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Diffuse Lung Disease: a Practical Approach: Pulmonary Circulation: Diseases and Their Treatment FREE TO VIEW

Gabriel Laszlo, MD
Chest. 2006;130(2):627-628. doi:10.1378/chest.130.2.627
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Diffuse Lung Disease: a Practical Approach

By Robert P. Baughman, Roland M. du Bois, Joseph P. Lynch, and Athol U. Wells, eds. London, UK: Arnold, 2004; 294 pp; $125

Pulmonary Circulation: Diseases and Their Treatment

By Andrew J. Peacock and Lewis J. Rubin, eds. London, UK: Arnold, 2004, 599 pp; $198.50

Diffuse Lung Disease: a Practical Approach is a short book for trainees and practicing pulmonologists on the subject of the pulmonary disorders affecting mainly the interstitium and alveolar walls. These are much less commonly seen in the clinic than airflow obstruction; approximately 1 in 10 of the patients referred to my pulmonary function laboratory with puzzling breathlessness had results that suggested the diagnosis of an interstitial disorder. There are scores of different conditions like this, most of them very rare; many, especially those associated with idiopathic pulmonary fibrosis, are unresponsive to antiinflammatory treatment and have an unpredictable prognosis. Until recently, it was thought that fibrosing lung conditions started with an inflammatory process that stimulated the proliferation of fibroblasts, but it is now clear that fibrogenesis sometimes progresses without inflammation. Several drugs that are known to inhibit fibroblastic activity have been tested, so far to no avail. Consequently, the dilemma remains the same as before: how to identify those conditions that have a better prognosis than idiopathic pulmonary fibrosis, those that remain indolent and do not require treatment, and those that might respond to therapy.

Until 1990, the solution lay in open surgical biopsy of the lung, and the reputation of referral centers depended on their determination to proceed to this, and on the skill of their pathologists. Small lung biopsy samples obtained at fiberoptic bronchoscopy and cytology of lavage fluid yielded a few insights in the 1980s but also some misleading results. In the last decade, two advances have made it necessary to rewrite the story, and this book summarizes the practical aspects of these developments. Firstly, there has been a major reorganization of the pathologic classification of idiopathic pulmonary fibrosis, with the description of a new entity (nonspecific interstitial pneumonia) and more clarity about the appearances of some other entities such as the respiratory bronchiolitis of smokers. Secondly, radiologists can now diagnose idiopathic pulmonary fibrosis with a high degree of accuracy using high-resolution CT. In addition, many other conditions, such as lymphangioleiomyomatosis, can be diagnosed accurately by the use of good clinical and radiologic information.

The two excellent chapters that describe the current thinking about pathology and radiology are placed second and third and form the bedrock of this book. The essay on the place of radiology and how it should be improved by further research is lucid and scholarly and by itself justifies the publication of this work. There are essays on what can be learned from lung cytology and other tests, but the book moves speedily on to describe in variable detail the specific conditions under discussion. Idiopathic pulmonary fibrosis, sarcoidosis, and nonspecific interstitial pneumonia receive close attention, after which the other conditions are described succinctly but usually in sufficient detail to help the general reader to recognize these patients and point them toward appropriate treatment.

This very portable book covers a large area of respiratory medicine in fewer pages than are often allocated to it in general textbooks, so it is interesting to examine how this has been achieved. In the main, the book is firmly rooted in the present; apart from the radiologic chapter, the editors have ruthlessly put down any tendency to intellectual curiosity. There is no speculation about immunology and the differing roles of various cytokines. There are no reminiscences about the issues that used to fascinate academically inclined chest physicians, such as the precise definition of a restrictive disorder, whether there is a diffusion barrier to the passage of oxygen through the alveolar membrane, and alternative names for the disease process known as idiopathic pulmonary fibrosis in the United States. The term fibrosing alveolitis is dismissed in a word in this Anglo-American book (15 love in the US-UK medical version of Wimbledon), while bronchiolitis obliterans organizing pneumonia is unceremoniously buried in favor of cryptogenic organizing pneumonia (15 all). Most surprisingly, there are very few attempts to divine the future of this perplexing field.

Sometimes the pursuit of brevity weakens the book. There are chapters that are very terse, and the gist of the short opening clinical introduction, which was not written by any of the editors, is in one dense table summarizing the differential diagnosis of the interstitial lung diseases. Throughout the book, information about pulmonary function is generally reduced to a less than ideal minimum. Occasionally, this leads to misleading oversimplification; one of the contributors was allowed to write that lung function is normal in coal workers’ pneumoconiosis when the quoted reference was about ventilatory function. A few chapters are so brief that they are useless. It may be that the management of asbestosis does depend heavily on the chest radiograph, as is claimed, but this topic deserves better treatment than a bare column with no discussion about the place of CT, nothing about prognosis, and no mention of the word plaque. The laudable aim of the editors was to deal with mainly those aspects of the topic that are not well covered elsewhere, but there are no pointers toward reading material that can be consulted in order to fill in the areas mentioned only in outline.

Finally, several pages are devoted to illustrative cases. Some of these go back quite a few years, to judge from the elderly CT scans. This section may be seen as useful for pulmonologists in training, and these cases do make a few points, but they are almost all highly unusual and some contain algorithms and material that ought to be in the main text. The examples are probably of less value to practicing physicians updating their approach to patients with interstitial lung diseases, which is unfortunate because I suspect the book is mainly aimed at this group.

In summary, much of this timely book is very good and the most important parts are excellent. A somewhat enlarged second edition might be even better, if the publisher could allow the editors to increase the size of the pathologic plates, to improve the shorter sections by making them more authoritative and to write a relaxed and welcoming opening chapter informed by the material that is to follow. An example for the editors to follow may well be the new edition of Peacock and Rubin’s Pulmonary Circulation: Diseases and Their Treatment, which I happened to read just before Diffuse Lung Disease: a Practical Approach.

The first edition of Pulmonary Circulation: Diseases and Their Treatment appeared in 1996; this enlarged second edition is worth a mention because generalists need to know that it exists to be consulted on occasion and to be read with pleasure by those who feel they need a fresh look at the topic. There have been several recent advances in our understanding of the pulmonary circulation, a whole host of expensive new treatments and one or two conferences aimed at standardizing some of the terminology, so this revised version is welcome.

The book starts with physiology and anatomy, moves on to clinical findings and investigations, and then deals chapter by chapter with pulmonary hypertensive disorders and their treatment. The pathophysiology of the pulmonary circulation under unusual conditions is considered at the end. Science and medicine, history, and future trends are treated with equal rigor. The style is uniformly readable, and excellent use is made of the 600 pages. The concepts are fully explained in prose with the aid of good illustrations and plates. These are clear, and they benefit from the large page size. A number of novel features assist the reader: the new material is highlighted in detail in a foreword by John Reeves. The exhaustive list of references is made even more helpful by editorial comments pointing out which are classical texts and which are current reviews that might be helpful to the serious student. Apart from the clumsy title and a few liberties with the inevitable abbreviations, there is very little with which to find fault.

The philosopher and mathematician Blaise Pascal said in one of his letters, “I have made this longer, because I have not had the time to make it shorter.” These two books are each very useful in their own way. Readers who tackle both may conclude that too much brevity can lead to lack of clarity; condensed accounts may sometimes take longer to digest than lucid prose.

Dr. Laszlo has reported to the ACCP that no conflicts of interest exist with any companies whose products are discussed in this article.




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