European Respiratory Society Guidelines Research Articles

Prevalence and risk factors of high echocardiographic probability of pulmonary hypertension in myeloproliferative neoplasms patients.

Pulmonary hypertension (PH) is emerging as a complication of myeloproliferative neoplasms (MPNs). This was a prospective study conducted at Chiang Mai University Hospital. The primary objective was to determine the prevalence of high echocardiographic probability of PH in MPNs patients. The secondary objectives were to determine risk factors of PH and the correlation between risk factors and peak tricuspid regurgitation velocity (TRVmax). All MPNs patients aged over 18years, including polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF), were enrolled. All eligible patients underwent echocardiography for evaluation of the probability of PH in line with the 2015 European Society of Cardiology (ESC) and the European Respiratory Society (ERS) Guidelines. Sixty-six patients with a median age of 59years were enrolled. There were 35 PV, 25 ET, and 6 PMF patients included. The prevalence of high echocardiographic probability of PH was 4.55% (2 ET and 1 PMF). Risk factors associated with high echocardiographic probability of PHT were not analyzed. There were three risk factors associated with increased TRVmax, specifically lower hemoglobin, older age, and the presence of JAK2V617F mutation. The prevalence of high echocardiographic probability of PH in MPNs patients was 4.55%.

Mixed Venous Oxygen Saturation Is a Better Prognosticator Than Cardiac Index in Pulmonary Arterial Hypertension

European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines include thermodilution cardiac index (TDCI) and mixed venous oxygen saturation (SvO2) as two of the three hemodynamic determinations used in risk assessment of patients with pulmonary arterial hypertension (PAH). SvO2 may be a better measurement than TDCI to assess prognosis in patients with either idiopathic or heritable PAH. What is the concordance between TDCI and SvO2 ESC/ERS risk group allocation and their prognostic value in patients with PAH? In this retrospective study, we assessed the correlation between SvO2 and TDCI in patients with idiopathic and heritable PAH. We determined concordance in the ESC/ERS risk group allocation and association with survival, both at baseline and follow-up. A total of 158 patients (mean age, 58 ± 17 years; 72%women) with idiopathic (91%) and heritable (9%) PAH were included. There was moderate association between TDCI and SvO2 (r= 0.50; 95%CI, 0.37-0.62). Weighted kappa revealed a fair agreement between TDCI and SvO2 (κ= 0.30; 95%CI, 0.18-0.42), with concordance in risk group allocation in 49%of patients. During a median follow-up of 45months (interquartile range, 23-105), 62 patients (39%) died. Using Kaplan-Meier analysis, survival was impacted by the SvO2 (log rank= 0.002) but not by the TDCI risk group allocation (log-rank= 0.51). Using the Cox proportional hazard model, adjusted for age and sex, SvO2 (but not TDCI) was associated with mortality (hazard ratio per 1%change, 0.94; 95%CI, 0.91-0.97; P< .001). When using the cutoffs proposed by the ESC/ERS guidelines, we noted poor concordance in risk score allocation between TDCI and SvO2. In patients with idiopathic or heritable PAH, SvO2 measurements are superior to TDCI in predicting long-term mortality.

Clinical Approach to Non-cystic fibrosis Bronchiectasis Based on Recent Clinical Guideline

Non-cystic fibrosis bronchiectasis is a common respiratory disease that is frequently encountered in daily practice. However, it has been regarded as an orphan lung disease and had been often neglected by the physicians. Fortunately, recent studies have unveiled many important clinical aspects of bronchiectasis. Accordingly, international evidence-based practice guideline such as the European Respiratory Society guideline and the British Thoracic Society (BTS) guideline have been published recently. However, as there is no domestic evidence-based guideline, we introduce clinical approaches to diagnose bronchiectasis and discuss important aspects of bronchiectasis based on most recently published the BTS guideline. In addition, we cover the treatment of bronchiectasis based on the BTS guideline. We hope newly assembled a Korean bronchiectasis study group, name the Korean Multicenter Bronchiectasis Audit and Research Collaboration (KMBARC) would contribute to publishing Korean bronchiectasis guideline, soon.

Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline.

Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in patients without a clear indication. This document reports European Respiratory Society recommendations regarding ICS withdrawal in patients with COPD.Comprehensive evidence synthesis was performed to summarise all available evidence relevant to the question: should ICS be withdrawn in patients with COPD? The evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and the results were summarised in evidence profiles. The evidence synthesis was discussed and recommendations formulated by a committee with expertise in COPD and guideline methodology.After considering the balance of desirable and undesirable consequences, quality of evidence, and feasibility and acceptability of interventions, the guideline panel made: 1) conditional recommendation for the withdrawal of ICS in patients with COPD without a history of frequent exacerbations, 2) strong recommendation not to withdraw ICS in patients with blood eosinophil counts ≥300 eosinophils·µL-1 and 3) strong recommendation to treat with one or two long-acting bronchodilators if ICS are withdrawn.A conditional recommendation indicates that there was uncertainty about the balance of desirable and undesirable consequences of the intervention, and that well-informed patients may make different choices regarding whether to have or not have the specific intervention.

Modern approaches to the management of patients with bronchoectasia

The bronchoectasia (BE) is a chronic heterogeneous lung disease characterized by recurrent infection, inflammation, persistent cough and sputum discharge. The early BE diagnosis is one of the main recommendations of the European Respiratory Society (ERS) guidelines, which requires medical history collection and multispiral computed tomography (MSCT) of thoracic organs. Despite the complex examination, in most patients BE is classified as idiopathic. The minimum set of tests, including serum immunoglobulins, allergic bronchopulmonary aspergillosis tests and hematology is proposed in ERS guideline for detection of BE causes. Other examinations are recommended to perform based on disease history and radiological characteristics, indicating the importance of BE clinical phenotype identification by different healthcare specialists, for which special examinations are required. Initial examination algorithms and management of patients with BE, in particular, MSCT-semiotics and clinical features, which could help to identify specific reasons are presented in the article.

Evaluating Risk Factors in Patients with Severe Asthma: A Cross-Sectional Study

Severe asthma (SA) is a major health problem which can be controlled with highdoses of inhaled or systemic glucocorticoids. In this cross-sectional study, 96 patients with SA attending a pulmonary clinic in Rasht, Iran were included. They were identified based on the American Thoracic Society and European Respiratory Society guidelines. Data were collected from spirometry results, asthma control test (ACT), and depression anxiety stressscales. Among these 96 patients with SA, 69 were women (71.9%) and 27 (28.1%) were men. Mean age of patients was 54.5 ± 12.4 years. There was a significant relationship between gender and ACT score (P= 0.03). However, there was no significant relationship between depression severity and ACT score (P> 0.00). This study showed a significant relationshipbetween anxiety and ACT score (P= 0.008). In addition, a significant relationship was seen between frequency of asthma exacerbation, stress, forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity (P< 0.05). Thus there are many risk factors in our patients with SA including psychological disorders such as anxiety and depression which cause asthma exacerbations. The study also showed that increased sputum neutrophils are associated with asthma exacerbations.

Risk assessment in pulmonary arterial hypertension: Insights from the GRIPHON study

Approaches to risk assessment in pulmonary arterial hypertension (PAH) include the noninvasive French risk assessment approach (number of low-risk criteria based on the European Society of Cardiology and European Respiratory Society guidelines) and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL) 2.0 risk calculator. The prognostic and predictive value of these methods for morbidity/mortality was evaluated in the predominantly prevalent population of GRIPHON, the largest randomized controlled trial in PAH. GRIPHON randomized 1,156 patients with PAH to selexipag or placebo. Post-hoc analyses were performed on the primary composite end-point of morbidity/mortality by the number of low-risk criteria (World Health Organization functional class I-II; 6-minute walk distance >440 m; N-terminal pro-brain natriuretic peptide <300 ng/liter) and REVEAL 2.0 risk category. Hazard ratios and 95% confidence intervals were calculated using Cox proportional hazard models. Both the number of low-risk criteria and the REVEAL 2.0 risk category were prognostic for morbidity/mortality at baseline and any time-point during the study. Patients with 3 low-risk criteria at baseline had a 94% reduced risk of morbidity/mortality compared to patients with 0 low-risk criteria and were all categorized as low-risk by REVEAL 2.0. The treatment effect of selexipag on morbidity/mortality was consistent irrespective of the number of low-risk criteria or the REVEAL 2.0 risk category at any time-point during the study. Selexipag-treated patients were more likely to increase their number of low-risk criteria from baseline to week 26 than placebo-treated patients (odds ratio 1.69, p = 0.0002); similar results were observed for REVEAL 2.0 risk score. These results support the association between risk profile and long-term outcome and suggest that selexipag treatment may improve risk profile.

Retrospective Database Analysis of Treatment Patterns Among Patients with Pulmonary Arterial Hypertension.

IntroductionRelease of the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines put increased emphasis on using combination therapy, either as upfront or sequential therapy among patients with pulmonary arterial hypertension (PAH). However, with these recommendations and the therapy advances made in the last several years, little is known on the real-world treatment patterns among patients with PAH, particularly before and after publication of the 2015 ESC/ERS guidelines.MethodsThis was a retrospective study of adult commercial and Medicare Advantage with Part D (MAPD) enrollees with at least one claim for a PAH-related medication from January 01, 2012 to March 31, 2017, at least one medical claim with a pulmonary hypertension diagnosis, and continuous health plan enrollment at least 6 months prior to and at least 12 months following the date of the first pharmacy claim for PAH-related therapy (index date). Patients were divided into cohorts based on prescription of monotherapy or combination therapy and index date category (2012–2013, January 2014–July 2015, and August 2015–March 2017).ResultsOut of 1878 patients, 90.8% initiated with monotherapy and 9.2% initiated with combination therapy. The percentage of patients with index combination therapy increased from 5.7% in 2012–2013 to 13.0% in August 2015–March 2017. Patients with index combination therapy had better persistence (11.6 months versus 10.3 months) and adherence (0.95 versus 0.85). Overall, the discontinuation rate was 40% and was higher in monotherapy versus combination therapy patients (42.8% versus 12.2%). Approximately 30.2% of patients had a second regimen, of which 50% were combination regimens. The time to combination therapy initiation decreased from 10.5 months in 2012–2013 to 3.4 months in August 2015–March 2017.ConclusionsThe majority of patients initiated monotherapy treatment for PAH, most often a phosphodiesterase 5 inhibitor (PDE5i). Patients with upfront combination therapy increased following publication of the 2015 ESC/ERS guidelines, indicating that physicians responded to the guideline’s option of prescribing upfront combination therapy.

Airway and Esophageal Eosinophils in Children With Severe Uncontrolled Asthma

To examine the frequency of and correlation between esophageal and airway eosinophils in children with severe uncontrolled asthma (SUA).Researchers in the study included children with SUA according to international European Respiratory Society and American Thoracic Society guidelines who were referred for refractory respiratory symptoms to the Aerodigestive Center at Hassenfeld’s Children’s Hospital at New York University Langone Health from April 2015 to June 2017. All children had either poor symptom control despite use of high-dose inhaled corticosteroids with long-acting β-agonists medication or worsening of asthma control during attempts to taper those medications.This was a retrospective review of prospectively collected data on 24 children aged 2 to 16 years old (n = 24, 21 boys). All children had skin prick tests to food and/or aeroallergens. All subjects underwent triple endoscopy (sleep laryngoscopy, bronchoscopy with bronchoalveolar lavage [BAL] and endobronchial biopsy [EBB], and esophagogastroduodenoscopy with esophageal biopsy). Elevated BAL eosinophils were defined as >1% and neutrophils as >3.5%. Eosinophils in EBB were considered elevated if ≥1 per high-power field. Presence of 1 or more eosinophils per high-power field on esophagogastroduodenoscopy with esophageal biopsy was considered elevated. Airway eosinophils were defined as elevated BAL and/or elevated EBB eosinophils. Aerodigestive eosinophils were defined as the presence of elevated airway eosinophils and elevated esophageal eosinophils together.There was no difference at enrollment in gastrointestinal symptoms, previous diagnosis of reflux and allergy, and use of inhaled corticosteroids, long-acting β-agonists, and proton pump inhibitors between children with and without elevated esophageal eosinophils, airway eosinophils, and aerodigestive eosinophils. All patients with eosinophilic esophagitis (>15 eosinophils per high-power field) (n = 3) and 5 of 8 patients with reflux esophagitis (>5 eosinophils per high-power field) had elevated aerodigestive eosinophils, but only eosinophilic esophagitis correlated with gastrointestinal symptoms and food allergies. Elevated airway eosinophils were present in 71% of patients, and elevated esophageal eosinophils were present in 46% of patients. The number of eosinophils correlated between the BAL and EBB, which then correlated with esophageal eosinophils. Laryngomalacia, tracheal stenosis, or tracheomalacia were present in 4 patients. Over half had bacterial bronchitis on the basis of positive BAL culture results. All patients had BAL neutrophilia, which did not correlate with EBB or BAL eosinophils or the BAL culture.Children with SUA frequently have elevated airway and esophageal eosinophils, and there is a correlation between the airway and esophageal eosinophils.Reflux esophagitis has been strongly associated with increased airway hyperreactivity, and this study suggests that reflux esophagitis should be suspected even in asymptomatic severe asthmatics. Limitations include the small sample size and the low cutoff in defining elevated esophageal eosinophils, which could reduce the significance of this measure. Also, this study does not provide any specific implications for pathogenesis or how this would modify treatment of SUA. Collecting a larger sample size and potentially studying other eosinophil or inflammatory biomarkers would help to better characterize the role, if any, of aerodigestive eosinophils in SUA.

Echocardiographic Probability of Pulmonary Hypertension in Myeloproliferative Neoplasms Patients in Chiang-Mai University

Introduction: Pulmonary hypertension (PHT) is an emerging complication of myeloproliferative neoplasms (MPNs). The aim of this study was to determine the prevalence and risk factors of high echocardiographic probability of PHT according to 2015 The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) Guideline. The echocardiographic probability of PHT was assessed by peak tricuspid regurgitation velocity (TRV max) and echocardiographic signs suggesting PHT. Methods: This was a cross-sectional study conducted in Chiang-Mai University Hospital during January 2019 and July 2019. Patients aged 18 years or older with Philadelphia chromosome negative MPNs including polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) were eligible after obtaining informed consents. Patients who were known to have a preexisting PHT from any causes were excluded. All enrolled patients had an echocardiography performed by a cardiologist for evaluating the probability of PHT according to 2015 ESC/ERS guideline. Primary outcome of the study was the prevalence of MPNs patients who had high echocardiographic probability of PHT. Secondary outcomes were risk factor of high echocardiographic probability of PHT. Results: A total of 23 patients with a median age of 64 years (range 45-87) were enrolled. There were 14 PV (60.9%), 8 ET (34.8%), 1 MF (4.3%) patients included. There were13 male patients (56.5%). The most common driver mutation was JAK2V617F mutation (19 patients, 82.6%). Common co-morbid diseases were hypertension (26.1%), combined hypertension and dyslipidemia (13%), and combined hypertension and diabetes (8.7%), respectively. The majority of patients (73.9%) did not have history of thrombosis. However, 57.2% and 62.5% of PV and ET patients were classified as high risk of thrombosis. Twenty two patients (95.6%) received both antiplatelets and cytoreductive agents with 9 patients (39.1%) also underwent phlebotomy. Hydroxyurea was only cytoreductive drug prescribed in this study. The median time from diagnosis to echocardiogram evaluation was 66 months (range 9-6,242 months). Median (range) hemoglobin was 11.7 g/dl (9.7-16.8), median white blood cells count was 7.5x109/L (4.0-24.1), and median platelet count was 374x109/L (171-931). No patient with high echocardiographic probability of PHT was detected. One patient (4.3%) patient had intermediate probability and 22 (95.7%) patients had low probability. The median value of TRV max was 2.42 m/s (range 1.93-2.90). Conclusions: No MPNs patients (0/23) with high echocardiographic probability of PHT detected in this study. Further study with higher number of patients is warrant for determine the prevalence of PHT in Thai MPN patients. Table Disclosures No relevant conflicts of interest to declare.

COPD, smoking behaviour, and the importance of teachers as role-models for adolescents

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European Respiratory Society guideline on long-term management of children with bronchopulmonary dysplasia.

This document provides recommendations for monitoring and treatment of children in whom bronchopulmonary dysplasia (BPD) has been established and who have been discharged from the hospital, or who were >36 weeks of postmenstrual age. The guideline was based on predefined Population, Intervention, Comparison and Outcomes (PICO) questions relevant for clinical care, a systematic review of the literature and assessment of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. After considering the balance of desirable (benefits) and undesirable (burden, adverse effects) consequences of the intervention, the certainty of the evidence, and values, the task force made conditional recommendations for monitoring and treatment of BPD based on very low to low quality of evidence. We suggest monitoring with lung imaging using ionising radiation in a subgroup only, for example severe BPD or recurrent hospitalisations, and monitoring with lung function in all children. We suggest to give individual advice to parents regarding daycare attendance. With regards to treatment, we suggest the use of bronchodilators in a subgroup only, for example asthma-like symptoms, or reversibility in lung function; no treatment with inhaled or systemic corticosteroids; natural weaning of diuretics by the relative decrease in dose with increasing weight gain if diuretics are started in the neonatal period; and treatment with supplemental oxygen with a saturation target range of 90-95%. A multidisciplinary approach for children with established severe BPD after the neonatal period into adulthood is preferable. These recommendations should be considered until new and urgently needed evidence becomes available.

European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD.

While the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients. The European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients. The task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode. Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.

Chronic thromboembolic pulmonary hypertension suspicion after pulmonary embolism in cancer patients

IntroductionChronic thromboembolic pulmonary hypertension (CTEPH) is a severe condition which should be screened in patient with persistent dyspnea after pulmonary embolism (PE). After PE, CTEPH incidence was estimated between 0.1 and 9.1% in overall patients. Although cancer is associated with an increased risk of CTEPH, CTEPH incidence is still unknown in cancer patients with PE. We aimed to estimate the frequency CTEPH-likely patients after PE, in cancer patients. MaterialsWe individualized cancer patients of a monocentric prospective registry including consecutive patients with symptomatic PE. The primary outcome was the frequency of “CTEPH-likely” patients defined by the European Respiratory Society (ERS) guidelines (an accelerated tricuspid regurgitation more than 2.8m/s and at least 1–2 segmental or larger-sized defects, after more than 3 months of therapeutic anticoagulation). ResultsWe included 129 cancer patients with PE. Colorectal cancer (19%), breast cancer (17%) and prostate cancer (15%) were the most frequent cancers. PE occurred after surgery or medical immobilization in 17% of patients, while 26% of patients had history of venous thromboembolism. During the follow-up, 2 patients (1.5%) had a clinical suspicion of CTEPH and only 1 patient with ovarian cancer (0.75% 95%CI [0.0%–2.2%]) was classified as “CTEPH-likely”, 6 months after PE. ConclusionThe frequency of screening for CTEPH seems negligible in PE patients with cancer. Concomitant cancer may affect the clinical suspicion of CTEPH.

Bronchiectasis in India: results from the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) and Respiratory Research Network of India Registry

Bronchiectasis is a common but neglected chronic lung disease. Most epidemiological data are limited to cohorts from Europe and the USA, with few data from low-income and middle-income countries. We therefore aimed to describe the characteristics, severity of disease, microbiology, and treatment of patients with bronchiectasis in India. The Indian bronchiectasis registry is a multicentre, prospective, observational cohort study. Adult patients (≥18 years) with CT-confirmed bronchiectasis were enrolled from 31 centres across India. Patients with bronchiectasis due to cystic fibrosis or traction bronchiectasis associated with another respiratory disorder were excluded. Data were collected at baseline (recruitment) with follow-up visits taking place once per year. Comprehensive clinical data were collected through the European Multicentre Bronchiectasis Audit and Research Collaboration registry platform. Underlying aetiology of bronchiectasis, as well as treatment and risk factors for bronchiectasis were analysed in the Indian bronchiectasis registry. Comparisons of demographics were made with published European and US registries, and quality of care was benchmarked against the 2017 European Respiratory Society guidelines. From June 1, 2015, to Sept 1, 2017, 2195 patients were enrolled. Marked differences were observed between India, Europe, and the USA. Patients in India were younger (median age 56 years [IQR 41-66] vs the European and US registries; p<0·0001]) and more likely to be men (1249 [56·9%] of 2195). Previous tuberculosis (780 [35·5%] of 2195) was the most frequent underlying cause of bronchiectasis and Pseudomonas aeruginosa was the most common organism in sputum culture (301 [13·7%]) in India. Risk factors for exacerbations included being of the male sex (adjusted incidence rate ratio 1·17, 95% CI 1·03-1·32; p=0·015), P aeruginosa infection (1·29, 1·10-1·50; p=0·001), a history of pulmonary tuberculosis (1·20, 1·07-1·34; p=0·002), modified Medical Research Council Dyspnoea score (1·32, 1·25-1·39; p<0·0001), daily sputum production (1·16, 1·03-1·30; p=0·013), and radiological severity of disease (1·03, 1·01-1·04; p<0·0001). Low adherence to guideline-recommended care was observed; only 388 patients were tested for allergic bronchopulmonary aspergillosis and 82 patients had been tested for immunoglobulins. Patients with bronchiectasis in India have more severe disease and have distinct characteristics from those reported in other countries. This study provides a benchmark to improve quality of care for patients with bronchiectasis in India. EU/European Federation of Pharmaceutical Industries and Associations Innovative Medicines Initiative inhaled Antibiotics in Bronchiectasis and Cystic Fibrosis Consortium, European Respiratory Society, and the British Lung Foundation.

Spirometric reference values in heathy Chinese adults in Taiwan: The secular changes and comparison with other Asian populations

Although the lung function test has played an important role in respiratory care for a long time, valid spirometry reference values in the Chinese population in Taiwan remain to be elucidated. 2963 healthy Taiwanese subjects aged 21 to 88 years (1765 males, 59.6%) from February 2015 to February 2017 were enrolled. The subjects attempted to meet the 2005 American Thoracic Society (ATS) and the European Respiratory Society (ERS) guidelines when performing forced expiratory spirograms. We would like to establish the spirometry predictive equations for forced expiratory volume (FEV1), forced vital capacity (FVC), FEV1/FVC, and lower limit of normal (LLN) in Taiwan and compare with other Asian populations. We established the spirometry predictive equations using a linear model for the entire population, using age and height as independent variables, which best predicted all spirometry parameters for sea level and highland subjects. We found that the values of FEV1 and FVC for the Taiwanese subjects in our study were systematically lower than those reported in South Korea, Japan, and China, but higher than the values in Yang's 1993 and Pan's 1997 Taiwan study. This study addressed the up-to-date spirometry reference equations and values for a healthy adult Chinese population in Taiwan.

Microbiological changes observed over 48 weeks of treatment with inhaled liposomal ciprofloxacin in individuals with non-cystic fibrosis bronchiectasis and chronic Pseudomonas aeruginosa lung infection

ObjectivesNon-cystic fibrosis bronchiectasis (NCFBE) with Pseudomonas aeruginosa has been associated with increased pulmonary exacerbation (PEx) and mortality risk. European Respiratory Society guidelines conditionally recommend inhaled antimicrobials for persons with NCFBE, P aeruginosa and three or more PEx/year. We report microbiological results of two randomized, 48-week placebo-controlled trials of ARD-3150 (inhaled liposomal ciprofloxacin) in individuals with NCFBE with P aeruginosa and PEx history [Lancet Respir Med 2019;7:213–26]. MethodsRespiratory secretions from 582 participants receiving up to six 28-day on/off treatment cycles were analysed for sputum P. aeruginosa, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus and Escherichia coli densities, P. aeruginosa susceptibilities to ciprofloxacin and nine other antimicrobials, and prevalence of other bacterial opportunists. Associations between PEx risk and sputum density, antimicrobial susceptibility and opportunist prevalence changes were studied. ResultsSputum P. aeruginosa density reductions from baseline after ARD-3150 treatments ranged from 1.77 (95% CI 2.13–1.40) versus 0.54 (95% CI 0.89–0.19) log10 CFU/g for placebo (second period) to 2.07 (95% CI 2.45–1.69) versus 0.70 (95% CI 1.11–0.29) log10 CFU/g for placebo (fourth period) with only modest correlation between density reduction magnitude and PEx benefit. ARD-3150 (but not placebo) treatment was associated with increased P. aeruginosa ciprofloxacin MIC but not emergence of other bacterial opportunists across the study; ciprofloxacin MIC50 increased from 0.5 to 1 mg/L, MIC90 increased from 4 to 16 mg/L. Other antimicrobial MIC were mostly unaffected. ConclusionMicrobiological changes over 48 weeks of ARD-3150 treatment appear modest. Ciprofloxacin susceptibility (but not other antimicrobial susceptibility) decreases were observed that did not appear to preclude PEx risk reduction benefit.

Non-invasive ventilation during surgery under neuraxial anaesthesia: apathophysiological perspective on application and benefits and asystematic literature review.

Unlike general anaesthesia, neuraxial anaesthesia (NA) reduces the burden and risk of respiratory adverse events in the post-operative period. However, both patients affected by chronic obstructive pulmonary disease (COPD) and chest wall disorders and/or neuromuscular diseases may experience the development or the worsening of respiratory failure, even during surgery performed under NA; this latter negatively affects the function of accessory respiratory muscles, resulting in a blunted central response to hypercapnia and possibly in an exacerbation of cardiac dysfunction (NA-induced relative hypovolemia). According to European Respiratory Society (ERS) and American Thoracic Society (ATS) guidelines, non-invasive ventilation (NIV) is effective in the post-operative period for the treatment of both impaired pulmonary gas exchange and ventilation, while the intra-operative use of NIV in association with NA is just anecdotally reported in the literature. Whilst NIV does not assure a protected patent airway and requires the patient's cooperation, it is a handy tool during surgery under NA: NIV is reported to be successful for treatment of acute respiratory failure; it may be delivered through the patient's home ventilator, may reverse hypoventilation induced by sedatives or inadvertent spread of anaesthetic up to cervical dermatomes, and allow the avoidance of intubation in patients affected by chronic respiratory failure, prolonging the time of non-invasiveness of respiratory support (i.e., neuromuscular patients needing surgery). All these advantages could make NIV preferable to oxygen in carefully selected patients.

State-of-the-Art Session: Respiratory Infections

In recent decades, there has been growing interest in the recognition and management of both bronchiectasis and nontuberculous mycobacteria (NTM) pulmonary disease. More specifically, interest in diagnosing NTM infection in patients with bronchiectasis has dramatically increased. Publication of the European Respiratory Society (ERS) guidelines and results from a number of large clinical trials have resulted in an exciting year for bronchiectasis research. Despite the increased knowledge and expanding options for disease management, a number of challenges persist. There remains a paucity of evidence to support management recommendations, which have not kept pace with the growing attention given to these diseases. To explore these limitations, Prof Chalmers summarised the reasoning behind the new guidelines. The main objectives of these two presentations were to provide an expert overview of the challenges and achievements in the management of bronchiectasis and NTM pulmonary diseases, as well as predicting future trends. Dr van Ingen called for caution when managing these diseases because neither bronchiectasis nor NTM pulmonary disease can be described as single disease entities and, therefore, cannot be treated as such. The presence of NTM pulmonary disease is often a sign of multiple underlying conditions that must be addressed in tandem with culture conversion. Likewise, bronchiectasis pathogenesis is complex and failure of antibiotic therapy to offer consistent clinical benefit suggests infection is not central to pathogenesis in all patients, and a holistic approach is required. Finally, these interactive sessions uncovered and discussed various aspects and attitudes associated with disease management and highlighted how quality of care may be closely linked to clinical outcomes.

Microbiological testing of adults hospitalised with community-acquired pneumonia: an international study.

This study aimed to describe real-life microbiological testing of adults hospitalised with community-acquired pneumonia (CAP) and to assess concordance with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) and 2011 European Respiratory Society (ERS) CAP guidelines.This was a cohort study based on the Global Initiative for Methicillin-resistant Staphylococcus aureus Pneumonia (GLIMP) database, which contains point-prevalence data on adults hospitalised with CAP across 54 countries during 2015.In total, 3702 patients were included. Testing was performed in 3217 patients, and included blood culture (71.1%), sputum culture (61.8%), Legionella urinary antigen test (30.1%), pneumococcal urinary antigen test (30.0%), viral testing (14.9%), acute-phase serology (8.8%), bronchoalveolar lavage culture (8.4%) and pleural fluid culture (3.2%). A pathogen was detected in 1173 (36.5%) patients. Testing attitudes varied significantly according to geography and disease severity. Testing was concordant with IDSA/ATS and ERS guidelines in 16.7% and 23.9% of patients, respectively. IDSA/ATS concordance was higher in Europe than in North America (21.5% versus 9.8%; p<0.01), while ERS concordance was higher in North America than in Europe (33.5% versus 19.5%; p<0.01).Testing practices of adults hospitalised with CAP varied significantly by geography and disease severity. There was a wide discordance between real-life testing practices and IDSA/ATS/ERS guideline recommendations.