What's new in pulmonary and critical care medicine

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ASTHMA

Tapering inhaled corticosteroids in asthma patients responding to biologics (December 2023)

Strategies for tapering other asthma therapies, such as inhaled corticosteroids (ICS), for patients who achieve good asthma control with biologics has not been well studied. In an open-label, randomized trial of 168 adults with a history of severe eosinophilic asthma and good control on benralizumab and high-dose ICS, 43 patients were assigned to an ongoing high-dose ICS-formoterol regimen and 125 patients were assigned to a 32-week taper protocol (medium-, low-, and as-needed dosing of ICS-formoterol) [1]. In the tapering arm, 92 percent of patients achieved lower doses of ICS, with only 9 percent experiencing exacerbations. However, significant decreases in FEV₁ and increases in fraction of exhaled nitric oxide occurred in patients using the least amount of as-needed ICS-formoterol after their taper. These data suggest that most patients well-controlled on biologics may be successfully tapered to regimens containing medium- or low-dose ICS with long-acting bronchodilators. However, the safety and efficacy of tapering to as-needed ICS-formoterol requires further study. (See "Treatment of severe asthma in adolescents and adults", section on 'Tapering therapy'.)

Long distance effect of wildfire smoke on asthma symptoms (October 2023)

Wildfire fine particulate matter (PM_2.5) has been shown to affect respiratory health; however, previous work has focused on populations residing near and directly affected by wildfires. In June 2023, smoke from wildfires in Canada drifted hundreds of miles to New York City, resulting in increased ambient PM_2.5. During smoke waves, emergency department visits for asthma in both pediatric and adult patients increased to 261 per day (reference during nonsmoke periods, 181.5 per day; incidence rate ratio 1.4) [2]. Wildfires have health effects far from their source and are particularly hazardous to those with underlying lung disease. (See "Climate emergencies", section on 'Changing wildfire exposure'.)

COPD

Significance of airway dilation on computed tomography and symptoms in patients at risk for COPD (October 2023)

Smokers and former smokers without airway obstruction but with respiratory symptoms or pulmonary imaging abnormalities are considered at risk for COPD, but their long-term prognosis is uncertain. In a recent study of over 3200 smokers and former smokers with normal spirometry, individuals with a computed tomography (CT)-derived marker of airway dilation and clinical symptoms (cough, phlegm production, dyspnea, or respiratory exacerbations) had increased 10-year mortality compared with those without CT-derived airway dilation (23 versus 11 percent, adjusted mortality difference 15 percent) [3]. These investigational data suggest that clinical and imaging features of airway disease have prognostic significance in patients at risk for COPD, but further study is needed to determine the value of detecting airway dilation in this population. (See "Chronic obstructive pulmonary disease: Diagnosis and staging", section on 'Additional testing'.)

Pulmonary embolism in patients with severe COPD exacerbation (September 2023)

Pulmonary embolism (PE) is an important potential trigger for COPD exacerbation. In a recent multicenter study, 1580 patients with COPD who were admitted to the hospital with acute worsening of respiratory symptoms were all screened for PE with computed tomography pulmonary angiogram within 48 hours of admission [4]. PE was identified in 266 (17 percent), with 166 patients (11 percent) having PE involving the main or lobar pulmonary arteries. Purulent sputum production decreased the odds of PE by 60 percent. We suggest obtaining imaging for PE in patients requiring admission for COPD exacerbation who do not have evidence of other triggers (eg, infection or heart failure). (See "COPD exacerbations: Clinical manifestations and evaluation", section on 'Triggers' and "COPD exacerbations: Clinical manifestations and evaluation", section on 'Additional testing'.)

Longitudinal risk of airway obstruction in symptomatic current or former smokers (August 2023)

Whether current or former smokers with early respiratory symptoms have a different risk for COPD development or complications is not well understood. In one longitudinal cohort of patients aged 40 to 80 years with a >20 pack-year smoking history, the risk of developing airway obstruction over five years was 30 to 35 percent regardless of the presence of respiratory symptoms [5]. However, patients with symptoms were significantly more likely to have respiratory exacerbations during follow-up. (See "Chronic obstructive pulmonary disease: Risk factors and risk reduction", section on 'Cigarette smoking'.)

CRITICAL CARE

Routine prone positioning not beneficial in ARDS during ECMO (January 2024)

Whether prone positioning benefits patients with acute respiratory distress syndrome (ARDS) undergoing venovenous extracorporeal membrane oxygenation (V-V ECMO) is unclear. In a recent randomized trial of 170 patients with mostly COVID-related ARDS, routine prone positioning during V-V ECMO did not alter outcomes including ECMO duration, length of stay, and 90-day mortality when compared with V-V ECMO in the supine position [6]. However, a significant proportion of patients were prone before enrollment which may have impacted the results. In addition, the results are not generalizable to the non-COVID ARDS population. Until data show benefit, we do not support the routine application of prone positioning during V-V ECMO in ARDS. (See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Management of refractory hypoxemia during ECMO'.)

Emerging microbiologic colonization in mechanically ventilated patients (January 2024)

Mechanically ventilated patients act as reservoirs for hospital-acquired pathogens, including Staphylococcus, Pseudomonas, and Aspergillus species. However, a recent surveillance study of 51 acute care and long-term health care facilities reported the emergence of two additional species in mechanically ventilated patients, Acinetobacter baumannii (31 percent of patients, and one-half were carbapenem-resistant) and Candida auris (7 percent, and one-third were newly identified) [7]. Clinicians should be aware of emerging microbiologic species in their local facility so that appropriate surveillance can be conducted and antimicrobial therapy initiated, if indicated. (See "Clinical and physiologic complications of mechanical ventilation: Overview", section on 'Aspiration and ventilator-associated pneumonia and microbial colonization'.)

Extracorporeal cardiopulmonary resuscitation (December 2023)

Extracorporeal cardiopulmonary resuscitation (ECPR) is being increasingly used, but data are limited and the benefits are uncertain. In a recent meta-analysis of 11 studies (10,000 patients) who underwent CPR, compared with standard CPR, ECPR was associated with decreased in-hospital mortality and increased long-term favorable neurologic outcome and survival at one year [8]. The benefit of ECPR was confined to patients with in-hospital cardiac arrest. These data support the growing practice of ECPR in select patients likely to benefit. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Sudden cardiac arrest (extracorporeal cardiopulmonary resuscitation)'.)

Sighs during mechanical ventilation (December 2023)

A ventilatory sigh refers to the administration of a deep breath every few minutes, which in prior studies was proven to maintain lung volume and to avoid atelectasis. However, sighs subsequently fell out of favor when high lung volumes were shown to be harmful. In a recent trial of over 500 ventilated trauma patients, compared with usual care, intermittent sigh volumes delivered every six minutes (plateau pressure 35 cm H₂0) did not increase the number of ventilator-free days or 28-day mortality [9]. There were few adverse events, but sigh-related hypotension was seen in 2 percent. While encouraging, further data are needed before sighs can be routinely applied during mechanical ventilation. (See "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit", section on 'Intermittent sigh'.)

Heart rate control in septic shock (December 2023)

Beta blockade has the potential to limit harm from the adrenergic overdrive that occurs in septic shock. However, data to support heart rate control in patients with septic shock are limited. In a recent, unblinded randomized trial of 126 patients with septic shock-related tachycardia (heart rate ≥95/min) who were receiving norepinephrine, the beta blocker landiolol did not reduce organ failure as measured by the sequential organ failure assessment score [10]. Furthermore, landiolol was associated with increased 28-day mortality compared with standard care (37 versus 25 percent). We continue to avoid the routine use of beta blockers in patients with septic shock. (See "Investigational and ineffective pharmacologic therapies for sepsis", section on 'Heart rate control'.)

No benefit to tight glucose control in critically ill patients (December 2023)

In earlier studies that showed benefit from tight glucose control in critically ill patients, early parenteral nutrition was a potential variable that influenced the outcome. In a recent study of over 9000 patients in whom parenteral nutrition was withheld for a week, 90-day mortality, duration of intensive care unit care, and several other outcomes (eg, infections) were similar when liberal glucose control was compared with tight glucose control [11]. These results are consistent with more recent studies that support the use of liberal rather than tight targets for glucose control in critically ill patients. (See "Glycemic control in critically ill adult and pediatric patients", section on 'Adults'.)

Liberal transfusion strategy for acute myocardial infarction (December 2023)

Restrictive transfusion (transfusing at a lower hemoglobin, typically <7 or 8 g/dL) is appropriate for most patients based on evidence from randomized trials, but trial data for patients with acute myocardial infarction (MI) have been slower to accumulate. In the MINT trial, which randomly assigned 3504 patients with acute MI and anemia to a restrictive or liberal (transfusing for hemoglobin <10 g/dL) strategy, there was a trend toward better outcomes with the liberal strategy without an increased risk of adverse events [12]. We now suggest a liberal strategy for acute MI. A slightly lower hemoglobin may be reasonable for stable, asymptomatic patients, and patients with hemodynamic instability may require a higher hemoglobin. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Acute MI'.)

Nasal decolonization in intensive care units (November 2023)

To reduce hospital-acquired infections, many hospitals provide nasal decolonization with either mupirocin or an iodophor to all patients in intensive care units (ICUs). In a cluster-randomized trial in over 130 hospitals that used universal nasal mupirocin and daily chlorhexidine bathing for ICU patients, switching to nasal iodophor was associated with a higher rate of Staphylococcus aureus growth on clinical cultures than continuing with mupirocin [13]. There was no difference in the rate of bloodstream infection from any pathogen. For hospitals that elect to use nasal decolonization in the ICU, we suggest mupirocin rather than iodophors. This practice may be particularly beneficial in ICUs with high rates of S. aureus infections, including methicillin-resistant strains. (See "Nosocomial infections in the intensive care unit: Epidemiology and prevention", section on 'Patient bathing plus decolonization'.)

Guidelines for fever management in critically ill patients (November 2023)

Updated guidelines on the management of fever in the intensive care unit have been recently published by the Society for Critical Care Medicine and the Infectious Diseases Society of America [14]. Differences with the previous guidelines include an emphasis on the use of core methods when feasible (eg, pulmonary artery catheter, bladder, esophageal) and oral or rectal measurement when not feasible. Also promoted was the use of bedside imaging (eg, ultrasonography) in the evaluation process and biomarkers to facilitate duration of antimicrobial therapy. We agree with the recommendations, most of which were based upon weak evidence. (See "Fever in the intensive care unit", section on 'Temperature measurement'.)

Diagnostic "mini" bronchoalveolar lavage for ventilator-associated pneumonia (November 2023)

Bronchoscopic bronchoalveolar lavage (BAL) is the gold standard for the diagnosis of ventilator-associated pneumonia (VAP). Mini-BAL is less invasive than BAL and can be performed in ventilated patients by nurses and respiratory therapists with lower rates of complications. A meta-analysis of six studies in which patients underwent both mini- and bronchoscopic BAL (in succession) reported a sensitivity of mini-BAL for VAP that was 0.9 and a specificity that was 0.83 [15]. These results confirm the role of mini-BAL as a reasonable alternative to bronchoscopic BAL for the diagnosis of VAP. (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Invasive respiratory sampling'.)

Adverse effects with piperacillin-tazobactam versus cefepime (November 2023)

Observational data have raised concerns for nephrotoxicity with piperacillin-tazobactam (when given with vancomycin) and neurotoxicity with cefepime. In an open-label trial of over 2500 patients randomly assigned to piperacillin-tazobactam versus cefepime, the incidence of major kidney events was comparable between groups (9 versus 10 percent), including among the 1900 patients who also received vancomycin [16]. Median antibiotic use was three days. Although the incidence of neurotoxicity (primarily delirium) was higher with cefepime (21 versus 17 percent), imbalances in baseline delirium rates reduce confidence in that finding. These data reduce concern for nephrotoxicity with short-term coadministration of piperacillin-tazobactam and vancomycin (eg, for initial empiric therapy). For those who warrant prolonged therapy with vancomycin plus an antipseudomonal agent, we weigh the uncertain risks of nephrotoxicity and neurotoxicity when choosing between piperacillin-tazobactam and cefepime. (See "Beta-lactam antibiotics: Mechanisms of action and resistance and adverse effects", section on 'Renal reactions'.)

Sulbactam-durlobactam for Acinetobacter infections (November 2023)

Antibiotic options for infections due to Acinetobacter spp are limited due to high rates of resistance. The US Food and Drug Administration recently approved a new beta-lactam/beta-lactamase inhibitor antibiotic, sulbactam-durlobactam. In an international randomized trial of 125 patients with carbapenem-resistant Acinetobacter infection (mainly hospital-acquired or ventilator-associated pneumonia), sulbactam-durlobactam resulted in a trend toward lower all-cause mortality that was not statistically significant (19 versus 32 percent) and a higher clinical cure rate (62 versus 40 percent) compared with colistin [17]. We reserve this agent for patients with hospital-acquired pneumonia or bacteremia due to susceptible Acinetobacter baumannii complex isolates that are resistant to other first-line agents (ie, other beta-lactams, carbapenems, and fluoroquinolones). (See "Acinetobacter infection: Treatment and prevention", section on 'First-line antibiotics'.)

Uncertain role for inhaled antibiotics in prevention of ventilator-associated pneumonia (November 2023)

Whether inhaled antibiotics are effective in preventing ventilator-associated pneumonia (VAP) is unclear. In a randomized trial of 850 patients on mechanical ventilation for 72 to 96 hours, daily inhaled amikacin for the next 3 days reduced the 28-day incidence of VAP compared with placebo (15 versus 22 percent) but did not reduce the number of days on mechanical ventilation, days of antibiotic utilization, or mortality [18]. While promising, the lack of benefit for patient-important outcomes reduces our confidence in the preventive value of inhaled antibiotics, and thus we have not adopted this practice in our intensive care units. (See "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults", section on 'Inhaled antibiotics'.)

Variable transfusion practices in the ICU (November 2023)

Adherence to restrictive transfusion thresholds (transfusing at a hemoglobin of <7 or <8 g/dL, depending on the indication) is an important principle of patient blood management, but clinical judgment remains important in transfusion decisions, especially for symptomatic patients. In a multicenter study involving patients in 233 intensive care units (ICUs) across six continents, most ICUs gave transfusions to individuals with hemoglobin above the restrictive threshold of 7 g/dL [19]. Common transfusion indications other than low hemoglobin were active bleeding and hemodynamic instability. Further study of the variabilities in transfusion practice are warranted, especially in critically ill individuals. (See "Use of blood products in the critically ill", section on 'Symptomatic patients may require higher hemoglobin targets'.)

Convalescent plasma in mechanically ventilated patients with COVID-19 (November 2023)

Most randomized trials have not demonstrated a benefit for convalescent plasma in hospitalized patients with COVID-19, and we do not routinely use it in this setting. However, an open-label trial of 475 patients who were mechanically ventilated for severe COVID-19 did report a reduction in 28-day mortality with high-titer convalescent plasma compared with standard care (35 versus 45 percent) [20]. The inconsistency of this finding compared with the lack of effect in most other trials decreases confidence in the mortality benefit. Furthermore, the value of convalescent plasma against Omicron variants and in the context of contemporary management remains uncertain, as only a few patients in the trial had Omicron infection and most received only dexamethasone without other immunomodulatory agents. (See "COVID-19: Management in hospitalized adults", section on 'Limited role for antibody-based therapies (monoclonal antibodies and convalescent plasma)'.)

Small-volume blood collection tubes to reduce anemia in the intensive care unit (October 2023)

Patients in the intensive care unit (ICU) undergo numerous blood draws that could contribute to anemia, but the magnitude and clinical significance are unknown. In a recent trial, switching to small-volume blood collection tubes led to a smaller decline in hemoglobin and a slightly reduced need for transfusion without compromising laboratory analysis [21]. Use of smaller collection tubes may be a useful approach to minimizing anemia in ICU patients. (See "Use of blood products in the critically ill", section on 'Preventing and treating other causes of anemia'.)

Aerosol generation during noninvasive respiratory support modalities (October 2023)

Studies have reported conflicting data as to whether high levels of aerosols are generated when noninvasive ventilation (NIV) or high-flow nasal oxygen (HFNO) is used. In a 2023 systematic review including 12 studies in patients with respiratory infections and 15 studies in healthy volunteers, use of NIV or HFNO was not associated with increased generation of pathogen-laden aerosols compared with controls with unsupported normal or labored breathing, low-flow nasal oxygen, or oxygen or nonrebreather mask [22]. Inconsistency among studies may reflect differences in sampling and detection methodologies and operating room ventilation. Notably, the National Health Service in the United Kingdom has removed mask ventilation, intubation, and extubation from its list of aerosol-generating procedures. (See "Overview of infection control during anesthetic care", section on 'Considerations during aerosol-generating procedures'.)

No benefit of routine V-A ECMO in patients with AMI-related cardiogenic shock (September 2023)

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can increase survival for patients with refractory cardiogenic shock caused by a variety of conditions. However, benefit from the routine use of V-A ECMO for cardiogenic shock due to acute myocardial infarction (AMI) is unproven. In a meta-analysis of four randomized trials (nearly 570 patients with AMI-related cardiogenic shock), routine V-A ECMO use showed no mortality benefit and increased rates of both major bleeding and peripheral vascular ischemia compared with medical care alone [23]. Limitations of this meta-analysis include crossover between groups and a low rate of active left ventricular uploading during ECMO therapy, which may have biased the study in favor of the control group. These findings suggest no meaningful benefit for the routine use of V-A ECMO for patients with AMI-related cardiogenic shock but does not preclude benefit in selected patients who are candidates for salvage procedures such as heart transplant. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Refractory cardiogenic shock'.)

Adjunctive immunomodulators for severe COVID-19 (August 2023)

For patients hospitalized for COVID-19 who require high-flow oxygen or ventilatory support, we suggest adding baricitinib or tocilizumab to dexamethasone to further reduce mortality. Other immunomodulatory agents may also improve outcomes. In a randomized trial of patients with severe COVID-19, most of whom were on remdesivir and glucocorticoids, infliximab and abatacept each reduced 28-day mortality compared with placebo (10 and 11 versus 15 percent) but did not improve time to clinical improvement [24]. The trial did not detect a benefit with cenicriviroc. Despite their potential efficacy, we do not routinely use infliximab or abatacept for COVID-19, because they do not offer clear advantages over baricitinib or tocilizumab, which have more established benefit and, in the United States, are approved for this indication. (See "COVID-19: Management in hospitalized adults", section on 'Limited roles for alternative immunomodulators'.)

High-flow oxygen for acute hypoxemic respiratory failure (August 2023)

In adult patients with acute nonhypercapnic hypoxemic respiratory failure, the benefits of high-flow oxygen delivered via nasal cannulae (HFNC) compared with conventional low-flow oxygen (COT) are unclear. A recent meta-analysis of six trials (over 2700 patients with acute hypoxemic respiratory failure) reported that while HFNC did not reduce 28-day mortality compared with COT, it did significantly reduce the rate of reintubation (relative risk 0.89, 95% CI 0.81-0.97) [25]. These data support the use of HFNC in patients with acute hypoxemic respiratory failure who have escalating oxygen needs. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)

INTERSTITIAL LUNG DISEASE

Silicosis in engineered stone fabrication workers (September 2023)

Artificial stone used in fabrication of countertops typically has greater than 90 percent silica content, exposing workers to high concentrations of silica dust. Over the past 15 years, engineered stone countertops have become increasingly popular, leading to reports of silicosis in stone fabrication workers worldwide. One recent report of 52 cases from California illustrates the prevalence of severe disease (38 percent) even after relatively short exposure history (median 15 years) [26]. These concerning cases highlight the need for implementation of workplace exposure controls, identification and surveillance of at-risk workers, and increased clinician awareness of this occupational hazard. (See "Silicosis", section on 'Silica in the work environment'.)

Sirolimus-related survival in lymphangioleiomyomatosis (August 2023)

The impact of sirolimus on the survival of patients with lymphangioleiomyomatosis (LAM) is unclear. One retrospective study recently reported an improved eight-year cumulative survival rate in LAM patients treated with sirolimus compared with patients not on sirolimus (90 versus 78 percent) [27]. Improved survival occurred despite worse baseline lung function in the sirolimus group. These data support our recommendation for sirolimus as the first-line agent in patients with moderate to severe lung dysfunction due to LAM. (See "Sporadic lymphangioleiomyomatosis: Treatment and prognosis", section on 'Mortality'.)

INTERVENTIONAL PULMONOLOGY

Bleeding control during bronchoscopy (August 2023)

When topical application of ice-cold saline fails to control bleeding during bronchoscopy, topical epinephrine is usually administered. The role of topical tranexamic acid (TXA) as a hemostatic agent in this setting is unknown. In a recent randomized trial of topical epinephrine versus TXA in 130 patients with bleeding during bronchoscopy, the rate of hemostasis was 83 percent in both groups [28]. There were no adverse events in either group. Although this is a single trial and larger studies are needed, topical TXA may be considered a third-line agent for bronchoscopic bleeding if epinephrine fails. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Bleeding'.)

LUNG CANCER

Updated lung cancer screening reporting system (Lung-RADS) (January 2024)

A new version of the lung computed tomographic screening reporting and data system (Lung-RADS [LR]) has been published (table 1) [29]. LR categories of 0 to 4 were retained (ie, low-risk to high-risk findings). New changes compared with the older version include the description of atypical pulmonary cysts as well as juxtapleural and airway nodules, and new surveillance options for inflammatory lesions. Clarification was also given on the definition of a growing nodule. We agree with the updated changes. (See "Lung-RADS standardized reporting for low-dose computed tomography for lung cancer screening", section on 'Lung-RADS (LR) categories: Assigning lung cancer risk'.)

LUNG TRANSPLANTATION

Thyroid hormone administration in deceased organ donors (December 2023)

Thyroid hormone administration has been a longstanding component of some organ procurement protocols due to concern that acute hypothyroidism might contribute to hemodynamic instability and left ventricular dysfunction, reducing heart and other organ procurement; however, evidence for the practice has been inconsistent. In a recent trial of 838 hemodynamically unstable, brain-dead donors assigned to receive a levothyroxine infusion or saline placebo, there was little to no difference in number of hearts transplanted or 30-day cardiac graft survival [30]. Recovery of other organs was similarly unaffected. More cases of severe hypertension or tachycardia occurred in the levothyroxine group than in the saline group. Based on these data, we suggest avoiding thyroid hormone administration in deceased organ donors. (See "Management of the deceased organ donor", section on 'Thyroid hormone'.)

Lung transplant outcomes for COVID-19 end-stage lung disease (September 2023)

COVID-19 end-stage lung disease is a new indication for lung transplantation with limited outcome data. Two groups have recently analyzed overlapping cohorts of approximately 400 patients who underwent lung transplantation in the United States for COVID-19-associated end-stage lung disease between March 2020 and August 2022 and who comprised almost 9 percent of all lung transplants performed during this time period [31,32]. Compared with other lung transplant recipients, these patients were generally younger and more likely to need mechanical ventilation or extracorporeal membrane oxygenation support before transplantation. Despite longer hospital stays, overall survival over the first 12 months was similar to that seen in patients who received lung transplantation for other causes (86 to 87 percent). Lung transplantation provides effective treatment for carefully selected patients with irreversible end-stage lung disease caused by COVID-19. (See "Lung transplantation: General guidelines for recipient selection", section on 'Lung disease due to COVID-19'.)

PLEURAL DISEASE

Guidelines for primary spontaneous pneumothorax (December 2023)

The British Thoracic Society (BTS) has recently issued new guidelines for the management of primary spontaneous pneumothorax (PSP) [33]. Major changes since 2010 include a symptom- rather than size-based approach. For patients with mild symptoms who are stable following adequate analgesia, monitored observation is preferred, while those with significant dyspnea should undergo a drainage procedure (eg, aspiration or catheter/chest tube thoracostomy). Also promoted was ambulatory management in select patients with adequate outpatient support. We agree with these recommendations. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Initial evaluation and management'.)

PULMONARY VASCULAR DISEASE

Direct oral anticoagulants for cancer-related venous thromboembolism (August 2023)

In patients with cancer-related venous thromboembolism (VTE), accumulating evidence suggests that direct oral anticoagulants (DOACs) and subcutaneous low molecular weight heparin (LMWH) have similar efficacy and safety. In a recent randomized trial of over 670 patients with cancer-related VTE, there were no significant differences between rates at six months for recurrent VTE (6.1 [DOACs] versus 8.8 percent [LMWH]) and major bleeding (5.2 [DOACs] versus 5.6 percent [LMWH]) [34]. Despite limitations such as lack of blinding, late randomization, and poor adherence rates with LMWH, these data are in keeping with previous evidence and support our suggestion for DOACs rather than LMWH in patients with cancer-associated VTE. (See "Anticoagulation therapy for venous thromboembolism (lower extremity venous thrombosis and pulmonary embolism) in adult patients with malignancy", section on 'Direct oral anticoagulant mono- or dual therapy'.)

OTHER PULMONARY MEDICINE

Efficacy and side effects of gefapixant treatment for refractory chronic cough (September 2023)

P2X3 inhibitors decrease sensitivity of airway sensory nerve fibers and are under investigation for the treatment of refractory chronic cough. In a recent meta-analysis of over 2000 patients receiving 45 mg twice daily of the P2X3 inhibitor gefapixant or placebo, the gefapixant group demonstrated greater reduction in 24-hour cough frequency (66 versus 50 percent) and improved cough quality of life (4- versus 3-point improvement on a 19-point scale), but nearly one-third of patients developed a taste disturbance [35]. The modest benefit compared with significant risk of adverse side effects continues to be a barrier to regulatory approval and widespread use of this agent. (See "Evaluation and treatment of subacute and chronic cough in adults", section on 'P2X3 antagonists'.)