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Seminars in Respiratory and Critical Care Medicine

Neeraj R Desai, Mihir S Parikh, Hans J Lee
Medical education and training are becoming more complex endeavors as technological and research advancements lead to new tools and methods to care for patients. In recent years, there has been a paradigm shift in medical education to competency-based assessments. Another important recent development in medical education has been the increasing use of simulation-based learning for procedural training. Interventional pulmonology (IP) is a relatively young and rapidly evolving procedural-based subspecialty. There are several well-validated competency-based assessment tools available to measure training adequacy in many of the most commonly performed procedures in IP...
December 2018: Seminars in Respiratory and Critical Care Medicine
Catherine L Oberg, Van K Holden, Colleen L Channick
Benign central airway obstruction (CAO) is responsible for significant morbidity due to dyspnea and impaired quality of life. While iatrogenic causes, including stenosis after endotracheal intubation, tracheostomy tube placement, and surgery, account for the majority of cases of benign CAO, there are a multitude of other causes including infections, inflammatory disorders, extrinsic compression, benign endobronchial tumors, and tracheobronchomalacia. The approach to management depends on the underlying process responsible for the disorder and may include systemic therapy, endoscopic therapy, and surgery...
December 2018: Seminars in Respiratory and Critical Care Medicine
Ziyad Al-Shathri, Irawan Susanto
Tracheostomy is a commonly performed surgical procedure in intensive care units (ICUs). Over the past three decades, there has been a substantial body of evidence to suggest percutaneous tracheostomy (PT) is at least as safe as surgical tracheostomy (ST) in the hands of trained clinicians. In most institutions, PT is more readily performed at bedside than ST in the ICU; hence, PT is an attractive alternative to ST in the ICU. Bedside PT generates significant cost savings by eliminating operating room and anesthesia charges...
December 2018: Seminars in Respiratory and Critical Care Medicine
Kyle Bramley, Erin DeBiasi, Jonathan Puchalski
Pleural effusions account for significant symptoms and morbidity. Recent studies demonstrate a high mortality in patients with "benign" pleural effusions, now better characterized as nonmalignant pleural effusions (NMPEs) based on their prognosis. The most common nonmalignant clinical conditions with recurrent pleural effusions are congestive heart failure and hepatic hydrothorax, although many other diseases exist in isolation or as comorbid conditions. When conventional therapy fails, thoracentesis is often performed for relief of dyspnea...
December 2018: Seminars in Respiratory and Critical Care Medicine
David J McCracken, Jose M Porcel, Najib M Rahman
Malignant pleural effusion (MPE) represents advanced metastatic malignancy and is associated with poor median survival. Incidence remains high and continues to rise, in part due to changing population demographics. This therefore represents a significant health care burden. Management is predominantly palliative in nature and multiple interventions are available within conventional treatment paradigms, all of which are proven to result in statistically significant patient benefit. This article further explores the methods available in the management of MPE along with the pitfalls, complications, and alternatives...
December 2018: Seminars in Respiratory and Critical Care Medicine
Pyng Lee, Erik Folch
Thoracoscopy is an increasingly common procedure that provides significant clinical information and therapeutic applications. The procedure allows the physician to biopsy the parietal pleura under direct visualization with high accuracy. In addition, one can drain pleural fluid, place a chest tube in a precise location, and perform poudrage pleurodesis. Medical thoracoscopy (MT) is carried out in the operating room or procedure suite under moderate sedation with spontaneous ventilation. In comparison, video-assisted thoracoscopic surgery (VATS) is performed under general anesthesia with single lung ventilation and through multiple ports in the operating room...
December 2018: Seminars in Respiratory and Critical Care Medicine
Sebastian Fernandez-Bussy, Gonzalo Labarca, Felix J F Herth
Bronchoscopic lung volume reduction (BLVR) is a minimally invasive procedure for patients with symptomatic severe emphysema who may not be candidates for surgical lung volume reduction. BLVR has been shown to improve both functional and clinical outcomes with a relatively low risk of severe complications. Any potential candidate to BLVR should be on optimal pharmacological and nonpharmacological treatment. Radiographic and pulmonary function testing provide key data to help identify potential BLVR candidates...
December 2018: Seminars in Respiratory and Critical Care Medicine
Javier Diaz-Mendoza, A Rolando Peralta, Labib Debiane, Michael J Simoff
Rigid bronchoscopy is one of the oldest medical techniques used in the respiratory and thoracic fields. Even though its use declined after the development of flexible bronchoscopy, it has again gained importance with the growth of interventional pulmonology, becoming a critical technique taught as part of the training in this subspecialty. The therapeutic advantages compared to other approaches of thoracic pathologies makes rigid bronchoscopy a primary component in the present and future of interventional pulmonary medicine...
December 2018: Seminars in Respiratory and Critical Care Medicine
Fayez Kheir, Adnan Majid
Excessive central airway collapse (ECAC) is characterized by excessive narrowing of the airway lumen during exhalation leading to dyspnea, cough, mucostasis, recurrent respiratory infections, and poor quality of life. Tracheobronchomalacia and excessive dynamic airway collapse are heterogeneous entities of ECAC and are characterized by a diverse nonspecific symptom profile. Although the pathophysiology of airway mechanics as well as morphology in both entities is different, current evidence so far shows no practical benefit in making such distinction since both have similar symptoms and the diagnostic and therapeutic work-ups are the same...
December 2018: Seminars in Respiratory and Critical Care Medicine
Udit Chaddha, Jonathan S Kurman, Amit Mahajan, D Kyle Hogarth
With the rising number of screening and incidentally detected lung nodules, there is an increasing need for evaluation in the safest and least invasive manner. The last two decades have seen substantial evolution in bronchoscopic approaches to diagnose these nodules. Innovative bronchoscopic techniques, often used in conjunction with each other, have significantly improved our ability to navigate to almost any part of the lung. A comprehensive knowledge of available technologies and the factors affecting diagnostic yield is essential to decide on the best way to approach a particular scenario...
December 2018: Seminars in Respiratory and Critical Care Medicine
Tao He, Atul C Mehta
Since its advent more than a decade ago, real-time linear endobronchial ultrasound (EBUS) guided transbronchial needle aspiration has revolutionized the diagnosis and staging of nonsmall cell lung cancer (NSCLC), and has become the standard of care with widespread acceptance. It is also extensively used to diagnose other disease entities such as malignancy besides NSCLC, benign diseases, or infectious processes. Ancillary studies have shown its superior safety profile and cost-effectiveness. In recent years, linear EBUS has been expanding its clinical applications owing to the emerging new tools such as the 19-gauge (19G) needle and miniforceps...
December 2018: Seminars in Respiratory and Critical Care Medicine
Scott S Oh, W Dean Wallace, Faisal Shaikh, Joseph P Lynch
Transbronchial lung cryobiopsy (TBLCB) is a relatively new and promising technique for the acquisition of larger amounts of higher quality lung tissue for the diagnosis of lung diseases. There is a growing body of literature describing a diagnostic yield comparable to surgical lung biopsy with a favorable safety profile. Due to its advantages TBLCB has garnered significant interest with more institutions beginning to adopt this technique. However, several questions remain including its role in the diagnostic algorithm, indications, and technique...
December 2018: Seminars in Respiratory and Critical Care Medicine
Scott S Oh, Erik Folch
No abstract text is available yet for this article.
December 2018: Seminars in Respiratory and Critical Care Medicine
Andrew J MacDonald, Constantine J Karvellas
Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are life-threatening illnesses requiring intensive care admission and potentially liver transplantation. Artificial extracorporeal liver support (ECLS) systems remove water-soluble and albumin-bound toxins to maintain normal serum chemistry, prevent further hepatic/organ system damage, and create an environment for potential hepatic regeneration/recovery (ALF) or bridge to liver transplantation (ALF and ACLF). Use of artificial ECLS has been studied in both ALF and ACLF...
October 2018: Seminars in Respiratory and Critical Care Medicine
Igor Barjaktarevic, Roxana Cortes Lopez, Randolph Steadman, Christopher Wray, Nida Qadir, Steven Y Chang, Tisha Wang
Liver transplantation (LT) has the potential to cure patients with acute and chronic liver failure as well as a number of hepatic and biliary malignancies. Over time, due to the increasing demand for organs as well as improvements in the survival of LT recipients, patients awaiting LT have become sicker, and often undergo the procedure while critically ill. This trend has made the process of preoperative assessment and planning, intraoperative management, and postoperative management even more crucial to the success of LT programs...
October 2018: Seminars in Respiratory and Critical Care Medicine
Nicolas M Intagliata, Jessica P E Davis, Stephen H Caldwell
Achieving hemostasis, preventing and treating thrombosis, and laboratory measurement of the hemostatic pathways constitute the core elements of managing the critically ill patient with liver failure. Uncontrolled bleeding in acutely decompensated cirrhosis and acute-on-chronic liver failure is probably the most familiar clinical challenge to intensivists. Bleeding in these patients can be broadly divided into pressure-driven (portal hypertension-related) bleeding with only limited dependence on hemostatic pathways and intractable mucosal/wound bleeding, which is much more directly related to a severely disturbed hemostatic system with imbalances in the coagulation cascade and the fibrinolytic system...
October 2018: Seminars in Respiratory and Critical Care Medicine
Matthew K Hensley, Jane C Deng
Both the adaptive and innate arms of immunity are altered in patients with cirrhosis, which have both prognostic and clinical implications. Acute on chronic liver failure (ACLF), defined as decompensated cirrhosis with associated organ failure, carries a high risk of 28-day mortality and is marked by a significant inflammatory response. Patients with decompensated chronic liver disease display a shift from a chronic low-grade inflammatory state to one of intense inflammation, followed by the development of immunoparalysis...
October 2018: Seminars in Respiratory and Critical Care Medicine
Amanda Cheung, Sajal Tanna, Michael G Ison
Infections remain a leading cause of morbidity and mortality among patients with liver failure. A number of factors, including relative immune dysfunction and systemic inflammation, bacterial translocation, gut dysbiosis, small intestine bacterial overgrowth, altered bile acid pools, and changes in pH due to acid suppression, contribute to the high rates of infection in this population. Though a range of infections can complicate the course of cirrhotic patients, spontaneous bacterial peritonitis (SBP), cholangitis, and cholecystitis in addition to other infections (i...
October 2018: Seminars in Respiratory and Critical Care Medicine
Kapil Rajwani, Brett E Fortune, Robert S Brown
Gastrointestinal (GI) bleeding and ascites are two significant clinical events that frequently present in critically ill patients with chronic liver failure or decompensated cirrhosis. GI bleeding in patients with cirrhosis, particularly portal hypertensive-associated bleeding, carries a high short-term mortality (15-25%) and requires early initiation of a vasoactive agent and antibiotics as well as timely endoscopic management. Conservative transfusion strategies and adequate airway protection are also imperative to assist in bleeding control...
October 2018: Seminars in Respiratory and Critical Care Medicine
Anthony Bonavia, Kai Singbartl
The liver and kidney are key organs of metabolic homeostasis in the body and display complex interactions. Liver diseases often have direct and immediate effects on renal physiology and function. Conversely, acute kidney injury (AKI) is a common problem in patients with both acute and chronic liver diseases. AKI in patients with acute liver failure is usually multifactorial and involves insults similar to those seen in the general AKI population. Liver cirrhosis affects and is directly affected by aberrations in systemic and renal hemodynamics, inflammatory response, renal handling of sodium and free water excretion, and additional nonvasomotor mechanisms...
October 2018: Seminars in Respiratory and Critical Care Medicine
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