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Background: Pulmonary function tests (PFTs) have historically used race-specific prediction equations. The recent American Thoracic Society guidelines recommend the use of a race-neutral approach in prediction equations. There are limited studies centering the opinions of practicing pulmonologists on the use of race in spirometry. Provider opinion will impact adoption of the new guideline. The aim of this study was to ascertain the beliefs of academic pulmonary and critical care providers regarding the use of race as a variable in spirometry prediction equations., Methods: We report data from 151 open-ended responses from a voluntary, nationwide survey (distributed by the Association of Pulmonary Critical Care Medicine Program Directors) of academic pulmonary and critical care providers regarding the use of race in PFT prediction equations. Responses were coded using inductive and deductive methods, and a thematic content analysis was conducted., Results: There was a balanced distribution of opinions among respondents supporting, opposing, or being unsure about the incorporation of race in spirometry prediction equations. Responses demonstrated a wide array of understanding related to the concept and definition of race and its relationship to physiology., Conclusions: There was no consensus among providers regarding the use of race in spirometry prediction equations. Concepts of race having biologic implications persist among pulmonary providers and will likely affect the uptake of the Global Lung Function Initiative per the American Thoracic Society guidelines., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Background: In Canada, COPD represents a significant burden to the patient and health system, as it is often under or misdiagnosed and sub-optimally treated. Cardiovascular disease (CVD) is a common co-morbidity in COPD and there is significant interplay between these two chronic conditions. Across all stages of COPD disease severity, deaths can be attributed not only to respiratory causes but also to cardiovascular-related factors. The established links between COPD and CVD suggest the need for a greater degree of collaboration between respirologists and cardiologists. This modified Delphi consensus was initiated to consider how optimal COPD care can be delivered within Canada, with specific consideration of reducing cardiopulmonary risk and outcomes in COPD patients., Methods: A steering group with interest in the management of COPD and CVD from primary care, cardiology, and respirology identified 40 statements formed from four key themes. A 4-point Likert scale questionnaire was sent to healthcare professionals working in COPD across Canada by an independent third party to assess agreement (consensus) with these statements. Consensus was defined as high if ≥75% and very high if ≥90% of respondents agreed with a statement., Results: A total of 100 responses were received from respirologists (n=30), cardiologists (n=30), and primary care physicians (n=40). Consensus was very strong (≥90%) in 28 (70%) statements, strong (≥75 and <90%) in 7 (17.5%) statements and was not achieved (<75%) in 5 (12.5%) of statements., Conclusion: Based on the consensus scores, 9 key recommendations were proposed by the steering group. These focus on the need to comprehensively risk stratify and manage COPD patients to help prevent exacerbations. Consensus within this study provides a call to action for the expeditious implementation of the latest COPD guidelines from the Canadian Thoracic Society., Competing Interests: No authors received honoraria from AstraZeneca for this project. Previous honoraria received by the authors includes: M Bhutani reports grants, contracts, consulting fees, support for travel, or honoraria from CIHR, AstraZeneca, GlaxoSmithKline, Novartis, Grifols, Sanofi, Takeda, Covis, Valeo, Lung Association of Saskatchewan, Canadian Thoracic Society, Lung Association of Alberta and Northwest Territories; leadership roles with Canadian Thoracic Society and Alberta Health Services; Canadian Thoracic Society Executive Committee, Co-Chair of the CTS COPD Clinical Assembly; Chair of the Royal College of Physicians and Surgeons Adult Respiratory Examination. J Bourbeau reports grants from McGill University, the McGill University Health Centre Foundation, the Canadian Institute Health Research, Grifols, Novartis, Sanofi, and the Respiratory Health Network of the Fonds de la recherche en santé du Québec; grants and personal fees (honoraria) from Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, and Trudell Canada Ltd; and personal fees (honoraria) from Pfizer Canada Ltd, and COVIS Pharma Canada Ltd, outside the submitted work. SG Goodman reports research grant support (eg, steering committee or data and safety monitoring committee) and/or speaker/consulting honoraria (eg, advisory boards) from: Amgen, Alnylam, Anthos Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL Behring, CYTE Ltd., Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, HLS Therapeutics, Idorsia, JAMP Pharma, Merck, Novartis, Novo Nordisk A/C, Pendopharm/Pharmascience, Pfizer, Regeneron, Roche, Sanofi, Servier, Tolmar Pharmaceuticals, Valeo Pharma; and salary support/honoraria from the Canadian Heart Failure Society, Canadian Heart Research Centre and MD Primer, Canadian VIGOUR Centre, Cleveland Clinic Coordinating Centre for Clinical Research, Duke Clinical Research Institute, Jewish General Hospital\ CIUSSS Centre-Ouest-de-l’Ile-de-Montreal, Peter Munk Cardiac Centre Clinical Trials and Translation Unit, Ted Rogers Centre for Heart Research, New York University Clinical Coordinating Centre, PERFUSE Research Institute, TIMI Study Group (Brigham Health). NM Hawkins reports research grant support, served on advisory boards for, or speaker engagements with AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, Servier. AG Kaplan reports consulting fees or honoraria from AstraZeneca, ALK, Bellus, BI, Covis, Cipla, Eisai, GSK, Merck Frosst, Metapharm, Moderna, Novo Nordisk, Pfizer Sanofi, Teva, Trudell, Valeo; Chairperson of Family Physician Airways Group of Canada; Vice president of Respiratory Effectiveness Group. AGK is an honorary professor of primary care Respiratory Research, Observational and Pragmatic Research Institute; Medical director, local pulmonary rehabilitation program; Board member, Thrombosis Canada; Senate member of the International Primary Care Respiratory Group. P Lin reports speaker honorarium for CME events from AstraZeneca, GlaxoSmithKline, Medexus, Moderna, Pfizer, Amgen, Novo Nordisk, Boehringer-Ingelheim, and Eli Lilly. ED Penz reports consulting fees, support for travel, or honoraria from AstraZeneca, GlaxoSmithKline, Sanofi, Covis, LungSask, Canadian Thoracic Society, Valeo; research funds from CIHR, Saskatchewan Health Research Foundation, Respiratory Research Center, LungSask, Saskatchewan Centre for Patient oriented research, and AstraZeneca. She reports contract with Saskatchewan Cancer Agency for her role as medical advisor for the Saskatchewan Lung Screening program, board member of Institute of Cancer Research Advisory Board (CIHR), Canadian Thoracic Society Executive Committee, and Past Co-Chair of the CTS COPD Clinical Assembly. S Verma holds a Tier 1 Canada Research Chair in Cardiovascular Surgery, and reports receiving research grants and/or speaking honoraria from Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Canadian Medical and Surgical Knowledge Translation Research Group, Eli Lilly, HLS Therapeutics, Janssen, Novartis, Novo Nordisk, Pfizer, PhaseBio, S & L Solutions Event Management Inc, and Sanofi. He is the President of the Canadian Medical and Surgical Knowledge Translation Research Group, a federally incorporated not-for-profit physician organization. S Zieroth reports research grant support, served on advisory boards for, or speaker engagements with AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Cytokinetics, Eli Lilly, GSK, Janssen, Merck, Novartis, Novo-Nordisk, Otsuka, Pfizer, Roche, Servier and Vifor Pharma; and serves on a clinical trial committee or as a national lead for studies sponsored by AstraZeneca, Bayer, Boehringer Ingelheim, Merck, Novartis, and Pfizer. The authors report no other conflicts of interest in this work., (© 2024 Bhutani et al.)

According to this study., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Pediatric pulmonologists have the expertise to be advocates in many areas that affect the respiratory health of children. This article provides an overview of selected advocacy topics related to health equity and provides key examples that can improve child respiratory health in the clinical encounter and beyond., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Inhaler education for patients with asthma and patients with COPD is typically provided by non-pulmonologists. We studied inhaler education by pulmonologists to determine changes in clinical outcomes and inhaler use., Methods: This was a retrospective study of 296 subjects diagnosed with asthma, COPD, or both that evaluated use of inhaler technique education and its impact on (1) inhaler/dosage change consisting of dosage change in the same class of inhaler and/or change in number of inhalers, (2) forced expiratory volume in one second/forced vital capacity (FEV 1 /FVC%), (3) disease symptom control, (4) out-patient visits, (5) urgent care visits (6) emergency department visits, and (7) hospital admissions. One group received inhaler technique education by a pulmonologist while the other group did not., Results: The pulmonologist inhaler technique-educated group had significantly decreased relative risk for inhaler/dosage increase (relative risk 0.57 [95% CI 0.34-0.96], P = .03) and significantly increased odds for symptom control (odds ratio 2.15 [95% CI 1.24-3.74], P = .01) at 1-y follow-up as compared to the no education group. No differences occurred for FEV 1 /FVC%, out-patient visits, urgent care visits, emergency department visits, and hospital admissions., Conclusions: Pulmonologist education of inhaler technique for patients with asthma and patients with COPD was associated with decreased relative risk for inhaler/dosage increase and increased odds for symptom control. We recommend pulmonologists provide education of inhaler technique to patients with asthma and patients with COPD and not rely on non-pulmonologist education alone. Prospective research is needed to confirm the importance of proper inhaler techniques., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

The pericardium comprises a double-walled fibrous-serosal sac that encloses the heart. Reflections of the serosal layer form sinuses and recesses. With advances in multidetector computed tomography (CT) technology, pericardial recesses are frequently detected with thin-section CT. Knowledge of pericardial anatomy on imaging is crucial to avoid misinterpretation of fluid-filled pericardial sinuses and recesses as adenopathy/pericardial metastasis or aortic dissection, which can impact patient management and treatment decisions. The authors offer a comprehensive review of pericardial anatomy and its variations observed on CT, potential pitfalls in image interpretation, and implications for the pulmonologist with respect to unnecessary diagnostic procedures or interventions., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Interstitial lung disease is a leading cause of mortality in patients with systemic sclerosis. Currently, there is a lack of consensus regarding screening, rescreening, diagnosis, and follow-up practices in interstitial lung disease associated with systemic sclerosis (SSc-ILD) in Colombia., Methods: A structured survey focused on clinical practices in patients with SSc-ILD was conducted. Members of the Asociación Colombiana de Neumología y Cirugía de Tórax (Asoneumocito) and the Asociación Colombiana de Reumatología (Asoreuma) were invited to participate from March 2023 to May 2023., Results: We surveyed 51 pulmonologists and 44 rheumatologists. Overall, 51.6% reported having access to multidisciplinary team discussion in ILD. Among the 95 participants, 78.9% would routinely perform a high-resolution computed tomography scan of the chest once a diagnosis of systemic sclerosis was established. This practice is more frequent among rheumatologists (84.1%) than among pulmonologists (74.5%). Approximately half of the participants would rescreen patients annually with computed tomography scan (56.8%) if baseline images were negative. Spirometry (81.1%), diffusing capacity of the lung for carbon monoxide (80.0%), and 6-min walk test (55.8%) were the most frequently performed tests upon diagnosis of systemic sclerosis. During follow-up, participants would consider repeating pulmonary function tests mostly every 6 months., Conclusions: Screening of SSc-ILD is high among pulmonologists and rheumatologists. Decision-making on diagnosis and follow-up is similar between specialties, but there are variations in their frequency and indications. Further research is needed to evaluate how to adapt recommendations for assessing SSc-ILD in different settings., (Copyright © 2024 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.)

Purpose: Chronic obstructive pulmonary disease (COPD) poses a significant global health burden despite being largely preventable and treatable. Despite the availability of guidelines, COPD care remains suboptimal in many settings, including high-income countries (HICs) and upper-middle-income countries (UMICs), with varied approaches to diagnosis and management. This study aimed to identify common and unique barriers to COPD care across six countries (Australia, Spain, Taiwan, Argentina, Mexico, and Russia) to inform global policy initiatives for improved care., Methods: COPD care pathways were mapped for each country and supplemented with epidemiological, health-economic, and clinical data from a targeted literature review. Semi-structured interviews with 17 respiratory care clinicians were used to further validate the pathways and identify key barriers. Thematic content analysis was used to generate the themes., Results: Six themes were common in most HICs and UMICs: "Challenges in COPD diagnosis", "Strengthening the role of primary care", "Fragmented healthcare systems and coordination challenges", "Inadequate management of COPD exacerbations", "Limited access to specialized care" and, "Impact of underfinanced and overloaded healthcare systems". One theme, "Insurance coverage and reimbursement challenges", was more relevant for UMICs. HICs and UMICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and availability of specialized care. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. In addition, UMICs also grapple with resource limitations and healthcare infrastructure challenges., Conclusion: Many challenges to COPD care are the same in both HICs and UMICs, underscoring the pervasive nature of these issues. While country-specific issues require customized solutions, there are untapped possibilities for implementing global respiratory strategies that support countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritization of COPD to allocate the essential resources it requires., Competing Interests: Orjola Shahaj, Anne Meiwald, Krishnan Puri-Sudhir, Rupert Gara Adams, and Elisabeth Adams worked at Aquarius Population Health at the time of the project. Aquarius Population Health receives consultancy and research fees from other pharmaceutical and MedTech companies that are unrelated to this work. Abelardo Elizondo Rios has served on boards for trials sponsored by AstraZeneca, Bayern, Novartis and GSK. Alexis Cazaux has no conflict of interest concerning the topic of this research. Outside of the submitted work, Sergey Avdeev reports receiving consulting fees and/or fees for attending lectures, meetings and conferences and/or travel expenses and/or research grants from AstraZeneca, Novartis, GSK, Teva, Sanofi, and Chiesi. Peter Wark has no conflict of interest concerning the topic of this research., (© 2024 Shahaj et al.)

Objective: During the COVID-19 pandemic, universal mask-wearing became one of the main public health interventions. Because of this, most physical examinations, including lung auscultation, were done while patients were wearing surgical face masks. The aim of this study was to investigate whether mask wearing has an impact on pulmonologist assessment during auscultation of the lungs., Methods: This was a repeated measures crossover design study. Three pulmonologists were instructed to auscultate patients with previously verified prolonged expiration, wheezing, or crackles while patients were wearing or not wearing masks (physician and patients were separated by an opaque barrier). As a measure of pulmonologists' agreement in the assessment of lung sounds, we used Fleiss kappa (K)., Results: There was no significant difference in agreement on physician assessment of lung sounds in all three categories (normal lung sound, duration of expiration, and adventitious lung sound) whether the patient was wearing a mask or not, but there were significant differences among pulmonologists when it came to agreement of lung sound assessment., Conclusion: Clinicians and health professionals are safer from respiratory infections when they are wearing masks, and patients should be encouraged to wear masks because our research proved no significant difference in agreement on pulmonologists' assessment of auscultated lung sounds whether or not patients wore masks., Competing Interests: The authors declare there are no competing interests., (©2024 Folnožić et al.)

Significant inconsistencies in respiratory care provision for Duchenne muscular dystrophy (DMD) are reported across different specialist neuromuscular centres in the UK. The absence of robust clinical evidence and expert consensus is a barrier to the implementation of care recommendations in public healthcare systems as is the need to increase awareness of key aspects of care for those living with DMD. Here, we provide evidenced-based and/or consensus-based best practice for the respiratory care of children and adults living with DMD in the UK, both as part of routine care and in an emergency., Methodology: Initiated by an expert working group of UK-based respiratory physicians (including British Thoracic Society (BTS) representatives), neuromuscular clinicians, physiotherapist and patient representatives, draft guidelines were created based on published evidence, current practice and expert opinion. After wider consultation with UK respiratory teams and neuromuscular services, consensus was achieved on these best practice recommendations for respiratory care in DMD., Result: The resulting recommendations are presented in the form of a flow chart for assessment and monitoring, with additional guidance and a separate chart setting out key considerations for emergency management. The recommendations have been endorsed by the BTS., Conclusions: These guidelines provide practical, reasoned recommendations for all those managing day-to-day and acute respiratory care in children and adults with DMD. The hope is that this will support patients and healthcare professionals in accessing high standards of care across the UK., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: COPD is the third cause of death globally and in Argentina COPD has a prevalence of 14.5%, but the management of patients in real life is unknown. The objectives of this work were: a) To know the opinions of pulmonologists in Argentina who manage patients with COPD in different aspects of daily practice. b) Compare our findings with specialists from Spain and c) Consider our results to plan future directives in the management of COPD in our country., Material and Methods: 89 pulmonologists from Argentina, experts in COPD, participated in a Delphi consensus, who responded to a survey with five domains. a) Adherence to treatment, b) Control of COPD, c) Treatable features, d) Inhalation devices and e) Accessibility to therapeutic resources., Results: After two rounds of questions, total consensus was achieved in 77.6% of the statements and discriminating by domain: Treatment adherence: 5/9 (55.5%). COPD control: 10/14 (71.4%). Treatable traits: 6/6 (100%). Inhalation devices: 10/14 (71.4%) and Accessibility to treatment: 6/6 (100%). In most of the affirmations, the results were similar to those obtained by Spanish pulmonologists., Conclusions: Pulmonologists from Argentina manage COPD patients in a similar way and with minimal differences with our Spanish colleagues. It became evident that, in daily practice, there are factors that negatively impact access to the indicated treatments. Our work could serve as a starting point to improve this situation., (© 2024 Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Published by Elsevier España, S.L.U.)

Introduction: Despite evidence of the benefits of the written asthma action plans (WAP) in asthma control, they remain poorly applied. The aim of our study was to assess the practices of French-speaking pulmonologists and paediatricians in their use of WAP for asthma control and to analyse the contents of several WAPs routinely consulted in treatment of asthma patients., Methods: Members of three French medical societies (SPLF, G2A, SP2A) were requested to share their WAPs for asthma patients and to participate in an online survey about the possible influence of these documents on their practices., Results: Most (95%) of the 41 WAPs taken into consideration were symptom-based and 34% included peak expiratory flow measurement. All of these action plans were in full compliance with current guidelines. Among the 110 survey respondents, while 65% systematically provided a WAP to their asthma patients, only 30% often or always supplemented the written document with therapeutic education sessions. In almost every case, it was the doctor who presented the WAP to the patient, generally devoting to less than 10minutes to explanation of what they were handing out., Conclusions: In France, WAPs are generally presented to the patient by the physician, which probably limits the time devoted to explanation of their contents. Furthermore, WAPs are rarely reinforced with therapeutic education. The current study suggests ways of improving the utilization of WAPs in asthma care and treatment., (Copyright © 2024 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Ultrasonography is an emerging tool that helps to assess diaphragmatic function. It is now widely used in ICUs to predict weaning from mechanical ventilation. Ultrasonography is readily available, harmless (no radiation), and repeatable with good interoperator reproducibility. Over the past few years, ultrasonography has seen increasing use in patients with chronic pulmonary pathologies., State of the Art: The aim of this review is (1) to describe the ultrasound techniques used to assess diaphragmatic excursion and thickening, (2) to indicate the expected, normal values in healthy patients, and (3) to summarize the main findings and clinical applications in treatment of chronic respiratory disorders., Conclusions: Chronic pulmonary diseases are associated with diaphragmatic dysfunction that can be assessed with ultrasound. Diaphragmatic dysfunction is primary in neuromuscular disorders and secondary to respiratory disease in other chronic pulmonary conditions (COPD, ILD). Ultrasound is correlated with the severity of the underlying disease (functional and clinical parameters)., Perspectives: The prognostic interest of diaphragm ultrasonography remains to be established, after which its utilization should become routine., (Copyright © 2023 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: The coronavirus disease-19 (COVID-19) increased the already heavy workload in the pulmonary and respiratory departments, which therefore possibly increased the prevalence of burnout among pulmonologists or respiratory therapists. We aimed to compare the differences in burnout among pulmonologists or respiratory therapists pre- and post-COVID-19 by doing a systematic review with meta-analysis., Methods: We searched pulmonologist, or pulmonary, or respiratory, and burnout up to 29 January 2023 in six databases. We included studies investigating pulmonologists or respiratory therapists and reporting the prevalence of burnout among them. The risk of bias was assessed by a tool for prevalence studies. The overall prevalence of burnout was pooled., Results: A total of 2859 records were identified and 16 studies were included in the final analysis. The included studies reported 3610 responding individuals and 2336 burnouts. The pooled prevalence of burnout was 61.7% (95% confidence interval (CI), 48.6-73.2%; I 2  = 96.3%). The pooled prevalence of burnout during COVID-19 was significantly higher than it was prior to the outbreak (68.4% vs. 41.6%, p  = .01). The result of the meta-regression revealed that COVID-19 coverage was significantly associated with the prevalence of burnout ( p  = .04)., Conclusions: Burnout was widely prevalent among pulmonologists or respiratory therapists and increasingly perceived during COVID-19. Therefore, interventions were needed to reduce burnout in this specialty.KEY MESSASGESThe coronavirus disease-19 increased the already heavy workload in the pulmonary and respiratory departments.Burnout was widely prevalent among pulmonologists or respiratory therapists and increasingly perceived during COVID-19.

In this review, we present the effects of lung hyperinflation on the cardiovascular system (CVS) and the beneficial outcomes of different deflation treatment modalities. We discuss the effects of long-acting bronchodilator drugs, medical and surgical lung volume reduction on the performance of the CVS. Although there is a small number of studies investigating lung deflation and the CVS, the short-term improvement in heart function was clearly demonstrated. However, more studies, with longer duration, are needed to verify these significant beneficial effects of deflation of the lungs on the CVS. Dynamic hyperinflation during exercise could be a research model to investigate further the effects of lung hyperinflation and/or deflation on the CVS., (Copyright © 2023 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: Ultrasound guided lung biopsy (USLB) is a minimally invasive diagnostic tool with short examination time and real-time monitoring conducted bedside for accurate diagnosis in order to provide the best treatment. However, it is not widely performed by pulmonologists. We aim to explicate the efficacy and safety of USLB led by pulmonologists. The objective of this study is to assess safety and efficacy of USLB performed by pulmonologists in an outpatient setting., Materials and Methods: We retrospectively enrolled patients who underwent the procedure from January 2018 to April 2022. Under real time ultrasound (Hitachi Medical ProSound F37), thoracic lesions adjacent to the chest wall were sampled with a full-core biopsy needle (CT Core Single Action Biopsy Device, 18G × 15 cm, Vigeo, Italy). Chest x-ray was performed 30 minutes post procedure ruling out pneumothorax. Patients were discharged home 1-2 hours post biopsy. Data was analysed using Microsoft Excel 2010 and Statistical Package for Social Science (SPSS) Version 26., Results: A total of 18 patients (14 males, 4 females) underwent USLB for lung tumours. Biopsies were histologically deemed adequate with an overall diagnostic yield of 77.8% (14/18). A total of 57% were positive for thoracic malignancy (21% squamous cell carcinoma, 21% adenocarcinoma, 15% small cell carcinoma) and another 43% were positive for extra thoracic malignancy (1 hepatocellular carcinoma, 2 DLBCL, 1 Hodgkin's lymphoma, 1 seminoma, 1 thymoma). Four patients had inconclusive results but managed to get positive results from surgical or lymph node biopsy (thymoma and adenocarcinoma). Statistical analysis showed more than two passes are needed to achieve a positive HPE yield (p value<0.05). There were nil complications to all the cases done., Conclusions: USLB can safely and effectively be performed by trained pulmonologists with excellent accuracy and low complication rate in outpatients.

Background: Idiopathic pulmonary fibrosis (IPF) is a serious illness with an unpredictable disease course and survival rates comparable with some cancers. Patients with IPF suffer considerable symptom burden, declining quality of life, and high health care resource utilization. Patients and caregivers report many unmet needs, including a desire for more education regarding diagnosis and assistance with navigating disease trajectory. Compelling evidence suggests that palliative care (PC) provides an extra layer of support for patients with serious illness., Research Question: The purpose of this survey was to gain perspectives regarding PC for patients with IPF by board-certified pulmonologists in South Carolina (SC)., Study Design and Methods: A 24-item survey was adapted (with permission) from the Pulmonary Fibrosis Foundation PC Survey instrument. Data were analyzed and results are presented., Results: Pulmonologists ( n  = 32, 44%) completed the survey; 97% practice in urbanized settings. The majority agreed that PC and hospice do not provide the same service. There were varying views about comfort in discussing prognosis, disease trajectory, and addressing advance directives. Options for ambulatory and inpatient PC are limited and early PC referral does not occur. None reported initiating a PC referral at time of initial IPF diagnosis., Interpretation: Pulmonologists in SC who participated in this survey are aware of the principles of PC in providing comprehensive care to patients with IPF and have limited options for PC referral. PC educational materials provided early in the diagnosis can help facilitate and guide end-of-life planning and discussions. Minimal resources exist for patients in underserved communities., Competing Interests: No competing financial interests exist., (© Kathleen Oare Lindell et al., 2023; Published by Mary Ann Liebert, Inc.)

Asthma, a chronic inflammatory lung disease affecting about 10 % of the population, involves both the general internist and the pulmonologist. The risk of over and underdiagnosis generates significant health costs and evitable clinical consequences. Improved screening through dedicated anamneses and questionnaires, as well as use of fractional exhaled nitric oxide (FeNO) may improve the diagnosis of asthma in general internal medicine., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background and Objectives : Pulmonary arterial hypertension (PAH) is a rare chronic disease of the small pulmonary arteries that causes right heart failure and death. Accurate management of PAH is necessary to decrease morbidity and mortality. Understanding current practices and perspectives on PAH is important. For this purpose, we intended to determine physicians' knowledge, attitudes, and practice patterns in adult pulmonary arterial hypertension (PAH) in Turkey. Materials and Methods : Between January and February 2022, an online questionnaire was sent via e-mail to all cardiologists and pulmonologists who were members of the Turkish Society of Cardiology (TSC) and the Turkish Thoracic Society (TTS). Results : A total of 200 physicians (122 pulmonologists and 78 cardiologists) responded to the questionnaire. Cardiologists were more frequently involved in the primary diagnosis and treatment of PAH than pulmonologists (37.2% vs. 23.8%, p = 0.042). More than half of the physicians had access to right heart catheterization. In mild/moderate PAH patients with a negative vasoreactivity test, the monotherapy option was most preferred (82.8%) and endothelin receptor antagonists (ERAs) were the most preferred group in these patients (73%). ERAs plus phosphodiesterase-5 inhibitors (PDE-5 INH) were the most preferred (69%) combination therapy, and prostacyclin analogues plus PDE-5 INH was preferred by only pulmonologists. Conclusions : Overall, clinical management of patients with PAH complied with guideline recommendations. Effective clinical management of PAH in specialized centers that having right heart catheterization achieve better outcomes.

COVID-19 Acute Respiratory Distress Syndrome (CARDS) is the most serious complication of COVID-19. The SARS-CoV-2 outbreaks rapidly saturated intensive care unit (ICU), forcing the application of non-invasive respiratory support (NIRS) in respiratory intermediate care unit (RICU). The primary aim of this study is to compare the patients' clinical characteristics and outcomes (Helmet-Continuous Positive Airway Pressure (H-CPAP) success/failure and survival/death). The secondary aim is to evaluate and detect the main predictors of H-CPAP success and survival/death. A total of 515 patients were enrolled in our observational prospective study based on CARDS developed in RICU during the three Italian pandemic waves. All selected patients were treated with H-CPAP. The worst ratio of arterial partial pressure of oxygen (PaO 2 ) and fraction of inspired oxygen (FiO 2 ) PaO 2 /FiO 2 during H-CPAP stratified the subjects into mild, moderate and severe CARDS. H-CPAP success has increased during the three waves (62%, 69% and 77%, respectively) and the mortality rate has decreased (28%, 21% and 13%). H-CPAP success/failure and survival/death were related to the PaO 2 /FiO 2 (worst score) ratio in H-CPAP and to steroids' administration. D-dimer at admission, FiO 2 and positive end expiratory pressure (PEEP) were also associated with H-CPAP success. Our study suggests good outcomes with H-CPAP in CARDS in RICU. A widespread use of steroids could play a role.

Background: The Hepatic hydrothorax is a pleural effusion related to portal hypertension; its diagnosis and therapeutic management may be difficult. The aims of this article are which follows: To gather the practices of hepatogastroenterologists or pulmonologists practitioners regarding the diagnosis and management of the hepatic hydrothorax., Methods: Practitioners from 13 French- speaking countries were invited to answer an online questionnaire on the hepatic hydrothorax diagnosis and its management., Results: Five hundred twenty-eight practitioners (80% from France) responded to this survey. 75% were hepatogastroenterologists, 20% pulmonologists and the remaining 5% belonged to other specialities. The Hepatic hydrothorax can be located on the left lung for 64% of the responders (66% hepatogastroenterologists vs 57% pulmonologists; p = 0.25); The Hepatic hydrothorax can exist in the absence of clinical ascites for 91% of the responders (93% hepatogastroenterologists vs 88% pulmonologists; p = 0.27). An Ultrasound pleural scanning was systematically performed before a puncture for 43% of the responders (36% hepatogastroenterologists vs 70% pulmonologists; p < 0.001). A chest X-ray was performed before a puncture for 73% of the respondeurs (79% hepatogastroenterologists vs 54% pulmonologists; p < 0.001). In case of a spontaneous bacterial empyema, an albumin infusion was used by 73% hepatogastroenterologists and 20% pulmonologists (p < 0.001). A drain was used by 37% of the responders (37% hepatogastroenterologists vs 31% pulmonologists; p = 0.26).An Indwelling pleural catheter was used by 50% pulmonologists and 22% hepatogastroenterologists (p < 0.01). TIPS was recommended by 78% of the responders (85% hepatogastroenterologists vs 52% pulmonologists; p < 0.001) and a liver transplantation, by 76% of the responders (86% hepatogastroenterologists vs 44% pulmonologists; p < 0.001)., Conclusions: The results of this large study provide important data on practices of French speaking hepatogastroenterologists and pulmonologists; it appears that recommendations are warranted., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung disorder with a complex clinical picture. The diagnosis may be difficult at times, as COPD may develop insidiously and remain unnoticed for a long time. Therefore, general practitioners play a central role in early detection of disease. Suspected COPD may be confirmed by further investigations in collaboration with a pulmonologist. The most recent GOLD guideline defines three COPD risk groups (A-B-E) which should guide the personalized treatment concept. General practitioners are crucial for implementing non-pharmacological measures such as smoking cessation, regular exercise, vaccinations, and patient self-management education. However, this also underlines the challenges to implement the GOLD recommendations in daily practice., Competing Interests: J. Leuppi est soutenu par des bourses du Fonds national suisse (SNF160072 et 185592) et par le Swiss Personalised Health Network (SPHN 2018DR108). Il a également reçu des honoraires de conférencier et des soutiens sans restriction d’Astra-Zeneca AG Schweiz, Boehringer Ingelheim GmbH Schweiz, GSK AG Schweiz, MSD AG Schweiz, Novartis AG, Schweiz et d’OM Pharma Schweiz. P.-O. Bridevaux a reçu des honoraires de conférencier et des soutiens sans restriction d’AstraZeneca, Boehringer Ingelheim, GSK, Novartis, OM Pharma, Sanofi et de la Ligue Pulmonaire Valaisanne. C. von Garnier a reçu des honoraires d’AstraZeneca, Boehringer Ingelheim, GSK, Mundipharma, Novartis, Pfizer, OM Pharma, PneumRx, Pulmonx, Sanofi et de Pharma Schwabe AG. Il est également récipient d’un financement de recherche par OM Pharma. N. Pavlov a reçu des honoraires de conférencier et d’Advisory Board d’AstraZeneca, CSL Behring, GSK, Novartis, Olympus, OM Pharma, Sanofi. F. Charbonnier a reçu des honoraires de conférencier et des soutiens sans restriction d’AstraZeneca, GSK, Mundipharma, Novartis, OM Pharma, et Sanofi. C. Clarenbach a reçu des honoraires de conférencier et d’Advisory Board de la part de Roche, Novartis, Boehringer, GSK, Astra Zeneca, Sanofi, Vifor, OM Pharma, CSL Behring, Grifols, Daiichi Sankyo et de MSD. Ces auteurs n’ont aucun autre lien ou intérêt financier particulier avec des organisations ou des entreprises qui ont un intérêt financier ou un conflit financier avec les sujets ou les documents traités dans le manuscrit à l’exception des liens divulgués. Les autres auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Introduction: Pulmonologists can biopsy structures below the diaphragm using the convex curvilinear ultrasound bronchoscope via the esophagus (EUS-B). The literature with respect to the value of EUS-B, rapid on-site evaluation, and final diagnostic yield for structures below the diaphragm is limited. We review our institutional experience., Materials and Methods: Our database was queried retrospectively for EUS-B fine needle aspirations (FNAs) from 2013 to 2021. All procedures involving EUS-B-FNA of subdiaphragmatic structures were selected for analysis. The following data elements were collected for each patient: age, gender, clinical indication, sample site, on-site adequacy (OSA), preliminary and final diagnoses, and sufficiency of cell block for ancillary studies., Results: A total of 75 subdiaphragmatic sites were biopsied in 74 patients. Of which, 87% of samples subjected to rapid on-site evaluation were deemed to contain adequate material (OSA+). There were no false-positive OSAs. Six cases remained nondiagnostic at the final diagnosis. The final diagnostic yield (with cell block) was 92% (69/75 cases). Cell block was sufficient for immunohistochemistry or special stains in all applicable cases (n = 36). Molecular testing was requested for 11 cases and successful in 10 (91%). Sampling of subdiaphragmatic sites changed the stage in 67% (38/57) of lung cancer patients., Conclusions: Pulmonologists can perform EUS-B-FNA of subdiaphragmatic sites with high OSA and final diagnostic yield when assisted by cytopathologists. Strong correlations exist between OSA, cell block adequacy, and subsequent capacity to perform ancillary testing. EUS-B below the diaphragm can make an important contribution to the diagnosis of lung cancer, nonpulmonary malignancies, and other diseases., (Copyright © 2023 American Society of Cytopathology. Published by Elsevier Inc. All rights reserved.)

Rationale: The healthcare industry sometimes makes payments to physicians for nonresearch and research purposes in the United States. Objectives: We aimed to evaluate the trends in nonresearch and research industry payments to pulmonologists since the inception of the Open Payments database in 2013. Methods: Using the Open Payments database between August 2013 and December 2021, this population-based observational cohort study examined nonresearch and research payments made by the healthcare industry to pulmonologists registered in the National Plan and Provider Enumeration System in the United States. We performed descriptive analyses on payment data and generalized estimating equations for payment trends. Results: Of 12,488 active pulmonologists, 11,074 (88.7%) accepted a total of 2,246,412 payments totaling $1,053,344,669. Total payments were $253,405,965 (24.1%) in nonresearch, $17,382,904 (1.7%) in direct research, and $782,555,800 (74.3%) in associated research payments between 2013 and 2021. Median per-physician payments (interquartile range) were $2,342 ($496 to $8,299) for nonresearch, $4,688 ($1,435 to $21,803) for direct research, and $95,927 ($20,300 to $344,995) for associated research payments. The top 1%, 5%, and 10% of pulmonologists accepted 37.3%, 71.9%, and 83.7% of the total nonresearch payments. The per-physician nonresearch payments increased by 2.9% (95% confidence interval [CI], 1.2 to 4.7; P  = 0.001) annually between 2014 and 2019 and decreased by 50.2% (95% CI, -55.3 to -44.6; P  < 0.001) in 2020, whereas there was no yearly change in research payments. Conclusions: Nearly 90% of pulmonologists received nonresearch and research payments from the healthcare industry in the United States. Nonresearch payments have been increasing since the inception of the Open Payments database.

Chest X-ray (CXR) is an important tool in the assessment of children with suspected foreign body aspiration (FBA), although it can falsely be interpreted as normal in one-third of the cases. The aim of this study is to evaluate the positive predictive value of CXR in children hospitalized with suspected FBA, when interpreted by three disciplines: pediatric pulmonology, pediatric radiology, and pediatric residents. This is a retrospective study that included children aged 0-18 years, admitted with suspected FBA, between 2009 and 2020 in one tertiary center. All patients underwent CXR and a flexible/rigid bronchoscopy for the definitive diagnosis of FBA, up to 1 week apart. Two physicians from each discipline interpreted the CXR, independently. Intra-raters' and inter-raters' agreements were assessed. Sensitivity, specificity, and area under the curve (AUC) were calculated for each discipline. Four hundred seventy-three children were included in the study, 175 (37%) with FBA and 298 (63%) without FBA on flexible/rigid bronchoscopy. The most common radiological findings, as interpreted by a pediatric pulmonologist, were unilateral hyperinflation (47%), radiopaque FB (37.6%), lobar atelectasis (10.3%), unilateral hyperinflation with atelectasis (3.4%), and lobar consolidation (1.7%). Intra-raters' agreement ranged from 0.744 (p < 0.001) among pediatric pulmonologists to 0.326 (p < 0.001) among pediatric radiologists. AUC for predicting FBA based on a CXR was 0.81, 0.77, and 0.7 when interpreted by pediatric pulmonologists, pediatric residents, and radiologists, respectively (p < 0.001)., Conclusions: CXR has a high positive predictive value and independently predicts FBA in children; however, normal CXR should not rule out FBA. Predictability is variable among different disciplines., What Is Known: • Chest X-ray is an important tool in the assessment of children with suspected foreign body aspiration (FBA). • Chest X-ray can be interpreted as normal in one-third of the cases., What Is New: • Chest X-ray independently predicts FBA in children, with a high positive predictive value. • The ability of chest x-ray to predict FBA in children differs between pediatric residents, pediatric radiologists, and pediatric pulmonologists., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Hemoptysis resembles a clinical emergency and necessitates a fast and well-coordinated diagnostic and therapeutic approach. While up to 50% of the underlying causes remain unidentified, the majority of cases in the western world can be attributed to respiratory infections and pulmonary neoplasm. While 10% of the patients present with massive, life-threatening hemoptysis, which require a timely airway protection in order to secure a sustained pulmonary gas-exchange, the vast majority presents with non-critical pulmonary bleeding events. Most critical pulmonary bleeding events arise from the bronchial circulation. An early chest imaging is key for identifying the bleeding cause and localization. While chest x-rays are widely implemented in the clinical work-flow and rapidly applicable, computed tomography and computed tomography angiography exhibit the highest diagnostic yield. Bronchoscopy can add diagnostic information especially in pathologies of the central airways, while offering multiple therapeutic options to maintain pulmonary gas exchange. The initial therapeutic regimen comprises early supportive care, but treatment of the underlying etiology is of prognostic relevance and avoids recurrent bleeding events. Bronchial arterial embolization usually is the therapy of choice in patients with massive hemoptysis, while definitive surgery is reserved for patients with refractory bleeding and complex pathologies., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein Erklärung zu nichtfinanziellen Interessen TW ist Vorstandsmitglied des Deutschen Zentrums für Lungenforschung, Stiftungsratsvorsitzender der CAPNETZ Stiftung, Kuratioriumsvorsitzender der Deutschen Lungenstiftung und der Sepsisstiftung., (Thieme. All rights reserved.)

Objective: Burnout syndrome is common in physicians, but little is known about burnout in lung transplant physicians specifically. The purpose of this study was to explore burnout and its relationship to job factors and depression in lung transplant physicians. Design: A cross-sectional study that included lung transplant pulmonologists and surgeons was performed via electronic survey. Setting: The lung transplant physicians surveyed practiced worldwide. Methods: The survey incorporated questions about demographics and job characteristics as well as the Maslach Burnout Inventory and Patient Health Questionnaire-2. Burnout was defined by high emotional exhaustion or depersonalization. Participants: Ninety physicians worldwide completed the survey. Results: Of the 90 physicians who completed the entire survey, 44 (48.9%) had burnout with 38 (42.2%) having high emotional exhaustion, 15 (16.7%) having high depersonalization, and 9 (10.0%) with both. Of the respondents, 14 (15.6%) had high risk of depression, and of these, 13 also had high emotional exhaustion. There was a positive correlation between depression score and emotional exhaustion score ( P =0.67, P <0.001). Depression was more common in surgeons compared with pulmonologists (35.7% versus 11.8%, P =0.02). There was a trend toward more burnout by emotional exhaustion in physicians with more versus less work experience (68.4% versus 31.6%, P =0.056). Conclusions: Emotional exhaustion is common in lung transplant physicians and is associated with depression and a negative impact on life., Competing Interests: Disclosures: The authors have no conflicts of interest or financial support to disclose., (Copyright © 2023 Marshfield Clinic Health System.)

There is a significant variation in symptoms and clinical presentation of connective tissue disorders (CTD) associated with interstitial lung disease (ILD) (CTD-ILD). This presents difficulties in the diagnosis and treatment of CTD-ILD. Early detection and treatment of CTD-ILD using a multidisciplinary approach have been shown to enhance patient outcomes. This exercise aims to explore clinical components to develop a screening tool for pulmonologists for early detection of CTD in ILD and to provide a framework for a multidisciplinary approach in managing CTD-ILD. This in turn will lead to early treatment of CTD-ILD in collaboration with rheumatologists. A panel of 12 leading rheumatologists from the Middle East and North Africa (MENA) region met virtually to select the most relevant clinical findings to aid in identifying CTD-ILD. Twelve panellists opted to investigate seven of the most common inflammatory autoimmune disorders. The panel discussed how to improve the early detection of CTD-ILD. Clinical characteristics were categorized, and a nine-item questionnaire was created. A biphasic algorithm was developed to guide early referral to a rheumatologist based on the presence of one of nine clinical features of CTD (Phase 1) or the presence of CTD-specific antibodies (Phase 2). A brief questionnaire has been developed to serve as a simple and practical screening tool for CTD-ILD detection. Additional research is needed to validate and evaluate the tool in longitudinal cohorts., Competing Interests: The authors report no conflicts of interest in this work., (© 2023 Namas et al.)

Background: Few studies have investigated the collaborative potential between artificial intelligence (AI) and pulmonologists for diagnosing pulmonary disease. We hypothesised that the collaboration between a pulmonologist and AI with explanations (explainable AI (XAI)) is superior in diagnostic interpretation of pulmonary function tests (PFTs) than the pulmonologist without support., Methods: The study was conducted in two phases, a monocentre study (phase 1) and a multicentre intervention study (phase 2). Each phase utilised two different sets of 24 PFT reports of patients with a clinically validated gold standard diagnosis. Each PFT was interpreted without (control) and with XAI's suggestions (intervention). Pulmonologists provided a differential diagnosis consisting of a preferential diagnosis and optionally up to three additional diagnoses. The primary end-point compared accuracy of preferential and additional diagnoses between control and intervention. Secondary end-points were the number of diagnoses in differential diagnosis, diagnostic confidence and inter-rater agreement. We also analysed how XAI influenced pulmonologists' decisions., Results: In phase 1 (n=16 pulmonologists), mean preferential and differential diagnostic accuracy significantly increased by 10.4% and 9.4%, respectively, between control and intervention (p<0.001). Improvements were somewhat lower but highly significant (p<0.0001) in phase 2 (5.4% and 8.7%, respectively; n=62 pulmonologists). In both phases, the number of diagnoses in the differential diagnosis did not reduce, but diagnostic confidence and inter-rater agreement significantly increased during intervention. Pulmonologists updated their decisions with XAI's feedback and consistently improved their baseline performance if AI provided correct predictions., Conclusion: A collaboration between a pulmonologist and XAI is better at interpreting PFTs than individual pulmonologists reading without XAI support or XAI alone., Competing Interests: Conflict of interest: N. Das holds a patent on automated quality control of spirometry. E. Derom reports consultancy fees from Chiesi, GlaxoSmithKline, AstraZeneca and Boehringer Ingelheim. G. Brusselle reports payment or honoraria for lectures from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Sanofi. F. Burgos reports consultancy fees from Medical Graphics Corporation Diagnostics. M. Contoli reports grants from the University of Ferrara, Chiesi and GlaxoSmithKline, consultancy fees and honoraria from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline and Novartis, as well as support for attending meetings from Chiesi, AstraZeneca, GlaxoSmithKline and ALK-Abelló. W.D-C. Man is part funded by a NIHR Artificial Intelligence Award, and reports grants from the NIHR and British Lung Foundation, as well as honoraria from Mundipharma, Novartis, European Conference and Incentive Services DMC; and is the Honorary President of the Association for Respiratory Technology and Physiology (ARTP, UK). J.K. Quint reports grants from the MRC, HDR UK, GlaxoSmithKline, AstraZeneca and Chiesi, and consultancy fees from Insmed and Evidera. E. Vanderhelst reports grants from Chiesi, and consultancy fees and honoraria from Boehringer Ingelheim, Vertex and GlaxoSmithKline. M. Topalovic is part funded by a NIHR Artificial Intelligence Award, and is co-founder and shareholder of ArtiQ. W. Janssens reports grants from Chiesi and AstraZeneca, consultancy and lecture fees from AstraZeneca, Chiesi and GlaxoSmithKline, and he is co-founder and shareholder of ArtiQ. The remaining authors report no potential conflicts of interest., (Copyright ©The authors 2023.)

Background: The differential diagnosis of asthma and chronic obstructive pulmonary disease (COPD) poses a challenge in clinical practice and its misdiagnosis results in inappropriate treatment, increased exacerbations, and potentially death., Objective: To investigate the diagnostic accuracy of the Asthma/COPD Differentiation Classification (AC/DC) tool compared with primary care physicians and pulmonologists in asthma, COPD, and asthma-COPD overlap., Methods: The AC/DC machine learning-based diagnostic tool was developed using 12 parameters from electronic health records of more than 400,000 patients aged 35 years and older. An expert panel of three pulmonologists and four general practitioners from five countries evaluated 119 patient cases from a prospective observational study and provided a confirmed diagnosis (n = 116) of asthma (n = 53), COPD (n = 43), asthma-COPD overlap (n = 7), or other (n = 13). Cases were then reviewed by 180 primary care physicians and 180 pulmonologists from nine countries and by the AC/DC tool, and diagnostic accuracies were compared with reference to the expert panel diagnoses., Results: Average diagnostic accuracy of the AC/DC tool was superior to that of primary care physicians (median difference, 24%; 95% posterior credible interval: 17% to 29%; P < .0001) and was noninferior and superior (median difference, 12%; 95% posterior credible interval: 6% to 17%; P < .0001 for noninferiority and P = .0006 for superiority) to that of pulmonologists. Average diagnostic accuracies were 73%, 50%, and 61% by AC/DC tool, primary care physicians, and pulmonologists versus expert panel diagnosis, respectively., Conclusion: The AC/DC tool demonstrated superior diagnostic accuracy compared with primary care physicians and pulmonologists in the diagnosis of asthma and COPD in patients aged 35 years and greater and has the potential to support physicians in the diagnosis of these conditions in clinical practice., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Introduction: The diagnosis of Idiopathic pulmonary fibrosis (IPF) requires the careful exclusion of secondary causes of interstitial lung disease (ILD), and the collaboration among different specialists is considered paramount to establish a diagnosis with high diagnostic confidence. The multidisciplinary discussion (MDD) has assumed an increasing importance over the years in the different phases of the IPF diagnostic work-up., Areas Covered: The role of MDD in the diagnosis and management of IPF will be described. Practical insights will be provided into how and when to perform MDD based on the available scientific evidence. Current limitations and future perspectives will be discussed., Expert Opinion: In the absence of high diagnostic confidence, agreement between different specialists during MDD is recognized as a surrogate indicator of diagnostic accuracy. Often, despite a lengthy evaluation, the diagnosis remains unclassifiable in a significant percentage of patients. MDD therefore appears to be pivotal in attaining an accurate diagnosis of ILDs. The discussion among different specialists can also include other specialists, such as rheumatologists and thoracic surgeons, in addition to the core group of pulmonologists, radiologists, and pathologists. Such discussions can allow greater diagnostic accuracy and have important effects on management, pharmacologic therapies, and prognosis.

Background: Lung auscultation is an important tool for diagnosing respiratory diseases. However, the ability of observers to recognize respiratory sounds varies considerably and depends on the sound. The present study aimed to assess the auscultatory skills of healthcare professionals and medical students., Methods: A total of 295 physicians (185 pediatricians, 69 pulmonologists, and 41 physicians of general/internal medicine and subspecialties), 55 residents, and 50 medical students participated in the survey. They listened to five audio-recorded respiratory sounds and described them in free-form answers., Results: The rates of correct answers were 55.2% for fine crackles, 74.5% for coarse crackles, 72.2% for wheezes, 18.75% for squawks, and 11.25% for pleural friction rub. The medical specialty was correlated with the correct answers and both pediatricians and physicians of general/internal medicine and subspecialties recognized fewer sounds compared with respiratory physicians (odds ratio [OR]: 0.37; confidence interval [CI]: 0.22-0.62; p < 0.001 and, OR: 0.47; CI: 0.22-0.99, p = 0.048, respectively). Years of experience were negatively correlated with the number of correct answers (OR: 0.73; CI:0.62-0.84; p = 0.001)., Conclusions: Gaps remain in both terminology and recognition of lung sounds among a wide population of Greek physicians. Less experienced physicians perform better on lung auscultation, indicating that continuing education with critical feedback should be offered., (© 2022 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

Introduction: Recent news points to the eventuality of an armed conflict on the national territory., State of the Art: In this situation, pulmonologists will in all likelihood have a major role to assume in caring for the injured, especially insofar as chest damage is a major cause of patient death., Perspectives: The main injuries that pulmonologists may be called upon to treat stem not only from explosions, but also from chemical, biological and nuclear hazards. In this article, relevant organizational and pedagogical aspects are addressed. Since exhaustiveness on this subject is unattainable, we are proposing training on specific subjects for interested practitioners., Conclusion: The resilience of the French health system in a situation of armed conflict depends on the active participation of all concerned parties. With this in mind, it is of prime importance that the pneumological community be sensitized to the potential predictable severity of war-related injuries., (Copyright © 2023 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Background: Bronchoscopy and endobronchial ultrasound (EBUS) are standard procedures for the diagnosis and staging of patients suspected of lung cancer. If the patient simultaneously presents with suspicious liver lesions, it is tradition to refer the patient to a radiologist for ultrasound-guided percutaneous liver biopsy., Objective: The aim of this study was to investigate the results and complications when the pulmonologist performs all three procedures in the same setting., Methods: We retrospectively identified patients who during 2018-2020 underwent invasive workup of suspected lung cancer and liver metastases with percutaneous liver lesion biopsy with or without same-day endoscopy (bronchoscopy and EBUS). We compared diagnostic yield and safety of liver lesion biopsy stratified by same-day endoscopy or not., Results: In total, 89 patients were included, of whom 28 patients (31%) underwent same-day endoscopy. All liver lesion biopsies were fine-needle aspiration biopsies performed by experienced pulmonologists. No complications were reported, and overall diagnostic yield was 88%. The diagnostic yield was significantly lower in the same-day endoscopy group (71% vs. 95%), and undergoing endoscopy was significantly associated with having fewer liver lesions, higher prevalence of lung cancer, and lower overall prevalence of a malignant diagnosis., Conclusion: Liver biopsy in the same session as endoscopy during lung cancer workup was feasible and safe. Confounding by indication was present in our study.

Background Diagnosis of pulmonary hypertension (PH) is often delayed or missed, leading to disease progression and missed treatment opportunities. In this study, we measured variation in care provided by board-certified cardiologists and pulmonologists in simulated patients with potentially undiagnosed PH. Methods and Results In a cross-sectional study (https://www.clinicaltrials.gov, NCT04693793), 219 US practicing cardiologists and pulmonologists cared for simulated patients presenting with symptoms of chronic dyspnea and associated signs of potential PH. We scored the clinical quality-of-care decisions made in a clinical encounter against predetermined evidence-based criteria. Overall, quality-of-care scores ranged from 18% to 74%, averaging 43.2%±11.5%. PH, when present, was correctly suspected 49.1% of the time. Conversely, physicians incorrectly identified PH in 53.7% of non-PH cases. Physicians ordered 2-dimensional echocardiography in just 64.3% of cases overall. Physicians who ordered 2-dimensional echocardiography in the PH cases were significantly more likely to get the presumptive diagnosis (61.9% versus 30.7%; P <0.001). Ordering other diagnostic work-up items showed similar results for ventilation/perfusion scan (81.5% versus 51.4%; P =0.005) and high-resolution computed tomography (60.4% versus 43.2%; P =0.001). Physicians who correctly identified PH were significantly more likely to order confirmatory right heart catheterization or refer to PH center (67.3% versus 15.8%; P <0.001). Conclusions A wide range of care in the clinical practice among simulated patients presenting with possible PH was found, specifically in the evaluation and plan for definitive diagnosis of patients with PH. The delay or misdiagnosis of PH is likely attributed to a low clinical suspicion, nonspecific symptoms, and underuse of key diagnostic tests. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04693793.

Background and Objectives: Gender inequality in medicine remains an issue. Despite the increasing proportion of female physicians, women still appear underrepresented in interventional pulmonology (IP) careers. To date, no data are available on the gender distribution in IP., Method: An online survey was sent to pulmonary physicians internationally between July and December 2022. The survey included questions on gender diversity in the pulmonology departments, such as the proportion of male, female, and gender diverse physicians performing bronchoscopy, career progression, and social life., Results: Responses from 92 physicians (mean age 45 ± 10 years) from 47 hospitals across 17 countries were analysed, of whom 52% were women. Overall, 79% of the respondents were pulmonologists and 83% perform bronchoscopy. Although men continue to dominate bronchoscopy (65 vs. 43%) and are more likely to be involved in research (89 vs. 77%), the observed difference is statistically not significant (p = 0.135 and p = 0.281). Leading positions are held by 60% of male respondents and 23% of female respondents (p = 0.002). Men are also more often reported to have academic awards. Discrimination based on gender was reported by 5.3% of all men and 26.8% of all women (p = 0.023)., Conclusions: Men and women are almost equally involved in IP, especially in female-led bronchoscopy units. However, leading positions and academic awards are still predominantly held by men., (© 2023 S. Karger AG, Basel.)

Objective: The objective of this study was to evaluate and compare knowledge, attitude, and practice patterns between pulmonologists and allergists for adult asthma in Turkey. Methods: Questionnaire-based data were gathered from 236 pulmonologists and 62 allergists, who had been members of the Turkish Thoracic Society and Turkish National Society of Allergy and Clinical Immunology in January-March 2021. Univariate and multivariate statistics were used to determine the factors associated with primary reliever preferences. Results Of the 298 physicians, 39% encountered at least five asthma patients daily. Spirometer was used frequently by both the allergists (82.3%) and pulmonologists (77.5%) for asthma diagnosis. Budesonide was the most preferred inhaler corticosteroid. Formoterol/budesonide was the most preferred ICS/LABA combination, followed by beclomethasone/formoterol and fluticasone/salmeterol for asthma treatment. For mild asthmatics, formoterol/ICS was the most preferred (72.6%) reliever among allergists, whereas salbutamol was the most preferred (66.1%) among pulmonologists ( : Of the 298 physicians, 39% encountered at least five asthma patients daily. Spirometer was used frequently by both the allergists (82.3%) and pulmonologists (77.5%) for asthma diagnosis. Budesonide was the most preferred inhaler corticosteroid. Formoterol/budesonide was the most preferred ICS/LABA combination, followed by beclomethasone/formoterol and fluticasone/salmeterol for asthma treatment. For mild asthmatics, formoterol/ICS was the most preferred (72.6%) reliever among allergists, whereas salbutamol was the most preferred (66.1%) among pulmonologists ( p The use of diagnostic tools, such as a spirometer, for asthma diagnosis was compatible with the guidelines. While recent updates of the guidelines indicate that salbutamol should not be used solely in mild asthmatics due to its harmful effects in long-term use, it still was the most preferred drug by pulmonologists. Postgraduate education programs are needed to improve compliance with the guidelines. Conclusions : The use of diagnostic tools, such as a spirometer, for asthma diagnosis was compatible with the guidelines. While recent updates of the guidelines indicate that salbutamol should not be used solely in mild asthmatics due to its harmful effects in long-term use, it still was the most preferred drug by pulmonologists. Postgraduate education programs are needed to improve compliance with the guidelines.

Pulmonologists in primary care clinics are positioned between those in tertiary hospitals and general practitioners in clinics and are anticipated to promote hospital-clinic collaboration for patients with chronic obstructive pulmonary disease (COPD). However, the clinical features of patients in primary respiratory clinics are unclear. This multicenter study cross-sectionally compared the characteristics of patients with COPD in a respiratory clinic (n = 69) with those in a university hospital (n = 124). More patients visited the clinic for symptom relief without a referral, whereas more visited the hospital for consultation of abnormal spirometry/computed tomography (CT). The patients in the clinic showed female predilection, higher prevalence of current smokers, severe dyspnea, and concomitant heart failure, and higher CT-measured cross-sectional area ratio of pectoralis muscle to adjacent subcutaneous adipose tissue compared to those in the hospital (all p < 0.05). The observed differences between the two groups suggest the need to establish the role of primary pulmonologists in hospital-clinic collaboration for better COPD management., Competing Interests: Conflict of Interest N.T., S.S., and T.H. were supported by a grant from FUJIFILM Co., Ltd. S.S. received grants from Nippon Boehringer Ingelheim, Philips-Respironics, Fukuda Denshi, Fukuda Lifetec Keiji, and ResMed outside of the submitted work. None of these companies played a role in the design or analysis of the study or the writing of the manuscript. The other authors have no conflicts of interest to declare., (Copyright © 2022 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Cardiothoracic surgical critical care medicine is practiced by a diverse group of physicians including surgeons, anesthesiologists, pulmonologists, and cardiologists. With a wide array of specialties involved, the training of cardiothoracic surgical intensivists lacks standardization, creating significant variation in practice. Additionally, it results in siloed physicians who are less likely to collaborate and advocate for the cardiothoracic surgical critical care subspeciality. Moreover, the current model creates credentialing dilemmas, as experienced by some cardiothoracic surgeons. Through the lens of critical care anesthesiologists, this article addresses the shortcomings of the contemporary cardiothoracic surgical intensivist training standards. First, we describe the present state of practice, summarize past initiatives concerning specific training, outline why standardized education is needed, provide goals of such training standardization, and offer a list of desirable competencies that a trainee should develop to become a successful cardiothoracic surgical intensivist.