Background: Pulmonary complications of sickle cell disease (SCD) are diverse and encompass acute and chronic disease. The understanding of the natural history of pulmonary complications of SCD is limited, no specific therapies exist, and these complications are a primary cause of morbidity and mortality. Methods: We gathered a multidisciplinary group of pediatric and adult hematologists, pulmonologists, and emergency medicine physicians with expertise in SCD-related lung disease along with an SCD patient advocate for an American Thoracic Society–sponsored workshop to review the literature and identify key unanswered clinical and research questions. Participants were divided into four subcommittees on the basis of expertise: 1 ) acute chest syndrome, 2 ) lower airways disease and pulmonary function, 3 ) sleep-disordered breathing and hypoxia, and 4 ) pulmonary vascular complications of SCD. Before the workshop, a comprehensive literature review of each subtopic was conducted. Clinically important questions were developed after literature review and were finalized by group discussion and consensus. Results: Current knowledge is based on small, predominantly observational studies, few multicenter longitudinal studies, and even fewer high-quality interventional trials specifically targeting the pulmonary complications of SCD. Each subcommittee identified the three or four most important unanswered questions in their topic area for researchers to direct the next steps of clinical investigation. Conclusions: Important and clinically relevant questions regarding sickle cell lung disease remain unanswered. High-quality, multicenter, longitudinal studies and randomized clinical trials designed and implemented by teams of multidisciplinary clinician-investigators are needed to improve the care of individuals with SCD.

The use of high oxygen concentrations is frequently necessary in the treatment of acute respiratory distress syndrome (ARDS) and bronchopulmonary dysplasia (BPD). High oxygen concentrations, however, are detrimental to cell growth and cell survival. Glutamine (Gln) may be protective to cells during periods of stress and recently has been shown to increase survival in A549 cells exposed to lethal concentrations of oxygen (95% O2). We found that supplemental Gln enhances cell growth in A549 cells exposed to moderate concentrations of oxygen (60% O2). We therefore evaluated the effect of moderate hyperoxia on the cell cycle distribution of A549 cells. At 48 h there was no significant difference in the cell cycle distribution between 2 mM Gln cells in 60% O2 and 2 mM cells in room air. Furthermore, 2 mM Gln cells in 60% O2 had stable protein levels of cyclin B1 consistent with ongoing cell proliferation. In contrast, at 48 h, cells not supplemented with glutamine (Gln-) in 60% O2 had evidence of growth arrest by both flow cytometry (increased percentage of G1 cells) and by decreased protein levels of cyclin B1. G1 growth arrest in the Gln- cells exposed to 60% O2 was not, however, associated with induction of p21 protein. At 72 and 96 h, Gln- cells in 60% O2, began to demonstrate a partial loss of G1 checkpoint regulation and an increase in apoptosis, indicating an increased sensitivity to oxygen toxicity. Glutathione (GSH) concentrations were then measured. 2 mM Gln cells in 60% O2 were found to have higher concentrations of GSH compared to Gln- cells in 60% O2, suggesting that Gln confers protection to the cell during exposure to hyperoxia through up-regulation of GSH. When cells in 60% O2 were given higher concentrations of Gln (5 and 10 mM), cell growth at 96 h was increased compared to cells grown in 2 mM Gln (P<0.04). Clonal survival was also increased in cells exposed 60% O2 and supplemented with higher concentrations of Gln compared to Gln- cells in 60% O2. These studies suggest that supplemental glutamine may improve cell growth and cell viability and therefore may be beneficial to the lung during exposure to moderate concentrations of supplemental oxygen.

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Although a common complication of mechanical ventilation in acute respiratory failure, spontaneous pneumothorax has been rarely reported among patients on chronic, intermittent, noninvasive positive pressure support. We report the first case of recurrent pneumothoraces associated with nocturnal bilevel positive airway pressure ventilation via a nasal mask.A 26-year old man with chronic respiratory failure secondary to an unclassified neuromuscular condition suffered four separate episodes of spontaneous pneumothorax over a 12-month period. Two episodes occurred while he was asleep on bilevel positive airway pressure support. He was found to have numerous subpleural blebs, and we propose a mechanism for their development. Following open pleurodesis and blebectomy, the patient has not had another pneumothorax. Given the increasing utilization of chronic nocturnal bilevel positive airway pressure ventilation, we suggest that healthcare providers and patients be made aware of this potentially life-threatening complication.