Current Respiratory Medicine Reviews - Volume 11, Issue 3, 2015

Malignant mesothelioma is an insidious cancer with a long latency period from the initial exposure to asbestos, the most common causative agent. Patients show minimal response to current treatment options, resulting in a median survival time from diagnosis ranging between 12-18 months. Although recent studies have enhanced our understanding of mesotheliomas, treatment strategies that range from supportive care to radical trimodality therapy have limited efficacy. Aside from being an essential component of trimodality therapy for mesotheliomas, radiation therapy has been also utilized as a prophylaxis for drain-site recurrence and palliation of pain. However, the efficacy of radiation therapy is limited by the development of radiation resistance due to the activation of pro-survival cell signaling pathways. Blocking these important signaling pathways with pharmaceutical inhibitors or other approaches such as RNA interference has considerable potential to enhance the efficacy of radiation therapy in mesothelioma. This brief review focuses on the effects of radiation therapy in mesothelioma and resultant activation of pro-survival signaling pathways.

Medication nonadherence has an unfavorable effect on asthma outcomes in both adult and pediatric patients. In asthma, nonadherence is associated with more frequent exacerbations, increased emergency room visits, and higher costs. Thus, understanding risk factors for nonadherence and identifying barriers to good adherence is crucial. Although adults and pediatric patients share many risk factors for nonadherence, methods to optimize adherence differ. Measuring adherence can be challenging and methods to do so have not been well-defined. The aim of this review is to identify risk factors for, and define consequences of, nonadherence and to suggest methods to measure and improve adherence for both adults and pediatrics.

Chronic Obstructive Pulmonary Disease (COPD) remains the fourth recognized cause of death worldwide. Smoking is known as the most important risk factor for COPD with nicotine abstinence being the most effective COPD prophylaxis. Smoking cessation programs are less effective and may be considered as disease secondary prevention actions with smoking cessation slowing down lung function decline. Severe exacerbations, if not treated, on time (no comma) are responsible for the highest number of lung related deaths among COPD patients. As the definition of COPD exacerbation may be subjective, attributing symptoms to an exacerbation can be difficult, especially among less educated patients. This problem may be even more important in areas where the doctor/patient ratio is small and where patients need to travel long distances to obtain consultation and medical help. For these reasons COPD telemonitoring programs are being tested and implemented in some countries. This review is an updated overview of the current scientific evidence regarding patient education and telemonitoring implementation in COPD, based on the article on this topic published herein in 2013. The evidence provided, herein, is presented to help identify the effectiveness of education and telemonitoring in COPD in societies with different economies.

The practice of flexible bronchoscopy is not standardized across geographical areas, institutions, and even individual clinicians. Route of insertion of the bronchoscope (nasal, oral, or via ETT) is one aspect of this lack of standardization. We have attempted to present the history of the origin of the routes of insertion, why they are practiced the way they are practiced today, and merits and demerits of each, with the emphasis on the importance of standardizing the route of insertion of the flexible bronchoscope for its attendant benefits.

For the past three to four decades, the onset of acute respiratory distress syndrome (ARDS) has brought substantial insight into its epidemiology and pathophysiology. It is characterised by an acute lung injury resulting in widespread pulmonary oedema due to increased alveolar capillary permeability. Acute lung injury arises from the damaging effects of inflammatory mediators. Treatment of ARDS involves various modalities of supportive care categorised as ventilator and nonventilator measures. Berlin’s conference consensus definition of ARDS has been widely accepted in defining and categorising ARDS. The promising therapies for future include use of statins, aspirin, nebulised heparin, AdrenoMedulin, Interferon beta, Tumour necrosis factor (TNF alpha) receptor blockade, Angiotensin converting enzyme and keratinocytes growth factors.

Bronchial asthma (BA) at high altitude (HA) has been studied for decades, but studies were limited to relatively low altitudes (below 3000 meters above sea level (MASL). Very scarce scientific evidence is available whether BA subjects can proceed to HA for recreational purposes and for work, and if they can, how well they will do. This paper summarizes past and current experience of BA patients stay at HA in Kyrgyzstan, mainly on a course of high-altitude climate therapy, and also reviews existing data from other countries, where BA patients travel to HA for various reasons. The existing conservative approach in assessing patients should be reassessed, and BA patients with well-controlled disease may be well at high altitude in light of evidence of beneficial effects of pollen concentration reduction, endogenous cortisol stimulation and reduced markers of inflammation.

Objective: To identify low and high-risk sub-groups of patients admitted for Health-Care Associated Pneumonia (HCAP). Methods: We conducted a retrospective study of patients hospitalized for HCAP. Demographic data, co-morbidity, clinical features, laboratory findings, and chest radiographic changes were used to construct logistic regression models that employed Pneumonia Severity Index (PSI) or CURB-65 to predict 30-day mortality and guide the creation of low- and high-risk sub-groups. Results: Among 798 hospital episodes for HCAP, the median age was 80 years and 67. 9% of patients had pre-morbid ambulation impairment. The 30-day mortality was 35.3 %. For the subgroup (3.5%) of patients with PSI class II with no pre-morbid ambulation impairment, 30-day mortality was 0%. At the other end, CURB-65 score of 4 or 5 with pre-morbid ambulation impairment identified a subgroup (3.0%) of patients with 30-day mortality of 83.3%. Conclusion: Combining either PSI or CURB-65 with pre-morbid ambulation status, we were able to identify very low and high-risk mortality subgroups among HCAP patients. In the appropriate clinical context, early discharge may be considered for the very low risk subgroup, while de-escalation of antibiotic therapy and symptom palliation may be considered for the very high-risk subgroup.

Asthma is a chronic disease that continues to be an important public health problem. While there have been published guidelines for diagnosis and treatment of asthma, the real medical practice varies among different healthcare providers. Aim: To describe the asthma care modalities among asthma specialists in Lebanon. Methods: This cross-sectional study included a survey of demographic characteristics of asthma specialists, parameters of asthma diagnosis, follow-up, treatment, patient education, use of asthma guidelines, and involvement in continuous medical education. Results: A total of 100 registered asthma specialists in Lebanon who attended the 2013 annual meeting of Lebanese Pulmonary Society (LPS) were approached. Seventy-five questionnaires were returned achieving a response rate of 75%. Seventy participants (50 males and 20 females) filled out the questionnaire. The average age was 43 ±8.5years. 33% of the specialists reported seeing 10-20 asthmatic patients weekly. Spirometry was used by 81.4% of respondents on newly diagnosed patients while 36% used peak flow monitoring. Most of the specialists (91%) asked about cough and wheezing, 22% monitored spirometry during follow-up visits. The rate of different medications reported to be "often" used for moderate asthma were: 94% for inhaled steroids, 61% for long-acting beta-agonists (LABA). About 88% of respondents indicated that they were aware of asthma practice guidelines. Moreover, 93% of specialists attended continuous medical education on asthma in the past year. Conclusion: This survey showed deficiencies in asthma care in line with international guidelines (GINA and NAEPP) among asthma specialists in Lebanon. However, their practice was comparable to their peers in Chicago in regard of diagnostic tools utilization.