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The connective tissue diseases (CTDs) are inflammatory, immune-mediated disorders in which interstitial lung disease (ILD) is common and clinically important. Interstitial lung disease may be the first manifestation of a CTD in a previously healthy patient. CTD-associated ILD frequently presents with the gradual onset of cough and dyspnea, although rarely may present with fulminant respiratory failure. Infection and drug reaction should always be ruled out. A diagnosis of idiopathic ILD should never be made without a careful search for subtle evidence of underlying CTD. Treatment of CTD-ILD typically includes corticosteroids and immunosuppressive agents., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Lung cancer is the leading cause of cancer death in the United States and around the world. A vast majority of lung cancer deaths are attributable to cigarette smoking, and curbing the rates of cigarette smoking is imperative. Understanding the epidemiology and causal factors of lung cancer can provide additional foundation for disease prevention. This article focuses on modifiable risk factors, including tobacco smoking, occupational carcinogens, diet, and ionizing radiation. It also discusses briefly the molecular and genetic aspects of lung carcinogenesis., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Pulmonary disease is a major source of morbidity and mortality in rheumatoid arthritis, manifesting most commonly as interstitial lung disease, airways disease, rheumatoid nodules, and pleural effusions. The diagnostic assessment of respiratory abnormalities is complicated by underlying risk for infection, the use of drugs with known pulmonary toxicity, and the frequency of lung disease related to rheumatoid arthritis itself. Evaluation and management of rheumatoid arthritis-associated pulmonary disease frequently necessitates a multidisciplinary approach.

Obesity is becoming a worldwide problem of epidemic proportions, and its effect on the heart is increasingly being recognized. Obesity is often associated with an increased risk for heart failure. In this article, the authors review the evidence for obesity-related cardiomyopathy. The importance of metabolic disturbances in the development of cardiomyopathy in obese patients is highlighted. The authors also briefly explore whether obesity plays a role in the development of pulmonary hypertension. Better recognition and understanding of both obesity cardiomyopathy and pulmonary hypertension are needed in the obese patient population.

Noncardiogenic pulmonary edema, and, to a lesser extent, acute respiratory distress syndrome (ARDS), are common clinical manifestations of drug-induced lung diseases. Clinical features and radiographic appearances are generally indistinguishable from other causes of pulmonary edema and ARDS. Typical manifestations include dyspnea, chest discomfort, tachypnea, and hypoxemia. Chest radiographs commonly reveal interstitial and alveolar filling infiltrates. Unlike pulmonary edema that is due to congestive heart failure, cardiomegaly and pulmonary vascular redistribution are generally absent in cases that are drug-related. Rare cases of drug-induced myocarditis with heart failure and pulmonary edema have been described. Results from laboratory evaluation and respiratory function tests are nonspecific.

Lung cancer is the leading cause of cancer deaths in the United States. The individual therapeutic approach and prognosis depends on accurate diagnosis and staging. Flexible bronchoscopy (FB) and transthoracic needle biopsy (TNB) are the most widely used techniques for this purpose. This article provides a critical overview of indications, diagnostic yield, and limitations of bronchoscopy and TNB in the diagnosis of lung cancer.

Over the past century, lung cancer has gone from an obscure disease to the leading cause of cancer death worldwide. Initially an epidemic disease among men in industrialized nations, lung cancer now has become the leading cancer killer in both sexes in the United States and an increasingly common disease of both sexes in developing countries. Lung cancer incidence largely mirrors smoking prevalence, with a latency period of several decades. Other important risk factors for the development of lung cancer include environmental exposure to tobacco smoke, radon, occupational carcinogens, and pre-existing nonmalignant lung disease. Studies in molecular biology have elucidated the role that genetic factors play in modifying an individual's risk for lung cancer. Although chemopreventive agents may be developed to prevent lung cancer, prevention of smoking initiation and promotion of smoking cessation are currently the best weapons to fight lung cancer. No other malignancy has been shown to have such a strong epidemiologic relation between a preventable behavior and incidence of disease. Despite this knowledge, more than 20% of all Americans smoke, and tobacco use is exploding in developing countries. Based on current and projected smoking patterns, it is anticipated that lung cancer will remain the leading cause of cancer death in the world for decades to come.

Sjögren's syndrome is one of the most common systemic rheumatic diseases. Pulmonary disease is prevalent in Sjögren's syndrome; respiratory manifestations include chronic cough, obstructive airways disease, pulmonary lymphoma, and interstitial lung disease that may progress to severe pulmonary fibrosis.

Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women. The respiratory system is more commonly involved in SLE than in any other collagen vascular disease. SLE may affect virtually all components of the respiratory system, including the upper airway, lung parenchyma, pulmonary vasculature, pleura, and respiratory muscles. Respiratory system involvement ranges from symptomatic to fulminant and life threatening. This article reviews the pulmonary manifestations of SLE, including drug-induced SLE.

One half of all cases of lung cancer occur in patients aged 65 years and older. Although adenocarcinoma is the predominant histologic subtype in the general population, squamous cell carcinoma has remained the most common type in the elderly. Although lung cancer tends to present at a less advanced stage with increasing age, the percentage of elderly patients undergoing treatment tends to decline despite the fact that they can tolerate the aggressive therapy that may enhance survival.

Flexible fiberoptic bronchoscopy is the most useful invasive technique for diagnosing lung cancer. This article details the use and efficacy of bronchoscopy with such established techniques as forceps biopsy, brush biopsy, and bronchial washing in the diagnosis and staging of bronchoscopically visible central lung cancer and peripheral lung cancer. The efficacy of such newer techniques as transbronchial needle aspiration, transbronchial curettage, ultrathin fiberoptic bronchoscopy, and quantitation of tumor markers in bronchoalveolar lavage fluid is also discussed, along with the complications of bronchoscopy and new techniques for detecting early lung cancer.

We have discussed the complex hemodynamic changes that occur throughout the respiratory cycle during spontaneous and mechanical ventilation. In patients, many cumulative factors account for the total hemodynamic burden of inspiration and expiration. Thus, the change in pleural pressure, ventilation rate, mode of ventilation, amount of spontaneous ventilation, underlying lung and cardiac disease, and intravascular volume status all affect cardiocirculatory equilibrium. In addition, in the patient with ARDS, various immune mediators that are released into the circulation will affect LV function. Knowledge of the effects discussed in this article will aid the physician in choosing therapeutic options for patients with ARDS.

The development of pulmonary hypertension and right ventricular failure in COPD patients signals a poor prognosis. In hypoxic patients, long-term oxygen therapy prolongs life and appears to prevent or lessen the progression of pulmonary hypertension. However, oxygen therapy does not benefit and is not indicated for all COPD patients, and even in those patients who improve with oxygen, there remains a need to further improve survival. Therefore, there continues to be active investigations into pharmacologic agents that might reduce pulmonary hypertension or improve right ventricular function. Although many agents appear to have salutary acute effects, it has been more difficult to establish evidence for sustained hemodynamic benefits from chronic drug therapy. Furthermore, some effective agents may not provide additive benefit when combined with standard supplemental oxygen use, although the available data are limited. Clearly, further research is necessary to identify which COPD patients, if any, may benefit from either beta-agonists or vasodilators for the treatment or prevention of cor pulmonale at some time during the natural history of their disease.

Multiple chemotherapeutic agents have been reported to cause pulmonary injury, usually manifested as interstitial pneumonitis and fibrosis. Several unique presentations have been described for mitomycin, methotrexate, and the combinations of mitomycin and vinca alkaloids. Mechanisms of lung injury remain mostly speculative, although ongoing investigations may someday elucidate such pathways of injury. With a greater understanding of how these agents damage lung tissue, physicians may be able to more safely administer these drugs to patients. The drugs which have been shown to cause pulmonary injury most frequently are BCNU, mitomycin (with and without vinca alkaloids), and methotrexate. All physicians using cytotoxic drugs must be aware of the potential for lung injury with these agents.

This article reviews factors that may limit exercise performance in patients with COPD. These factors include alteration in pulmonary mechanics, respiratory muscle fatigue, impairment in pulmonary gas exchange, abnormal perception of breathlessness and ventilatory control, cor pulmonale, and poor nutritional status. The clinical application of exercise testing in patients with COPD and the role of various therapeutic modalities in altering exercise performance in COPD are discussed.

The respiratory and gastrointestinal systems share several functional similarities. In health, the two systems remain structurally distinct and functionally integrated, so as to maintain physiologic homeostasis. However, in the setting of disease, pathophysiologic alterations in one system may be reflected in the other. This article focuses upon the nonmalignant gastrointestinal causes of respiratory illness. Using an anatomic approach, the pulmonary manifestations of selected gastrointestinal diseases are outlined. Emphasis is placed on the distinguishing features, pathophysiology, and therapy of the pulmonary sequelae of digestive diseases.

Metastatic spread of nonpulmonary malignancies to the lung is a common clinical problem. However, the evaluation and treatment of metastatic lung disease may be confusing. This article considers both pulmonary and pleural metastases. The basic biology of the metastatic process is discussed, together with the pathologic, clinical, radiologic, diagnostic, and therapeutic features of pulmonary metastases. Metastatic disease to the pleura is reviewed in detail, including etiology and incidence, pathogenesis, clinical manifestations, diagnosis, prognosis, and treatment.

The collagen vascular diseases are a heterogeneous group of immunologically mediated inflammatory disorders. The organs and tissues that compose the respiratory system are frequently affected by these diseases. Potential targets of the inflammation and injury include the lung parenchyma, tracheobronchial tree, pulmonary vasculature, pleura, larynx, and respiratory muscles. In this article, the spectrum of respiratory disease caused by systemic lupus erythematosus, rheumatoid arthritis, scleroderma, polymyositis/dermatomyositis, mixed connective tissue disease, ankylosing spondylitis, relapsing polychondritis, and Sjögren's syndrome is reviewed. Where appropriate, therapeutic options are discussed.

We have discussed the complex hemodynamic changes that occur throughout the respiratory cycle during mechanical ventilation and have reviewed the physiologic changes associated with spontaneous respiration. In patients, many cumulative factors account for the total hemodynamic burden of mechanical inspiration and expiration. Thus, the change in pleural pressure, respiratory rate, mode of ventilation, amount of spontaneous ventilation, underlying lung and cardiac disease, and intravascular volume status all affect cardiocirculatory equilibrium during the respiratory cycle. Knowledge of the effects presented in this article will aid the physician in choosing the therapeutic options in instrumented, mechanically ventilated patients.