Pulmonary Health Hub

Assessment of upper airway cross-sectional area using acoustic pharyngometry is no better than the use of clinical variables to diagnose obstructive sleep apnea (OSA), according to a study in the Annals of the American Thoracic Society.

Tetyana Kendzerska, PhD, of the Institute for Clinical Evaluative Sciences, Toronto, and her colleagues found that the median upper airway cross-sectional area at functional residual capacity when sitting was significantly reduced in individuals with OSA, compared with those without the condition (3.3 cm² vs. 3.7 cm²).

©designer491/Thinkstock

Assessment of upper airway cross-sectional area using acoustic pharyngometry is no better than the use of clinical variables to diagnose obstructive sleep apnea (OSA), according to a study in the Annals of the American Thoracic Society.

Tetyana Kendzerska, PhD, of the Institute for Clinical Evaluative Sciences, Toronto, and her colleagues found that the median upper airway cross-sectional area at functional residual capacity when sitting was significantly reduced in individuals with OSA, compared with those without the condition (3.3 cm² vs. 3.7 cm²).

©designer491/Thinkstock

Assessment of upper airway cross-sectional area using acoustic pharyngometry is no better than the use of clinical variables to diagnose obstructive sleep apnea (OSA), according to a study in the Annals of the American Thoracic Society.

Tetyana Kendzerska, PhD, of the Institute for Clinical Evaluative Sciences, Toronto, and her colleagues found that the median upper airway cross-sectional area at functional residual capacity when sitting was significantly reduced in individuals with OSA, compared with those without the condition (3.3 cm² vs. 3.7 cm²).

©designer491/Thinkstock

Patients with chronic obstructive pulmonary disease or interstitial lung disease have longer stays in the intensive care unit, yet are less likely than patients with metastatic cancer to receive comprehensive palliative care.

This finding, reported in Annals of the American Thoracic Society, underscores the need to expand palliative care programs, incorporate elements of palliative care into routine ICU practices, and identify the most effective components of palliative care, said several experts who were not involved in the study.

“Patients with metastatic cancer are more likely to discuss goals of therapy and code status with their inpatient physician and then receive referrals to palliative care,” said Dr. Michael J. Waxman, medical director of the intensive care unit at Research Medical Center in Kansas City. “I can share many anecdotes over the years where a patient is admitted to my ICU with metastatic cancer, or severe COPD [chronic obstructive pulmonary disease] or IPF [idiopathic pulmonary fibrosis],” he added. “The cognition of these patients in some cases may have been normal, but I learned during my review that they did not receive a good discussion of desires regarding resuscitation or intensity of care. It was regularly assumed that there would be no limits on intensity of care.”

Palliative care historically has focused on patients with cancer, even though mortality rates can be high in noncancer lung disease, Dr. Crystal Brown and her associates at the University of Washington in Seattle wrote in their article (Ann Am Thorac Soc. 2016;13:684-9.). Their secondary analysis of the randomized Integrating Palliative and Critical Care trial examined medical chart data for 592 patients with COPD, 158 patients with metastatic cancer, and 79 patients with interstitial lung disease (ILD) who died in the ICUs of 15 Seattle-area hospitals between 2003 and 2008. The investigators performed regression modeling to test associations between diagnosis and eight elements of palliative care – avoidance of cardiopulmonary resuscitation during the hour before death, pain assessment during the 24 hours before death, the presence of a do-not-resuscitate order at the time of death, discussion of prognosis within 72 hours of ICU admission, withdrawal of life support measures before death, involvement of a spiritual care provider, consultation with a palliative care specialist, and the presence of an advance directive. The statistical models controlled for many potential confounders, including age, sex, race and ethnicity, education level, hospital, and whether patients died before or after hospitals implemented a palliative care quality improvement intervention.

Even though median lengths of ICU stay were significantly longer for ILD patients (4.2 days) and COPD patients (2.9 days) than for metastatic cancer patients (2.3 days), patients with COPD were significantly less likely to avoid CPR in the hour before death (adjusted odds ratio, 0.43; 95% confidence interval, 0.20-0.90), while ILD patients were less likely to have a documented pain assessment in the 24 hours before death (OR, 0.43; 95% CI, 0.19-0.97), compared with metastatic cancer patients. Patients with ILD or COPD also were significantly less likely to have a do-not-resuscitate order in place or documentation of a discussion of their prognosis, Dr. Brown and her associates reported.

The findings raise several concerns. “Clearly, this points to both intensivists and palliative care consultants needing to do more to target patients with nonmalignant end-stage chronic lung diseases, such as some patients with COPD and ILD,” said Dr. Robert Hyzy, director of the critical care medicine unit at the University of Michigan Hospital, Ann Arbor. The difference in length of stay also suggests a need to recognize earlier when critically ill patients have not responded to an appropriate time period of treatment (sometimes called a “time-limited trial”), “which signals the transition from cure to comfort,” he added.

Vera De Palo, MD, MBA, FCCP, who is chief of medicine at Signature Healthcare Brockton (Mass.) Hospital, agreed. “While treatment plans for patients with end-stage ILD and COPD do at times include palliative care, the study points out what is often the experience for most patients,” she said. “Our oncology colleagues have better understood the time line of transition between curative care and palliative care than those of us who also manage noncancer chronic diseases. They are more likely to participate in the development of palliative care programs, ensuring that this avenue of care is also available to their patients.”

This is not the only study to reveal gaps in palliative care for advanced nonmalignant lung disease. In a recent analysis of the Nationwide Inpatient Sample, only 2.6% of COPD patients who were home on oxygen and then were hospitalized with an exacerbation received a palliative care referral (CHEST. 2016 Jul 4. doi:10.1016/j.chest.2016.06.023). Such findings belie the most recent palliative care guidelines from the American Thoracic Society for patients with respiratory diseases and critical illnesses, which not only emphasize most of the same palliative care elements as the study by Dr. Brown and her colleagues, but also recommend “early consultation” with palliative care experts to help manage difficult end-of-life discussions (Am J Respir Crit Care Med. 2008;177:912-27).

Oncology palliative care includes both primary and secondary (specialty-level) services, Dr. Arif Kamal of Duke Cancer Institute at Duke University Medical Center, Durham, N.C., and his associates wrote in a viewpoint published in JAMA. Primary services, such as assessing and managing symptoms, discussing priorities and what to expect, and ensuring continuity of care, are usually left to the oncology team. Secondary services are reserved for more complex or time-consuming cases and are provided by palliative care consultants. “This ‘manage first, refer second’ practice reflects the ethos of the oncology profession – the notion that ‘this is our job’ – while also reflecting a practical humility – ‘It’s hard to be everything to everyone all the time,’ ” Dr. Kamal and his associates wrote.

When it comes to palliative care for advanced nonmalignant lung disease, Dr. De Palo said, patients and families may not feel ready to discuss end-of-life issues, and providers may find it difficult to initiate these conversations. “From the moment of diagnosis, the focus of a patient’s care for providers is curative care.” Including a palliative focus can be difficult.

Nonmalignant pulmonary diseases often carry an “uncertain short-term prognosis,” the ATS guidelines stated, and experts echoed that point. “I believe our confidence in determination of prognosis is a key factor in hesitation or delay in engaging palliative care,” said David Bowton, MD, a professor specializing in critical care at Wake Forest School of Medicine, Winston-Salem, N.C. Oncology patients needing ICU care usually have “considerably higher” mortality than the rates of 20%-45% and 15%-30% that are cited for ILD and COPD patients, respectively, he said. Furthermore, there are seemingly accurate scoring systems for predicting short-term mortality in critically ill cancer patients, which is not the case for ILD or COPD, he added.

Such factors point to differences in disease trajectory. “In this study, it is likely that the patients with cancer diagnoses more often received the elements of palliative care in the ICU because it was clearly communicated to the intensive care providers that the opportunities for curative care were exhausted,” Dr. De Palo said. “With care for end-stage chronic respiratory diseases, ICU care can usually optimize breathing enough to get the patient off the vent and stabilized at their previous functional plateau or, more often, at a lower functional plateau, until the next shortness of breath episode.”

Given these challenges and uncertainties, how can clinicians improve palliative care for patients with advanced nonmalignant lung diseases? “Simple. Have a discussion with everyone about what their expectations are,” said Dr. Waxman. “Find out what is important to them and what their goals of therapy are. Help them understand the reality of what actually will be possible to accomplish in a hospitalization, a surgery, or a therapy.”

Dr. De Palo agreed. “For my patients with end-stage respiratory disease, we often discuss whether a sustaining therapy of mechanical ventilation would offer any benefit, and what role cardiopulmonary resuscitation should play in the context of their wishes for care as their disease progresses,” she said. “I believe that providers and health care organizations should offer patients the spectrum of curative and palliative care, and work together to develop a palliative care program where one does not exist,” she stressed. Access to “the full spectrum of care – from curative to palliative – will provide the compassion and quality of life at each stage of their chronic disease.”

Intensivists should also ensure that all ICU patients receive consultations with providers “who can look more at the big picture of their health care, not just at their admission diagnosis and the specific treatment they are receiving,” Dr. Waxman said. And Dr. Bowton offered a final caveat. “While it appears obvious that providing palliative care consultation or integrating elements of palliative care into our routine ICU care will improve the experience for our patients and their families, this has been difficult to demonstrate in well-designed studies,” he said. “Thus, rather than focusing solely on our apparent shortcomings in providing palliative care to our ICU patients with ILD and COPD, we should vigorously support efforts to ascertain what components of palliative care and what ‘dose’ are most effective in alleviating physical and emotional distress.”

The National Institute of Nursing Research funded the study by Dr. Brown and her associates, who reported no relevant financial conflicts of interest.

Patients with chronic obstructive pulmonary disease or interstitial lung disease have longer stays in the intensive care unit, yet are less likely than patients with metastatic cancer to receive comprehensive palliative care.

This finding, reported in Annals of the American Thoracic Society, underscores the need to expand palliative care programs, incorporate elements of palliative care into routine ICU practices, and identify the most effective components of palliative care, said several experts who were not involved in the study.

“Patients with metastatic cancer are more likely to discuss goals of therapy and code status with their inpatient physician and then receive referrals to palliative care,” said Dr. Michael J. Waxman, medical director of the intensive care unit at Research Medical Center in Kansas City. “I can share many anecdotes over the years where a patient is admitted to my ICU with metastatic cancer, or severe COPD [chronic obstructive pulmonary disease] or IPF [idiopathic pulmonary fibrosis],” he added. “The cognition of these patients in some cases may have been normal, but I learned during my review that they did not receive a good discussion of desires regarding resuscitation or intensity of care. It was regularly assumed that there would be no limits on intensity of care.”

Palliative care historically has focused on patients with cancer, even though mortality rates can be high in noncancer lung disease, Dr. Crystal Brown and her associates at the University of Washington in Seattle wrote in their article (Ann Am Thorac Soc. 2016;13:684-9.). Their secondary analysis of the randomized Integrating Palliative and Critical Care trial examined medical chart data for 592 patients with COPD, 158 patients with metastatic cancer, and 79 patients with interstitial lung disease (ILD) who died in the ICUs of 15 Seattle-area hospitals between 2003 and 2008. The investigators performed regression modeling to test associations between diagnosis and eight elements of palliative care – avoidance of cardiopulmonary resuscitation during the hour before death, pain assessment during the 24 hours before death, the presence of a do-not-resuscitate order at the time of death, discussion of prognosis within 72 hours of ICU admission, withdrawal of life support measures before death, involvement of a spiritual care provider, consultation with a palliative care specialist, and the presence of an advance directive. The statistical models controlled for many potential confounders, including age, sex, race and ethnicity, education level, hospital, and whether patients died before or after hospitals implemented a palliative care quality improvement intervention.

Even though median lengths of ICU stay were significantly longer for ILD patients (4.2 days) and COPD patients (2.9 days) than for metastatic cancer patients (2.3 days), patients with COPD were significantly less likely to avoid CPR in the hour before death (adjusted odds ratio, 0.43; 95% confidence interval, 0.20-0.90), while ILD patients were less likely to have a documented pain assessment in the 24 hours before death (OR, 0.43; 95% CI, 0.19-0.97), compared with metastatic cancer patients. Patients with ILD or COPD also were significantly less likely to have a do-not-resuscitate order in place or documentation of a discussion of their prognosis, Dr. Brown and her associates reported.

The findings raise several concerns. “Clearly, this points to both intensivists and palliative care consultants needing to do more to target patients with nonmalignant end-stage chronic lung diseases, such as some patients with COPD and ILD,” said Dr. Robert Hyzy, director of the critical care medicine unit at the University of Michigan Hospital, Ann Arbor. The difference in length of stay also suggests a need to recognize earlier when critically ill patients have not responded to an appropriate time period of treatment (sometimes called a “time-limited trial”), “which signals the transition from cure to comfort,” he added.

Vera De Palo, MD, MBA, FCCP, who is chief of medicine at Signature Healthcare Brockton (Mass.) Hospital, agreed. “While treatment plans for patients with end-stage ILD and COPD do at times include palliative care, the study points out what is often the experience for most patients,” she said. “Our oncology colleagues have better understood the time line of transition between curative care and palliative care than those of us who also manage noncancer chronic diseases. They are more likely to participate in the development of palliative care programs, ensuring that this avenue of care is also available to their patients.”

This is not the only study to reveal gaps in palliative care for advanced nonmalignant lung disease. In a recent analysis of the Nationwide Inpatient Sample, only 2.6% of COPD patients who were home on oxygen and then were hospitalized with an exacerbation received a palliative care referral (CHEST. 2016 Jul 4. doi:10.1016/j.chest.2016.06.023). Such findings belie the most recent palliative care guidelines from the American Thoracic Society for patients with respiratory diseases and critical illnesses, which not only emphasize most of the same palliative care elements as the study by Dr. Brown and her colleagues, but also recommend “early consultation” with palliative care experts to help manage difficult end-of-life discussions (Am J Respir Crit Care Med. 2008;177:912-27).

Oncology palliative care includes both primary and secondary (specialty-level) services, Dr. Arif Kamal of Duke Cancer Institute at Duke University Medical Center, Durham, N.C., and his associates wrote in a viewpoint published in JAMA. Primary services, such as assessing and managing symptoms, discussing priorities and what to expect, and ensuring continuity of care, are usually left to the oncology team. Secondary services are reserved for more complex or time-consuming cases and are provided by palliative care consultants. “This ‘manage first, refer second’ practice reflects the ethos of the oncology profession – the notion that ‘this is our job’ – while also reflecting a practical humility – ‘It’s hard to be everything to everyone all the time,’ ” Dr. Kamal and his associates wrote.

When it comes to palliative care for advanced nonmalignant lung disease, Dr. De Palo said, patients and families may not feel ready to discuss end-of-life issues, and providers may find it difficult to initiate these conversations. “From the moment of diagnosis, the focus of a patient’s care for providers is curative care.” Including a palliative focus can be difficult.

Nonmalignant pulmonary diseases often carry an “uncertain short-term prognosis,” the ATS guidelines stated, and experts echoed that point. “I believe our confidence in determination of prognosis is a key factor in hesitation or delay in engaging palliative care,” said David Bowton, MD, a professor specializing in critical care at Wake Forest School of Medicine, Winston-Salem, N.C. Oncology patients needing ICU care usually have “considerably higher” mortality than the rates of 20%-45% and 15%-30% that are cited for ILD and COPD patients, respectively, he said. Furthermore, there are seemingly accurate scoring systems for predicting short-term mortality in critically ill cancer patients, which is not the case for ILD or COPD, he added.

Such factors point to differences in disease trajectory. “In this study, it is likely that the patients with cancer diagnoses more often received the elements of palliative care in the ICU because it was clearly communicated to the intensive care providers that the opportunities for curative care were exhausted,” Dr. De Palo said. “With care for end-stage chronic respiratory diseases, ICU care can usually optimize breathing enough to get the patient off the vent and stabilized at their previous functional plateau or, more often, at a lower functional plateau, until the next shortness of breath episode.”

Given these challenges and uncertainties, how can clinicians improve palliative care for patients with advanced nonmalignant lung diseases? “Simple. Have a discussion with everyone about what their expectations are,” said Dr. Waxman. “Find out what is important to them and what their goals of therapy are. Help them understand the reality of what actually will be possible to accomplish in a hospitalization, a surgery, or a therapy.”

Dr. De Palo agreed. “For my patients with end-stage respiratory disease, we often discuss whether a sustaining therapy of mechanical ventilation would offer any benefit, and what role cardiopulmonary resuscitation should play in the context of their wishes for care as their disease progresses,” she said. “I believe that providers and health care organizations should offer patients the spectrum of curative and palliative care, and work together to develop a palliative care program where one does not exist,” she stressed. Access to “the full spectrum of care – from curative to palliative – will provide the compassion and quality of life at each stage of their chronic disease.”

Intensivists should also ensure that all ICU patients receive consultations with providers “who can look more at the big picture of their health care, not just at their admission diagnosis and the specific treatment they are receiving,” Dr. Waxman said. And Dr. Bowton offered a final caveat. “While it appears obvious that providing palliative care consultation or integrating elements of palliative care into our routine ICU care will improve the experience for our patients and their families, this has been difficult to demonstrate in well-designed studies,” he said. “Thus, rather than focusing solely on our apparent shortcomings in providing palliative care to our ICU patients with ILD and COPD, we should vigorously support efforts to ascertain what components of palliative care and what ‘dose’ are most effective in alleviating physical and emotional distress.”

The National Institute of Nursing Research funded the study by Dr. Brown and her associates, who reported no relevant financial conflicts of interest.

Patients with chronic obstructive pulmonary disease or interstitial lung disease have longer stays in the intensive care unit, yet are less likely than patients with metastatic cancer to receive comprehensive palliative care.

This finding, reported in Annals of the American Thoracic Society, underscores the need to expand palliative care programs, incorporate elements of palliative care into routine ICU practices, and identify the most effective components of palliative care, said several experts who were not involved in the study.

“Patients with metastatic cancer are more likely to discuss goals of therapy and code status with their inpatient physician and then receive referrals to palliative care,” said Dr. Michael J. Waxman, medical director of the intensive care unit at Research Medical Center in Kansas City. “I can share many anecdotes over the years where a patient is admitted to my ICU with metastatic cancer, or severe COPD [chronic obstructive pulmonary disease] or IPF [idiopathic pulmonary fibrosis],” he added. “The cognition of these patients in some cases may have been normal, but I learned during my review that they did not receive a good discussion of desires regarding resuscitation or intensity of care. It was regularly assumed that there would be no limits on intensity of care.”

Palliative care historically has focused on patients with cancer, even though mortality rates can be high in noncancer lung disease, Dr. Crystal Brown and her associates at the University of Washington in Seattle wrote in their article (Ann Am Thorac Soc. 2016;13:684-9.). Their secondary analysis of the randomized Integrating Palliative and Critical Care trial examined medical chart data for 592 patients with COPD, 158 patients with metastatic cancer, and 79 patients with interstitial lung disease (ILD) who died in the ICUs of 15 Seattle-area hospitals between 2003 and 2008. The investigators performed regression modeling to test associations between diagnosis and eight elements of palliative care – avoidance of cardiopulmonary resuscitation during the hour before death, pain assessment during the 24 hours before death, the presence of a do-not-resuscitate order at the time of death, discussion of prognosis within 72 hours of ICU admission, withdrawal of life support measures before death, involvement of a spiritual care provider, consultation with a palliative care specialist, and the presence of an advance directive. The statistical models controlled for many potential confounders, including age, sex, race and ethnicity, education level, hospital, and whether patients died before or after hospitals implemented a palliative care quality improvement intervention.

Even though median lengths of ICU stay were significantly longer for ILD patients (4.2 days) and COPD patients (2.9 days) than for metastatic cancer patients (2.3 days), patients with COPD were significantly less likely to avoid CPR in the hour before death (adjusted odds ratio, 0.43; 95% confidence interval, 0.20-0.90), while ILD patients were less likely to have a documented pain assessment in the 24 hours before death (OR, 0.43; 95% CI, 0.19-0.97), compared with metastatic cancer patients. Patients with ILD or COPD also were significantly less likely to have a do-not-resuscitate order in place or documentation of a discussion of their prognosis, Dr. Brown and her associates reported.

The findings raise several concerns. “Clearly, this points to both intensivists and palliative care consultants needing to do more to target patients with nonmalignant end-stage chronic lung diseases, such as some patients with COPD and ILD,” said Dr. Robert Hyzy, director of the critical care medicine unit at the University of Michigan Hospital, Ann Arbor. The difference in length of stay also suggests a need to recognize earlier when critically ill patients have not responded to an appropriate time period of treatment (sometimes called a “time-limited trial”), “which signals the transition from cure to comfort,” he added.

Vera De Palo, MD, MBA, FCCP, who is chief of medicine at Signature Healthcare Brockton (Mass.) Hospital, agreed. “While treatment plans for patients with end-stage ILD and COPD do at times include palliative care, the study points out what is often the experience for most patients,” she said. “Our oncology colleagues have better understood the time line of transition between curative care and palliative care than those of us who also manage noncancer chronic diseases. They are more likely to participate in the development of palliative care programs, ensuring that this avenue of care is also available to their patients.”

This is not the only study to reveal gaps in palliative care for advanced nonmalignant lung disease. In a recent analysis of the Nationwide Inpatient Sample, only 2.6% of COPD patients who were home on oxygen and then were hospitalized with an exacerbation received a palliative care referral (CHEST. 2016 Jul 4. doi:10.1016/j.chest.2016.06.023). Such findings belie the most recent palliative care guidelines from the American Thoracic Society for patients with respiratory diseases and critical illnesses, which not only emphasize most of the same palliative care elements as the study by Dr. Brown and her colleagues, but also recommend “early consultation” with palliative care experts to help manage difficult end-of-life discussions (Am J Respir Crit Care Med. 2008;177:912-27).

Oncology palliative care includes both primary and secondary (specialty-level) services, Dr. Arif Kamal of Duke Cancer Institute at Duke University Medical Center, Durham, N.C., and his associates wrote in a viewpoint published in JAMA. Primary services, such as assessing and managing symptoms, discussing priorities and what to expect, and ensuring continuity of care, are usually left to the oncology team. Secondary services are reserved for more complex or time-consuming cases and are provided by palliative care consultants. “This ‘manage first, refer second’ practice reflects the ethos of the oncology profession – the notion that ‘this is our job’ – while also reflecting a practical humility – ‘It’s hard to be everything to everyone all the time,’ ” Dr. Kamal and his associates wrote.

When it comes to palliative care for advanced nonmalignant lung disease, Dr. De Palo said, patients and families may not feel ready to discuss end-of-life issues, and providers may find it difficult to initiate these conversations. “From the moment of diagnosis, the focus of a patient’s care for providers is curative care.” Including a palliative focus can be difficult.

Nonmalignant pulmonary diseases often carry an “uncertain short-term prognosis,” the ATS guidelines stated, and experts echoed that point. “I believe our confidence in determination of prognosis is a key factor in hesitation or delay in engaging palliative care,” said David Bowton, MD, a professor specializing in critical care at Wake Forest School of Medicine, Winston-Salem, N.C. Oncology patients needing ICU care usually have “considerably higher” mortality than the rates of 20%-45% and 15%-30% that are cited for ILD and COPD patients, respectively, he said. Furthermore, there are seemingly accurate scoring systems for predicting short-term mortality in critically ill cancer patients, which is not the case for ILD or COPD, he added.

Such factors point to differences in disease trajectory. “In this study, it is likely that the patients with cancer diagnoses more often received the elements of palliative care in the ICU because it was clearly communicated to the intensive care providers that the opportunities for curative care were exhausted,” Dr. De Palo said. “With care for end-stage chronic respiratory diseases, ICU care can usually optimize breathing enough to get the patient off the vent and stabilized at their previous functional plateau or, more often, at a lower functional plateau, until the next shortness of breath episode.”

Given these challenges and uncertainties, how can clinicians improve palliative care for patients with advanced nonmalignant lung diseases? “Simple. Have a discussion with everyone about what their expectations are,” said Dr. Waxman. “Find out what is important to them and what their goals of therapy are. Help them understand the reality of what actually will be possible to accomplish in a hospitalization, a surgery, or a therapy.”

Dr. De Palo agreed. “For my patients with end-stage respiratory disease, we often discuss whether a sustaining therapy of mechanical ventilation would offer any benefit, and what role cardiopulmonary resuscitation should play in the context of their wishes for care as their disease progresses,” she said. “I believe that providers and health care organizations should offer patients the spectrum of curative and palliative care, and work together to develop a palliative care program where one does not exist,” she stressed. Access to “the full spectrum of care – from curative to palliative – will provide the compassion and quality of life at each stage of their chronic disease.”

Intensivists should also ensure that all ICU patients receive consultations with providers “who can look more at the big picture of their health care, not just at their admission diagnosis and the specific treatment they are receiving,” Dr. Waxman said. And Dr. Bowton offered a final caveat. “While it appears obvious that providing palliative care consultation or integrating elements of palliative care into our routine ICU care will improve the experience for our patients and their families, this has been difficult to demonstrate in well-designed studies,” he said. “Thus, rather than focusing solely on our apparent shortcomings in providing palliative care to our ICU patients with ILD and COPD, we should vigorously support efforts to ascertain what components of palliative care and what ‘dose’ are most effective in alleviating physical and emotional distress.”

The National Institute of Nursing Research funded the study by Dr. Brown and her associates, who reported no relevant financial conflicts of interest.

Tuberculosis patients admitted to intensive care units with acute respiratory failure had significantly better survival at 90 days after treatment with corticosteroids and anti-TB drugs, compared with patients not treated with the steroids, according to a retrospective study.

An adjusted inverse probability of treatment weighted analysis using propensity scores revealed corticosteroid use to be independently associated with a significantly reduced 90-day mortality rate (OR = 0.47; 95% CI, 0.22-0.98). This statistical approach was used because it reduces selection bias and other potential confounding factors in a way that a multivariate analysis cannot, wrote Ji Young Yang, MD, of Busan (South Korea) Paik Hospital and Inje University College of Medicine in Busan.

Zerbor/Thinkstock

Tuberculosis patients admitted to intensive care units with acute respiratory failure had significantly better survival at 90 days after treatment with corticosteroids and anti-TB drugs, compared with patients not treated with the steroids, according to a retrospective study.

An adjusted inverse probability of treatment weighted analysis using propensity scores revealed corticosteroid use to be independently associated with a significantly reduced 90-day mortality rate (OR = 0.47; 95% CI, 0.22-0.98). This statistical approach was used because it reduces selection bias and other potential confounding factors in a way that a multivariate analysis cannot, wrote Ji Young Yang, MD, of Busan (South Korea) Paik Hospital and Inje University College of Medicine in Busan.

Zerbor/Thinkstock

Tuberculosis patients admitted to intensive care units with acute respiratory failure had significantly better survival at 90 days after treatment with corticosteroids and anti-TB drugs, compared with patients not treated with the steroids, according to a retrospective study.

An adjusted inverse probability of treatment weighted analysis using propensity scores revealed corticosteroid use to be independently associated with a significantly reduced 90-day mortality rate (OR = 0.47; 95% CI, 0.22-0.98). This statistical approach was used because it reduces selection bias and other potential confounding factors in a way that a multivariate analysis cannot, wrote Ji Young Yang, MD, of Busan (South Korea) Paik Hospital and Inje University College of Medicine in Busan.

Zerbor/Thinkstock

Azithromycin maintenance therapy may be best reserved for patients with mild to moderate chronic obstructive pulmonary disease (COPD) and few symptoms, according to an analysis from the COLUMBUS randomized controlled trial. The study, reported on in Family Practice News, also revealed that patients with a high serum eosinophil level… http://www.familypracticenews.com/specialty-focus/pulmonary-sleep-medicine/single-article-page/copd-patient-characteristics-predict-response-to-maintenance-drug/f29efaba9a4874ed9b754fb87b77b663.html.

Azithromycin maintenance therapy may be best reserved for patients with mild to moderate chronic obstructive pulmonary disease (COPD) and few symptoms, according to an analysis from the COLUMBUS randomized controlled trial. The study, reported on in Family Practice News, also revealed that patients with a high serum eosinophil level… http://www.familypracticenews.com/specialty-focus/pulmonary-sleep-medicine/single-article-page/copd-patient-characteristics-predict-response-to-maintenance-drug/f29efaba9a4874ed9b754fb87b77b663.html.

Azithromycin maintenance therapy may be best reserved for patients with mild to moderate chronic obstructive pulmonary disease (COPD) and few symptoms, according to an analysis from the COLUMBUS randomized controlled trial. The study, reported on in Family Practice News, also revealed that patients with a high serum eosinophil level… http://www.familypracticenews.com/specialty-focus/pulmonary-sleep-medicine/single-article-page/copd-patient-characteristics-predict-response-to-maintenance-drug/f29efaba9a4874ed9b754fb87b77b663.html.

Long-acting bronchodilators, including tiotropium, do not appear to increase the risk of cardiovascular events in the first year of use, according to a study in patients with chronic obstructive pulmonary disease.

Long-acting bronchodilators are recommended as first-line maintenance therapy for chronic obstructive pulmonary disease (COPD), but they can cause cardiac complications, wrote Samy Suissa, PhD, and his colleagues at the Centre for Clinical Epidemiology, Lady Davis Institute, Montreal.

“Indeed, long-acting anticholinergics are believed to suppress parasympathetic control, while LABAs [long-acting beta2-agonists] stimulate sympathetic tone, possibly leading to tachyarrhythmia and coronary insufficiency,” the authors wrote (Chest. 2016 Aug 20. doi: 10.1016/j.chest.2016.08.001). “Furthermore, these pharmacologic effects would be expected to occur immediately at initiation of therapy.”

However, the observational studies and randomized trials comparing the safety of LABAs and the long-acting anticholinergic tiotropium have shown inconclusive results, possibly because of insufficient numbers, short follow-ups or “treatment-experienced” patients.

Dr. Suissa and his colleagues analyzed data from 26,442 new tiotropium users and 26,442 LABA initiators from a U.K. primary care database. Participants in each arm were matched on high-dimensional propensity scores and prior inhaled corticosteroid use, and followed for 1 year for occurrence of acute myocardial infarction, stroke, heart failure, arrhythmia, and pneumonia.

The researchers saw no significant difference between tiotropium and LABA users in the risk of acute myocardial infarction (hazard ratio, 1.10; 95% CI, 0.88-1.38), stroke (HR, 1.02; 95% CI, 0.78-1.34), arrhythmia (HR, 0.81; 95% CI, 0.60-1.09), or heart failure (HR, 0.90; 95% CI, 0.79-1.02). This was the case even when the current exposure time window was varied from 60-day periods to 30- or 90-day periods.

There was a significantly lower incidence of pneumonia in individuals treated with tiotropium (HR, 0.81; 95% CI, 0.72-0.92), which the authors suggested was likely due to the presence of inhaled corticosteroids in many LABAs.

“In our study, 78% of the LABA users were receiving a combined inhaler that included an inhaled corticosteroid, two-thirds of which were for fluticasone, which has been associated with an up to twofold increase in the risk of pneumonia,” they reported.

The authors acknowledged that the presence of an inhaled corticosteroid in combination with many of the LABAs could attract criticism that the study was therefore not a strict comparison between tiotropium and a LABA. However, they noted that the study aimed to represent the real-world experience of clinical practice.

“In this real-world–setting study of the treatment of COPD, the initiation of maintenance treatment with tiotropium compared with a LABA does not increase cardiovascular risk, but reduces significantly the risk of pneumonia, albeit a likely adverse effect of the inhaled corticosteroid component present in many LABA inhalers,” the authors wrote.

“This differential risk that appears to confer a safety advantage to tiotropium as the initial long-acting bronchodilator in COPD should be considered against the comparative effectiveness of these two treatments at initiation,” they noted.

The Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and Boehringer Ingelheim supported the study. One author disclosed ties with Boehringer Ingelheim, AstraZeneca, Novartis, and Pfizer. No other conflicts of interest were declared.

Long-acting bronchodilators, including tiotropium, do not appear to increase the risk of cardiovascular events in the first year of use, according to a study in patients with chronic obstructive pulmonary disease.

Long-acting bronchodilators are recommended as first-line maintenance therapy for chronic obstructive pulmonary disease (COPD), but they can cause cardiac complications, wrote Samy Suissa, PhD, and his colleagues at the Centre for Clinical Epidemiology, Lady Davis Institute, Montreal.

“Indeed, long-acting anticholinergics are believed to suppress parasympathetic control, while LABAs [long-acting beta2-agonists] stimulate sympathetic tone, possibly leading to tachyarrhythmia and coronary insufficiency,” the authors wrote (Chest. 2016 Aug 20. doi: 10.1016/j.chest.2016.08.001). “Furthermore, these pharmacologic effects would be expected to occur immediately at initiation of therapy.”

However, the observational studies and randomized trials comparing the safety of LABAs and the long-acting anticholinergic tiotropium have shown inconclusive results, possibly because of insufficient numbers, short follow-ups or “treatment-experienced” patients.

Dr. Suissa and his colleagues analyzed data from 26,442 new tiotropium users and 26,442 LABA initiators from a U.K. primary care database. Participants in each arm were matched on high-dimensional propensity scores and prior inhaled corticosteroid use, and followed for 1 year for occurrence of acute myocardial infarction, stroke, heart failure, arrhythmia, and pneumonia.

The researchers saw no significant difference between tiotropium and LABA users in the risk of acute myocardial infarction (hazard ratio, 1.10; 95% CI, 0.88-1.38), stroke (HR, 1.02; 95% CI, 0.78-1.34), arrhythmia (HR, 0.81; 95% CI, 0.60-1.09), or heart failure (HR, 0.90; 95% CI, 0.79-1.02). This was the case even when the current exposure time window was varied from 60-day periods to 30- or 90-day periods.

There was a significantly lower incidence of pneumonia in individuals treated with tiotropium (HR, 0.81; 95% CI, 0.72-0.92), which the authors suggested was likely due to the presence of inhaled corticosteroids in many LABAs.

“In our study, 78% of the LABA users were receiving a combined inhaler that included an inhaled corticosteroid, two-thirds of which were for fluticasone, which has been associated with an up to twofold increase in the risk of pneumonia,” they reported.

The authors acknowledged that the presence of an inhaled corticosteroid in combination with many of the LABAs could attract criticism that the study was therefore not a strict comparison between tiotropium and a LABA. However, they noted that the study aimed to represent the real-world experience of clinical practice.

“In this real-world–setting study of the treatment of COPD, the initiation of maintenance treatment with tiotropium compared with a LABA does not increase cardiovascular risk, but reduces significantly the risk of pneumonia, albeit a likely adverse effect of the inhaled corticosteroid component present in many LABA inhalers,” the authors wrote.

“This differential risk that appears to confer a safety advantage to tiotropium as the initial long-acting bronchodilator in COPD should be considered against the comparative effectiveness of these two treatments at initiation,” they noted.

The Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and Boehringer Ingelheim supported the study. One author disclosed ties with Boehringer Ingelheim, AstraZeneca, Novartis, and Pfizer. No other conflicts of interest were declared.

Long-acting bronchodilators, including tiotropium, do not appear to increase the risk of cardiovascular events in the first year of use, according to a study in patients with chronic obstructive pulmonary disease.

Long-acting bronchodilators are recommended as first-line maintenance therapy for chronic obstructive pulmonary disease (COPD), but they can cause cardiac complications, wrote Samy Suissa, PhD, and his colleagues at the Centre for Clinical Epidemiology, Lady Davis Institute, Montreal.

“Indeed, long-acting anticholinergics are believed to suppress parasympathetic control, while LABAs [long-acting beta2-agonists] stimulate sympathetic tone, possibly leading to tachyarrhythmia and coronary insufficiency,” the authors wrote (Chest. 2016 Aug 20. doi: 10.1016/j.chest.2016.08.001). “Furthermore, these pharmacologic effects would be expected to occur immediately at initiation of therapy.”

However, the observational studies and randomized trials comparing the safety of LABAs and the long-acting anticholinergic tiotropium have shown inconclusive results, possibly because of insufficient numbers, short follow-ups or “treatment-experienced” patients.

Dr. Suissa and his colleagues analyzed data from 26,442 new tiotropium users and 26,442 LABA initiators from a U.K. primary care database. Participants in each arm were matched on high-dimensional propensity scores and prior inhaled corticosteroid use, and followed for 1 year for occurrence of acute myocardial infarction, stroke, heart failure, arrhythmia, and pneumonia.

The researchers saw no significant difference between tiotropium and LABA users in the risk of acute myocardial infarction (hazard ratio, 1.10; 95% CI, 0.88-1.38), stroke (HR, 1.02; 95% CI, 0.78-1.34), arrhythmia (HR, 0.81; 95% CI, 0.60-1.09), or heart failure (HR, 0.90; 95% CI, 0.79-1.02). This was the case even when the current exposure time window was varied from 60-day periods to 30- or 90-day periods.

There was a significantly lower incidence of pneumonia in individuals treated with tiotropium (HR, 0.81; 95% CI, 0.72-0.92), which the authors suggested was likely due to the presence of inhaled corticosteroids in many LABAs.

“In our study, 78% of the LABA users were receiving a combined inhaler that included an inhaled corticosteroid, two-thirds of which were for fluticasone, which has been associated with an up to twofold increase in the risk of pneumonia,” they reported.

The authors acknowledged that the presence of an inhaled corticosteroid in combination with many of the LABAs could attract criticism that the study was therefore not a strict comparison between tiotropium and a LABA. However, they noted that the study aimed to represent the real-world experience of clinical practice.

“In this real-world–setting study of the treatment of COPD, the initiation of maintenance treatment with tiotropium compared with a LABA does not increase cardiovascular risk, but reduces significantly the risk of pneumonia, albeit a likely adverse effect of the inhaled corticosteroid component present in many LABA inhalers,” the authors wrote.

“This differential risk that appears to confer a safety advantage to tiotropium as the initial long-acting bronchodilator in COPD should be considered against the comparative effectiveness of these two treatments at initiation,” they noted.

The Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and Boehringer Ingelheim supported the study. One author disclosed ties with Boehringer Ingelheim, AstraZeneca, Novartis, and Pfizer. No other conflicts of interest were declared.

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

Individuals with type 2 diabetes should receive the seasonal influenza vaccines annually, as doing so significantly mitigates their chances of being hospitalized for – or dying from – cardiovascular complications such as stroke, heart failure, and myocardial infarction.

“Studies assessing influenza vaccine effectiveness in people with diabetes are scarce and have shown inconclusive results,” wrote Eszter P. Vamos, MD, PhD, of Imperial College London and her coauthors in a study published in the Canadian Medical Association Journal. “None of the previous studies adjusted for residual confounding, and most of them reported composite endpoints such as admission to hospital for any cause.”

lisafx/istockphoto.com

[email protected]

Individuals with type 2 diabetes should receive the seasonal influenza vaccines annually, as doing so significantly mitigates their chances of being hospitalized for – or dying from – cardiovascular complications such as stroke, heart failure, and myocardial infarction.

“Studies assessing influenza vaccine effectiveness in people with diabetes are scarce and have shown inconclusive results,” wrote Eszter P. Vamos, MD, PhD, of Imperial College London and her coauthors in a study published in the Canadian Medical Association Journal. “None of the previous studies adjusted for residual confounding, and most of them reported composite endpoints such as admission to hospital for any cause.”

lisafx/istockphoto.com

[email protected]

Individuals with type 2 diabetes should receive the seasonal influenza vaccines annually, as doing so significantly mitigates their chances of being hospitalized for – or dying from – cardiovascular complications such as stroke, heart failure, and myocardial infarction.

“Studies assessing influenza vaccine effectiveness in people with diabetes are scarce and have shown inconclusive results,” wrote Eszter P. Vamos, MD, PhD, of Imperial College London and her coauthors in a study published in the Canadian Medical Association Journal. “None of the previous studies adjusted for residual confounding, and most of them reported composite endpoints such as admission to hospital for any cause.”

lisafx/istockphoto.com

[email protected]

ROME – A newly validated, simplified algorithm for the management of patients with suspected acute pulmonary embolism enables physicians to safely exclude the disorder in roughly half of patients without resorting to CT pulmonary angiography, Tom van der Hulle, MD, reported at the annual congress of the European Society of Cardiology.

“This is the largest study ever performed in the diagnostic management of suspected pulmonary embolism. Based on our results, I think the YEARS algorithm is ready to be used in daily clinical practice,” declared Dr. van der Hulle of the department of thrombosis and hemostasis at Leiden (the Netherlands) University Medical Center.

Bruce Jancin/Frontline Medical News

[email protected]

ROME – A newly validated, simplified algorithm for the management of patients with suspected acute pulmonary embolism enables physicians to safely exclude the disorder in roughly half of patients without resorting to CT pulmonary angiography, Tom van der Hulle, MD, reported at the annual congress of the European Society of Cardiology.

“This is the largest study ever performed in the diagnostic management of suspected pulmonary embolism. Based on our results, I think the YEARS algorithm is ready to be used in daily clinical practice,” declared Dr. van der Hulle of the department of thrombosis and hemostasis at Leiden (the Netherlands) University Medical Center.

Bruce Jancin/Frontline Medical News

[email protected]

ROME – A newly validated, simplified algorithm for the management of patients with suspected acute pulmonary embolism enables physicians to safely exclude the disorder in roughly half of patients without resorting to CT pulmonary angiography, Tom van der Hulle, MD, reported at the annual congress of the European Society of Cardiology.

“This is the largest study ever performed in the diagnostic management of suspected pulmonary embolism. Based on our results, I think the YEARS algorithm is ready to be used in daily clinical practice,” declared Dr. van der Hulle of the department of thrombosis and hemostasis at Leiden (the Netherlands) University Medical Center.

Bruce Jancin/Frontline Medical News

[email protected]

A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology of the infection, according to an updated Clinical Practice Guidelines for managing adults with these disorders.

In addition, every hospital should develop its own antibiogram to align clinicians’ choice of treatments with the local distribution of likely pathogens and their antimicrobial susceptibilities. Both of these recommendations, as well as others that are also new to the updated guidelines, are intended to minimize patient exposure to unnecessary antibiotics and reduce antibiotic resistance, said Andre C. Kalil, MD, and Mark L. Metersky, MD, cochairs of the guidelines panel of 18 experts in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, pharmacology, and guideline methodology.

A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology of the infection, according to an updated Clinical Practice Guidelines for managing adults with these disorders.

In addition, every hospital should develop its own antibiogram to align clinicians’ choice of treatments with the local distribution of likely pathogens and their antimicrobial susceptibilities. Both of these recommendations, as well as others that are also new to the updated guidelines, are intended to minimize patient exposure to unnecessary antibiotics and reduce antibiotic resistance, said Andre C. Kalil, MD, and Mark L. Metersky, MD, cochairs of the guidelines panel of 18 experts in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, pharmacology, and guideline methodology.

A 1-week course of antibiotics is sufficient for most hospital-acquired and ventilator-associated pneumonia, regardless of the microbial etiology of the infection, according to an updated Clinical Practice Guidelines for managing adults with these disorders.

In addition, every hospital should develop its own antibiogram to align clinicians’ choice of treatments with the local distribution of likely pathogens and their antimicrobial susceptibilities. Both of these recommendations, as well as others that are also new to the updated guidelines, are intended to minimize patient exposure to unnecessary antibiotics and reduce antibiotic resistance, said Andre C. Kalil, MD, and Mark L. Metersky, MD, cochairs of the guidelines panel of 18 experts in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, pharmacology, and guideline methodology.

Children experiencing an anaphylactic event at school may frequently encounter staff members who are not permitted to administer potentially life-saving epinephrine, according to recent survey study.

Of 6,574 surveys submitted by schools, there were 1,140 anaphylactic events reported in 736 schools.

A total of 6,088 schools provided data on staff training for recognizing anaphylaxis recognition: 30% provided training for all staff, 28% for most staff, 37% for the school nurse and select staff, and 2% for just the school nurse. Of 6,053 schools providing data on who is permitted to administer epinephrine to treat anaphylaxis, 22% permitted all staff, 16% permitted most staff, 55% permitted the school nurse and select trained staff, and 3% permitted the school nurse only, reported Martha V. White, MD, Institute for Asthma and Allergy, Wheaton, Md., and her associates (Pediatr Allerg Immunol Pulmonol. 2016. doi: 10.1089/ped.2016.0675).

©piotr_malczyk/Thinkstock

These findings “suggest that there may be an opportunity to improve school staff training programs. Only 58.6% of schools surveyed trained all or most staff members to recognize the signs and symptoms of anaphylaxis. Similarly,only 37% of responding schools permitted all or most staff to administer epinephrine. ... School policies should be designed to allow for prompt administration of epinephrine during the early stages of an anaphylactic attack,” Dr. White and her associates concluded.

Among students having events for whom grade information was available, 33% occurred in elementary school students, 19% occurred in middle school students, and 45% occurred in high school students. In 1,049 anaphylactic events, the allergy history was known: 68% of events occurred in students with known allergies and 25% were in students with no known allergies.

When triggers were identified (in 78% of cases), food was the most common trigger, occurring in 60%, followed by insect bites or stings in 8%; environmental, medication, or health related triggers in 9%; and latex in 1%.

Data on use of epinephrine autoinjectors (EAIs) was available in 1,059 cases. EAIs were administered in 76% of anaphylactic events, were not administered in 23% cases, and it was unknown whether EAIs were given in the remaining 1%.

This study was supported by Mylan Specialty. Dr. White has served as a consultant for Mylan and Merck, and has received grants, fees, or support from numerous pharmaceutical companies. Christopher Herrem, PhD, is a paid employee of Mylan and may hold stock within the company. The remaining authors reported that they had no conflicts of interest.

[email protected]

Children experiencing an anaphylactic event at school may frequently encounter staff members who are not permitted to administer potentially life-saving epinephrine, according to recent survey study.

Of 6,574 surveys submitted by schools, there were 1,140 anaphylactic events reported in 736 schools.

A total of 6,088 schools provided data on staff training for recognizing anaphylaxis recognition: 30% provided training for all staff, 28% for most staff, 37% for the school nurse and select staff, and 2% for just the school nurse. Of 6,053 schools providing data on who is permitted to administer epinephrine to treat anaphylaxis, 22% permitted all staff, 16% permitted most staff, 55% permitted the school nurse and select trained staff, and 3% permitted the school nurse only, reported Martha V. White, MD, Institute for Asthma and Allergy, Wheaton, Md., and her associates (Pediatr Allerg Immunol Pulmonol. 2016. doi: 10.1089/ped.2016.0675).

©piotr_malczyk/Thinkstock

These findings “suggest that there may be an opportunity to improve school staff training programs. Only 58.6% of schools surveyed trained all or most staff members to recognize the signs and symptoms of anaphylaxis. Similarly,only 37% of responding schools permitted all or most staff to administer epinephrine. ... School policies should be designed to allow for prompt administration of epinephrine during the early stages of an anaphylactic attack,” Dr. White and her associates concluded.

Among students having events for whom grade information was available, 33% occurred in elementary school students, 19% occurred in middle school students, and 45% occurred in high school students. In 1,049 anaphylactic events, the allergy history was known: 68% of events occurred in students with known allergies and 25% were in students with no known allergies.

When triggers were identified (in 78% of cases), food was the most common trigger, occurring in 60%, followed by insect bites or stings in 8%; environmental, medication, or health related triggers in 9%; and latex in 1%.

Data on use of epinephrine autoinjectors (EAIs) was available in 1,059 cases. EAIs were administered in 76% of anaphylactic events, were not administered in 23% cases, and it was unknown whether EAIs were given in the remaining 1%.

This study was supported by Mylan Specialty. Dr. White has served as a consultant for Mylan and Merck, and has received grants, fees, or support from numerous pharmaceutical companies. Christopher Herrem, PhD, is a paid employee of Mylan and may hold stock within the company. The remaining authors reported that they had no conflicts of interest.

[email protected]

Children experiencing an anaphylactic event at school may frequently encounter staff members who are not permitted to administer potentially life-saving epinephrine, according to recent survey study.

Of 6,574 surveys submitted by schools, there were 1,140 anaphylactic events reported in 736 schools.

A total of 6,088 schools provided data on staff training for recognizing anaphylaxis recognition: 30% provided training for all staff, 28% for most staff, 37% for the school nurse and select staff, and 2% for just the school nurse. Of 6,053 schools providing data on who is permitted to administer epinephrine to treat anaphylaxis, 22% permitted all staff, 16% permitted most staff, 55% permitted the school nurse and select trained staff, and 3% permitted the school nurse only, reported Martha V. White, MD, Institute for Asthma and Allergy, Wheaton, Md., and her associates (Pediatr Allerg Immunol Pulmonol. 2016. doi: 10.1089/ped.2016.0675).

©piotr_malczyk/Thinkstock

These findings “suggest that there may be an opportunity to improve school staff training programs. Only 58.6% of schools surveyed trained all or most staff members to recognize the signs and symptoms of anaphylaxis. Similarly,only 37% of responding schools permitted all or most staff to administer epinephrine. ... School policies should be designed to allow for prompt administration of epinephrine during the early stages of an anaphylactic attack,” Dr. White and her associates concluded.

Among students having events for whom grade information was available, 33% occurred in elementary school students, 19% occurred in middle school students, and 45% occurred in high school students. In 1,049 anaphylactic events, the allergy history was known: 68% of events occurred in students with known allergies and 25% were in students with no known allergies.

When triggers were identified (in 78% of cases), food was the most common trigger, occurring in 60%, followed by insect bites or stings in 8%; environmental, medication, or health related triggers in 9%; and latex in 1%.

Data on use of epinephrine autoinjectors (EAIs) was available in 1,059 cases. EAIs were administered in 76% of anaphylactic events, were not administered in 23% cases, and it was unknown whether EAIs were given in the remaining 1%.

This study was supported by Mylan Specialty. Dr. White has served as a consultant for Mylan and Merck, and has received grants, fees, or support from numerous pharmaceutical companies. Christopher Herrem, PhD, is a paid employee of Mylan and may hold stock within the company. The remaining authors reported that they had no conflicts of interest.

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