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Relationship Between Gastro-Oesophageal Reflux and Airway Diseases: The Airway Reflux Paradigm.

Our understanding of the relationship between gastro-oesophageal reflux and respiratory disease has recently undergone important changes. The previous paradigm of airway reflux as synonymous with the classic gastro-oesophageal reflux disease (GORD) causing heartburn has been overturned.

Numerous epidemiological studies have shown a highly significant association of the acid, liquid, and gaseous reflux of GORD with conditions such as laryngeal diseases, chronic rhinosinusitis, treatment resistant asthma, COPD and even idiopathic pulmonary fibrosis. However, it has become clear from studies on cough hypersensitivity syndrome that much reflux of importance in the airways has been missed, since it is either non- or weakly acid and gaseous in composition.

The evidence for such a relationship relies on the clinical history pointing to symptom associations with known precipitants of reflux. The tools for the diagnosis of extra-oesophageal reflux, in contrast to the oesophageal reflux of GORD, lack sensitivity and reproducibility.

Unfortunately, methodology for detecting such reflux is only just becoming available and much additional work is required to properly delineate its role.

Innate immune responses are increased in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is characterised by irreversible airflow obstruction, neutrophilic airway inflammation and chronic bacterial colonisation, however the role of the innate immune response in the pathogenesis of COPD remains unclear.

2009 H1N1 Influenza and Experience in Three Critical Care Units.

Aim: We describe futures of ICU admission, demographic characteristics, treatment and outcome for critically ill patients with laboratory-confirmed and suspected infection with the H1N1 virus admitted to the three different critical care departments in Turkey.

Methods: Retrospective study of critically ill patients with 2009 influenza A(H1N1) at ICU. Demographic data, symptoms, comorbid conditions, and clinical outcomes were collected using a case report form.

Results: Critical illness occurred in 61 patients admitted to an ICU with confirmed (n=45) or probable and suspected 2009 influenza A(H1N1). Patients were young (mean, 41.5 years), were female (54%). Fifty-six patients, required mechanical ventilation (14 invasive, 27 noninvasive, 15 both) during the course of ICU. On admission, mean APACHE II score was 18.7±6.3 and median PaO(2)/FIO(2) was 127.9±70.4. 31 patients (50.8%) was die. There were no significant differences in baseline PaO(2)/FIO(2 )and ventilation strategies between survivors and nonsurvivors. Patients who survived were more likely to have NIMV use at the time of admission to the ICU.

Conclusion: Critical illness from 2009 influenza A(H1N1) in ICU predominantly affects young patients with little major comorbidity and had a high case-fatality rate. NIMV could be used in 2009 influenza A (H1N1) infection-related hypoxemic respiratory failure.

Inhaler device, administration technique, and adherence to inhaled corticosteroids in patients with asthma.

AIM: To compare inhaled corticosteroid (ICS) inhaler type with user technique and ICS medication adherence among adults with asthma.

METHODS: We classified 270 adults into two groups by ICS device type: metered-dose inhaler (MDI) or dry powder inhaler (DPI). Inhaler technique was assessed using standardised checklists. Medication adherence was evaluated using the Medication Adherence Report Scale (MARS). Differences in inhaler technique and MARS score among patients using MDIs versus DPIs were evaluated.

RESULTS: Univariate analysis showed no difference in technique scores between the groups (p=0.46), but better ICS adherence among DPI users (p=0.001). In multivariable analysis, DPI use remained significantly associated with higher rates of adherence (OR 2.2; 95% CI 1.2 to 3.8) but not with inhaler technique (-0.2; 95% CI -0.5 to 0.1) after adjusting for potential confounders.

CONCLUSIONS: Type of inhaler device appears to be associated with adherence to asthma controller medications. Prospective studies are needed to elucidate further the potential effect of the type of ICS delivery device on asthma self-management.

Recent advances in the treatment of Pseudomonas aeruginosa infections in Cystic Fibrosis.

Chronic Pseudomonas aeruginosa lung infection in cystic fibrosis (CF) patients is caused by biofilm-growing mucoid strains. Biofilms can be prevented by early aggressive antibiotic prophylaxis or therapy, and they can be treated by chronic suppressive therapy.

New results from one small trial suggest that addition of oral ciprofloxacin to inhaled tobramycin may reduce lung inflammation. Clinical trials with new formulations of old antibiotics for inhalation therapy (aztreonam lysine) against chronic P. aeruginosa infection improved patient-reported outcome, lung function, time to acute exacerbations and sputum density of P. aeruginosa. Other drugs such as quinolones are currently under investigation for inhalation therapy. A trial of the use of anti-Pseudomonas antibiotics for long-term prophylaxis showed no effect in patients who were not already infected. Use of azithromycin to treat CF patients without P. aeruginosa infection did not improve lung function.

Here I review the recent advances in the treatment of P. aeruginosa lung infections with a focus on inhalation treatments targeted at prophylaxis and chronic suppressive therapy.

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