Cystic Fibrosis Foundation consensus conference report on pulmonary complications of cystic fibrosis

Morphological chest CT changes in cystic fibrosis and massive hemoptysis

BACKGROUND

Massive hemoptysis (MH) is a rare but potentially life-threatening condition of patients with mainly advanced cystic fibrosis (CF). Morphological lung changes are aggravated with disease progression. The aim of this study was to determine whether morphological lung changes differ between patients with CF (pwCF) who have MH and pwCF without MH.

METHODS

Chest computed tomography (CT) scans of pwCF and MH acquired at a maximum of 4 months prior to MH (1/2008 to 2/2015) were evaluated for morphological changes and bronchial artery (BA) diameters. Lung lobes with MH were compared with lobes without MH and with matched control patients with end-stage CF and no hemoptysis using the Helbich scoring system.

RESULTS

The study included 26 patients with MH (PMH; 15 female, median age 29 years, interquartile range [IQR]: 25-33.75) and 17 matched control patients (11 male, median age 24 years, IQR: 19.5-30). No difference in Helbich score was detected between lobes with MH and matched control patients (p = 0.051). Higher scores were detected in lobes with MH compared to lobes without MH in PMH (p = 0.021), but no difference was detected in the subscores. The BA diameters were larger in PMH (p = 0.02); 85% of PMH had unilateral MH, with 65% of MH involving only one or two lobes.

CONCLUSION

Morphological changes are more severe in lobes with MH in the same patient, but there is no difference when compared with matched control patients. Besides abscess/sacculation, no specific changes for MH were identified. Other factors such as BA hypertrophy might play a pivotal role in the pathogenesis of MH in pwCF. Commonly used scores to evaluate chest CT in pwCF cannot be used to assess MH, and other factors, e.g., hypertrophied BA, not represented and not measured in these scores, might be more suitable for assessing the risk for MH.

Association of Oxygen Therapy with the Natural Disease Progression of Cystic Fibrosis: A Multi-State Model of the European Cystic Fibrosis Society Patient Registry

Background

Association between dependence on oxygen therapy (OT) and natural disease progression in people with cystic fibrosis (pwCF) has not been estimated yet. The aim of this study is to understand the prognosis for pwCF on OT, evaluating how the transition probabilities from being alive without lung transplantation (LTx) to LTx and to death, and from being alive after LTx to death change in pwCF with and without OT.

Methods

We used 2008-2017 data from the 35-country European CF Society Patient Registry. A multi-state model was fitted to assess the effects of individual risk factors on transition probabilities.

Results

We considered 48,343 pwCF aged from 6 to 50 years. OT (HR 5.78, 95% CI: 5.32-6.29) and abnormal FEV₁ (HR 6.41, 95% CI: 5.28-7.79) were strongly associated with the probability of having LTx; chronic infection with Burkholderia cepacia complex (HR 3.19, 95% CI: 2.78-3.67), abnormal FEV₁ (HR 5.00, 95% CI: 4.11-6.08) and the need for OT (HR 4.32, 95% CI: 3.93-4.76) showed the greatest association with the probability of dying without LTx. Once pwCF received LTx, OT (HR 1.75, 95% CI: 1.41-2.16) and abnormal FEV₁ (HR 1.63, 95% CI: 1.18-2.25) were the main factors associated with the probability of dying. An association of gross national income with the probability of receiving LTx and with the probability of dying without LTx was also found.

Conclusion

Oxygen therapy is associated with poor survival in pwCF with and without LTx; harmonization of CF care throughout European countries and minimization of the onset of pulmonary gas exchange abnormalities using all available means remains of paramount importance.

Role of Bronchial Artery Embolization as Early Treatment Option in Stable Cystic Fibrosis Patients with Sub-Massive Hemoptysis: Personal Experience and Literature Review

(1) Background: We describe our experience with cystic fibrosis (CF) patients treated with bronchial artery embolization (BAE) for sub-massive hemoptysis to understand if early treatment of sub-massive hemoptysis can reduce the volume of any subsequent bleedings. (2) Materials: We performed a retrospective study including CF patients who underwent angiographic procedures for BAE following sub-massive hemoptysis, from March 2016 to December 2021. All patients underwent an initial chest angio-CT study. BAE was realized with microspheres or coils. (3) Results: Thirteen patients were included, subjected to at least one BAE after sub-massive hemoptysis, for a total of 19 procedures. Technical success was 94.7%; in a single case, the catheterization of the bronchial arterial feeder was not achievable and the procedure was repeated. Primary clinical success was 92.3%; secondary clinical success was 69.2%. Relative clinical success was 85%. A higher incidence of recurrent hemoptysis following treatment with coils was observed (100% of cases) compared to treatment with microspheres (54.5% of cases) χ2 = 5.43 (p < 0.05). (4) Conclusions: BAE is a safe and effective method for the treatment of hemoptysis in CF patients; it should be practiced not only after massive or recurrent hemoptysis but also in patients with sub-massive bleeding to improve their life expectancy and quality of life.

Outcomes of artery embolisation for cystic fibrosis patients with haemoptysis: a 20-year experience at a major Australian tertiary centre

There are no published data on Australian adult cystic fibrosis (CF) patient outcomes post bronchial arterial embolisation (BAE). We report 20 years of experience of BAE at a major Australian tertiary adult CF centre, where 46 patients underwent 100 BAE during this period. Mortality rate was comparable to previous studies (4% per year) and most who died had repeat BAE requirements. A higher proportion (9 out of 45) of patients were transplanted compared to previous publications. Repeat BAE was common and significantly higher in patients already on tranexamic acid.

Life-Threatening Hemoptysis in a Pediatric Referral Center

OBJECTIVES

Hemoptysis is uncommon in children, even among the critically ill, with a paucity of epidemiological data to inform clinical decision-making. We describe hemoptysis-associated ICU admissions, including those who were critically ill at hemoptysis onset or who became critically ill as a result of hemoptysis, and identify predictors of mortality.

DESIGN

Retrospective cohort study. Demographics, hemoptysis location, and management were collected. Pediatric Logistic Organ Dysfunction-2 score within 24 hours of hemoptysis described illness severity. Primary outcome was inhospital mortality.

SETTING

Quaternary pediatric referral center between July 1, 2010, and June 30, 2017.

PATIENTS

Medical/surgical (PICU), cardiac ICU, and term neonatal ICU admissions with hemoptysis during or within 24 hours of ICU admission.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

There were 326 hemoptysis-associated ICU admissions in 300 patients. Most common diagnoses were cardiac (46%), infection (15%), bronchiectasis (10%), and neoplasm (7%). Demographics, interventions, and outcomes differed by diagnostic category. Overall, 79 patients (26%) died inhospital and 109 (36%) had died during follow-up (survivor mean 2.8 ± 1.9 yr). Neoplasm, bronchiectasis, renal dysfunction, inhospital hemoptysis onset, and higher Pediatric Logistic Organ Dysfunction-2 score were independent risk factors for inhospital mortality (p < 0.02). Pharmacotherapy (32%), blood products (29%), computerized tomography angiography (26%), bronchoscopy (44%), and cardiac catheterization (36%) were common. Targeted surgical interventions were rare. Of survivors, 15% were discharged with new respiratory support. Of the deaths, 93 (85%) occurred within 12 months of admission. For patients surviving 12 months, 5-year survival was 87% (95% CI, 78-92) and mortality risk remained only for those with neoplasm (log-rank p = 0.001).

CONCLUSIONS

We observed high inhospital mortality from hemoptysis-associated ICU admissions. Mortality was independently associated with hemoptysis onset location, underlying diagnosis, and severity of critical illness at event. Additional mortality was observed in the 12-month posthospital discharge. Future directions include further characterization of this vulnerable population and management recommendations for life-threatening pediatric hemoptysis incorporating underlying disease pathophysiology.

Pulmonary Complications in Cystic Fibrosis: Past, Present, and Future

Cystic fibrosis (CF) is an autosomal recessive genetic condition with multisystemic disease manifestations, the most prominent of which occur in the respiratory system. Despite significant developments in disease understanding and therapeutics, each contributing to improved lung function and survival in patients with CF, several pulmonary complications, including pneumothorax, massive hemoptysis, and respiratory failure, continue to occur. In this review, we briefly describe each of these complications and their management and discuss how they impact the care and disease trajectory of individuals in whom they occur. Finally, we discuss the evolving role that palliative care and CF transmembrane conductance regular modulator therapies play in the natural disease course and care of patients with CF.

Sleep-disordered breathing in cystic fibrosis

Sleep-disordered breathing (SBD) is an under recognized comorbidity in the cystic fibrosis (CF) population across the lifespan. Nocturnal hypoxemia, obstructive sleep apnea, and nocturnal hypoventilation are respiratory abnormalities that occur commonly during sleep in patients with lung disease, and have deleterious consequences to the quality of life in people with CF. Effective screening for these abnormalities is needed to allow for timely initiation of treatment, which has been reported to be efficacious. Lack of treatment leads to worsened pulmonary, cardiovascular, and metabolic outcomes in patients. In this review, we give an overview of SBD for the CF clinician, including prevalence, treatment, and suggestions for future research. We strongly encourage the CF community to incorporate evaluation for SBD in CF clinical care so that outcomes for the subset of the CF patients with comorbid SBD improve.

Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization

Background

Although not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles.

Case presentation

In this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA).

Conclusions

The Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

A bird eye view on cystic fibrosis: An underestimated multifaceted chronic disorder

Cystic fibrosis (CF) is an autosomal recessive disease which involves the mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. CF involves in the inflammatory processes and is considered as a multisystem disorder that is not confined to lungs, but it also affects other vital organs that leads to numerous co-morbidities. The respiratory disorder in the CF results in mortality and morbidity which is characterized by series of serious events involving mucus hypersecretion, microbial infections, airways obstruction, inflammation, destruction of epithelium, tissue remodeling and terminal lung diseases. Mucins are the high molecular weight glycoproteins important for the viscoelastic properties of the mucus, play a significant role in the disease mechanisms. Determining the functional association between the CFTR and mucins might help to identify the putative target for specific therapeutic approach. In fact, furin enzyme which helps in the entry of novel COVID-19 virus into the cell, is upregulated in CF and this can also serve as a potential target for CF treatment. Moreover, the use of nano-formulations for CF treatment is an area of research being widely studied as they have also demonstrated promising outcomes. The in-depth knowledge of non-coding RNAs like miRNAs and lncRNAs and their functional association with CFTR gene expression and mutation can provide a different range of opportunity to identify the promising therapeutic approaches for CF.

Predictors of massive haemoptysis after a first episode of mild-to-moderate haemoptysis in patients with cystic fibrosis

The main cause of death of cystic fibrosis (CF) patients is respiratory disease due to secondary infections, haemoptysis, pneumothorax, and respiratory failure [1]. In a study of 129 French CF patients who died between 2007 and 2010 without receiving lung transplantation, 8.5% of deaths were due to haemoptysis [2]. Factors associated with an increased risk of haemoptysis in CF patients include older age, advanced lung disease (forced expiratory volume in 1 s (FEV₁) <70% predicted), airway colonisation by Pseudomonas aeruginosa [3], CF-related diabetes, portal hypertension, and liver cirrhosis [4]. To our knowledge, there have been no studies of the risk factors for the development of massive haemoptysis (MH) in CF patients who have previously experienced an episode of mild-to-moderate haemoptysis.

Mild-to-moderate haemoptysis (m-mH) is common in patients with cystic fibrosis but the risk of subsequent massive haemoptysis (MH) is not known. Allergic bronchopulmonary aspergillosis and diabetes were significant predictors of MH subsequent to m-mH.https://bit.ly/30093Hw

Predictors of sleep hypoxemia in children with cystic fibrosis

OBJECTIVES

To identify the determinants of nocturnal hypoxemia in children with CF using clinical parameters, polysomnography (PSG), and lung function.

HYPOTHESIS

Sleep hypoxemia in children with CF is predicted by both apnea hypopnea index (AHI) and percent predicted forced expiratory volume in one second (pFEV1).

DESIGN

Retrospective case series.

METHODS

Children aged 5-18 years were included based on (i) a diagnosis of CF; and (ii) availability of concurrent PSG and pFEV1 data. The impact of (i) demographic and clinical parameters; and (ii) PSG and pFEV1, on the total sleep time spent with arterial oxygen saturation below 90% (TSpO₂  < 90) was measured using regression analysis. P-value <0.05 was considered significant.

RESULTS

The mean age was 11.6 years (95% confidence interval: 9.5, 13.1). Twenty of 35 (57%) were boys and the mean body mass index percentile was 42.1 (31.5, 52.6). The most common ethnicity was white (66%). OSA was diagnosed in 50%. Neither demographic predictors nor clinical variables predicted the severity of hypoxemia (R²  = 0.23, P = 0.09). While pFEV1 and PSG variables accounted for significant proportion of the overall variance in TSpO₂  < 90 (R²  = 0.53, P < 0.001), pFEV1 was identified as the single best predictor of sleep hypoxemia. A pFEV1 cut-off of 53% indicated a sensitivity of 0.80 and a specificity of 0.87 in predicting sleep hypoxemia.

CONCLUSIONS

pFEV1 is the best predictor of sleep hypoxemia in children with CF and referred for PSG. No demographic or clinical predictors of hypoxemia were identified in this population.

Antifibrinolytic Agents for Hemoptysis Management in Adults With Cystic Fibrosis

BACKGROUND

Hemoptysis is a major cause of morbidity and mortality in patients with cystic fibrosis (CF). Antifibrinolytic agents have shown efficacy in a broad range of bleeding disorders and conditions.

OBJECTIVES

The goal of this study was to examine the use of antifibrinolytic agents in managing hemoptysis in CF. We developed a clinical treatment pathway for inpatient and outpatient use, and rates of admission for bleeding prior to and following implementation of the pathway are reported.

METHODS

All adult patients with CF treated with systemic antifibrinolytic agents over a 54-month period according to the treatment pathway were analyzed. Data collected included demographic characteristics, baseline CF-related characteristics, and bleeding and treatment parameters. Effectiveness of the pathway was evaluated via comparison of annualized hemoptysis admission rates prior to and following pathway enrollment.

RESULTS

Seventy-two distinct episodes of hemoptysis treated with antifibrinolytic agents were analyzed in a total of 21 adult patients with CF. Two-thirds of episodes treated involved moderate or massive hemoptysis. Bleeding ceased following a median of 2 days. Outpatient treatment was associated with a 50% reduction in the annualized hemoptysis admission rate following pathway enrollment (2.44 vs 1.23 admissions per year; P = .0024) that was independent of other changes in management. Antifibrinolytic therapy was well tolerated. One central catheter-associated upper extremity DVT was observed in a patient with previous thrombosis in the same vessel.

CONCLUSIONS

A pathway using systemic antifibrinolytic therapy to treat hemoptysis in patients with CF was associated with a reduction in hospital admissions. No serious adverse events were observed. Additional studies are needed to further define the benefits of systemic antifibrinolytic use in patients with CF.

Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency)

First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.

Bacterial proteases and haemostasis dysregulation in the CF lung

BACKGROUND

Pathogenic bacteria which chronically colonise the cystic fibrosis (CF) lung produce a number of virulence determinants, including distinct proteolytic activities. The potential role bacterial proteases play on haemostatic dysregulation within the CF lung is, however, poorly defined, despite haemoptysis being a common complication in CF.

METHODS

The potential impact of known CF pathogens (Pseudomonas aeruginosa and Burkholderia cepacia complex spp.) on haemostasis was examined for their ability to degrade fibrinogen and dysregulate fibrin clot formation and platelet aggregation.

RESULTS

Results demonstrate that key CF pathogens growing as a biofilm on mucin exhibit considerable fibrinogenolytic activity, resulting in fibrinogen breakdown, impaired clot formation, and modulation of platelet aggregation. Human neutrophil elastase may also contribute to fibrinogen breakdown and dysregulated clot formation at high concentration.

CONCLUSION

Bacterial-derived proteases may play an important role in the dysregulation of airway haemostasis, and potentially contribute to episodes of haemoptysis within the CF lung.

Respiratory System Disease

Respiratory system involvement in cystic fibrosis is the leading cause of morbidity and mortality. Defects in the cystic fibrosis transmembrane regulator (CFTR) gene throughout the sinopulmonary tract result in recurrent infections with a variety of organisms including Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and nontuberculous mycobacteria. Lung disease occurs earlier in life than once thought and ideal methods of monitoring lung function, decline, or improvement with therapy are debated. Treatment of sinopulmonary disease may include physiotherapy, mucus-modifying and antiinflammatory agents, antimicrobials, and surgery. In the new era of personalized medicine, CFTR correctors and potentiators may change the course of disease.

Clinical presentation of air leak in an infant with undiagnosed cystic fibrosis: a case report

Introduction

Air leak is a well-recognized complication of advanced cystic fibrosis in older children and adults but is extremely rare in infants. To the best of our knowledge, this is the youngest reported pediatric case of an air leak from a major airway.

Case presentation

A 4-month-old Yamani baby girl with a family history of cystic fibrosis initially presented with a history of a persistent paroxysmal cough for 3 weeks and vomiting for 1 week. Laboratory evaluation indicated pseudo-Bartter’s syndrome. Imaging showed a tracheal tear with pneumomediastinum and subcutaneous emphysema that was treated conservatively.

Conclusions

This case highlights the possibility of air leak in the population of young patients with cystic fibrosis and it shows a successful conservative management of tracheal tear. Physicians should consider cystic fibrosis in infants presenting with air leak.

Inhalable tranexamic acid for haemoptysis treatment

PURPOSE

An inhalable dry powder formulation of tranexamic acid (TA) was developed and tested in a novel high-dose Orbital® multi-breath inhaler. The formulation was specifically intended for the treatment of pulmonary haemorrhage and wound healing associated with haemoptysis.

METHODS

Inhalable TA particles were prepared by spray drying and the powder characterised using laser diffraction, electron microscopy, thermal analysis, moisture sorption and X-ray powder diffraction. The aerosol performance was evaluated using cascade impaction and inline laser diffraction and interaction with epithelia cells and wound healing capacity investigated using Calu-3 air interface model.

RESULTS

The spray dried TA particles were crystalline and spherical with a D0.5 of 3.35 μm. The powders were stable and had limited moisture sorption (0.307%w/w at 90%RH). The Orbital device delivered ca. 38 mg powder per 'inhalation' at 60 l · min(-1) across four sequential shots with an overall fine particle fraction (⩽ 6.4 μm) of 59.3 ± 3.5% based on the emitted mass of ca. 150 mg. The TA particles were well tolerated by Calu-3 bronchial epithelia cells across a wide range of doses (from 1 nM to 10nM) and no increase in inflammatory mediators was observed after deposition of the particles (a decrease in IL-1β, IL-8 and INFγ was observed). Time lapse microscopy of a damaged confluent epithelia indicated that wound closure was significantly greater in TA treated cells compared to control.

CONCLUSION

A stable, high performance aerosol of TA has been developed in a multi-breath DPI device that can be used for the treatment of pulmonary lesions and haemoptysis.

Oxygen therapy for cystic fibrosis

BACKGROUND

The most serious complications of cystic fibrosis (CF) relate to respiratory insufficiency. Oxygen supplementation therapy has long been a standard of care for individuals with chronic lung diseases associated with hypoxemia. Physicians commonly prescribe oxygen therapy for people with CF when hypoxemia occurs. However, it is unclear if empiric evidence is available to provide indications for this therapy with its financial costs and often profound impact on lifestyle.

OBJECTIVES

To assess whether oxygen therapy improves the longevity or quality of life of individuals with CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Latest search of Group's Trials Register: 15 May 2013.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials comparing oxygen, administered at any concentration, by any route, in people with documented CF for any time period.

DATA COLLECTION AND ANALYSIS

Authors independently assessed the risk of bias for included studies and extracted data.

MAIN RESULTS

This review includes 11 published studies (172 participants); only one examined long-term oxygen therapy (28 participants). There was no statistically significant improvement in survival, lung, or cardiac health. There was an improvement in regular attendance at school or work in those receiving oxygen therapy at 6 and 12 months. Four studies examined the effect of oxygen supplementation during sleep by polysomnography. Although oxygenation improved, mild hypercapnia was noted. Participants fell asleep quicker and spent a reduced percentage of total sleep time in rapid eye movement sleep, but there were no demonstrable improvements in qualitative sleep parameters. Six studies evaluated oxygen supplementation during exercise. Again, oxygenation improved, but mild hypercapnia resulted. Participants receiving oxygen therapy were able to exercise for a significantly longer duration during exercise. Other exercise parameters were not altered by the use of oxygen.

AUTHORS' CONCLUSIONS

There are no published data to guide the prescription of chronic oxygen supplementation to people with advanced lung disease due to CF. Short-term oxygen therapy during sleep and exercise improves oxygenation but is associated with modest and probably clinically inconsequential hypercapnia. There are improvements in exercise duration, time to fall asleep and regular attendance at school or work. There is a need for larger, well-designed clinical trials to assess the benefits of long-term oxygen therapy in people with CF administered continuously or during exercise or sleep or both. However, we do not expect any new research to be undertaken in this area any time soon and do not plan to update this review again until any new evidence does become available.

Chemical pleurodesis versus surgical intervention for persistent and recurrent pneumothoraces in cystic fibrosis

BACKGROUND

Pneumothorax is a potentially life-threatening complication for people with cystic fibrosis. Spontaneous pneumothorax is the presence of air in the pleural space and can be subdivided into first episode and recurrent. The recurrence of pneumothorax is when it occurs on the same side seven days or more after initial resolution. A pneumothorax is persistent if the air leak lasts for more than five days (Schidlow 1993). Managing spontaneous pneumothoraces is controversial and there is no standard treatment. Medical and surgical intervention are the two main categories for the treatment of recurrent pneumothoraces in people with cystic fibrosis. While surgical interventions are felt to be more effective in people without cystic fibrosis, the complications directly related to the procedure, as well as the post-operative complications make surgical interventions riskier for people with cystic fibrosis. Additionally, these interventions have the potential to make people with cystic fibrosis ineligible for lung transplantation in the future. Therefore, the benefits and side effects or disadvantages for the medical and surgical treatment of recurrent pneumothoraces in people with cystic fibrosis need to be systematically reviewed.

OBJECTIVES

To determine the clinical efficacy and safety of different treatment interventions for managing spontaneous persistent and recurrent pneumothoraces in people with cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 29 October 2012.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials which compared the use of chemical pleurodesis to surgical interventions for the treatment of persistent and recurrent pneumothoraces in CF.

DATA COLLECTION AND ANALYSIS

No relevant trials were identified.

MAIN RESULTS

No trials were included in this review

AUTHORS' CONCLUSIONS

Pneumothorax is a potentially life-threatening complication for people with cystic fibrosis and the management of spontaneous pneumothoraces remains a topic of considerable controversy. Medical and surgical intervention are the two main categories for the treatment of recurrent pneumothoraces in this population. However, it is disappointing that neither intervention has been assessed by randomised controlled trials. This systematic review identifies the need for a multicentre randomised controlled trial assessing both efficacy and possible adverse effects of the use of chemical pleurodesis versus surgical interventions for the treatment of persistent and recurrent pneumothoraces in people with cystic fibrosis.

Cystic fibrosis: management of haemoptysis

Haemoptysis is a common complication in cystic fibrosis (CF), occurring in approximately 9% of the population. Massive haemoptysis is associated with older patients, more severe disease and carries a high mortality rate. Despite this there are few robust published studies of effective treatments and knowledge of the precise pathogenesis is limited. Current guidelines for treatment from the Cystic Fibrosis Foundation (CFF) are based on consensus opinion of experts. Patients with massive haemoptysis who do not respond to initial medical treatments should undergo bronchial artery embolization. This will control the bleeding in the majority of cases but recurrence rates are high and there are little data to support long-term improved outcomes. Surgery is a last resort in patients with CF.

Pneumothorax in cystic fibrosis

PURPOSE OF REVIEW

Cystic fibrosis (CF) is a complex genetic disease affecting many organs, although 85% of the mortality is a result of lung disease. The natural history of the lung disease consists of early and persistent infection, an exaggerated inflammatory response, structural airway changes (i.e. bronchiectasis), and progressive airways obstruction, ultimately resulting in respiratory failure. As airways disease worsens, there is an increased likelihood of respiratory complications, such as pneumothorax, that may be serious. This review describes our current understanding of the pathogenesis of pneumothorax in CF and its treatment.

RECENT FINDINGS

The CF Foundation Pulmonary Therapies Committee recently published their recommendations for the treatment of hemoptysis and pneumothorax. As insufficient data exist from which a systematic review of the literature could be used to develop guidelines, the recommendations were derived from a formalized expert panel consensus process.

SUMMARY

We now have recommendations on specific care of the patient with CF who has a pneumothorax.

Cystic fibrosis and the thoracic surgeon

Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.

Padrões ventilatórios na espirometria em pacientes adolescentes e adultos com fibrose cística

OBJETIVO: Avaliar os padrões dos distúrbios ventilatórios observados na espirometria em pacientes com fibrose cística (FC) e suas relações com a gravidade funcional e com o comportamento dos fluxos máximos expiratórios a baixos volumes. MÉTODOS: Estudo transversal e retrospectivo, incluindo pacientes adolescentes e adultos com FC. Todos os pacientes foram submetidos à espirometria. Os pacientes foram classificados como tendo função ventilatória preservada, distúrbio ventilatório obstrutivo (DVO), DVO com CVF reduzida, sugestivo de distúrbio ventilatório restritivo (DVR) ou distúrbio ventilatório combinado (DVC). Os fluxos máximos expiratórios a baixos volumes foram avaliados utilizando-se FEF25-75%, FEF75%e FEF75%/CVF. O grupo controle incluiu 65 indivíduos normais, também submetidos à espirometria. RESULTADOS: Foram incluídos 65 pacientes no grupo de estudo: 8 (12,3%) com função pulmonar preservada, 18 (27,7%) com DVO, 24 (36,9%) com DVO com CVF reduzida, 5 (7,7%) com padrão sugestivo de DVR e 10 (15,4%) com DVC. O VEF1 foi significativamente menor nos grupos DVO com CVF reduzida e DVC, comparados com os outros grupos (p < 0,001). Nos pacientes com função ventilatória preservada, FEF25-75% e FEF75% foram significativamente reduzidos em 1 paciente, assim como FEF75%/CVF em 2 pacientes. CONCLUSÕES: O padrão ventilatório estava alterado em 88% dos pacientes com FC. O distúrbio mais frequente foi DVO com CVF reduzida. Houve maior prejuízo funcional nos pacientes com DVO e CVF reduzida e com DVC. Os fluxos expiratórios máximos a baixos volumes foram alterados em uma pequena percentagem de pacientes com função pulmonar preservada.

Simultaneous bilateral spontaneous pneumothorax in an adult patient with cystic fibrosis

Pneumothorax is a common complication in cystic fibrosis and is associated with worsening of lung function. However, bilateral simultaneous pneumothorax in cystic fibrosis is a rare condition. We describe the case of a 17-year-old female with cystic fibrosis who presented with spontaneous pneumothorax. Clinically, she presented right-sided chest pain and progressive breathlessness. The pneumothorax failed to resolve after the initial treatment (chest drainage). However, the patient was later successfully treated with additional chest drainage and talc pleurodesis. We also discuss the etiology and management of pneumothorax in patients with cystic fibrosis, since pneumothorax is associated with increased morbidity and mortality among such patients.

Recombinant activated factor VII for massive hemoptysis in patients with cystic fibrosis

Massive hemoptysis is a common complication in patients with cystic fibrosis (CF) and is associated with significant morbidity and mortality. Conventional treatment with antibiotic therapy and early bronchial artery embolization (BAE) is usually successful in achieving hemostasis in the majority of patients. Recombinant activated factor VII (rFVIIa), originally developed for use in patients with hemophilia, has emerged as a general hemostatic agent that is potentially useful in the management of many life-threatening bleeding conditions. In this article, we present four patients with CF lung disease and massive hemoptysis who were treated successfully with rFVIIa. We suggest that in patients with CF who present with massive hemoptysis, the use of rFVIIa can be considered in patients with refractory hemoptysis despite conventional therapy or as a temporizing therapy when BAE is not immediately available.

[Oxygen therapy in acute and chronic conditions: Indications, oxygen systems, assessement and follow-up]

Oxygen therapy has become a major tool for infants with acute and chronic respiratory failure. Appropriate goals when prescribing supplemental oxygen are reduction and prevention of hypoxemia, prevention and treatment of pulmonary hypertension and decrease in respiratory and cardiac overload. This is commonplace in the acute setting and is also becoming widespread in chronic pathologies. However, there is a lack of consensus on many fundamental issues, such as appropriate indications, desirable targets and outcome measures amongst centres, reflecting a variety of clinical practices. The Techniques Group of the Spanish Society of Pediatric Pneumology undertook to design recommendations for a rational approach to oxygen therapy, reviewing the existing literature in order to establish its indications, benefits and potential risks as well as its cost-effectivenes. General aspects of oxygen treatment are reviewed including physiological mechanisms, indications, delivery systems and assessment methods. Management of patients on home oxygen therapy is also addressed with discussion of benefits and potential risks of supplemental oxygen use.

Implementation of European standards of care for cystic fibrosis--control and treatment of infection

BACKGROUND

Several guidelines on infection control and treatment of infection exist for cystic fibrosis (CF) caregivers, although the extent of implementation is variable.

METHODS

Adherence to European Consensus Guidelines for CF was studied by sending surveys to named healthcare professionals in 487 European CF centres/units. Qualitative data analysis was performed.

RESULTS

A total of 177/547 (32%) surveys were returned. Infection control policies were implemented by most (77%) respondents. Separation of patients with Burkholderia cepacia was more common in adults (95%) than children (9%), and was implemented by 53% of respondents for Pseudomonas aeruginosa. Nebulised colistin plus oral ciprofloxacin was the most common (43%) therapy for P. aeruginosa infection. First infections of P. aeruginosa were usually treated with inhaled tobramycin; 41% of repondents did not intervene until lung function deteriorated. Most exacerbations were treated for less than the recommended period.

CONCLUSIONS

European Consensus Guidelines are widely adhered to. Areas for improvement include: initiating therapy for exacerbations early, separating infected patients and optimising duration of antibiotic therapy.

Chemical pleurodesis versus surgical intervention for persistent and recurrent pneumothoraces in cystic fibrosis

BACKGROUND

Pneumothorax is a potentially life-threatening complication for people with cystic fibrosis. Spontaneous pneumothorax is the presence of air in the pleural space and can be subdivided into first episode and recurrent. The recurrence of pneumothorax is when it occurs on the same side seven days or more after initial resolution. A pneumothorax is persistent if the air leak lasts for more than five days (Schidlow 1993). Managing spontaneous pneumothoraces is controversial and there is no standard treatment. Medical and surgical intervention are the two main categories for the treatment of recurrent pneumothoraces in people with cystic fibrosis. While surgical interventions are felt to be more effective in people without cystic fibrosis, the complications directly related to the procedure, as well as the post-operative complications make surgical interventions riskier for people with cystic fibrosis. Additionally, these interventions have the potential to make people with cystic fibrosis ineligible for lung transplantation in the future. Therefore, the benefits and side effects or disadvantages for the medical and surgical treatment of recurrent pneumothoraces in people with cystic fibrosis need to be systematically reviewed.

OBJECTIVES

To determine the clinical efficacy and safety of different treatment interventions for managing spontaneous persistent and recurrent pneumothoraces in people with cystic fibrosis.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 19 August 2008.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials which compared the use of chemical pleurodesis to surgical interventions for the treatment of persistent and recurrent pneumothoraces in CF.

DATA COLLECTION AND ANALYSIS

No relevant trials were identified.

MAIN RESULTS

No trials were included in this review

AUTHORS' CONCLUSIONS

Pneumothorax is a potentially life-threatening complication for people with cystic fibrosis and the management of spontaneous pneumothoraces remains a topic of considerable controversy. Medical and surgical intervention are the two main categories for the treatment of recurrent pneumothoraces in this population. However, it is disappointing that neither intervention has been assessed by randomised controlled trials. This systematic review identifies the need for a multicentre randomised controlled trial assessing both efficacy and possible adverse effects of the use of chemical pleurodesis versus surgical interventions for the treatment of persistent and recurrent pneumothoraces in people with cystic fibrosis.

Domiciliary oxygen for children

Domiciliary oxygen is used increasingly in pediatric practice, and the largest patient group to receive it is ex-premature babies with chronic neonatal lung disease. Because of a scarcity of good evidence to inform clinicians, there is a lack of consensus over many issues, even those as fundamental as the optimum target oxygen saturation. Nevertheless, many children benefit from receiving supplemental oxygen at home, particularly because it helps to keep them out of the hospital.

Oxygen therapy for cystic fibrosis

BACKGROUND

The most serious complications of cystic fibrosis (CF) relate to respiratory insufficiency. Oxygen supplementation therapy has been a standard of care for individuals with chronic lung diseases associated with hypoxemia for decades. Physicians commonly prescribe oxygen therapy for people with CF when hypoxemia occurs. However, it is unclear if empiric evidence is available to provide indications for this therapy with its financial costs and often profound impact on lifestyle.

OBJECTIVES

To assess whether oxygen therapy improves the longevity or quality of life of individuals with CF.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings.Most recent search of Group's Trials Register: November 2008.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials comparing oxygen, administered at any concentration, by any route, in people with documented CF for any time period.

DATA COLLECTION AND ANALYSIS

Authors independently assessed study quality and extracted data.

MAIN RESULTS

Eleven published studies (172 participants) are included in this review, of which only one examined long-term oxygen therapy (28 participants). There was no statistically significant improvement in survival, lung, or cardiac health. There was an improvement in regular attendance at school or work in those receiving oxygen therapy at 6 and 12 months. Four studies examined the effect of oxygen supplementation during sleep by polysomnography. Although oxygenation improved, mild hypercapnia was noted. Participants took less time to fall asleep and spent a reduced percentage of total sleep time in rapid eye movement sleep, but there were no demonstrable improvements in qualitative sleep parameters. Six studies evaluated oxygen supplementation during exercise. Again, oxygenation improved, but mild hypercapnia resulted. Participants receiving oxygen therapy were able to exercise for a significantly longer duration during exercise. Other exercise parameters were not altered by the use of oxygen.

AUTHORS' CONCLUSIONS

There are no published data to guide the prescription of chronic oxygen supplementation to people with advanced lung disease due to CF. Short-term oxygen therapy during sleep and exercise improves oxygenation but is associated with modest and probably clinically inconsequential hypercapnia. There are improvements in exercise duration, time to fall asleep and regular attendance at school or work. There is a need for larger, well-designed clinical trials to assess the benefits of long-term oxygen therapy in people with CF administered continuously or during exercise or sleep or both.

Haemoptysis and bronchial artery embolization in children

Haemoptysis varies in significance from trivial to fatal. The most common causes in children are tuberculosis, fungal infections and bronchiectasis of any cause. In populations of European origin, cystic fibrosis is the most common predisposing factor. Chronic or life-threatening haemoptysis requires further investigation. Various forms of treatment are possible, and management is optimized when a multidisciplinary team is available. Bronchial artery embolization (BAE) is effective in controlling haemoptysis in most cases, although recurrent bleeding is not uncommon. BAE is often technically challenging, however, and requires angiographic skills that are not always available in children's hospitals. Although the procedure is usually regarded as relatively safe, complications are not uncommon and may be severe or even fatal.

Intensive care management of the patient with cystic fibrosis

Cystic fibrosis was previously thought to be a disease of childhood. With a better understanding of this condition along with improvements in therapy, patients with cystic fibrosis are now living well into adulthood. The aim of this article is to familiarize the intensive care unit physician with cystic fibrosis care, to discuss complications associated with cystic fibrosis specifically related to the intensive care unit, and to detail the current recommendations for the clinical management of the patient with cystic fibrosis. With advancing disease, the most severely affected organs are the lungs. Obstruction, infection, and inflammation contribute to the decline of pulmonary function, ultimately leading to death. Some patients may be eligible for lung transplantation, but choosing wisely will affect posttransplant survival. Because other organs are affected by the genetic defect and associated treatments, serious complications related to the liver, pancreas, intestines, and kidneys must be considered by the intensivist faced with a patient with cystic fibrosis. As practitioners, the fact that not all patients will survive and help our patients and families gracefully through the end-of-life process should be accepted.

[Cystic fibrosis: review]

Cystic Fibrosis (CF) is the recessive autossomic disease more frequent in the caucasian race. The main characteristic is a mutation in CFTR, a trans-membranar protein, responsible for chlorates transportation. This protein has a diffuse epithelial distribution, which gives a multissistemic involvement to this disease, with clinical manifestations with variable degrees of severity. The development of better health care associated with new therapeutic options became responsible for an increase of survival, so CF is no longer a paediatric disease. Lung transplantation also has an important role, bringing new treatment perspectives. So, this pathology has an increased multi-disciplinary involvement in which the pulmonologist have a preponderant role.

Hemoptysis in Israeli CF patients--prevalence, treatment, and clinical characteristics

OBJECTIVE

To identify the characteristics of CF patients with hemoptysis in Israel and to compare clinical features and risk factors to a control group of CF patients without hemoptysis.

DESIGN

Retrospective chart review.

PATIENTS

All CF patients in Israel who experienced hemoptysis between 2001 and 2005 and a control group of sex- and age-matched patients with no history of hemoptysis.

RESULTS

40/440 CF patients (9.1%) experienced hemoptysis during the study period, 50% were male. Ten patients (25%) were under 13 years old at the first hemoptysis episode. Pulmonary exacerbation was the precipitating factor in 90%. Twenty three patients showed moderate or major hemoptysis. 35/40 patients responded well to conservative therapy. Bronchial artery embolization (BAE) was performed in 5 patients with no recurrence of bleed within 24 h. However all of these patients experienced recurrent hemoptysis. One patient died during the follow-up period because of end stage lung disease. Pulmonary function tests, body-mass index, coagulation tests, pancreatic status, presence of bronchiectasis, sputum cultures and genetic mutations were similar in the two groups. A high incidence (57.5%) of associated diseases including cystic fibrosis related diabetes, cirrhosis and portal hypertension, and distal intestinal obstruction syndrome was found among hemoptysis patients, compared to only 5.2% in the control group (p<0.001).

CONCLUSIONS

Hemoptysis, even major, did not seem to be a risk factor for mortality in our patients. A higher incidence of hemoptysis was found in our pediatric patients compared to other series. BAE shows a high immediate rate of success in controlling hemoptysis, but does not prevent future disease.

Cystic fibrosis: a review of epidemiology and pathobiology

Improvements in outcomes for patients who have cystic fibrosis (CF) have been striking in the last 30 years. Median survival now approaches the fifth decade of life. Advances in the understanding of the basic defect and the pathobiology of CF have led to new treatments, some of which have undoubtedly contributed to this success. Improved understanding of the basic defect and the acquisition and maintenance of epidemiologic resources for the CF population in the United States have allowed us to determine predictors of survival and identify genetic, environmental, and therapeutic factors that may influence it. This article reviews some of the key epidemiologic and pathobiologic factors discovered thus far.

Mucus structure and properties in cystic fibrosis

The biophysical properties of airway secretions are largely determined by the polymeric components. In normal airway mucus, the gel-forming mucins, MUC5AC and MUC5B, are responsible not only for the viscoelastic properties essential for clearance and protecting the airway epithelium from invaders and water evaporation. With chronic airway infection, inflammatory cell necrosis leads to a predominance of polymeric DNA and F-actin. There is almost no mucin in the sputum of patients with established cystic fibrosis lung disease. Sputum viscoelastic and surface properties determine how well secretions can be cleared by cilia or cough. In this mini-Symposium on Airway Clearance in Cystic Fibrosis, the physiology of CF secretion structure and rheology is discussed in the context of medications and physical maneuvers for enhancing sputum clearance.

Pneumothorax in cystic fibrosis: a retrospective case series

Pneumothorax is a known complication in cystic fibrosis (CF), associated with poor outcome. Records of CF patients with pneumothorax at the Royal Children's Hospital, Melbourne between 1990 and 2004 were reviewed, and the characteristics, sputum culture results, lung function, treatment, and outcome for the 11 patients who had pneumothoraces were described.

Evaluation of Once Daily Tobramycin Versus the Traditional Three Time Daily for the Treatment of Acute Pulmonary Exacerbations in Adult Cystic Fibrosis Patients

Once daily tobramycin is convenient to use and achieves higher tissue levels that should kill Pseudomonas aeruginosa more rapidly. Small trials of OD compared with TDS aminoglycosides in CF patients have shown no dif-ference in efficacy or toxicity. No one has looked in detail at the impact on sputum microbiology. In a prospective, randomized study at Papworth Hospital, UK, we compared OD with TDS tobramycin, each plus a second anti-pseudomonal, for the treatment of acute infective exacer-bation in 15 adult cystic fibrosis patients colonized with Pseudomonas aeruginosa. Using the patients as their own control, the same individuals received the alternate treat-ment regime for the next exacerbation. We aimed to com-pare the clinical and bacteriological efficacy, toxicity>, and the effects on susceptibility of the organism among patients in both treatment groups. Isolates were identified, and the Minimum Inhibitory Concentration (MIC) of the antibi-otic in each patient was performed. Patients were assessed for clinical improvement, toxicity and the total viable count in their sputum on days 0\ 7 and 14. In both treatment groups there was a significant clinical improvement, and toxicity did not occur in either group. There was no differ-ence in clinical outcome, adverse events, or time to the next exacerbation. No difference was seen in the selection of antibiotic resistance. OD tobramycin appeared more ef-fective in reducing the number of bacteria in the group overall at day 7 and in two individuals, at day 14.

Surgical management of pulmonary and gastrointestinal complications in children with cystic fibrosis

PURPOSE OF REVIEW

Cystic fibrosis is a common disorder, affecting as many as 1:2500 Caucasian live births. Despite improved medical management, disease-specific complications are common and are responsible for substantial morbidity and ultimately mortality. Both pulmonary and gastrointestinal complications of cystic fibrosis are well known; however, the complications requiring surgical intervention in the pediatric population are infrequent. We provide a detailed review of the cystic fibrosis-associated pulmonary and gastrointestinal complications and potential surgical options for management in children with cystic fibrosis.

RECENT FINDINGS

Recent operative approaches are described that include application of minimally invasive surgical techniques primarily for intrathoracic disease. Novel medical therapies are also presented. Finally an attempt is made to put in perspective those surgical care advances that have had a benefit on disease outcomes.

SUMMARY

This report will provide the physician caring for the child with cystic fibrosis an understanding of those disease complications that will require surgical consultation and potential operative intervention.

Oxygen therapy for cystic fibrosis

BACKGROUND

The most serious complications of cystic fibrosis (CF) relate to respiratory insufficiency. Oxygen supplementation therapy has been a standard of care for individuals with chronic lung diseases associated with hypoxemia for decades. It is common for physicians to prescribe oxygen therapy for people with CF when hypoxemia occurs. However, it is unclear if empiric evidence is available to provide indications for this therapy with its financial costs and often profound impact on lifestyle.

OBJECTIVES

To assess whether oxygen therapy improves the longevity or quality of life of individuals with CF.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Most recent search of Group's Trials Register: April 2005.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials comparing oxygen, administered at any concentration, by any route, in people with documented CF for any time period.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data.

MAIN RESULTS

Nine published studies (149 participants) are included in this review, of which only one examined long-term oxygen therapy (28 participants). There was no statistically significant improvement in survival, lung, or cardiac health. Four studies examined the effect of oxygen supplementation during sleep by polysomnography. Although oxygenation improved, there were no demonstrable improvements in qualitative sleep parameters and modest hypoventilation was noted. In three studies, oxygen supplementation was evaluated during exercise. Hypoxemia was prevented, but mild hypercapnia resulted. Work performance was not improved, as measured in one study, but was improved in a second study. Furthermore, in two studies, exercise duration was enhanced by oxygen supplementation. In the study examining the impact of oxygen supplementation after exercise, recovery time was enhanced.

AUTHORS' CONCLUSIONS

There are no published data to guide the prescription of chronic oxygen supplementation to people with advanced lung disease due to CF. Short-term oxygen therapy during sleep and exercise improves oxygenation but is associated with modest and probably clinically inconsequential hypercapnia. During exercise, there are improvements in exercise duration and peak performance. There is a need for larger, well-designed clinical trials to assess the benefits of long-term oxygen therapy in people with CF administered continuously or during exercise or sleep or both.

Massive hemoptysis in cystic fibrosis

BACKGROUND

Massive hemoptysis is a complication commonly reported in patients with cystic fibrosis (CF). An understanding of the pathophysiology of this complication and its consequences is important for the management of patients with CF.

OBJECTIVES

To identify risk factors associated with massive hemoptysis, and to determine the prognosis of patients following an episode of massive hemoptysis.

DESIGN

A retrospective, observational cohort study of the National CF Patient Registry between the years 1990 to 1999.

PATIENTS

The Registry contained data on 28,858 patients with CF observed over 10 years at CF centers across the United States.

RESULTS

Massive hemoptysis occurred with an average annual incidence of 0.87% and in 4.1% of patients overall. There was no increased occurrence by sex, but it was more prevalent in older patients (mean age, 24.2 +/- 8.7 years [+/- SD]) with more severe pulmonary impairment (nearly 60% of patients who had an episode of massive hemoptysis had FEV1 < 40% predicted). The principal risks associated with an increased occurrence of massive hemoptysis included the presence of Staphylococcus aureus in sputum cultures (odds ratio [OR], 1.3) and diabetes (OR, 1.1). There was an increased morbidity (eg, increased hospitalizations and hospital days) and an increased 2-year mortality following massive hemoptysis.

CONCLUSION

Massive hemoptysis is a serious complication in CF patients, occurring more commonly in older patients with more advanced lung disease. Nearly 1 in 100 patients will have this complication each year. There is an attributable mortality to the complication and considerable morbidity, resulting in increased health-care utilization and a measurable decline in lung function.

Cystic fibrosis lung disease: genetic influences, microbial interactions, and radiological assessment

Cystic fibrosis (CF) is a multiorgan disease caused by mutation of the CF transmembrane conductance regulator (CFTR) gene. Obstructive lung disease is the predominant cause of morbidity and mortality; thus, most efforts to improve outcomes are directed toward slowing or halting lung-disease progression. Current therapies, such as mucolytics, airway clearance techniques, bronchodilators, and antibiotics, aim to suppress airway inflammation and the processes that stimulate it, namely, retention and infection of mucus plaques at the airway surface. New approaches to therapy that aim to ameliorate specific CFTR mutations or mutational classes by restoring normal expression or function are being investigated. Because of its sensitivity in detecting changes associated with early airway obstruction and regional lung disease, high-resolution CT (HRCT) complements pulmonary function testing in defining disease natural history and measuring response to both conventional and experimental therapies. In this review, perspectives on the genetics and microbiology of CF provide a context for understanding the increasing importance of HRCT and other imaging techniques in assessing CF therapies.