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DeBoer EM, Kimbell JS, Pickett K, Hatch JE, Akers K, Brinton J, Hall GL, King L, Ramanauskas F, Rosenow T, Stick SM, Tiddens HA, Ferkol TW, Ranganathan SC, Davis SD. Lung inflammation and simulated airway resistance in infants with cystic fibrosis. Respir Physiol Neurobiol 2021; 293:103722. [PMID: 34157384 PMCID: PMC8330801 DOI: 10.1016/j.resp.2021.103722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/17/2021] [Accepted: 06/17/2021] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis (CF) is characterized by small airway disease; but central airways may also be affected. We hypothesized that airway resistance estimated from computational fluid dynamic (CFD) methodology in infants with CF was higher than controls and that early airway inflammation in infants with CF is associated with airway resistance. Central airway models with a median of 51 bronchial outlets per model (interquartile range 46,56) were created from chest computed tomography scans of 18 infants with CF and 7 controls. Steady state airflow into the trachea was simulated to estimate central airway resistance in each model. Airway resistance was increased in the full airway models of infants with CF versus controls and in models trimmed to 33 bronchi. Airway resistance was associated with markers of inflammation in bronchoalveolar lavage fluid obtained approximately 8 months earlier but not with markers obtained at the same time. In conclusion, airway resistance estimated by CFD modeling is increased in infants with CF compared to controls and may be related to early airway inflammation.
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Affiliation(s)
- Emily M DeBoer
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States; Breathing Institute at Children's Hospital Colorado, Aurora, CO, United States.
| | - Julia S Kimbell
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Kaci Pickett
- Colorado School of Public Health, Aurora, CO, United States
| | - Joseph E Hatch
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Kathryn Akers
- Washington University School of Medicine, St. Louis, MO, United States
| | - John Brinton
- Breathing Institute at Children's Hospital Colorado, Aurora, CO, United States; Colorado School of Public Health, Aurora, CO, United States
| | - Graham L Hall
- Telethon Kids Institute and Perth Children's Hospital, U. of Western Australia, Perth, WA, Australia; School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | - Louise King
- Royal Children's Hospital and Murdoch Children's Research Institute, U. of Melbourne, Parkville, VIC, Australia
| | - Fiona Ramanauskas
- Royal Children's Hospital and Murdoch Children's Research Institute, U. of Melbourne, Parkville, VIC, Australia
| | - Tim Rosenow
- Telethon Kids Institute and Perth Children's Hospital, U. of Western Australia, Perth, WA, Australia
| | - Stephen M Stick
- Telethon Kids Institute and Perth Children's Hospital, U. of Western Australia, Perth, WA, Australia
| | - Harm A Tiddens
- Erasmus MC and Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Thomas W Ferkol
- Washington University School of Medicine, St. Louis, MO, United States
| | - Sarath C Ranganathan
- Royal Children's Hospital and Murdoch Children's Research Institute, U. of Melbourne, Parkville, VIC, Australia
| | - Stephanie D Davis
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
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Mondéjar-López P, Horsley A, Ratjen F, Bertolo S, de Vicente H, Asensio de la Cruz Ò. A multimodal approach to detect and monitor early lung disease in cystic fibrosis. Expert Rev Respir Med 2021; 15:761-772. [PMID: 33843417 DOI: 10.1080/17476348.2021.1908131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: In the early stages, lung involvement in cystic fibrosis (CF) can be silent, with disease progression occurring in the absence of clinical symptoms. Irreversible airway damage is present in the early stages of disease; however, reliable biomarkers of early damage due to inflammation and infection that are universally applicable in day-to-day patient management have yet to be identified.Areas covered: At present, the main methods of detecting and monitoring early lung disease in CF are the lung clearance index (LCI), computed tomography (CT), and magnetic resonance imaging (MRI). LCI can be used to detect patients who may require more intense monitoring, identify exacerbations, and monitor responses to new interventions. High-resolution CT detects structural alterations in the lungs of CF patients with the best resolution of current imaging techniques. MRI is a radiation-free imaging alternative that provides both morphological and functional information. The role of MRI for short-term follow-up and pulmonary exacerbations is currently being investigated.Expert opinion: The roles of LCI and MRI are expected to expand considerably over the next few years. Meanwhile, closer collaboration between pulmonology and radiology specialties is an important goal toward improving care and optimizing outcomes in young patients with CF.
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Affiliation(s)
- Pedro Mondéjar-López
- Pediatric Pulmonologist, Pediatric Pulmonology and Cystic Fibrosis Unit, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Alexander Horsley
- Honorary Consultant, Respiratory Research Group, Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
| | - Felix Ratjen
- Head, Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Silvia Bertolo
- Radiologist, Department of Radiology, Ca'Foncello Regional Hospital, Treviso, Italy
| | | | - Òscar Asensio de la Cruz
- Pediatric Pulmonologist, Pediatric Unit, University Hospital Parc Taulí de Sabadell, Sabadell, Spain
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Darrah RJ, Mitchell AL, Campanaro CK, Barbato ES, Litman P, Sattar A, Hodges CA, Drumm ML, Jacono FJ. Early pulmonary disease manifestations in cystic fibrosis mice. J Cyst Fibros 2016; 15:736-744. [PMID: 27231029 DOI: 10.1016/j.jcf.2016.05.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 04/30/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Altered pulmonary function is present early in the course of cystic fibrosis (CF), independent of documented infections or onset of pulmonary symptoms. New initiatives in clinical care are focusing on detection and characterization of preclinical disease. Thus, animal models are needed which recapitulate the pulmonary phenotype characteristic of early stage CF. METHODS We investigated young CF mice to determine if they exhibit pulmonary pathophysiology consistent with the early CF lung phenotype. Lung histology and pulmonary mechanics were examined in 12- to 16-week-old congenic C57bl/6 F508del and R117H CF mice using a forced oscillation technique (flexiVent). RESULTS There were no significant differences in the resistance of the large airways. However, in both CF mouse models, prominent differences in the mechanical properties of the peripheral lung compartment were identified including decreased static lung compliance, increased elastance and increased tissue damping. CF mice also had distal airspace enlargement with significantly increased mean linear intercept distances. CONCLUSIONS An impaired ability to stretch and expand the peripheral lung compartment, as well as increased distances between gas exchange surfaces, were present in young CF mice carrying two independent Cftr mutations. This altered pulmonary histopathophysiology in the peripheral lung compartment, which develops in the absence of infection, is similar to the early lung phenotype of CF patients.
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Affiliation(s)
- Rebecca J Darrah
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States.
| | - Anna L Mitchell
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Cara K Campanaro
- Department of Medicine, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Eric S Barbato
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Paul Litman
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Abdus Sattar
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Craig A Hodges
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Mitchell L Drumm
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Pediatrics, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Frank J Jacono
- Department of Medicine, Case Western Reserve University, Cleveland, OH 44106, United States; Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, OH 44106, United States
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Pittman JE. Assessment and Detection of Early Lung Disease in Cystic Fibrosis. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:212-219. [DOI: 10.1089/ped.2015.0568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jessica E. Pittman
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, Saint Louis, Missouri
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Cystic fibrosis: NHLBI Workshop on the Primary Prevention of Chronic Lung Diseases. Ann Am Thorac Soc 2015; 11 Suppl 3:S161-8. [PMID: 24754825 DOI: 10.1513/annalsats.201312-444ld] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Cystic fibrosis (CF) is a life-limiting, monogenic disorder characterized by chronic sinopulmonary and gastrointestinal involvement. Progressive pulmonary disease leads to death in the majority of patients. Despite its well-defined molecular basis related to defects in the cystic fibrosis transmembrane conductance regulator anion transport channel, there are large gaps in our understanding of the origin of CF lung disease. Disease has been shown to be present in infancy, and there is mounting evidence that abnormalities begin in utero. Heterogeneity of clinical presentations and severity suggest that many factors involved in lung disease have yet to be fully elucidated. Although new advances in therapeutic treatments have shown promise in delaying disease progression, the prevention of pulmonary disease at its origin (primary prevention) should be a key goal of CF care. The objective of this workshop was to (1) review our understanding of the origins of CF lung disease, (2) determine gaps in the knowledge base that are most significant and most likely to enable prevention of CF lung disease, and (3) prioritize new research questions that will promote pulmonary health in both CF and other childhood lung diseases. The goal of this report is to provide recommendations for future research that will improve our understanding of pulmonary development in health and disease, improve outcome measures and biomarkers for early lung disease, and determine therapeutic targets and strategies to prevent the development of lung disease in children with CF.
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Hutchison AA, Leclerc F, Nève V, Pillow JJ, Robinson PD. The Respiratory System. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7193717 DOI: 10.1007/978-3-642-01219-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This chapter addresses upper airway physiology for the pediatric intensivist, focusing on functions that affect ventilation, with an emphasis on laryngeal physiology and control in breathing. Effective control of breathing ensures that the airway is protected, maintains volume homeostasis, and provides ventilation. Upper airway structures are effectors for all of these functions that affect the entire airway. Nasal functions include air conditioning and protective reflexes that can be exaggerated and involve circulatory changes. Oral cavity and pharyngeal patency enable airflow and feeding, but during sleep pharyngeal closure can result in apnea. Coordination of breathing with sucking and nutritive swallowing alters during development, while nonnutritive swallowing at all ages limits aspiration. Laryngeal functions in breathing include protection of the subglottic airway, active maintenance of its absolute volume, and control of tidal flow patterns. These are vital functions for normal lung growth in fetal life and during rapid adaptations to breathing challenges from birth through adulthood. Active central control of breathing focuses on the coordination of laryngeal and diaphragmatic activities, which adapts according to the integration of central and peripheral inputs. For the intensivist, knowledge of upper airway physiology can be applied to improve respiratory support. In a second part the mechanical properties of the respiratory system as a critical component of the chain of events that result in translation of the output of the respiratory rhythm generator to ventilation are described. A comprehensive understanding of respiratory mechanics is essential to the delivery of optimized and individualized mechanical ventilation. The basic elements of respiratory mechanics will be described and developmental changes in the airways, lungs, and chest wall that impact on measurement of respiratory mechanics with advancing postnatal age are reviewed. This will be follwowed by two sections, the first on respiratory mechanics in various neonatal pathologies and the second in pediatric pathologies. The latter can be classified in three categories. First, restrictive diseases may be of pulmonary origin, such as chronic interstitial lung diseases or acute lung injury/acute respiratory distress syndrome, which are usually associated with reduced lung compliance. Restrictive diseases may also be due to chest wall abnormalities such as obesity or scoliosis (idiopathic or secondary to neuromuscular diseases), which are associated with a reduction in chest wall compliance. Second, obstructive diseases are represented by asthma and wheezing disorders, cystic fibrosis, long term sequelae of neonatal lung disease and bronchiolitis obliterans following hematopoietic stem cell transplantation. Obstructive diseases are defined by a reduced FEV1/VC ratio. Third, neuromuscular diseases, mainly represented by DMD and SMA, are associated with a decrease in vital capacity linked to respiratory muscle weakness that is better detected by PImax, PEmax and SNIP measurements.
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Abstract
Assessments of pulmonary function play an integral part in the clinical management of school age children as well as providing objective outcome measures in clinical and epidemiological research studies. Pulmonary function tests (PFTs) can also be undertaken in sleeping infants and in awake young children from 3 years of age. However, the clinical utility of such assessments, which are generally confined to specialist centres, has yet to be established. Whether requesting or undertaking paediatric PFTs, or simply reading about how these tests have been applied in research studies, it is essential to question whether results have been interpreted in a meaningful way. This review summarises some of the issues that need to be considered, including: why the tests are being performed; which tests are most likely to detect the suspected pathophysiology; how often such tests should be repeated; whether results are likely to be reliable (in terms of data quality, repeatability and the availability of suitable reference equations with which to distinguish the effects of disease from those of growth and development), and whether the selected tests are likely to be feasible in the individual child or study group under investigation.
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Ratjen F, Durham T, Navratil T, Schaberg A, Accurso FJ, Wainwright C, Barnes M, Moss RB. Long term effects of denufosol tetrasodium in patients with cystic fibrosis. J Cyst Fibros 2012; 11:539-49. [PMID: 22682898 DOI: 10.1016/j.jcf.2012.05.003] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 05/08/2012] [Accepted: 05/12/2012] [Indexed: 11/30/2022]
Abstract
RATIONALE Denufosol stimulates chloride secretion independent of the chloride channel which is dysfunctional in cystic fibrosis (CF) and therefore has the potential to benefit CF patients regardless of genotype. OBJECTIVES To assess the efficacy of denufosol in CF patients with mild lung function impairment age 5 years and older. METHODS This multicenter, randomized, parallel group double-blind placebo-controlled trial was conducted at 102 CF care centers in Australia, Canada and the United States (NCT00625612) The active group (n=233) received 60 mg denufosol via inhalation three times daily The primary efficacy endpoint was change in FEV(1) in liters from Day 0 to week 48. MEASUREMENTS AND MAIN RESULTS 685 patients were screened for the study and 466 patients (233 in each group) were randomized to study treatment. The adjusted mean change in FEV(1)was 40 mL for denufosol and 32 mL for placebo with a resulting treatment effect of 8 mL (95% CI -0.040, 0.056). The average rate of change in FEV(1) percent of predicted over 0 to 48 weeks was -3.04% for placebo vs. -2.30 for denufosol (a difference of 24% relative to placebo) among all patients. The incidence of pulmonary exacerbation was 26% vs. 21% for the placebo and denufosol groups with no differences in the time to first event. The study treatments were well tolerated and there was no evidence of systemic effects in any safety parameter assessed. CONCLUSIONS In patients with CF treatment with denufosol for 48 weeks did not improve pulmonary function or reduce the incidence of pulmonary exacerbations.
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Affiliation(s)
- Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, and Program in Physiology and Experimental Medicine, SickKids Research Institute, The Hospital for Sick Children, and University of Toronto, Toronto, Canada.
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Shukla M, Kumar P, Mishra V, Chaudhari BP, Munjal AK, Tripathi SS, Raisuddin S, Paul BN. Carryover of cigarette smoke effects on hematopoietic cytokines to F1 mouse litters. Mol Immunol 2011; 48:1809-17. [DOI: 10.1016/j.molimm.2011.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 05/05/2011] [Accepted: 05/09/2011] [Indexed: 01/25/2023]
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Watts KD, McColley SA. Elevated vascular endothelial growth factor is correlated with elevated erythropoietin in stable, young cystic fibrosis patients. Pediatr Pulmonol 2011; 46:683-7. [PMID: 21365780 DOI: 10.1002/ppul.21428] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 11/02/2010] [Accepted: 11/11/2010] [Indexed: 11/06/2022]
Abstract
Angiogenesis is an important mechanism of airway remodeling in lung disease. We previously demonstrated that serum vascular endothelial growth factor (VEGF) is elevated in cystic fibrosis (CF) patients and declines with therapy for pulmonary exacerbation. We hypothesized that VEGF is elevated early in the course of CF and is associated with markers of tissue hypoxia. A prospective, single-visit evaluation of thirty stable infants and children with CF was performed. Serum was analyzed for VEGF and for other markers of tissue hypoxia (erythropoietin (EPO), insulin-like growth factor binding protein-1 (IGFBP-1)) and for inflammatory mediators (IL-1 beta, IL-6, IL-8, and tumor necrosis factor alpha (TNFα)) using Meso Scale multi-spot serum immunoassays. Measurements were correlated between assay groups; and with age in months and pulmonary function (FEV0.5 or FEV1). VEGF, EPO, TNFα and IL-8 were elevated compared to published normative values. VEGF levels were not significantly correlated with any inflammatory mediators. However, VEGF correlated with EPO (r=0.505; P<0.05). There was no correlation between lung function and markers of inflammation or tissue hypoxia. VEGF is elevated in young, stable infants and children suggesting angiogenesis as a contributing mechanism for early lung disease in CF. VEGF elevation does not show significant correlation with inflammatory mediators known to be increased in CF, but is significantly correlated with EPO levels. We propose that VEGF elevation and angiogenesis contribute to early lung disease and may result from a direct tissue hypoxia pathway in CF.
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Affiliation(s)
- Kimberly Danieli Watts
- The Division of Pulmonary Medicine, Children's Memorial Hospital, 2300 Children's Plaza, Chicago, IL 60614, USA.
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Accurso FJ, Moss RB, Wilmott RW, Anbar RD, Schaberg AE, Durham TA, Ramsey BW. Denufosol tetrasodium in patients with cystic fibrosis and normal to mildly impaired lung function. Am J Respir Crit Care Med 2010; 183:627-34. [PMID: 21169471 DOI: 10.1164/rccm.201008-1267oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
RATIONALE Intervention for cystic fibrosis lung disease early in its course has the potential to delay or prevent progressive changes that lead to irreversible airflow obstruction. Denufosol is a novel ion channel regulator designed to correct the ion transport defect and increase the overall mucociliary clearance in cystic fibrosis lung disease by increasing chloride secretion, inhibiting sodium absorption, and increasing ciliary beat frequency in the airway epithelium independently of cystic fibrosis transmembrane conductance regulator genotype. OBJECTIVES To evaluate the efficacy and safety of denufosol in patients with cystic fibrosis who had normal to mildly impaired lung function characteristic of early cystic fibrosis. METHODS A total of 352 patients greater than or equal to 5 years old with cystic fibrosis who had FEV(1) greater than or equal to 75% of predicted normal were randomized to receive inhaled denufosol, 60 mg, or placebo three times daily in a Phase 3, randomized, double-blind, placebo-controlled, 24-week trial. MEASUREMENTS AND MAIN RESULTS Main outcome measures included change in FEV(1) from baseline to Week 24 endpoint and adverse events. Mean change from baseline to Week 24 endpoint in FEV(1) (primary efficacy endpoint) was 0.048 L for denufosol (n = 178) and 0.003 L for placebo (n = 174; P = 0.047). No significant differences between groups were observed for secondary endpoints including exacerbation rate and other measures of lung function. Denufosol was well tolerated with adverse event and growth profiles similar to placebo. CONCLUSIONS Denufosol improved lung function relative to placebo in cystic fibrosis patients with normal to mildly impaired lung function. Clinical trial registered with www.clinicaltrials.gov (NCT00357279).
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Affiliation(s)
- Frank J Accurso
- University of Colorado Denver, 13123 East 16th Avenue, B395, Aurora, CO 80045.
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Pillarisetti N, Linnane B, Ranganathan S. Early bronchiectasis in cystic fibrosis detected by surveillance CT. Respirology 2010; 15:1009-11. [PMID: 20456672 DOI: 10.1111/j.1440-1843.2010.01765.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There is emerging evidence that cystic fibrosis lung disease begins early in infancy. Newborn screening allows early detection and surveillance of pulmonary disease and the possibility of early intervention in this life-shortening condition. We report two children with cystic fibrosis who underwent a comprehensive assessment from diagnosis that included measurement of lung function, limited-slice high-resolution CT and BAL performed annually. Early aggressive surveillance enabled significant lung disease and bronchiectasis to be detected during the first few years of life and led to a change in management, highlighting a clinical role for CT scanning during the preschool years in children with cystic fibrosis.
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Affiliation(s)
- Naveen Pillarisetti
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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Current World Literature. Curr Opin Pulm Med 2009; 15:638-44. [DOI: 10.1097/mcp.0b013e3283328a80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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