Current American Thoracic Society Research Articles

Race and Ethnicity in Pulmonary Function Test Interpretation: An Official American Thoracic Society Statement.

Current American Thoracic Society (ATS) standards promote the use of race and ethnicity-specific reference equations for pulmonary function test (PFT) interpretation. There is rising concern that the use of race and ethnicity in PFT interpretation contributes to a false view of fixed differences between races and may mask the effects of differential exposures. This use of race and ethnicity may contribute to health disparities by norming differences in pulmonary function. In the United States and globally, race serves as a social construct that is based on appearance and reflects social values, structures, and practices. Classification of people into racial and ethnic groups differs geographically and temporally. These considerations challenge the notion that racial and ethnic categories have biological meaning and question the use of race in PFT interpretation. The ATS convened a diverse group of clinicians and investigators for a workshop in 2021 to evaluate the use of race and ethnicity in PFT interpretation. Review of evidence published since then that challenges current practice and continued discussion concluded with a recommendation to replace race and ethnicity-specific equations with race-neutral average reference equations, which must be accompanied with a broader re-evaluation of how PFTs are used to make clinical, employment, and insurance decisions. There was also a call to engage key stakeholders not represented in this workshop and a statement of caution regarding the uncertain effects and potential harms of this change. Other recommendations include continued research and education to understand the impact of the change, to improve the evidence for the use of PFTs in general, and to identify modifiable risk factors for reduced pulmonary function.

Microvascular damage evaluation based on nailfold videocapillarosopy in sarcoidosis.

Microvascular damage is thought to play a role in the pathogenesis of sarcoidosis. We aimed to evaluate the nailfold capillaroscopy (NVC) pattern to detect microvascular changes in patients with sarcoidosis and the relationship of capillaroscopic parameters with clinical variables and disease-related measurements. Forty-two patients with sarcoidosis and 42 age- and sex-matched patients with systemic sclerosis (SSc) and healthy individuals were included in this cross-sectional case-control study. Patients aged 18-80years who met the current American Thoracic Society criteria for sarcoidosis were included. NVC was performed by a digital microscope under a magnification of × 200. Capillary density, number of dilated, giant and neoangiogenic capillaries, capillary loop diameter, capillary shape, micro-hemorrhages, and number of avascular areas, were evaluated by an assessor who was blind to the groups allocation. Among the capillaroscopic parameters, neoangiogenesis and dilated capillaries, which can be seen in the pattern of scleroderma, were detected in patients with sarcoidosis but not significantly different from the control group (p = 0.055; p = 0.433, respectively). The rate of tortuosity and crossing capillaries of 50% and above was significantly higher in the sarcoidosis group than in SSc and healthy controls (p < 0.05). In patients with sarcoidosis, the only statistically significant finding was; forced expiratory volume (FEV1) in one second was lower in patients with a crossed capillary rate > 50% than in patients with a crossed capillary rate of less than 50% (FEV1; 87.21 ± 19.3, 102.5 ± 14.8, p = 0.04; respectively). Patients with a diagnosis of sarcoidosis have different capillaroscopic patterns. The presence of these nonspecific abnormal patterns may reflect microvascular damage in the pathophysiology of sarcoidosis. Key Points • Microvascular damage may play a role in the pathogenesis of sarcoidosis. • There may be some nonspecific abnormal findings in capillaroscopy findings in sarcoidosis. • Capillaroscopy may be valuable in reflecting sarcoidosis lung injury.

Urinary Antigen Testing for Respiratory Infections: Current Perspectives on Utility and Limitations.

Pneumonia is a leading cause of hospitalization and death due to infection worldwide. Streptococcus pneumoniae and Legionella pneumophila remain among the most commonly identified bacterial pathogens. Unfortunately, more than half of all pneumonia cases today lack an etiologic diagnosis due to limitations in traditional microbiological methods like blood and sputum cultures, which are affected by poor sample collection, prior antibiotic administration, and delayed processing. Urinary antigen tests (UATs) for S. pneumoniae and L. pneumophila have emerged as powerful tools for improving the diagnosis of bacterial respiratory infections, enabling physicians to administer early directed therapy and improve antimicrobial stewardship. UATs are simple, rapid, and non-invasive diagnostic tests with high specificity (>90%) and moderate sensitivity (<80%). The potential impact of urinary antigen testing is especially significant for respiratory infections caused by Legionella. While all recommended community-acquired pneumonia (CAP) therapies are adequate for treating pneumococcal pneumonia, only certain antibiotics are effective against Legionella. Delayed therapy for Legionella is associated with worse clinical outcomes, which underscores the importance of rapid diagnostic methods like UATs. Despite their potential impact, current American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines argue against the routine use of urinary antigen testing for S. pneumoniae and L. pneumophila, except in patients with severe CAP and those with epidemiological risk factors for Legionella. Further research is necessary to evaluate the impact of early targeted treatment due to positive UAT results, as well as optimal strategies for UAT utilization. The purpose of this review is to summarize the UATs available for bacterial respiratory infections, describe current guidelines on their usage, and assess their impact on clinical outcomes and targeted therapy.

New testing guidelines for community-acquired pneumonia.

The purpose of this article is to review diagnostic testing recommendations outlined in the current American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) community-acquired pneumonia (CAP) guideline and the 2021 ATS guideline for noninfluenza respiratory viruses. Diagnostic testing in CAP with gram stain, lower respiratory and blood cultures, Streptococcal and Legionella urinary antigens are not routinely recommended unless identified as severe CAP or with risk factors for Methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa infection. Influenza virus testing remains a strong recommendation during periods of community viral spread.An additional 2021 ATS clinical practice guideline reviewed the use of molecular testing for noninfluenza viral pathogens in adults with suspected CAP and recommended testing in those hospitalized with severe CAP and/or various immunocompromising conditions. Diagnostic testing remains an important component of confirming and treating CAP. The CAP guideline includes recommendations surrounding diagnostic testing with lower respiratory gram stain and culture, blood cultures, Legionella and Pneumococcal urinary antigen, influenza viral testing and serum procalcitonin.There is a strong recommendation to obtain influenza virus testing during periods of community spread. However, the use of other diagnostics such as gram stain, lower respiratory and blood culture, and urinary antigen testing are dependent on severity of illness and whether a patient has been identified as having strong risk factors for MRSA or P. aeruginosa infection. The 2021 ATS clinical practice document did not routinely recommend testing noninfluenza respiratory viruses unless identified as having severe CAP and/or various immunocompromising conditions.

PM.85 Diagnosing PE in Maternity Patients. An Audit of Radiological Investigations and Clinical Interpretation

VTE is an important cause of maternal mortality but signs and symptoms are unreliable. Ionising radiation has hazards for the fetus and mother. Current American Thoracic Society guidelines recommend VQ...

53-Year-Old Man With a Swollen Finger

53-Year-Old Man With a Swollen Finger

Repeatability of spirometry in 18,000 adult patients.

The objective of this study was to determine the limits for repeatability of FEV1, FVC, and PEF during spirometry test sessions in adult outpatients. A retrospective chart review of 18,000 consecutive patients, aged 20 to 90 years, referred to a large outpatient pulmonary function laboratory for testing was performed. Measurements included the differences between the highest and second-highest FVC (dFVC), FEV1 (dFEV1), and PEF (dPEF), from prebronchodilator spirometry, and anthropometric factors. Ninety percent of the patients were able to reproduce FEV1 within 120 ml (6.1%), FVC within 150 ml (5.3%), and PEF within 0.80 L (12%). Patient characteristics, such as sex, age, height, smoking status, and FEV1 (% predicted), had very little effect on repeatability, explaining only 2 to 4% of the variation in repeatability (expressed in milliliters). We conclude that the ability of patients to meet or exceed spirometry repeatability goals does not depend on patient characteristics when testing is performed by experienced personnel. The current American Thoracic Society repeatability goal of 200 ml for FEV1 and FVC may be too lenient.

Measurement Variability in Single-Breath Diffusing Capacity of the Lung

The single-breath diffusing capacity of the lung (DLCO) is a commonly performed pulmonary function test. The current American Thoracic Society (ATS) recommendations for reproducibility of DLCO measurements suggest that two measurements for the DLCO agree within 10% or 3 mL/min/mm Hg of the average value. The European Respiratory Society (ERS) recommends that two measurements should agree within 10%. The objectives of the present study were to examine whether the current reproducibility criteria were met in a general pulmonary function laboratory and to determine whether alternative criteria might be appropriate. Cross-sectional study. University-based pulmonary function laboratory. Patients referred for spirometry, helium lung volumes, and DLCO measurement. None. In a sample of 6,193 patients referred for clinical testing, 98.3% had two DLCO values that fulfilled the current ATS criteria for reproducibility. The coefficient of variation (CV) and the percentage difference between two repeat measurements were inversely associated with the baseline DLCO and the FEV(1). As the baseline DLCO (percentage of predicted) or FEV(1) (percentage of predicted) decreased, there was an increase in the CV and the percentage difference. In contrast, the absolute difference between repeat measurements was relatively stable irrespective of the baseline DLCO or FEV(1) values. Other patient factors, such as gender and race, were not associated with measurement variability. Using an absolute difference of 2 to 2.5 mL/min/mm Hg between two DLCO measurements as alternative criteria for reproducibility, 91.5% and 95.8% of the patient sample fulfilled these criteria, respectively. Reproducibility of the DLCO measurement is generally much better than current standards allow. Future standards should consider an absolute difference rather than a percentage difference criterion for DLCO reproducibility.

The Role Of a Typical Pathogens in Nursing Home Pneumonia

The empiric coverage of atypical pathogens (Legionella, Chlamydia pneumoniae, and Mycoplasma pneumoniae) in nursing home pneumonia is a controversial area. Relatively recent reviews of nursing home pneumonia do not include recommendations for such empiric coverage. This includes recommendations from the Long-Term Care Committee of the Society for Healthcare Epidemiology in America (SHEA) published in 2000. 1 Nicolle LE Bentley DW Garibaldi R SHEA Long-Term-Care Committee et al. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol. 2000; 21: 537-545 Crossref PubMed Scopus (211) Google Scholar , 2 Muder RR Pneumonia in residents of long-term care facilities: Epidemiology, etiology, management and prevention. Am J Med. 1998; 105: 319-330 Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar , 3 Medina-Walpole AM Katz PR Nursing home-acquired pneumonia. J Am Geriatr Soc. 1999; 47: 1005-1015 Crossref PubMed Scopus (76) Google Scholar Data on the role of atypical pathogens in nursing homes is limited. Coverage of “atypicals” is not proven to be necessary and could contribute to the emergence of resistant pathogens. The Infectious Disease Society of America (IDSA) however, recommends that without a quality gram stain and/or laboratory evidence of a “strongly suspected” specific pathogen that empiric coverage of community-acquired pneumonia include atypical pathogens. 4 Bartlett JG Dowell SF Mandell LA et al. Practice Guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis. 2000; 31: 347-382 Crossref PubMed Scopus (1433) Google Scholar Current American Thoracic Society (ATS) guidelines for community-acquired pneumonia state that, “A sputum gram stain cannot be used to focus initial empiric antibiotic therapy (contrary to ISDA), but could be used to broaden initial therapy.” Committee members were concerned about co-infections with bacteria and atypical pathogens. Gram stain and culture was recommended if a resistant organism not covered by empiric treatment was suspected. Resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA) are endemic in many nursing homes. Recommended empiric coverage includes atypical pathogens. 5 Official statement of the American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia: Diagnosis, assessment of severity, antimicrobial therapy and prevention. Am J Resp Crit Care Med. 2001; 163: 1730 Crossref PubMed Scopus (2022) Google Scholar The Canadian guidelines recommend obtaining a quality sputum specimen in hospitalized patients stating, “Once an etiologic agent has been appropriately identified, the in vitro susceptibility of the pathogen has been confirmed, and infection with a co-pathogen has been excluded, initial empirical therapy should be modified so that treatment is directed at the specific pathogen(s) involved.” 6 Mandell LA Marrie TJ Grossman RF the Canadian Community-Acquired Pneumonia Working Group et al. Canadian guidelines for the initial management of community-acquired pneumonia: An evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clin Infect Dis. 2000; 31: 383-421 Crossref PubMed Scopus (623) Google Scholar However, exclusion of a co-pathogen (ie, an atypical) is seldom accomplished. Recommended empiric coverage includes the atypical pathogens. 6 Mandell LA Marrie TJ Grossman RF the Canadian Community-Acquired Pneumonia Working Group et al. Canadian guidelines for the initial management of community-acquired pneumonia: An evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. Clin Infect Dis. 2000; 31: 383-421 Crossref PubMed Scopus (623) Google Scholar

Mycobacterium avium-intracellulare Pulmonary Infection in HIV-Negative Patients Without Preexisting Lung Disease: Diagnostic and Management Limitations

To review the experience of an outpatient pulmonary clinic with Mycobacterium avium-intracellulare (MAI) pulmonary disease in the HIV-negative population without preexisting lung disease. Retrospective clinical series. University medical center. The clinic charts of all patients who fulfilled the current American Thoracic Society criteria for MAI pulmonary infection and who had no preexisting lung disease or immunosuppression were reviewed. Of 31 patients identified, 94% were female, 90% were white, and the median age at diagnosis was 63 years. The median time interval from symptom onset to diagnosis was 10 months. Bronchiectasis or small nodules without predilection for any lobe was found in 93%. Bronchoscopy or open lung biopsy for diagnosis was required in 45% because of nondiagnostic sputum cultures. At > or = 12 months, 50% failed therapy, 86% continued to be symptomatic, and 58% did not tolerate their initial multidrug regimen. These results emphasize the observed chronic nature of MAI pulmonary disease in this population, both before diagnosis and despite therapy. The sensitivity of sputum culture in this population is low, so an aggressive diagnostic approach, including bronchoscopy, should be considered if sputum cultures are negative. Current treatments are suboptimal because of poor drug tolerance and significant failure rates. Last, the preponderance of disease in older white women argues for a genetic or acquired immune deficiency to explain disease susceptibility.

Severe community-acquired pneumonia in the elderly: epidemiology and prognosis. Study Group for Severe Community-Acquired Pneumonia.

Ninety-five patients with severe community-acquired pneumonia (SCAP) who were > or = 65 years of age were studied prospectively. A definite pathogen was identified in 37 cases (38.9%) and was most commonly Streptococcus pneumoniae, Haemophilus influenzae, or another gram-negative bacillus. The overall death rate was 40%. Eighty-three patients required mechanical ventilation and 40 needed vasoactive drugs. Multivariate analysis showed that the risk of death was higher in cases involving rapid radiological spread (relative risk [RR] = 6.99; 95% confidence interval (95% CI) = 1.54-31.70), shock (RR = 6.70; 95% CI = 2.13-21.02), previous steroid treatment or immunosuppression (RR = 5.50; 95% CI = 0.77-39.10), acute renal failure (RR = 3.88; 95% CI = 1.30-11.59), or an APACHE II score of > 22 on admission (RR = 2.25; 95% CI = 0.73-6.95). We conclude that SCAP in elderly patients is associated with high mortality, but it is inappropriate to withhold intensive care on account of age. The presence of complications and the severity of illness at initial presentation were the major variables affecting outcome. Except for immunosuppression, comorbidities did not seem to influence outcome. Finally, our data reinforce the current American Thoracic Society guidelines concerning therapy for patients with SCAP.