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

Revised diagnostic criteria for allergic bronchopulmonary aspergillosis (May 2024)

Allergic bronchopulmonary aspergillosis (ABPA), a complex hypersensitivity reaction to airway colonization with Aspergillus fumigatus, can be hard to distinguish from difficult-to-treat asthma or cystic fibrosis. The International Society for Human and Animal Mycology (ISHAM) working group for ABPA recently published revised diagnostic criteria (table 1) that make some key changes to improve the sensitivity and specificity of the diagnosis [1]:

●Total serum immunoglobulin (Ig) E levels of ≥500 international units/mL are sufficient for the diagnosis, rather than the previously higher threshold of 1000 international units/mL.

●Elevated Aspergillus IgG levels by enzyme immunoassay or lateral flow assay are more sensitive for detecting sensitivity to Aspergillus antigens and should be used preferentially over Aspergillus serum precipitins.

We agree with the revised ISHAM diagnostic approach. (See "Clinical manifestations and diagnosis of allergic bronchopulmonary aspergillosis", section on 'Diagnostic criteria'.)

Pro-inflammatory airway phenotype associated with asthma susceptibility locus 17q21 (April 2024)

Multiple genome-wide association studies have identified the 17q21 locus as strongly associated with asthma susceptibility, but the mechanism of this association has been uncertain. In recent transcriptome-wide analyses of respiratory epithelium from three separate asthma cohorts, a strong genotype-phenotype link has been identified between the expression of Gasdermin B (GSDMB) and a pro-inflammatory cell-lytic type 1 immune transcriptome signature [2,3]. Higher GSDMB expression was associated with enhanced airway inflammation after respiratory viral infection both in cultured epithelial cells and in mice expressing human GSDMB in their airways. Mechanistically, GSDMB was shown to bind (virally produced) double-stranded RNA and subsequently activate pro-inflammatory signaling cascades. (See "Genetics of asthma", section on 'Expression quantitative trait (eQTL) mapping'.)

Association between gut bacteriophage abundance and asthma risk (April 2024)

The abundance and diversity of gut flora and their interaction with the immune system have been associated with a predisposition to childhood asthma. A recent study examined the role of the fecal virome, predominantly comprising temperate bacteriophages, in a Danish birth cohort of 647 one-year-old children who were subsequently longitudinally assessed for asthma [4]. The relative abundance of certain viral families was associated with subsequent asthma development, and the viromes in turn were associated with early life exposures (eg, siblings and season of birth). The association between virome and asthma was not mediated by the impact on gut bacteria, suggesting independent effects on the developing immune system. (See "Risk factors for asthma", section on 'Influence of microbiome'.)

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) [5]. 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'.)

COPD

Palliative telehealth for patients with COPD, HF, and ILD (February 2024)

Although adults with advanced chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) have poor quality of life, data on the efficacy of palliative care measures are limited. In a trial of 306 patients who were at high risk of death due to advanced COPD, HF, or ILD, those assigned to receive six nurse phone calls for symptom management and six social worker phone calls for psychosocial care had higher quality of life (based on standardized questionnaires) at six months compared with those who received usual care [6]. Telephonic palliative care interventions may be an important tool for patients with advanced cardiopulmonary disease. (See "Palliative care for adults with nonmalignant chronic lung disease", section on 'Use and benefits of palliative care'.)

CRITICAL CARE

SCCM guidelines on the management of hyperglycemia in critically ill patients (May 2024)

The Society of Critical Care Medicine (SCCM) has issued new guidelines for the management of hyperglycemia in critically ill adults and children [7,8]. Compared with the 2012 guidelines, emphasis was placed on the use of management protocols (with decision support tools) that avoid hypoglycemia and liberalization of blood glucose targets (eg, 7.8 to 11.1 mmol/L [140 to 200 mg/dL]) with frequent monitoring (≤1 hourly). We agree with the new SCCM recommendations. While we use a lower upper limit for blood glucose (180 mg/dL [10 mmol/L]) than that recommended by the SCCM, it is unlikely to be clinically meaningful. (See "Glycemic control in critically ill adult and pediatric patients", section on 'Our approach'.)

Machine learning model for oxygenation targets in mechanically ventilated patients (May 2024)

In mechanically ventilated patients, ideal oxygenation targets are unknown and vary depending on the population being treated. One recent study examined the ability of machine learning to individualize oxygen targets based upon data from previously published trials [9]. The use of an individual peripheral oxygen saturation (SpO₂) target based upon that predicted by the machine learning model would have reduced the absolute overall mortality by 6.4 percent compared with the randomized SpO₂ target. While these results are encouraging, a prospective trial is needed before a model such as this can be applied in routine practice. (See "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit", section on 'Fraction of inspired oxygen'.)

Incidence of transfusion-related acute lung injury (April 2024)

Transfusion-related acute lung injury (TRALI) is a potentially fatal complication of transfusion characterized by rapid-onset noncardiogenic pulmonary edema. The incidence is challenging to determine due to differing case definitions and reliance on passive reporting (requiring the clinician to notify the transfusion medicine service). A new meta-analysis that included approximately 176 million transfused blood components provides estimates from active surveillance studies [10]. For red blood cells, TRALI occurred with 0.17 of 10,000 units; for platelets, 0.31 of 10,000 units; and for plasma, 3.19 of 10,000 units (the incidence for plasma was much lower when two outlier studies were removed). TRALI remains rare and has been significantly reduced by mitigation measures such as excluding plasma from multiparous female donors; nevertheless, these numbers suggest it is more common than estimated by passive surveillance. (See "Transfusion-related acute lung injury (TRALI)", section on 'Epidemiology'.)

Gradual or one-step weaning for ventilatory withdrawal (April 2024)

Few studies have compared the two main approaches used to withdraw ventilatory support at the end of life: gradual weaning (gradual reduction in oxygen and pressure support with intermittent medication as needed) and one-step weaning (immediate extubation with peri-extubation medication support). A recent randomized study compared one-step weaning with a nurse-led gradual weaning algorithm in 168 patients [11]. Less respiratory distress was experienced by the 48 patients in the gradual weaning group, despite receiving less opioids and benzodiazepines. This study supports our practice of gradual weaning for most patients undergoing withdrawal of life support. However, one-step weaning may be suitable for select patients (eg, severe neurological injuries and minimal ventilatory support needs). (See "Withholding and withdrawing ventilatory support in adults in the intensive care unit", section on 'Withdrawal of ventilatory support'.)

Ideal oxygen targets in COVID-19 (April 2024)

In patients with acute respiratory failure due to coronavirus-2019 (COVID-19), ideal oxygenation targets are unclear. A recent study of spontaneously breathing or mechanically ventilated hospitalized adults with acute respiratory failure due to COVID-19 reported that targeting an arterial oxygen tension (PaO₂) ≥60 mmHg was associated with more days alive without ventilatory support compared with a target ≥90 mmHg [12]. However, there was no overall mortality benefit. Although the study was limited by lack of blinding and early cessation for slow enrollment, it supports our recommendation of targeting a peripheral oxygen saturation between 90 and 96 percent or PaO₂ ≥60 mmHg, when feasible. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Oxygenation targets'.)

ATS definition of a "time-limited trial" for potentially inappropriate therapies (March 2024)

When responding to requests for potentially inappropriate therapies, the American Thoracic Society (ATS) has recently promoted and defined the components of a "time-limited trial." The ATS describe it as a collaborative plan among clinicians and a patient and/or their surrogates to use life-sustaining therapy for a defined duration, after which the patient’s response to therapy informs the decision to continue care directed toward recovery, transition to comfort care, or extend the trial's duration [13]. They describe 16 core elements in four phases (consider, plan, support, and reassess) to be mostly implemented by intensivists. We agree with this approach. (See "Responding to requests for potentially inappropriate or futile therapies in adult intensive care unit", section on 'Placing limits on treatment'.)

Updated guideline on postoperative delirium in adults (February 2024)

The European Society of Anaesthesiology and Intensive Care Medicine has published an updated guideline on postoperative delirium (POD) [14]. Recommendations include preoperatively screening older adults for risk factors for POD and multicomponent nonpharmacological interventions for all patients with risk factors. In addition, review of recent evidence showed that perioperative use of dexmedetomidine was associated with a lower incidence of POD, particularly when administered postoperatively in the intensive care unit. We agree with the recommendations and often use dexmedetomidine in the perioperative period to reduce the incidence of POD in high-risk patients. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with lower risk'.)

Diagnostic errors in hospitalized patients (February 2024)

Diagnostic errors are important causes of preventable morbidity and mortality in hospitalized patients. In a retrospective cohort study conducted in 29 hospitals of 2428 adults who were transferred to an intensive care unit (ICU), 23.0 percent were judged to have experienced a diagnostic error [15]. In approximately 80 percent of these patients, errors were thought to have contributed to harm or death. Diagnostic errors in hospitalized patients can have serious consequences and are targets for safety improvements. (See "Diagnostic errors", section on 'Adult medicine'.)

Guidelines on management of acute respiratory distress syndrome (February 2024)

The American Thoracic Society recently updated their guidelines on the management of patients ventilated for acute respiratory distress syndrome (ARDS) [16]. Compared with previous recommendations, emphasis was placed on the value of systemic corticosteroid administration, early use of extracorporeal membrane oxygenation, and use of neuromuscular blockade, particularly in patients with severe ARDS. Recommendations also focus on the avoidance of recruitment maneuvers, especially prolonged maneuvers. We agree with these recommendations. (See "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Introduction'.)

New proposed definition for acute respiratory distress syndrome (February 2024)

A new "global definition" of acute respiratory distress syndrome has been proposed (table 2) [17]. This new definition expands upon the older Berlin definition to include ultrasound for the evaluation of pulmonary infiltrates, the additional use of peripheral oxygen saturation/fraction of inspired oxygen (SpO₂/FiO₂) to assess oxygenation, and the use of separate criteria for patients on high-flow oxygen or noninvasive ventilation. Accommodations were also made for diagnostic criteria for patients in resource-limited settings. We agree with the proposed changes and their future implementation. (See "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults", section on 'Clinical diagnosis'.)

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 [18]. 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) [19]. 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 [20]. 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 [21]. 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 [22]. 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'.)

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 [23]. 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 [24]. 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 [25]. 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 [26]. 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'.)

INTERSTITIAL LUNG DISEASE

Palliative telehealth for patients with COPD, HF, and ILD (February 2024)

Although adults with advanced chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) have poor quality of life, data on the efficacy of palliative care measures are limited. In a trial of 306 patients who were at high risk of death due to advanced COPD, HF, or ILD, those assigned to receive six nurse phone calls for symptom management and six social worker phone calls for psychosocial care had higher quality of life (based on standardized questionnaires) at six months compared with those who received usual care [6]. Telephonic palliative care interventions may be an important tool for patients with advanced cardiopulmonary disease. (See "Palliative care for adults with nonmalignant chronic lung disease", section on 'Use and benefits of palliative care'.)

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 3) [27]. 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

Tacrolimus versus cyclosporine for chronic lung transplant rejection (January 2024)

Effective strategies for the prevention of chronic lung allograft dysfunction (CLAD), a term for chronic rejection, have been limited. In a recent trial of 249 patients, individuals randomly assigned to daily tacrolimus after lung transplantation demonstrated decreased incidence of CLAD over 36 months compared with those assigned to twice daily cyclosporine (39 versus 13 percent) [28]. Patients in the tacrolimus group had fewer acute rejection episodes and a better side effect profile. Based upon these data and findings from previous trials, we recommend tacrolimus over cyclosporine as part of the initial maintenance immunosuppression regimen for lung transplant recipients. (See "Maintenance immunosuppression following lung transplantation", section on 'Tacrolimus versus cyclosporine'.)

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 [29]. 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'.)

PLEURAL DISEASE

Machine learning to narrow pleural effusion differential (May 2024)

Determining the etiology of a pleural effusion can be challenging. Machine learning has recently been used to help clinicians narrow the differential. One study of over 2200 patients who underwent thoracentesis found good performance when a machine learning model used 18 of 49 clinical, blood, and pleural fluid parameters to identify five common types of pleural effusion (transudative, malignant, parapneumonic, tuberculous, and other; area under the receiver operating characteristic curve 0.930 [validation set] and 0.916 [extra-validation set]) [30]. Further study in different populations and refinement are needed before a model such as this can be clinically useful. (See "Diagnostic evaluation of the hemodynamically stable adult with a pleural effusion", section on 'Making a preliminary diagnosis'.)

PULMONARY VASCULAR DISEASE

Unchanged emergency department discharge rates for pulmonary embolism (April 2024)

Outpatient anticoagulation to avoid hospitalization is safe for a select group of patients with acute pulmonary embolism (PE). However, a recent study of over 1.6 million emergency department (ED) visits for PE in the United States reported that ED discharge rates for PE were unchanged between 2012 and 2020 (38 versus 33 percent) [31]. Among low-risk patients, only one third were discharged from the ED. However, this study was unable to determine whether other factors may have prevented discharge such as drug accessibility, concurrent deep vein thrombosis, and right ventricular burden. Although not conclusive, this study suggests that increased physician awareness is needed to encourage safe ED discharge of low-risk patients with PE. (See "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults".)

Predicting venous thromboembolism risk in non-major orthopedic surgery (April 2024)

For patients with non-major extremity orthopedic injury or surgery, deciding who should undergo venous thromboembolism (VTE) prophylaxis is challenging due to the wide range of risk. The Thrombosis Risk Prediction for Patients with cast immobilization or TRiP(cast) score, which predicts VTE risk, was recently derived and validated in nearly 5000 patients with prolonged lower limb casting, mostly for ankle sprain [32]. Among those assessed as low VTE risk (score <7) and in whom anticoagulation was withheld, the rate of symptomatic VTE was 0.7 percent compared with 2.7 percent among those with a score ≥7 despite anticoagulation. The negative predictive value for this threshold was 99 percent. Use of the score reduced the prescription of anticoagulants by 26 percent compared with baseline prescription levels. While promising, further validation is needed. (See "Prevention of venous thromboembolism (VTE) in adults with non-major extremity orthopedic injury with or without surgical repair", section on 'Venous thromboembolism risk'.)

SLEEP MEDICINE

Uncertain role of adaptive servo-ventilation in patients with heart failure with reduced ejection fraction (February 2024)

In a prior trial (SERVE-HF), positive airway pressure therapy with adaptive servo-ventilation (ASV) increased mortality in patients with central sleep apnea (CSA) due to heart failure with reduced ejection fraction (HFrEF). In the subsequent ADVENT-HF trial, among 731 patients with sleep-disordered breathing (obstructive- or central-predominant) and HFrEF, ASV resulted in similar all-cause mortality relative to standard care for both the overall study population and the subgroup with CSA [33]. However, the number of patients with CSA was small and confidence intervals were wide for all outcomes. Thus, we continue to avoid use of ASV in patients with CSA due to HFrEF. (See "Central sleep apnea: Treatment", section on 'Patients with ejection fraction ≤40 percent'.)

Management of post-adenotonsillectomy obstructive sleep apnea in children (February 2024)

A new clinical practice guideline on management of persistent obstructive sleep apnea after adenotonsillectomy in children is available from the American Thoracic Society [34]. The guideline endorses a multidisciplinary evaluation, which may include drug-induced sleep endoscopy and cine magnetic resonance imaging to identify sites of obstruction and guide further interventions. It also provides conditional recommendations based on low certainty of evidence for interventions ranging from weight loss and continuous positive airway pressure to orthodontic treatments and adjuvant surgical procedures. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Positive airway pressure'.)

OTHER PULMONARY MEDICINE

Impact of transition to race-neutral spirometry interpretation (May 2024)

Use of race-neutral standards for interpretation of lung function is recommended by many experts to avoid racial bias in medical care. In a study of 360,000 participants in lung-health surveys in the United States and United Kingdom that compared differences for spirometry interpretations between race-neutral and race-specific equations, both equations demonstrated similar predictive performance for lung symptoms, health care utilization, and death [35]. However, use of race-neutral spirometry interpretation led to reclassification of 5 percent of the adult population, including a decrease in diagnosis of nonobstructive ventilatory impairments in approximately 3 percent of White and Hispanic individuals and a corresponding increase in diagnosis in about 8 percent of Black individuals. These data have large ramifications for thresholds for occupational qualifications, eligibility for lung transplantation, and disability compensation. Despite these tradeoffs for individual patients, we support the transition to race-neutral spirometry interpretation. (See "Selecting reference values for pulmonary function tests", section on 'Effect of race/ethnicity'.)

Risk of autoimmune inflammatory rheumatic disease following COVID-19 (May 2024)

The risk of developing autoimmune inflammatory rheumatic diseases (AIRDs) following COVID-19 has recently been studied (eg, rheumatoid, psoriatic, and spondyloarthritides and connective tissue disorders) [36]. A Korean and Japanese cohort analysis of 22 million patients reported an increased risk of AIRDs in patients who had COVID-19 compared with uninfected patients (hazard ratio [HR], 1.25 [Korea], 1.79 [Japan]) and with patients who had influenza (HR, 1.30 [Korea], 1.14 [Japan]). The risk appeared to diminish over time and was likely reduced by vaccination. Clinicians should be aware of the risk of AIRD following COVID-19 and investigate appropriately when suspected. (See "COVID-19: Clinical presentation and diagnosis of adults with persistent symptoms following acute illness ("long COVID")", section on 'Physical symptoms'.)

Benralizumab in the treatment of eosinophilic granulomatosis with polyangiits (March 2024)

Eosinophilic granulomatosis with polyangiitis (EGPA) is a chronic inflammatory disorder associated with asthma, chronic rhinosinusitis with or without polyposis, and peripheral blood eosinophilia that may be amenable to treatment with biologic agents targeting eosinophilic inflammation via the interleukin-5 (IL-5) pathway. In a randomized trial of 140 patients with relapsing or refractory EGPA, 59 percent of patients receiving benralizumab, an antibody targeting the IL-5 receptors, and 56 percent of patients receiving mepolizumab, an antibody targeting IL-5, achieved remission of disease [37]. Serious adverse events were uncommon and similar in each group. Based upon these findings, we suggest benralizumab or mepolizumab as glucocorticoid-sparing therapeutic options for individuals with non-severe relapsing or refractory EGPA. (See "Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): Treatment and prognosis", section on 'Anti-IL-5 or anti-IL-5R agents'.)