Follicular Bronchiolitis: A Literature Review.

Follicular bronchiolitis (FB) also known as hyperplasia of the bronchial associated lymphoid tissue (BALT), or bronchiolar nodular lymphoid hyperplasia, is an entity characterized by the development of lymphoid follicles with germinal centers in the walls of small airways. FB is thought to be caused by antigenic stimulation of BALT, followed by a polyclonal lymphoid hyperplasia. It is currently classified as one of the reactive pulmonary lymphoid disorders in a group known as the lymphoproliferative pulmonary diseases (LPDs). FB is a pathological diagnosis that can be seen in several clinical settings, including connective tissue diseases, immunodeficiency states, autoimmune diseases, infections, obstructive airway diseases, as well as several types of interstitial lung diseases (ILDs). Its characteristics need to be carefully identified and differentiated from other closely related diseases in the group of LPDs due to significant differences in treatment and prognosis.

Food Particle Aspiration Associated with Hemorrhagic Shock: A Diagnostic Dilemma.

The hemodynamic compromise caused by a large aspirated food particle in the airway can become the focus of medical attention and a distraction from rare but fatal Heimlich maneuver related injuries after an incident of food aspiration. We herein present a case of an 84-year-old man who was brought to the emergency department after an episode of choking at a restaurant followed by several failed Heimlich maneuver attempts. Despite relieving the airway obstruction by extracting a large piece of steak from the airway, the patient remained hypotensive and required continued hemodynamic support. Repeated laboratory tests within 24 hrs of aspiration showed a significant decline in the hemoglobin level. A computed tomography (CT) scan of the abdomen and pelvis showed a lacerated liver with a large subcapsular hematoma draining into the pelvis. Conclusion. Hepatic rupture is a rare complication of Heimlich maneuver; this paper represents the second case report in the literature. It emphasizes the necessity of early identification and surveillance of fatal Heimlich maneuver complications in a high risk population.

Shared medical appointments in pulmonary hypertension.

We aimed to adapt the shared medical appointment (SMA) model to the care of pulmonary hypertension (PH) patients and evaluate patient satisfaction. Our SMA team included a PH specialist, a PH nurse, and one research fellow. Eight to twelve PH patients with a family member were invited during office visits and by phone calls. Attendance was verified and encouraged by phone calls and informational letters. The meetings started with a 30-minute presentation on various PH topics, which was followed by each patient's individual visit and a focused examination in front of the group, allowing group questions and interaction. Of the total number of patients (n = 53), 84% stated that they would attend a future SMA. The care provided was rated excellent to very good by 98% of the patients. Ninety-two percent stated that they improved their understanding of the disease and treatment options, and 59% acknowledged a preference for the group visit over the private visit. Twenty-five percent of patients stated that they were very likely to likely to some extent to agree to change or seek a change in treatment modality on the basis of conversation with other patients in the SMA. The majority of our patients expressed no privacy concerns before the meeting (76%), and even more expressed no such concerns afterward (88%). In conclusion, the SMA model allows PH patients to increase understanding of their disease process while integrating peer support, promoting social interaction, and addressing patients' emotional needs. Other (rare) pulmonary diseases may benefit from this model.

Vanishing Lung Syndrome in a Patient with HIV Infection and Heavy Marijuana Use.

Vanishing lung syndrome (VLS) is a rare and distinct clinical syndrome that usually affects young men. VLS leads to severe progressive dyspnea and is characterized by extensive, asymmetric, peripheral, and predominantly upper lobe giant lung bullae. Case reports have suggested an additive role of marijuana use in the development of this disease in young male tobacco smokers. We herein report a case of a 65-year-old Hispanic male previously diagnosed with severe emphysema and acquired immune deficiency syndrome (AIDS), with a history of intravenous heroin use and active marijuana smoking who presents to the emergency department with severe progressive shortness of breath he was found to have multiple large subpleural bullae occupying more than one-third of the hemithorax on chest computerized tomography (CT), characteristic of vanishing lung syndrome. The patient was mechanically ventilated and later developed a pneumothorax requiring chest tube placement and referral for surgical bullectomy. Surgical bullectomy has shown high success rates in alleviating the debilitating symptoms and preventing the life threatening complications of this rare syndrome. This case further emphasizes the importance of recognizing VLS in patients with severe emphysema and heavy marijuana smoking.

Airbag pneumonitis.

The widespread and mandatory use of airbags has resulted in various patterns of injuries and complications unique to their use. Airbags have been implicated in a spectrum of pulmonary conditions ranging from exacerbation of asthma, reactive airway diseases to new onset asthma. We report a case of inhalational chemical pneumonitis that developed after exposure to the airbag fumes.

Physician alert suggesting alpha-1 antitrypsin deficiency testing in pulmonary function test (PFT) results.

Alpha-1 antitrypsin deficiency (AATD) is under-recognized by clinicians, with long diagnostic delays between patients' first symptom and initial diagnosis. Recent recommendations by official societies encourage testing for AATD in all symptomatic adults with spirometric evidence of COPD, though compliance with this recommendation has been variable. For 6 months, the following physician alert was added to PFT reports of patients with airflow obstruction of GOLD Stage II or higher: "The American Thoracic Society recommends testing for AATD in all patients with FEV1 < 80% predicted and FEV1/FVC less than 0.70, if clinically indicated. Appropriate counseling suggested." During the "Pre-alert Period," 821 spirometry tests were performed; 178 of these 821 unique patients (22%) satisfied spirometric criteria of > GOLD Stage II and 11 (6%) were tested for AATD. In contrast, during the "Physician Alert" intervention period, 689 spirometry tests were performed on 689 unique patients, of whom 140 (20%) satisfied criteria for > GOLD II airflow obstruction; AAT testing was done more frequently (18 [13%], p = 0.04). The overall rate of misclassifying patients' reports for testing by the respiratory therapists was very low (3.3%). An analysis of "number needed to test" suggests that 98-290 patients must be tested to have 95% certainty to identify a single patient with severe AATD. In conclusion, implementing a physician alert on PFT reports of patients with COPD can increase physicians' testing for AATD. The incomplete rate of testing suggests the need for additional strategies to enhance clinicians' detection of individuals with AATD.

The pulmonary consultation in the perioperative management of patients with neurologic diseases.

Postoperative pulmonary complications greatly contribute to peri-operative morbidity and mortality. Parkinson's disease, sleep apnea, stroke and neuromuscular disorders significantly increase the risk for pulmonary postoperative complications that result from associated changes in respiratory function. This article discusses perioperative pulmonary evaluation and management of the surgical patient who has neurologic disease.