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Supported by the National Health and Medical Research Council Centre of Research Excellence in Pulmonary Fibrosis (GNT1116371), and by foundation partner, Boehringer Ingelheim, and program partners, Roche and Galapagos. Rationale : The interstitial lung disease (ILD) multidisciplinary meetings (MDM), composed of pulmonologists, radiologists, and pathologists, is integral to the rendering of an accurate ILD diagnosis. However, there is significant heterogeneity in the conduct of ILD MDMs, and questions regarding their best practices remain unanswered. Objectives : To achieve consensus among ILD experts on essential components of an ILD MDM. Methods : Using a Delphi methodology, semi-structured interviews with ILD experts were used to identify key themes and features of ILD MDMs. These items informed two subsequent rounds of online questionnaires that were used to achieve consensus among a broader, international panel of ILD experts. Experts were asked to rate their level of agreement on a five-point Likert scale. An a priori threshold for consensus was set at a median score 4 or 5 with an interquartile range of 0. Results : We interviewed 15 ILD experts, and 102 ILD experts participated in the online questionnaires. Five items and two exploratory statements achieved consensus on being essential for an ILD MDM following two questionnaire rounds. There was consensus that the presence of at least one radiologist, a quiet setting with a visual projection system, a high-quality chest high-resolution computed tomography, and a standardized template summarizing collated patient data are essential components of an ILD MDM. Experts also agreed that it would be useful for ILD MDMs to undergo an annual benchmarking process and a validation process by fulfilling a minimum number of cases annually. Twenty-seven additional features were considered to be either highly desirable or desirable features based on the degree of consensus. Although our findings on desirable features are similar to the current literature, several of these remain controversial and warrant further research. The study also showed an agreement among participants on several future concepts to improve the ILD MDM, such as performing regular self-assessments and conducting research into shared practices to develop an international expert guideline statement on ILD MDMs. Conclusions : This Delphi study showed consensus among international ILD experts on essential and desirable features of an ILD MDM. Our data represent an important step toward potential collaborative research into future standardization of ILD MDMs. Postprint

Diagnosis of interstitial lung disease (ILD) requires a multidisciplinary discussion approach that includes clinicians, radiologists, and pathologists. Surgical lung biopsy (SLB) is currently the recommended standard in obtaining pathologic specimens for patients with ILD requiring a tissue diagnosis. The increased diagnostic confidence and accuracy provided by microscopic pathology assessment of SLB specimens must be balanced with the associated risks in patients with ILD. This document was developed by the SLB Working Group of the Pulmonary Fibrosis Foundation, composed of a multidisciplinary group of ILD physicians, including pulmonologists, radiologists, pathologists, and thoracic surgeons. In this document, we present an up-to-date literature review of the indications, contraindications, risks, and alternatives to SLB in the diagnosis of fibrotic ILD; outline an integrated approach to the decision-making around SLB in the diagnosis of fibrotic ILD; and provide practical information to maximize the yield and safety of SLB.

Objective In Japan, both medical oncologists and pulmonologists treat lung cancer patients; however, the difference in their attitude toward palliative care referral is unknown. Thus, we retrospectively investigated the difference in attitudes toward palliative care referral between medical oncologists and pulmonologists in Japan. Methods We retrospectively reviewed the charts of patients with thoracic malignancy who died at Shimane University Hospital between June 2011 and October 2015. We compared the patients' demographics and medical history according to their doctor's specialty (i.e., medical oncologist or pulmonologist). Results We identified 182 patients, among whom 90 were treated by medical oncologists and 56 by pulmonologists at the outpatient clinic. Thirty-six patients did not undergo outpatient clinic treatment. Out of 59 patients, 22 (37.3%) referred by medical oncologists, and 7 out of 36 patients (19.4%) referred by pulmonologists, were referred to palliative care specialists in the outpatient setting (p=0.107, Fisher's exact test). The median survival time after admission to PCU was 21 (95% CI: 13-32) and 9 (95% CI: 5-15) days among the patients treated by medical oncologists and pulmonologists, respectively (p=0.128). Conclusion Medical oncologists are more likely to refer their patients to palliative care in the outpatient setting, thus enabling patients to receive longer end of life care in the PCU. Bridging the research gap regarding differences between the physicians' attitudes toward palliative care referral may lead to patients receiving more quality palliative care. (227 words).

The treatment of cancer patients with immune checkpoint inhibitors (ICI) (anti-CTLA-4, anti-PD-1, anti-PD-L1, combined therapy anti-PD-1/PD-L1 with anti-CTLA-4) has without doubt been a significant breakthrough in the field of oncology in recent years and constitutes a major step forward as a novel type of immunotherapy in the treatment of cancer. ICIs have contributed to a significant improvement in the outcome of treatment and prognosis of patients with different types of malignancy. With the expansion of the use of ICIs, it is expected that caregivers will face new challenges, namely, they will have to manage the adverse side effects associated with the use of these drugs. New treatment options pose new challenges not only for oncologists but also for specialists in other clinical fields, including general practitioners (GPs). They also endorse the need for taking a holistic approach to the patient, which is a principle widely recognized in oncology and especially relevant in the case of the expanding use of ICIs, which may give rise to a wide variety of organ complications resulting from treatment. Knowledge and awareness of the spectrum of immune-related adverse events (irAEs) will allow doctors to qualify patients for treatment more appropriately, prevent complications, correctly recognize, and ultimately treat them. Additionally, patients with more non-specific symptoms would be expected, in the first instance, to consult their general practitioners, as complications may appear even after the termination of treatment and do not always proceed in line with disease progression. Dealing with any iatrogenic complications, will not only be the remit of oncologists but because of the likelihood that specific organs may be affected, is likely to extend also to specialists in various fields of internal medicine. These specialists, e.g., endocrinologists, dermatologists, pulmonologists, and gastroenterologists, are likely to receive referrals for patients suffering from specific types of adverse events or will be asked to provide care in cases requiring hospitalization of patients with complications in their field of expertise. In view of these considerations, we believe that there is an urgent need for multidisciplinary teamwork in the treatment of cancer patients undergoing immunotherapy and suffering the consequent adverse reactions to treatment.

The article presents literature review of the diseases associated with mutations in the FLNA gene encoding filamin A, which is a cytoskeleton protein with polymorphic functions. The mutations of this gene lead to the damage of the central nervous system (periventricular nodular heterotopy), respiratory organs (emphysema, interstitial lung disease), heart (congenital heart defects and minor heart abnormalities); the listed diseases can be diagnosed at different ages. The information presented in this review can be useful for clinical geneticists, specialists in rare (orphan) diseases, pediatricians, neonatologists, neurologists, epileptologists, pulmonologists, surgeons, cardiologists for timely diagnosis and improvement of medical care for patients requiring a multidisciplinary approach.

Introduction Ultrasonography has been shown to be a useful tool for diagnosing pneumothorax in the hands of experts. After performing bronchopleural procedures, the recommendation is to perform chest radiography to rule out complications. Our objective was to determine the validity of lung ultrasound, conducted by pulmonologists without experience in this procedure, to tule out pneumothorax after invasive procedures. Material and Methods Our prospective observational study consecutively included patients who underwent transbronchial lung biopsy (TBLB), therapeutic thoracentesis (TT) and/or transparietal pleural biopsies (PB) for whom subsequent chest radiography to rule out complications was indicated. In all cases, the same pulmonologist who performed the technique performed an ultrasound immediately after the procedure. A diagnosis of pneumothorax was considered in the presence of a lung point or the combination of the following signs: absence of pleural sliding, absence of B-lines and presence of the “barcode” sign. Results We included 275 procedures (149 TBLBs, 36 BPs, 90 TTs), which resulted in 14 (5.1%) iatrogenic pneumothoraxes. Ultrasonography presented a sensitivity of 78.5%, a specificity of 85% and positive and negative predictive value of 22% and 98.6%, respectively. Ultrasonography did not help detect the presence of 3 pneumothoraxes, one of which required chest drainage, but adequately diagnosed 2 pneumothoraxes that were not identified in the initial radiography. Conclusions Lung ultrasound performed by pulmonologists at the start of their training helps rule out pneumothorax with a negative predictive value of 98.6%, thereby avoiding unnecessary radiographic control studies in a considerable number of cases.

PURPOSE OF REVIEW: Severe Acute Respiratory Syndrome Coronavirus 2 presents as symptomatic coronavirus disease 2019 (COVID-19) disease in susceptible patients. Severe pediatric COVID-19 disease is rare, limiting potential data accumulation on associated respiratory failure in children. Pediatric intensivists and pulmonologists managing COVID-19 patients look to adult guidelines and pediatric-specific consensus statements to guide management. The purpose of this article is to review the current literature and recommended strategies for the escalation of noninvasive and invasive respiratory support for acute respiratory failure associated with COVID-19 disease in children. RECENT FINDINGS: There are no prospective studies comparing COVID-19 treatment strategies in children. Adult and pediatric ventilation management interim guidance is based on evidence-based guidelines in non-COVID acute respiratory distress syndrome, with considerations of (1) noninvasive positive pressure ventilation versus high-flow nasal cannula and (2) high versus lower positive end expiratory pressure strategies related to lung compliance and potential lung recruitability. SUMMARY: Management of acute respiratory failure from COVID-19 requires individualized titration of noninvasive and invasive ventilation modalities with consideration of preserved or compromised pulmonary compliance. Research regarding best practices in the management of pediatric severe COVID-19 with respiratory failure is lacking and is acutely needed as the pandemic surges and vaccination of the pediatric population will be delayed compared to adults.

This article summarizes modern information concerning the aspects of spirometry in children; focuses on the conditions, features of preparation, implementation and analysis of spirometry results in children in order to obtain reliable, reproducible and comparable results in various laboratories; this information is intended for pediatricians, pulmonologists, doctors and secondary medical personnel of functional diagnostics offices.

Background: Food allergy is an adverse health effect arising from a specific immune response that occurs reproducibly following exposure to a given food. The main cause of food allergies in children under three years old is Cow’s Milk Protein (CMP). The estimated prevalence of Cow’s Milk Protein Allergy (CMPA) is 2% to 3% in the first year of life. An observational study conducted in pediatricians’ offices revealed a gastroenterologist-diagnosed prevalence of 5% in the group of patients. Objective: to compare between general pediatricians and other sub-specialty of pediatrician regarding awareness of cow’s milk protein allergy. Patients and Methods: This study was conducted in El-Sharkia Governorate, Egypt. Pediatricians of both sexes of different subspecialties work in government facility with or without private facility and work in El-Sharkia Governorate. The sample size calculated using open Epi was 256 physicians. Results: This study showed that general pediatricians were 78.1%, gastroenterologists were 3.2%, immunologists were 2.7% and pulmonologists were 3.9%. There was a low level of knowledge about CMA among the studied group. Conclusion: Our findings revealed that there was a low knowledge about Cow’s Milk Protein Allergy among pediatricians. We found a huge variability in general pediatricians and other sub-specialty of pediatrics regarding CMPA.

Johanna MC Broese,1,2 Rianne MJJ van der Kleij,1 Els ML Verschuur,2 Huib AM Kerstjens,3 Yvonne Engels,4 Niels H Chavannes1 1Public Health & Primary Care, Leiden University Medical Center, Leiden, the Netherlands; 2Lung Alliance Netherlands, Amersfoort, the Netherlands; 3Respiratory Medicine & Tuberculosis, University of Groningen and University Medical Center Groningen, Groningen, the Netherlands; 4Anesthesiology, Pain & Palliative Medicine, Radboud University Medical Center, Nijmegen, the NetherlandsCorrespondence: Johanna MC BroesePublic Health and Primary Care, Leiden University Medical Centre, Post Zone V0-P, Postbox 9600, Leiden, 2300 RC, the NetherlandsEmail j.m.c.broese@lumc.nlIntroduction: Patients with advanced chronic obstructive pulmonary disease (COPD) experience significant symptom burden, leading to poor quality of life. Although guidelines recommend palliative care for these patients, this is not widely implemented and prevents them from receiving optimal care.Objective: A national survey was performed to map the current content and organization of palliative care provision for patients with COPD by pulmonologists and general practitioners (GPs) in the Netherlands.Methods: We developed a survey based on previous studies, guidelines and expert opinion. Dutch pulmonologists and GPs were invited to complete the survey between April and August 2019.Results: 130 pulmonologists (15.3%; covering 76% of pulmonology departments) and 305 GPs (28.6%) responded. Median numbers of patients with COPD in the palliative phase treated were respectively 20 and 1.5 per year. 43% of pulmonologists and 9% of GPs reported some formalized agreements regarding palliative care provision. Physicians most often determined the start of palliative care based on clinical expertise or the Surprise Question. 31% of pulmonologists stated that they often or always referred palliative patients with COPD to a specialist palliative care team; a quarter rarely referred. 79% of the respondents mentioned to often or always administer opioids to treat dyspnea. The topics least discussed were non-invasive ventilation and the patient’s spiritual needs. The most critical barrier to starting a palliative care discussion was difficulty in predicting the disease course.Conclusion: Although pulmonologists and GPs indicated to regularly address palliative care aspects, palliative care for patients with COPD remains unstructured and little formalized. However, our data revealed a high willingness to improve this care. Clear guidance and standardization of practice are needed to help providers decide when and how to initiate discussions, when to involve specialist palliative care and how to optimize information exchange between care settings.Keywords: COPD, palliative care, advance care planning, surprise question, organization

In 2018-2020, The American Thoracic Society's Pediatric Pulmonology Division Directors Association (PPDDA) and Pediatric Pulmonology Training Directors Association (PEPTDA) convened a series of workshops to analyze workforce issues from the perspectives of current leaders within the discipline. In this, the report from the 3rd workgroup, we examine future workforce issues from several perspectives. We describe a PPDDA survey regarding current state and future needs of the discipline; an assessment of the current NIH research funding portfolio for major children's respiratory disorders; and an estimate of workforce trends in training, based mainly on ABP data. We conclude that current fellowship graduation rates appear to be sufficient to maintain and even grow the total number of pulmonologists, but demand for pediatric pulmonologists may still be greater than supply, and there are geographical disparities in access to care. New treatments for CF, growth of hospitalist services, care of technology dependent children, and multidisciplinary care for complex chronic disease, will likely change our practice over the next 10 years. Research funding appears to be robust for asthma, CF, BPD, microbiome, and pulmonary hypertension, compared to other chronic respiratory disorders. Few of these grants are led by pediatric pulmonologists. Thus, our discipline needs to adjust our training of fellows and junior faculty to take advantage of existing funding opportunities as well as advocate for greater funding for the other disorders we manage. Finally, we highlight opportunities for the discipline to enhance its roles in addressing emerging respiratory pathogens and expanding the diversity of its workforce. This article is protected by copyright. All rights reserved.

The increasing life expectancy of HIV-infected persons due to antiretroviral therapy (ART) is associated with growing frequency of non-opportunistic respiratory diseases. This review of literature is devoted to chronic obstructive pulmonary disease (COPD), which is known to be the most common chronic noninfectious lung condition in HIV-patients. The prevalence of COPD in the global population with HIV is high and is associated with HIV.The article contains actual data on HIV/COPD comorbidity, presents current information on mechanism of COPD development in HIV-infection, factors contributing to the mutual influence and adverse course of comorbid conditions. The specialties of COPD treatment during ART and clinically significant drug interactions between different COPD medications and some antiretrovirals are highlighted.The socio-economic significance of both HIV-infection and COPD argues wide informing of pulmonologists, therapists and infectious disease specialists about the course and treatment of COPD in persons with HIV-infection.

The importance of vaccinations for COPD patients has been previously described. However, there is still a gap between guideline recommendations and the implementation of preventive care delivery for these patients. Specially, the rise of SARS-CoV-2 pandemic has made the significance of vaccination adherence more critical to address. Our study showed that referral to pulmonary clinic is associated with increased odds of receiving influenza (OR = 1.97, [95% CI 1.07, 3.65]) and pneumococcal vaccinations (PCV13 OR = 3.55, [1.47, 8.54]; PPSV23 OR = 4.92, [1.51, 16.02]). These data suggest that partnerships between primary care physicians and pulmonologists can potentially improve the vaccination rates for patients with COPD.

Background The treatment with short-acting beta-2 agonists (SABA) alone is no longer recommended due to safety issues. Instead, the current Global Initiative for Asthma (GINA) Report recommends the use of the combination of inhaled corticosteroids (ICS) with the rapid/long-acting beta-2 agonist formoterol, although the use in steps 1 and 2 is still off-label in the EU and in many countries. It is important to understand clinicians’ knowledge and opinions on the issue with the ultimate goal to encourage the implementation of the new approach in clinical practice. Methods We performed an international survey, directed to pulmonologists interested in the management of patients with asthma. Results Most participants reported that SABA alone should not be used in GINA Step 1 asthma treatment. As-needed low-dose ICS/formoterol combination to patients in step 1, and as-needed low-dose ICS/formoterol as reliever therapy in any step were found to be of current use prescribed in their real-life settings. SABA alone was still prescribed to a proportion of patients, although the pulmonologists’ opinion was that it should no longer be used. Conclusions Most specialists are up to date and understand the relevance of the changes in GINA reports from 2019. Nevertheless, dissemination and implementation of GINA novel management strategy is still needed.

Bronchoalveolar lavage (BAL) plays a role in the diagnosis of diffuse parenchymal lung diseases (DPLD); however, poor BAL fluid (BALF) recovery results in low diagnostic reliability. BAL is relatively safe, but its indications should be carefully considered in patients with risks. Therefore, estimating the likelihood of recovery failure is helpful in clinical practice. This study aimed to clarify predictors of BALF recovery failure and to develop its simple-to-use prediction models. We detected the predictors applying a logistic regression model on clinical, physiological, and radiological data from 401 patients with DPLD (derivation cohort). The discrimination performance of the prediction models using these factors was evaluated by the c-index. In the derivation cohort, being a man, the forced expiratory volume in one second/forced vital capacity, and a BAL target site other than right middle lobe or left lingula were independent predictors. The c-indices of models 1 and 2 that we developed were 0.707 and 0.689, respectively. In a separate cohort of 234 patients (validation cohort), the c-indices of the models were 0.689 and 0.670, respectively. In conclusion, we developed and successfully validated simple-to-use prediction models useful for pulmonologists considering BAL indications or target sites, based on independent predictors for BALF recovery failure.

Despite being especially used in its solid form, silicone is still injected as a liquid filler for breast contouring in many countries. Here, we present a rare case of a woman with silicone pneumonitis and extended breast scarring after breast silicone injection. Because of evidence of a restrictive syndrome due to the thoracic extensive scarring tissue and the high demand of oxygen therapy, as jointly agreed with the pulmonologists, we decided to perform a surgical asportation of the scarring tissue and covering with microsurgical flap. We chose the deep inferior epigastric perforator flap mainly because of the large amount of skin that is possible to use, the good skin texture matching, and the possibility of double team working without changing patient’s position.

Kartagener Syndrome (CS) is a rare autosomal recessive disease that is a part of primary ciliary dyskinesia (PCD), and is characterized by a triad of syndrome including bronchiectasis, polysinusitis and a complete mirror arrangement of the internal organs of the chest and abdominal cavities (situs inversus). In most patients, bronchiectasis in the lungs develops from the first years of life and progresses in time. The tardy diagnostic leads to a poor prognosis of the disease and adduce the development of persistent violations of the function of external respiration. Most often, patients with CS are observed by physicians and pulmonologists from early childhood, since respiratory infections often require annual hospitalization in specialized medical institutions due to abnormalities of the ciliary epithelium of the respiratory tract. However, to date, there are no generally accepted recommendations for the management and treatment of patients in this category. This article describes the case of a newly diagnosed CS in an older patient undergoing surgical treatment for gastric cancer. Despite the pronounced concomitant pathology on the part of the bronchopulmonary system, the perioperative period in the patient proceeded relatively satisfactorily and did not entail an increase in the length of hospitalization.

The ongoing pandemic of COVID-19 has presented multiple challenges to global healthcare services, dictating changes in almost every aspect of daily medical practice. Performing aerosol generating procedures (AGPs) in the field of interventional pulmonology can lead to profound formation of aerosols, leading to a high risk of infection among healthcare workers (HCWs). We share our experiences on performing AGPs in the midst of a COVID-19 pandemic by focusing on changes in AGP practices. In a pandemic, HCWs ought to adapt to the ever-changing situation and use available resources to provide the best possible healthcare to patients, ensure safety of staff, and continue medical education of future pulmonologists. Keywords: Bronchoscopy, infectious diseases, pulmonary, respiratory medicine

Significant variability in adherence to COPD management recommendations has been reported. We aimed to evaluate real-life COPD pharmacotherapy prescribing patterns and adherence to the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) global strategy in Switzerland. A questionnaire-based survey was conducted among Swiss general practitioners (GPs) and pulmonologists (PULs) from May 1 to November 30, 2017. Participants were invited to complete a questionnaire on their next 5-10 consecutive patients already receiving a pharmacological treatment for COPD. They were requested to assess dyspnea using the modified Medical Research Council (mMRC) dyspnea scale and to determine whether a treatment adjustment was indicated. Fifty-three PULs and 39 GPs completed questionnaires on 511 COPD patients. Dyspnea with mMRC grade ≥2 was reported in 62.5% of the patients, and 31.9% had had at least two exacerbations (or at least one with hospital admission) in the last 12 months. The vast majority (87.1%) of GOLD A patients were overtreated. In the GOLD B group, 52.2% of prescriptions were concordant with GOLD 2017 recommendations, but 37% of patients were overtreated. Among GOLD C patients, 49.2% received GOLD-adherent treatment and 47.5% were overtreated. In the GOLD D category, 78.8% of the patients received a treatment consistent with recommendations but 15.2% were undertreated. After reassessment of patient status, treatment was modified in 50.3% of the patients. This study confirms that discordance of real-world prescription patterns with international guidance is frequent. Further educational efforts are required to improve adherence to COPD management recommendations.

We herein report four cases of diffuse bronchiolitis proven by a transbronchial lung cryobiopsy (TBLC). Based on various aspects, including the pathological findings, we definitively diagnosed two patients with diffuse panbronchiolitis (DPB) and the other two with primary ciliary dyskinesia (PCD). One of the DPB patients had more severe peribronchiolar fibrosis than the other, and the disease course was refractory to macrolide therapy. One of the PCD patients was additionally diagnosed with combined constrictive bronchiolitis. This report highlights the importance of a TBLC in the differentiation of bronchiolitis, suggesting its utility for helping pulmonologists formulate a treatment strategy.

Background Diagnostic and treatment strategies for chronic obstructive pulmonary disease (COPD) vary greatly. Despite international efforts to standardize the management of COPD, two-thirds of primary care patients are not diagnosed, treated, or managed according to current evidence-based guidelines, probably because of the difficulty of applying these in routine practice. The aim of this study was to develop a simplified algorithm for diagnosing, treating, and managing COPD in primary care whose consistency, scientific relevance, and applicability to routine clinical practice met approval bct 3y family doctors (FDs) and pulmonologists. Methods The algorithm was developed in a series of sequential phases, consisting of a preliminary meeting among group coordinators to design the initial structure, an input meeting with FDs and pulmonologists to refine and validate the proposal, an algorithm design stage, and a Delphi survey in which FDs and pulmonologists evaluated and approved the final version. A target of 75% or more was established for each of the 20 items in the Delphi survey in the FDs group as well as the pulmonologists group. It was estimated that at least two Delphi rounds would be needed to reach consensus. Results In total, 118 physicians (75 FDs and 43 pulmonologists) participated in the Delphi process. Fourteen of the 20 items (70%) were approved in the first round. In the second round (in which 74 FDs and 42 pulmonologists participated), the remaining six items, which had been reformulated based on feedback from the first round, were approved, together with an additional question on the face validity of the algorithm as a whole. Dyspnea was positioned as the main determinant of treatment decisions in the new algorithm. Conclusion According to the experts consulted, this new simplified algorithm for the diagnosis, treatment, and management of COPD in primary care is a clear, functional, and useful tool for routine practice and meets the requirements for the correct management of this condition.

Context Although idiopathic pulmonary fibrosis (IPF) has worse outcomes compared with most malignancies, patients with IPF receive poor access to optimal palliative care. Objectives This study aimed to characterize the practice of pulmonologists regarding palliative care and end-of-life communication for patients with IPF and identify perceived difficulties and barriers thereto. Methods Self-administered questionnaires were sent by mail to representative pulmonologists from Shizuoka prefecture, Japan. Physician-reported practice, difficulties, timing of end-of-life communication, and barriers related to palliative care were investigated. Results Among the 135 participants, 130 (96%) completed the questionnaire. Most of the participants reported that patients with IPF complained of dyspnea and cough. However, less morphine was prescribed for IPF than for lung cancer. The participants experienced greater difficulty in providing palliative care for IPF than for lung cancer. Moreover, actual end-of-life discussions in patients with IPF were conducted later than the physician-perceived ideal timing. Among the barriers identified, few established treatment and difficulty in predicting prognosis (odds ratio [OR] 2.0; P = 0.04), discrepancies in understanding and care goals among patients, family, and medical staff (OR 2.2; P = 0.03), and inadequate communication about goal of care (OR 2.3; P = 0.003) were significantly associated with the physician-perceived difficulties in providing palliative care for patients with IPF. Conclusion Pulmonologists experienced greater difficulty in providing palliative care to patients with IPF than to those with lung cancer. Clinical studies on the optimal palliative care for patients with IPF are urgently required.

Background Food allergy (FA) is a chronic condition of emerging global concern. Surveys have been conducted in numerous countries to assess physician knowledge, attitude, and practices (KAP) pertaining to FA and anaphylaxis, and substantial deficits in their KAP were identified. Objective To assess the KAP of medical clinicians in Hyderabad, India, with respect to FA and anaphylaxis. Methods A regionally representative sample of 570 physicians including 113 general practitioners, 123 pediatricians, 110 pulmonologists, 113 dermatologists, and 111 gastroenterologists were recruited from all major institutions in Hyderabad, India. A validated questionnaire was used to assess their KAP. Results Overall, 90% of questions were correctly answered and differences emerged with respect to specific items, namely the following: (1) the lateral thigh being the preferred location for epinephrine administration (P = .001); (2) a positive skin prick test or radioallergosorbent test is sufficient for FA diagnosis (P = .04); and (3) the appropriate epinephrine dose for a 27-kg child (P = .006). Approximately 95% of the participants in each group were confident in their ability to care for patients with FA, yet 91% desired additional periodic FA training sessions. Conclusion Survey findings suggest that although FA knowledge among South Indian clinicians seems high across all major specialties who care for patients with FA, there are differences in the level of knowledge among them, which in turn reflects the differences in attitude and approach toward their patients. These FA care providers still desire to further participate in continuing medical education efforts in the field of food allergy. Efforts to provide periodic training and education for all FA clinical care providers remain vital in South India.

BACKGROUND Flexible bronchoscopy is an essential procedure for the evaluation and management of the pulmonary disease. However, this technology and related training is not available in many low-middle income countries (LMICs). We conducted a pilot training program for flexible bronchoscopy in Uganda. METHODS A multimodal curriculum was developed with pulmonologists from Uganda and the United States. The training included an online distance learning management system for video content, simulation, just-in-time training, and deliberate practice via clinical proctoring. Procedural standards and a de novo bronchoscopy suite were concurrently developed. Competency was assessed using the Bronchoscopic Skills and Tasks Assessment Tool written examination and the Ontario Bronchoscopy Assessment Tool. RESULTS We trained 3 pulmonary physicians with no prior experience in flexible bronchoscopy. Three bronchoscopies with bronchoalveolar lavage were performed during the training and an additional 11 cases were performed posttraining. All 3 Ugandan physicians had an increase in their written Bronchoscopic Skills and Tasks Assessment Tool and Ontario Bronchoscopy Assessment Tool in the competent range (P

Hepatic hydrothorax is the formation of transudative pleural effusion as a consequence of portal hypertension. Only a minority of cases resolve after sodium restriction and diuretics. Despite the relatively low incidence of 5-15% among patients with cirrhotic portal hypertension, the high morbidity and serious clinical implications associated with hepatic hydrothorax necessitate a well-defined treatment strategy to guide patient care. Management is typically multidisciplinary, involving hepatologists, interventional pulmonologists, interventional radiologists, surgeons, and other specialties. In this manuscript, we assemble a multidisciplinary team to critically review the available literature and provide an evidence-based guidance for management of hepatic hydrothorax.

La fracción exhalada de óxido nítrico (FeNO) se relaciona con el nivel de inflamación eosinofílica en las vías aéreas y los niveles de interleucina-13, por lo que podría ser una herramienta diagnóstica y de seguimiento en el asma. Se convocó un grupo de trabajo integrado por neumólogos, expertos en fisiología de la respiración y alergólogos, con la finalidad de establecer criterios para el uso de la FeNO en asma en México. Mediante un método Delphi simplificado y discusión grupal, se consensaron varios puntos clave en relación con el uso de la FeNO. Sugerimos que la medición de la FeNO sirve para el diagnóstico de asma en clínicas especializadas, tanto en niños como adultos, así como para determinar el nivel de tratamiento con corticosteroides. En asma grave, recomendamos la FeNO para la endotipificación, detectar la mala adherencia terapéutica, el subtratamiento y el riesgo de crisis. Sugerimos su uso para determinar el nivel de tratamiento con corticosteroides e identificar pacientes con riesgo de tener una pérdida de la función pulmonar. También la recomendamos en el adulto para mejorar la elección de medicamentos biológicos y, en este contexto, solo la sugerimos en casos selectos en niños.

The review presents information on epidemiology, clinical, laboratory and radiological manifestations of infectious and malignant respiratory diseases in HIV-infected patients.The data on the most common infections (communityacquired pneumonia, tuberculosis, Pneumocystis jiroveci pneumonia) and malignant diseases (Kaposhi’s sarcoma, lymphomas) as well as less frequent diseases (CMV-infection, MAC-infection, fungal pneumonias) are presented.The article contains facts about the incidence of pulmonary diseases according to the severity of HIV-associated immunodeficiency. This review also presents current information on the diagnostic criteria, treatment regimens and secondary prophylaxis for HIV-associated respiratory infections and malignancies. The specialties of ART initiation in definite cases of opportunistic infections and ART assignment during the diagnostic period are highlighted.The growing number of HIV-infected patients and the wide spectrum of possible pulmonary diseases argue the need for optimal clinical approach to HIV-infected patients with respiratory lesions for various physicians (general practitioners, pulmonologists and phthisiatricians).

Background The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs). Methods A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report. Results Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure. Conclusion This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.

OBJECTIVE To determine the performance of administrative-based algorithms for classifying interstitial lung disease (ILD) complicating rheumatoid arthritis (RA). METHODS Participants in a large, multicenter RA registry were screened for ILD using codes from the International Classification of Diseases, Ninth Revision (ICD-9) and the ICD-10. Medical record review confirmed ILD among participants screening positive and a random sample of those screening negative. ICD and procedure codes, provider specialty, and dates were extracted from Veterans Affairs administrative data to construct ILD algorithms. Performance of these algorithms against medical record review was assessed by sensitivity, specificity, positive predictive value (PPV), negative predictive value, and kappa using inverse probability weighting to account for sampling methods. RESULTS Medical records of 536 RA patients were reviewed, confirming 182 (stringent definition) and 203 (relaxed definition) cases of ILD. Initially, we identified ≥2 ICD codes from inpatient or outpatient encounters as optimal discriminating factors (specificity 96.0%, PPV 65.5%; κ = 0.70). Subsequently, we constructed a set of ICD-9 and ICD-10 codes that improved algorithm specificity (specificity 96.8%, PPV 69.5%; κ = 0.72). Algorithms that included a pulmonologist diagnosis or chest computed tomography plus pulmonary function testing or lung biopsy had improved performance (specificity 98.0%, PPV 77.4%; κ = 0.75). PPV increased with exclusion of other ILD causes (78.5%) in comparison with the relaxed ILD definition (82.4%) and in sensitivity analyses (83.4-86.3%). Gains in specificity and PPV with greater algorithm requirements were accompanied by declines in sensitivity. CONCLUSION Administrative algorithms with optimal combinations of ICD codes, provider specialty, diagnostic testing, and exclusion of other ILD causes accurately classify ILD in RA.

Introduction. According to the literature, involvement in the granulomatous inflammatory process of the pleura in thoracic sarcoidosis is an unusual occurrence. The range of occurrence is from 0.08 to 10%, the median is 3%. Most often (70%) pleural sarcoidosis manifests itself as a pleural effusion. For comparison, in the publications of pathologists, pleural involvement in sarcoidosis is observed much more often – in 35% of cases. Computed tomography and, above all, multispiral computed tomography (MSCT), with a wide range of tomographic image post-processing, offers great opportunities for improving the diagnosis of sarcoidosis. Aim . The desire to acquaint with new, diverse, not known to a wide range of radiologists and pulmonologists, a set of symptoms of pleural lesions in sarcoidosis, based on 3D-reformation of tomographic images. Materials and methods .A retrospective study analysis was carried out according to a special protocol to identify pleural pathology in 140 initially verified patients with thoracic sarcoidosis. As a tool for scientific research, the DICOM archive of the Far Eastern Scientific Center of Physiology and Pathology of Respiration from 2013 to 2020 was used, containing the results of MSCT examinations of 490 patients with sarcoidosis (85% morphologically verified), which a total of 1148 studies were performed in dynamics. Results. Pleural changes were detected in 48 of 140 (34.3%) retrospectively analyzed patients. Focal and plaque granulomatous changes in the pleura are predominantly registered. Pleural effusion was found in only two patients. It has been established that the main morphological elements, as is commonly believed (WASOG, Federal Clinical Guidelines for the Diagnosis and Treatment of Sarcoidosis), are not lymphadenopathy without pulmonary pleural changes (50% at stage I), but a combination of enlarged bronchopulmonary lymph nodes, granulomatous changes in the lung parenchyma and pleura (79% in stage II). According to our data, an increase in intrathoracic lymph nodes without pulmonary lesions (stage I) and granulomatous changes without an increase in intrathoracic lymph nodes (stage III) are a rather rare condition (6 and 7%, respectively), which is confirmed by the results of X-ray morphological studies with the maximum use of post-processing. Conclusion . The results of the completed assessment of the prevalence of the combined pulmonary-pleural form of sarcoidosis are more than 10 times (34.3%) higher than the data presented in the scientific literature, and to a greater extent correspond to the results of published pathological studies (35%). A significant correction of the staging of sarcoidosis, reflecting the dominance of the X-ray morphological basic structural elements characterizing thoracic sarcoidosis, was carried out.

Over the past decade, major breakthroughs in the understanding of lung cancer histology and mutational pathways have radically changed diagnosis and management. More specifically, in non-small cell lung cancer (NSCLC), tumour characterisation has shifted from differentiating based solely on histology to characterisation that includes genetic profiling and mutational status of Epidermal Growth Factor (EGFR), Anaplastic Lymphoma Kinase (ALK), c-ros oncogene 1 (ROS1) and BRAF. These genetic alterations can be targeted by specific drugs that result in improved progression-free survival, as well as higher response rates and are currently standard of care for NSCLC patients harbouring these mutations. In this a narrative, non-systematic review we aim to handpick through the extensive literature and critically present the ground-breaking studies that lead to the institution of tailored treatment options as the standard of care for the main targetable genetic alterations.

Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. Command of such vocabulary and its application is crucial for interventional pulmonologists to successfully establish financially sustainable bronchoscopy programs. Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value.

Utilizing complex lighting models, cinematic rendering is a novel technique for demonstrating computed tomography data with exquisite 3D anatomic detail. The tracheal lumen, tracheal wall, and adjacent soft tissue structures are represented with photorealistic detail exceeding that of conventional volume rendering or virtual bronchoscopy techniques. We applied cinematic rendering to a spectrum of emergent tracheal pathologies: traumatic tracheal tears, tracheoesophageal fistulas, tracheal foreign bodies, tracheal stenosis (intrinsic and extrinsic causes), tracheal neoplasms, and tracheomalacia. Cinematic rendering images enable visually accessible evaluation and comprehensive understanding of acute tracheal pathology, which is likely to be of value to both interventional pulmonologists and thoracic surgeons who are determining patient treatment plans.

Background The risks from potential exposure to coronavirus disease 2019 (COVID-19), and resource reallocation that has occurred to combat the pandemic, have altered the balance of benefits and harms that informed current (pre-COVID-19) guideline recommendations for lung cancer screening and lung nodule evaluation. Consensus statements were developed to guide clinicians managing lung cancer screening programs and patients with lung nodules during the COVID-19 pandemic. Methods An expert panel of 24 members, including pulmonologists (n = 17), thoracic radiologists (n = 5), and thoracic surgeons (n = 2), was formed. The panel was provided with an overview of current evidence, summarized by recent guidelines related to lung cancer screening and lung nodule evaluation. The panel was convened by video teleconference to discuss and then vote on statements related to 12 common clinical scenarios. A predefined threshold of 70% of panel members voting agree or strongly agree was used to determine if there was a consensus for each statement. Items that may influence decisions were listed as notes to be considered for each scenario. Results Twelve statements related to baseline and annual lung cancer screening (n = 2), surveillance of a previously detected lung nodule (n = 5), evaluation of intermediate and high-risk lung nodules (n = 4), and management of clinical stage I non–small-cell lung cancer (n = 1) were developed and modified. All 12 statements were confirmed as consensus statements according to the voting results. The consensus statements provide guidance about situations in which it was believed to be appropriate to delay screening, defer surveillance imaging of lung nodules, and minimize nonurgent interventions during the evaluation of lung nodules and stage I non–small-cell lung cancer. Conclusions There was consensus that during the COVID-19 pandemic, it is appropriate to defer enrollment in lung cancer screening and modify the evaluation of lung nodules due to the added risks from potential exposure and the need for resource reallocation. There are multiple local, regional, and patient-related factors that should be considered when applying these statements to individual patient care.

Background COPD patients suffer from respiratory symptoms and limitations in daily life. We aimed to characterize the impact of disease on overall health, daily life, and perceived well-being in COPD outpatients. Methods We conducted a national, cross-sectional study among pulmonologists and general practitioners (GPs). The St. George's Respiratory Questionnaire for COPD patients (SGRQ-C) was used. Inclusion criteria were a physician's diagnosis of COPD and age ≥40 years. Subjects with a history of lung surgery, lung cancer or COPD exacerbation within the last four weeks were excluded. Results Sixty-seven pulmonologists and 6 GPs enrolled 1175 COPD patients. Two hundred forty-eight of those did not fulfill GOLD criteria for COPD (FEV1/FVC

Understanding of coronavirus disease 2019 is rapidly evolving with new articles on the subject daily. This flood of articles can be overwhelming for busy practicing clinicians looking for key pieces of information that can be applied in daily practice. This review article synthesizes the reported imaging findings in pediatric COVID‐19 across the literature, offers imaging differential diagnostic considerations and useful radiographic features to help differentiate these entities from COVID‐19, and provides recommendations for ordering imaging studies to evaluate suspected cases of pediatric COVID‐19. This article is protected by copyright. All rights reserved.

Background: The main objective of this study was to investigate the safety of bedside percutaneous dilational tracheostomy (PDT) by pulmonologists in critically ill patients, and the factors associated with complications resulting from PDT. Methods: We retrospectively enrolled critically ill patients who had undergone bedside PDT in the intensive care units (ICUs) and respiratory care center from February 2016 to December 2018. Results: A total of 312 patients were included for analysis, with a mean age of 69.6 ± 17.7 years. Two hundred and eight of the patients were male (66.7%). The mean acute physiology and chronic health evaluation II score was 25.3 ± 6.3, and the mean body mass index was 22.4 ± 4.2. Most of the patients were intubated due to respiratory disorders (51.3%). Fifty-six patients (17.9%) received antiplatelet agents or an anticoagulant regularly prior to PDT. All enrolled patients were undergone bedside PDT successfully. The total complication rate of PDT was 14.4%. Patients who took antiplatelet agents or anticoagulants regularly before PDT had a higher risk of bleeding than patients who went without (26.8% versus 7.0%, adjusted odds ratio 4.93 [95% f 2.16–11.25], p

With more than 900,000 confirmed cases worldwide and nearly 50,000 deaths during the first 3 months of 2020, the coronavirus disease 2019 (COVID-19) pandemic has emerged as an unprecedented health care crisis. The spread of COVID-19 has been heterogeneous, resulting in some regions having sporadic transmission and relatively few hospitalized patients with COVID-19 and others having community transmission that has led to overwhelming numbers of severe cases. For these regions, health care delivery has been disrupted and compromised by critical resource constraints in diagnostic testing, hospital beds, ventilators, and health care workers who have fallen ill to the virus exacerbated by shortages of personal protective equipment. Although mild cases mimic common upper respiratory viral infections, respiratory dysfunction becomes the principal source of morbidity and mortality as the disease advances. Thoracic imaging with chest radiography and CT are key tools for pulmonary disease diagnosis and management, but their role in the management of COVID-19 has not been considered within the multivariable context of the severity of respiratory disease, pretest probability, risk factors for disease progression, and critical resource constraints. To address this deficit, a multidisciplinary panel comprised principally of radiologists and pulmonologists from 10 countries with experience managing patients with COVID-19 across a spectrum of health care environments evaluated the utility of imaging within three scenarios representing varying risk factors, community conditions, and resource constraints. Fourteen key questions, corresponding to 11 decision points within the three scenarios and three additional clinical situations, were rated by the panel based on the anticipated value of the information that thoracic imaging would be expected to provide. The results were aggregated, resulting in five main and three additional recommendations intended to guide medical practitioners in the use of chest radiography and CT in the management of COVID-19.

Purpose Primary care COPD guidelines indicate that COPD patients with asthma characteristics should be treated as having asthma. This study aims to describe the prevalence of asthma characteristics in patients with a pulmonologist-confirmed working diagnosis of COPD or ACO. Patients and methods This retrospective cross-sectional study used real-life data (collected between 2007 and 2017) from a Dutch asthma/COPD-service, a structured web-based system in which pulmonologists support general practitioners in their diagnosis of patients with suspicion of obstructive lung disease. The prevalence of asthma characteristics (history of asthma, atopy, symptoms, and reversibility) and blood eosinophil (Eos) counts were assessed in patients with a working diagnosis of COPD or ACO. Results Of the 14,141 patients, ≥40 years in the dataset, 4475 (31.6%) were diagnosed with asthma, 3532 (25.0%) with COPD, and 1276 (9.0%) with ACO. Asthma characteristics were present in 65.6% (n=1956) of the COPD and 90.9% (n=1059) of the ACO patients. Eos counts of ≥ 300 cells per μL were found in 35.7% (n=924) of the COPD patients and 35.3% (n=341) of the ACO patients. Conclusion In this group of COPD and ACO patients remotely diagnosed by pulmonologists, a substantial proportion would be considered to have asthma characteristics according to the guidelines. This may explain the high number of inhaled corticosteroid (ICS) prescriptions found in primary care COPD patients. Prospective studies are necessary to identify patients who may or may not benefit from ICS containing treatment. Hence, personalized care in primary care can be optimized.

The review presents literature data on therapeutic and diagnostic management of pulmonary diseases in HIV-infected patients. The article provides different practical approaches in the diagnosis of HIV-associated lung lesions and the spectrum of probable diseases, depending on the degree of immunodeficiency and the severity of clinical manifestations. The reference clinical signs of the most common opportunistic diseases with possible lung involvement are presented. The literature review highlights the feasibility of accurate etiological and invasive diagnosis of lung lesions in different clinical settings, as well as the need to designate various options of empirical antimicrobial therapy. The features of antimicrobial therapy and, in particular, the use of fluoroquinolones during the differential diagnosis of pulmonary lesions in HIV infection are discussed. The difficulties of verifying of HIV-associated lung diseases indicate the need of unified therapeutic and diagnostic approaches for use by various physicians (general practitioners, pulmonologists and phthisiologists).

Aim. This publication is devoted to a brief review of the unresolved questions of medical imaging and treatment of COVID-19.Materials and methods. The analysis of publications for the first quarter of 2020 on radiation diagnosis and treatment of COVID-19 with an emphasis on morpho-radiological comparisons was performed.Results. It was established that CT can be used for the initial “sorting” of patients in determining the need and conditions of hospitalization, but in the future, often leads to disagreement among pulmonologists and radiologists in assessing the dynamics of the development of the disease. In most patients with COVID-19, the pathomorphological and radiological patterns indicate the formation of the acute phase of diffuse alveolar damage, transforming into organizing pneumonia with typical CT manifestations. However, to date there are no established opinions on the management of patients with corresponding lung lesions.Conclusion. The literature data on the peculiarities of the pathomorphological and radiological patterns of COVID-19 COVID-19 justify the advisability of using corticosteroids in the treatment of this disease.

Approximately 12 million adults in the United States receive a diagnosis of chronic obstructive pulmonary disease (COPD) each year, and it is the fourth leading cause of death. Chronic obstructive pulmonary disease refers to a group of diseases that cause airflow obstruction and a constellation of symptoms, including cough, sputum production, and shortness of breath. The main risk factor for COPD is tobacco smoke, but other environmental exposures also may contribute. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2020 Report aims to provide a nonbiased review of the current evidence for the assessment, diagnosis, and treatment of patients with COPD. To date, no conclusive evidence exists that any existing medications for COPD modify mortality. The mainstay of treatment for COPD is inhaled bronchodilators, whereas the role of inhaled corticosteroids is less clear. Inhaled corticosteroids have substantial risks, including an increased risk for pneumonia. Here, 2 experts, both pulmonologists, reflect on the care of a woman with severe COPD, a 50-pack-year smoking history, frequent COPD exacerbations, and recurrent pneumonia. They consider the indications for inhaled corticosteroids in COPD, when inhaled corticosteroids should be withdrawn, and what other treatments are available.

Introduction The current gold standard for diagnosing interstitial lung disease (ILD) involves an ILD clinic evaluation, followed by discussion in a multidisciplinary meeting (MDM). However, there is a paucity of data on the impact of ILD MDMs on the diagnosis and management of ILDs in Southeast Asia. We studied the clinical impact of the ILD service on the diagnosis and management of ILDs at a university-affiliated tertiary hospital in Singapore. Methods A single-centre retrospective review was done on 97 consecutive patients referred for evaluation to the ILD service from March 2016 to August 2017. Results Mean age of the patients was 67 ± 11 years. Gender distribution was almost equal (52% male), with a majority of never-smokers (63%). Mean forced vital capacity (FVC) was 1.81 ± 0.66 L (66% ± 20% predicted). The three commonest referral diagnoses were ILD of uncertain classification (n = 38, 39%), connective tissue disease-associated ILD (CTD-ILD) (n = 24, 25%) and idiopathic pulmonary fibrosis (IPF) (n = 16, 17%). Following evaluation by the ILD service, there was a change of diagnosis in 60 (62%) patients and a change of management in 71 (73%) patients. The majority of consensus MDM diagnoses were IPF (n = 35, 36%), CTD-ILD (n = 30, 30%) and others (n = 15, 15%). There was a significant prognostic separation between the IPF and non-IPF diagnoses made following evaluation by the ILD service. Conclusion The ILD service allowed for more precise subtyping of various ILDs. This is particularly useful for IPF patients, who can benefit from antifibrotic therapies.

For severe, uncontrolled asthma (SUA), a gap exists between recent scientific advances and their incorporation into clinical practice. Using a Knowledge-to-Action Framework, new knowledge can be translated into evidence-based interventions to improve outcomes. The AstraZeneca U.S. PRECISION initiative aims to apply this Framework to improve recognition and management of SUA. The study objective was to identify factors contributing to gaps in care for patients with SUA. Results from a needs assessment survey of U.S. pulmonologists and allergists/immunologists were assessed within the Knowledge-to-Action Framework to advance bench-to-bedside care.Pulmonologists and allergists/immunologists from across the United States were invited to complete a customized, quantitative severe asthma survey in person at the 2017 American Thoracic Society annual meeting orOverall, 140 U.S. providers responded, most of whom were pulmonologists (84%). Most (60%) practiced in a community-based setting; 40% practiced at an academic medical center. Key challenges to providing care for patients with severe asthma included insurance company requirements and identification of the pathophysiology of an individual patient's severe asthma. Traditional measures of asthma-related morbidity were ranked as highly important by significantly more respondents compared with assessment of biomarkers (Survey results identified unmet needs for the identification and management of patients with SUA and opportunities to improve patient outcomes through evidence-based management of SUA, including testing for biologic eligibility and subsequent use of biologic therapies.

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency.

Background Preoperative exercise training (PET) studies show promising results in various patient populations. However, the lack of standardised programmes and uniformity in practice guidelines are barriers for implementation. Aim of this study was to assess the current opinions of pulmonologists and cardiothoracic surgeons on the clinical applicability of PET in patients scheduled for lung cancer surgery. Methods Dutch pulmonologists and cardiothoracic surgeons were asked to complete a 29-question survey regarding PET as an additional option to further optimise the health status of patients scheduled for lung cancer surgery. Results In total, 47 respondents (63% response rate), including 30 pulmonologists and 11 cardiothoracic surgeons and 6 residents in training completed the survey. A vast majority of the respondents had a positive attitude towards PET. Home-based exercise was considered less useful, as well as unsupervised exercise. Patient's motivation, improvements in physical capacity and quality of life, and lifestyle adjustments are important factors for the success of PET. The programme should at least contain inspiratory muscle training (95.7%), lifestyle interventions (95.7%), and supervised exercise training (91.5%). Cardiac and pulmonary risk assessment and medication assessment and optimisation were found less important. Conclusion Among pulmonologists and cardiothoracic surgeons, there is a tendency that PET can be a valuable addition to the perioperative care of lung surgery patients. Points of discussion are the contents of PET programmes, and there seems to be a lack of awareness among chest physicians.

Background Rigid bronchoscopy intubation poses a significant risk of complication to patients from mechanical trauma. Despite the importance of precision in forces exerted by surgeons during intubation, no prior study has analyzed the overall forces and torques involved in rigid bronchoscopy intubation, and whether existing training modalities accurately replicate them. Methods A bronchoscope was equipped with a 6-axis load sensor to measure forces and torques applied during rigid bronchoscopy intubation. The device was applied to measure intubation forces in low-fidelity manikins and patients by interventional pulmonologists. Results Axial and lateral forces were measured during rigid bronchoscope intubation from the mouth to the mid-trachea. The mean axial/lateral forces recorded during manikin trials were 6.93/18.06 N, whereas those recorded during patient trials were 4.57/9.43 N. Average axial and lateral force application was therefore 51.6% and 92.6% higher in manikin, respectively. Applied axial torque averaged across all human trials was 130.5 N-mm compared with 78.3 N-mm for manikin trials, 40% lower in manikin than in human. Lateral torque application during manikin intubation showed greater variation in between trials and a greater range of SDs within trials. Conclusion This was the first application of a rigid bronchoscope measurement device designed to measure forces applied at the handle. Force and torque discrepancies between manikin training and patient applications were found, indicating a possible mismatch between the haptic feedback received by physicians during rigid training and application. This inconsistency could be resolved via novel haptic training modalities and help increase atraumatic intubations.

Background Despite the release of a national guideline in 2016, the actual practices with respect to adult community-acquired pneumonia (CAP) remain unknown in China. We aimed to investigate CAP patient management practices in Shanghai to identify potential problems and provide evidence for policy making. Methods A short-period, 5-day prospective cross-sectional study was performed with sampled pulmonologists from 36 hospitals, encompassing all the administrative districts of Shanghai, during January 8-12, 2018. The medical information was recorded and analyzed for the patients with the diagnosis of CAP who were cared for by 46 pulmonologists during the study period. Results Overall, 435 patients were included in the final analysis, and 94.3% had a low risk of death in terms of CRB-65 criteria (C: disturbance of consciousness, R: respiratory rate, B: blood pressure, 65: age). When diagnosed with CAP, 70.1% of patients were not evaluated using the CURB-65 score (CRB-65 + U: urea nitrogen), but most patients (95.4%) were evaluated using CRB-65. Time to achieve clinical stability was longer in patients with hypoxemia than in those without hypoxemia (8.42±6.36 vs. 5.53±4.12 days, P=0.004). Overall, 84.4% of patients with a CRB-65 score of 0 were administered antibiotics intravenously, and 19.4% were still hospitalized after excluding hypoxemia and comorbidities. The average duration of antibiotic treatment was 10.4±4.9 days. Overall, 72.6% of patients received antibiotics covering atypical pathogens whose time to clinical stability was significantly shortened compared with those without coverage, but the antibiotic duration was similar and not correspondingly shortened. Conclusions CRB-65 seems to be more practical than CURB-65 for the initial evaluation of CAP in the context of local practice, and oxygenation assessment should be included in the evaluation of severity. Overtreatment may be relatively common in patients at low risk of death, including unreasonable hospitalization, intravenous administration, and antibiotic duration.

This article is co-authored by the mother of a patient with spinal muscular atrophy (SMA), two pediatric pulmonologists and the pediatric neurologist in the team. It describes the patient and their family's experience of living with SMA. This commentary describes the mother's experience of the diagnosis and treatment process of her daughter's SMA in an era of emerging treatments for a disease which was until recently considered incurable. SMA diagnosis and management in the context of the patient mother's experiences is discussed.

Purpose of Review: Myotonic dystrophy type 1 (DM1) is a severe, progressive genetic disease that affects approximately 1 in 2,500 individuals globally [Ashizawa et al.: Neurol Clin Pract 2018;8(6):507–20]. In patients with DM1, respiratory muscle weakness frequently evolves, leading to respiratory failure as the main cause of death in this patient population, followed by cardiac complications [de Die-Smulders et al.: Brain 1998;121(Pt 8):1557–63], [Mathieu et al.: Neurology 1999;52(8):1658–62], [Groh et al.: Muscle Nerve 2011;43(5):648–51]. This paper provides a more detailed outline on the diagnostic and management protocols, which can guide pulmonologists who may not have experience with DM1 or who are not part of a neuromuscular multidisciplinary clinic. A group of neuromuscular experts in DM1 including pulmonologists, respiratory physiotherapists and sleep specialists discussed respiratory testing and management at baseline and during follow-up visits, based on their clinical experience with patients with DM1. The details are presented in this report. Recent Findings: Myotonic recruited 66 international clinicians experienced in the treatment of people living with DM1 to develop and publish consensus-based care recommendations targeting all body systems affected by this disease [Ashizawa et al.: Neurol Clin Pract. 2018;8(6):507–20]. Myotonic then worked with 12 international respiratory therapists, pulmonologists and neurologists with long-standing experience in DM respiratory care to develop consensus-based care recommendations for pulmonologists using a methodology called the Single Text Procedure. This process generated a 7-page document that provides detailed respiratory care recommendations for the management of patients living with DM1. This consensus is completely based on expert opinion and not backed up by empirical evidence due to limited clinical care data available for respiratory care management in DM patients. Nevertheless, we believe it is of relevance for professionals treating adults with myotonic dystrophy because it addresses practical issues related to respiratory management and care, which have been adapted to meet the specific issues in patients with DM1. Summary: The resulting recommendations are intended to improve respiratory care for the most vulnerable of DM1 patients and lower the risk of untoward respiratory complications and mortality by providing pulmonologist who are less experienced with DM1 with practical indications on which tests and when to perform them, adapting the general respiratory knowledge to specific issues related to this multiorgan disease.