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  • The term pulmonary-renal syndrome refers to the combination of diffuse alveolar haemorrhage and rapidly progressive glomerulonephritis. It is usually a manifestation of an autoimmune systemic disease, Goodpasture’s syndrome included. A variety of mechanisms such as anti-glomerular membrane antibodies, antineutrophil cytoplasmic antibodies, immunocomplexes, thrombotic microangiopathy are implicated in the pathogenesis of this syndrome. The underlying pulmonary histologic lesion is small vessel vasculitis characterized by an inflammatory destructive process involving arterioles, venules and frequently alveolar capillaries (necrotic pulmonary capillaritis). Haemoptysis is the most frequent clinical manifestation of diffuse alveolar haemorrhage. However, 30-35% of patients may not present the symptom. In this case the following suggest the diagnosis: 1) a chest roentgenogram revealing multiple coalescent alveolar shadows, 2) acute decrease of hematocrit, 3) haemorrhagic bronchoalveolar lavage, and 4) increased Kco. In patients with evidence of diffuse alveolar haemorrhage and renal involvement, kidney biopsy should be considered to identify the underlying cause and help direct the therapy. Pulmonary-renal syndrome is related to significant morbidity and mortality and is often complicated by life threatening side effects attributed to immunosuppressive treatment. Its fulminant course requires early diagnosis and initiation of therapy including corticosteroids in high doses and cytotoxic agents. In some cases plasmapheresis is indicated. The role of new agents such as anti-TNFa is under investigation. Pneumon 2006, 19(3):168-179.
     
  • High frequency oscillatory ventilation is an alternative mode of mechanical ventilation featuring a combination of high respiratory rate and low tidal volume. Compared to conventional mechanical ventilation, it presents essential differences in principles of operation and mechanisms ensuring adequate blood gas exchange. The applied mean airway pressure is constant and produced by adjustable collateral airflow. Ventilation is achieved through an electromechanical oscillating piston, creating a pressure difference (ΔP) superimposed to the mean airway pressure. Thus, there is a constant cyclic volume supply; tidal volume is proportional to the pressure difference (ΔP). HFOV was initially applied only in neonates with acute respiratory distress syndrome. In the last decade, its use has expanded to adults with ARDS. Considering to-date available evidence, the use of HFOV in adults with ARDS has many advantages over conventional mechanical ventilation. Nevertheless, further comparative controlled randomized studies are necessary.
     
  • Massive hemoptysis may be defined as greater than 600 ml of blood loss from the lungs in 24 hours. The current mortality rate is approximately 13% and is related to drowning or suffocation rather than exsanguination. The most common cause, even nowadays is tuberculosis. Diagnosis and treatment typically include a chest x-ray and emergency bronchoscopy using a 10-mm rigid scope. Treatment options must be guided by the clinical situation and the findings. Bronchoscopy under general anesthesia is performed and bleeding is controlled so as to prevent soiling the contralateral (uninvolved) lung. Conservative management may consist simply of bronchoscopy, clearing the airway of blood, cough suppression, and bed rest. Patients with cystic fibrosis may require tamponade using a balloon catheter. Patients with aspergilloma fungus balls are at high risk for fatal hemorrhage and should be aggressively treated and undergo resection when possible. Angiographic catheterization for massive hemoptysis may be considered for patients with hemoptysis and inability to localize a bleeding site. The risk of quadriplegia must be considered in light of the overall patient condition. Pneumon 2006, 19(3):192-201.
     
  • In most developed countries 25% of adults with asthma are current cigarette smokers. Asthma and active cigarette smoking interact to cause more severe symptoms, accelerated decline in lung function, and impaired short-term therapeutic response to corticosteroids. Cigarette smoking may modify inflammation that is associated with asthma, although there are limited published data on airway pathology in smokers with asthma. To date, the evidence points towards a combination of both heightened and suppressed inflammatory responses in smokers compared with nonsmokers with asthma. The mechanisms of corticosteroid resistance in asthmatic smokers are unexplained, but could be as a result of alterations in airway inflammatory cell phenotypes, changes in the glucocorticoid receptor-a to b ratio and increased activation of pro-inflammatory transcription factors or reduced histone deacetylase activity. In conclusion, asthmatics who smoke should be strongly encouraged to stop, although the effects of smoking cessation upon reversing the adverse effects of tobacco smoke on asthma control, therapeutic response to corticosteroids and airway pathology have yet to be fully elucidated. Furthermore, alternative or additional therapies to inhaled corticosteroids are needed for asthmatic patients who are unable to quit smoking, and it seems that there may be a need for reassessment of current treatment guidelines in this population. Pneumon 2006, 19(3):202-215
     
  • Asthma is characterized by variable airflow obstruction and increase in bronchial responsiveness. It has a tendency to destabilize and get worse at night. Recent studies have shown that there are strong indications of increased association between asthma and obstructive sleep apnea syndrome. In a study it is reported that children were five times more likely to have experienced snoring if they reported wheezing in the last 12 months. In a similar research it is reported that the odds ratio of a child with asthma to have habitual snoring was 7,45%. The odds ratio of an adult with asthma to have snoring and/or apneas is 17,9% and 14,3% respectively. Asthma and obstructive sleep apnea syndrome might be linked because of common risk factors and path mechanisms such as airway inflammation, obesity, gastroesophageal reflux and sex-related differences. However, the exact mechanisms are yet unclear. Furthermore it is yet unclear if asthma leads to obstructive sleep apnea syndrome οr vice versa. Pneumon 2006, 19(3):216-222.
     
  • Intensive Care Unit, General Hospital of Lamia, 2Microbiology Laboratory, General Hospital of Lamia Nosocomial infections caused by Acinetobacter baumannii are of increasing concern in critically ill patients and the emergence of multi-drug resistant strains (MDRAB) complicates their treatment. The purpose of this retrospective study was to determine the incidence of MDRAB infections, as well as PNEUMON Number 3, Vol. 19, July - September 2006 229 to investigate the effect of antibiotic treatment on mortality. Medical records of all ICU admissions through a 21-month period were reviewed (N 240); patients with MDRAB-positive cultures were eligible for evaluation (N 35). According to infection type and origin, eligible patients were divided into three groups: group A included patients with ventilator-associated pneumonia (VAP); group B patients with sepsis of non-respiratory origin; and group C patients with respiratory colonization. The overall incidence of MDRAB-positive cultures was 14.58%. Of them, 71.4% of the patients (N 25) had VAP; 14.2% had sepsis of non-respiratory origin (N 5); and 14.2% (N 5) had respiratory colonization. Mean age was 58.14 years; male-to-female ratio was 21/14; and mean APACHE II score at ICU admission 18.2. The most important risk factors were CHF, CAD, COPD and surgical procedure. Treatment included ampicillin/sulbactam and colimycin alone or in combination. Crude mortality was 25.71% (N 9) and disease-specific mortality 23.33% (N 7). Clinical improvement was noted in 70% (N 21) and chronic colonization developed (group C encountered) in 11.42% (N 4). The incidence of infections due to MDRAB among ICU patients is clinically significant. VAP is the most frequently encountered infection. Combination treatment with ambicillin/sulbactam plus colimycin seems to be more effective due to the synergistic effects of colimycin and sulbactam, as evidenced by a reduction in mortality, which was nevertheless not statistically significant. Our results are based on a small series of patients and larger well-designed studies are needed to determine the efficacy of colimycin in combination treatment. Pneumon 2006, 19(3):231-237.
     
  • A variety of techniques have been used to palliate the effects of large airway obstruction. Tracheobronchial stenting is the optimal endoscopic management when the obstruction is caused by severe extrinsic compression, intraluminal spread of disease or loss of cartilaginous support. Between 1999 and 2004, 50 patients have had 57 silicone rubber stents to manage symptomatic central airway obstructions. The stents were placed through the Harell Universal rigid bronchoscope. The etiology was: malignant disease in 30/50 (60%), benign disease 17/50 (34%) and tracheoesophageal fistula in 3/50 (17%), whilst 6 of the 50 patients (12%) required two or more stents to achieve complete airway palliation. There were 2/50 complications (4%) and no procedure- or stent-related mortality. Most patients (92,5%) had successful airway palliation. Airway stenting provides immediate and reliable palliation in the majority of patients with malignant and benign central airway obstruction. Multiple stents are frequently required in order to achieve satisfactory airway patency. Pneumon 2006, 19(3):238-244.
     
  • Bronchopulmonary sequestration is a rare clinical entity. Αn 18-year old patient with a history of recurrent lower respiratory tract infections, who was given the diagnosis of intralobar bronchopulmonary sequestration is presented. A spiral CT angiography showed that the lesion received its arterial blood supply from the lower thoracic aorta. Relevant literature is reviewed. Pneumon 2006, 19(3):252-257.
     
  • The case of a patient with an azygos lobe is described and the surgical specimen of the patient’s right upper lobe is presented. Pneumon 2006, 19(3):258-260.
     
  • Α case of a 66 years old man, ex smoker, admitted to our department complaining of productive cough since eight months, dyspnea on exertion since two-months, loss of weight and bilateral alveolar infiltrates on chest-x-ray is presented. The high resolution CT of the chest (HRCT) revealed pulmonary fibrosis. The administration of corticosteroids improved the respiratory failure of the patient. Bronchoscopy was diagnostic and cytological examination of the washing specimens revealed bronchoalveolar carcinoma. Pneumon 2006, 19(3):261-264.
     
  • We present a case report of a woman, 35 years old, smoker, who came to our clinic with cough, dyspnea, fatigue and loss of weight, reporting multiple recurrent pulmonary infections during last year. The CT of the lung showed bilateral multiple thin walled cysts, as well as nodular lesions, while the CT of the brain demonstrated osteolytic lesion in the left temporal bone. BAL showed that OCT-6 (CD1) were 12% and the diagnosis of eosinophilic granuloma of the lung was confirmed. Pneumon 2006, 19(3):265-271.
     
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