74-80.
     
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