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Background: Asthma epidemics associated with thunderstorms have had catastrophic effects on individuals and emergency services. Seasonal allergic rhinitis (SAR) is present in the vast majority of people who develop thunderstorm asthma (TA), but there is little evidence regarding risk factors for TA among the SAR population. Objective(s): We sought to identify risk factors for a history of TA and hospital presentation in a cohort of individuals with SAR. Method(s): This multicenter study recruited adults from Melbourne, Australia, with a past diagnosis of TA and/or self-reported SAR. Clinical information, spirometry results, white blood cell count, ryegrass pollen-specific (RGP-sp) IgE concentration, and fractional exhaled nitric oxide were measured to identify risk factors for a history of TA in individuals with SAR. Result(s): From a total of 228 individuals with SAR, 35% (80 of 228) reported SAR only (the I-SAR group), 37% (84 of 228) reported TA symptoms but had not attended hospital for treatment (the O-TA group), and 28% (64 of 228) had presented to the hospital for TA (the H-TA group). All patients in the H-TA group reported a previous asthma diagnosis. Logistic regression analysis of factors associated with O-TA and H-TA indicated that lower FEV1 value and an Asthma Control Questionnaire score higher than 1.5 were associated with H-TA. Higher blood RGP-sp IgE concentration, eosinophil counts, and fractional exhaled nitric oxide level were significantly associated with both O-TA and H-TA. Receiver operating curve analysis showed an RGP-sp IgE concentration higher than 10.1 kU/L and a prebronchodilator FEV1 value of 90% or lower to be biomarkers of increased H-TA risk. Conclusion(s): Clinical tests can identify risk of a history of TA in individuals with SAR and thereby inform patient-specific treatment recommendations.Copyright © 2021

Introduction: People with mild chronic obstructive pulmonary disease (COPD) experience exercise intolerance, dyspnoea and poor quality of life. However, the role of pulmonary rehabilitation (PR) in this group is unclear. Objective(s): This randomised controlled trial aimed to explore the effects of home-based PR in people with mild COPD. Method(s): People with mild COPD (FEV1/FVC < 70%; FEV1 > 80%predicted) with a smoking history of >=10 packet years were randomised to either 8 weeks of home-based PR (one home visit and seven once-weekly telephone calls) or standard care (weekly social telephone calls). Six minute walk distance (6MWD), and Modified Medical Research Council Dyspnoea Scale (mMRC) and Chronic Respiratory Disease Questionnaire (CRQ) scores were compared. Result(s): A total of 58 participants (34 males, mean age 68 (SD 9) years, FEV1%predicted 90 (7), 6MWD 496 (105) m) were included with 31 participants randomised to home-based PR. Participants attended an average of 6.8 of the 8 scheduled sessions, ranging from 3 to 8 sessions. Both groups showed improvements in exercise capacity, symptoms and health-related quality of life (HRQoL) over time, however there was no difference in 6MWD at end-intervention (mean difference -3 m, 95% confidence interval (CI) -64 to 58) or 6 months (7 m, 95% CI -59 to 72). At 6 months home-based PR participants were more likely to have clinically important improvements in CRQ emotional function (50% of home PR vs 0% control, P < 0.001) and CRQ total score (45% vs 17%, P = 0.05). Conclusion(s): For people with mild COPD, home-based PR did not improve exercise capacity more than standard care. The trial was registered at the Australia New Zealand clinical trial registry (https://www.anzctr.org.au, Trial ID: ACTRN12616000965404).Copyright © 2019 John Wiley & Sons Ltd

The TSANZ develops position statements where insufficient data exist to write formal clinical guidelines. In 2018, the TSANZ addressed the question of potential benefits and health impacts of electronic cigarettes (EC). The working party included groups focused on health impacts, smoking cessation, youth issues and priority populations. The 2018 report on the Public Health Consequences of E-Cigarettes from the United States NASEM was accepted as reflective of evidence to mid-2017. A search for papers subsequently published in peer-reviewed journals was conducted in August 2018. A small number of robust and important papers published until March 2019 were also identified and included. Groups identified studies that extended, modified or contradicted the NASEM report. A total of 3793 papers were identified and reviewed, with summaries and draft position statements developed and presented to TSANZ membership in April 2019. After feedback from members and external reviewers, a collection of position statements was finalized in December 2019. EC have adverse lung effects and harmful effects of long-term use are unknown. EC are unsuitable consumer products for recreational use, part-substitution for smoking or long-term exclusive use by former smokers. Smokers who require support to quit smoking should be directed towards approved medication in conjunction with behavioural support as having the strongest evidence for efficacy and safety. No specific EC product can be recommended as effective and safe for smoking cessation. Smoking cessation claims in relation to EC should be assessed by established regulators.Copyright © 2020 The Authors. Respirology published by John Wiley & Sons Australia, Ltd on behalf of Asian Pacific Society of Respirology.

In addition to facilitating healthcare delivery planning, reliable information about prognosis is essential for treatment decisions in patients with idiopathic pulmonary fibrosis (IPF). This review aimed to evaluate the prognosis of patients with IPF without anti-fibrotic therapy. We included all cohort studies and the placebo arms of randomised controlled trials (RCTs) in IPF and follow-up of 12 months. Two reviewers independently evaluated studies for inclusion, assessed risk of bias and extracted data. A total of 154 cohort studies and 16 RCTs were included. The pooled proportions of mortality were 0.12 (95% CI 0.09-0.14) at 1-2 years, 0.38 (95% CI 0.34-0.42) between 2-5 years, and 0.69 (95% CI 0.59-0.78) at 5 years. The pooled mean overall survival was 4 years (95% CI 3.7-4.6) for studies with a follow-up duration of 10 years. At <2 years, forced vital capacity and diffusing capacity of the lung for carbon monoxide declined by a mean of 6.76% predicted (95% CI -8.92-4.61) and 3% predicted (95% CI -5.14 -1.52), respectively. Although heterogeneity was high, subgroup analyses revealed lower pooled proportions of mortality at 1 year in the RCT participants (0.07 (95% CI 0.05-0.09)) versus cohort study participants (0.14 (95% CI 0.12-0.17)). This review provides comprehensive information on the prognosis of IPF, which can inform treatment discussions with patients and comparisons for future studies with new therapies.Copyright © ERS 2020.

The TSANZ develops position statements where insufficient data exist to write formal clinical guidelines. In 2018, the TSANZ addressed the question of potential benefits and health impacts of electronic cigarettes (EC). The working party included groups focused on health impacts, smoking cessation, youth issues and priority populations. The 2018 report on the Public Health Consequences of E-Cigarettes from the United States NASEM was accepted as reflective of evidence to mid-2017. A search for papers subsequently published in peer-reviewed journals was conducted in August 2018. A small number of robust and important papers published until March 2019 were also identified and included. Groups identified studies that extended, modified or contradicted the NASEM report. A total of 3793 papers were identified and reviewed, with summaries and draft position statements developed and presented to TSANZ membership in April 2019. After feedback from members and external reviewers, a collection of position statements was finalized in December 2019. EC have adverse lung effects and harmful effects of long-term use are unknown. EC are unsuitable consumer products for recreational use, part-substitution for smoking or long-term exclusive use by former smokers. Smokers who require support to quit smoking should be directed towards approved medication in conjunction with behavioural support as having the strongest evidence for efficacy and safety. No specific EC product can be recommended as effective and safe for smoking cessation. Smoking cessation claims in relation to EC should be assessed by established regulators.

© 2020 American College of Chest Physicians Smoking continues to be a burden to economies and health-care systems across the world. One proposed solution to the problem has been e-cigarettes; however, because they are a relatively new product in the market, little is known about their potential health impacts. Furthermore, e-cigarettes continue to evolve at a rapid rate, making it necessary to regularly review and summarize available studies. Although e-cigarettes are marketed as a smoking cessation tool by some manufacturers, the reality is that many nonsmokers, including youth, are using them. This review focuses on two major demographic groups (smokers and nonsmokers) and evaluates the most recent data (early 2017 to mid 2019) regarding the potential health effects of e-cigarettes. We assessed peer-reviewed studies on the health impacts of e-cigarettes, with a particular focus on common questions asked by policy makers, clinicians, and scientists: (1) What are the effects of e-cigarettes compared with air/not smoking?; (2) Is there any direct evidence of harm or benefit to humans?; (3) Is there a risk from secondhand exposure?; (4) What are the risks and/or benefits of e-cigarettes compared with tobacco cigarette use?; (5) Are there risks or benefits to specific populations (eg, people with COPD or asthma, pregnant women [and their offspring])?; (6) What are the effects of flavoring chemicals?; (7) What are the effects of including nicotine in e-liquids?; (8) How often is nicotine concentration labeling incorrect?; and (9) What are the risks when e-cigarettes explode?

Background : Seasonal allergic rhinitis (SAR) is commonly reported by thunderstorm asthma (TA) patients and ryegrass pollen is implicated as causal. However, not all SAR patients in the community experience TA. On November 21, 2016 Melbourne (Victoria, Australia) experienced the largest recorded epidemic of thunderstorm asthma with 3300 emergency department presentations, 476 asthmarelated hospital admissions and ten fatalities. We hypothesize that the impact of such TA episodes may be mitigated by identifying susceptible individuals and providing them with preventative therapy. The aim of this study was to determine risk factors for TA in a cohort of SAR patients. Method : Adults with either a past diagnosis of TA or self- reported SAR were recruited (Melbourne Health ethics approval: 2018.270) into an ambispective cohort study conducted across six hospitals in Melbourne. Spirometry, skin prick testing to common aeroallergens, measurement of fractional exhaled nitric oxide (FeNO), blood eosinophil counts, total IgE and ryegrass- specific IgE levels were performed at study entry. Differences between cases (TA patients) and controls (self- reported SAR patients) were analysed using logistic regression. Results : Two hundred and twenty- seven patients were recruited between October and December 2018 (Melbourne spring season) of whom 106/223 (47.5%) reported SAR and 117/223 (52.5%) had a history of clinician- diagnosed TA. Preliminary data suggest that TA patients had significantly higher blood eosinophils, total IgE, ryegrass- specific IgE and FeNO levels than SAR patients ( P < 0.0001 for all variables). Each unit increase in ryegrass- specific IgE levels (1ku/L) was associated with 2.21 times increased odds of presenting to hospital with TA; Odds Ratio = 2.21; 95% CI 1.68, 2.91; P < 0.0001. Conclusion : Our findings suggest that ryegrass- specific IgE and FeNO measurements can help to identify individuals at risk of TA. Multivariate analyses are currently underway t

Background: A multidisciplinary collaboration investigated the world's largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies. Method(s): Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions. Finding(s): Grass pollen concentrations on Nov 21, 2016, were extremely high (>100 grains/m3). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10degreeC, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p<0.0001) and south-east Asian birth (8% vs 1%, p<0.0001) compared with previous 3 years. Questionnaire data from 1435 (64%) of 2248 emergency department presentations showed a mean age of 32.0 years (SD 18.6), 56% of whom were male. Only 28% had current doctor-diagnosed asthma. 39% of the presentations were of Asian or Indian ethnicity (25% of the Melbourne population were of this ethnicity according to the 2016 census, relative risk [RR] 1.93, 95% CI 1.74-2.15, p <0.0001). Of ten individuals who died, six were Asian or Indian (RR 4.54, 95% CI 1.28-16.09; p=0.01). 35 individuals were admitted to an intensive care unit, all had asthma, 12 took inhaled preventers, and five died.

Introduction: People with mild chronic obstructive pulmonary disease (COPD) experience exercise intolerance, dyspnoea and poor health-related quality of life. However, the role of pulmonary rehabilitation in this group is unclear. Objective(s): This randomised controlled trial aimed to explore effects of home-based pulmonary rehabilitation (PR) in people with mild COPD. Method(s): People with mild COPD (FEV1/FVC<70%; FEV1>80%predicted) with a smoking history of >= 10 packet years were randomised to either 8-weeks of home-based PR (one home visit and seven once-weekly telephone calls) or attention control (weekly social telephone calls). Sixminute walk distance (6MWD), modified Medical Research Council (mMRC) dyspnoea score and Chronic Respiratory Questionnaire (CRQ) scores were compared between groups post intervention and at 6-months. Result(s): A total of 58 participants (34 females, mean age 68 (SD 9) years, FEV1 90 (7) %predicted, 6MWD 496 (105) metres) were included with 29 participants randomised to home-based PR. Participants attended an average of 6.8 of the eight scheduled sessions, ranging from three to eight sessions. Both groups showed improvements in exercise capacity, symptoms and health-related quality of life over time, however there was no betweengroup differences in the primary outcome of 6MWD at end-intervention (mean difference 1.4 metres, 95% confidence interval (CI) -28.7 to 31.4 metres) or six months (9.8 metres, 95% CI - 30.5 to 50.2 metres). At 6-months follow-up home-based PR participants were more likely to have clinically important improvements in CRQ emotional function (50% of home PR vs 0% control, p<0.001) and CRQ total score (45% vs 17%, p=0.05), however there were no other differences in symptoms or other aspects of health-related quality of life. Conclusion(s): For people with mild COPD, home-based pulmonary rehabilitation did not improve exercise capacity or health-related quality of life more than weekly social telephone calls.

Background: Pulmonary rehabilitation is an effective therapeutic intervention for people with chronic respiratory disease. However, fewer than 5% of eligible individuals receive pulmonary rehabilitation on an annual basis, largely due to limited availability of services and difficulties associated with travel and transport. The Rehabilitation Exercise At Home (REAcH) study is an assessor-blinded, multi-centre, randomised controlled equivalence trial designed to compare the efficacy of home-based telerehabilitation and traditional centre-based pulmonary rehabilitation in people with chronic respiratory disease. Method(s): Participants will undertake an 8-week group-based pulmonary rehabilitation program of twice-weekly supervised exercise training, either in-person at a centre-based pulmonary rehabilitation program or remotely from their home via the Internet. Supervised exercise training sessions will include 30 min of aerobic exercise (cycle and/or walking training). Individualised education and self-management training will be delivered. All participants will be prescribed a home exercise program of walking and strengthening activities. Outcomes will be assessed by a blinded assessor at baseline, after completion of the intervention, and 12-months post intervention. The primary outcome is change in dyspnea score as measured by the Chronic Respiratory Questionnaire - dyspnea domain (CRQ-D). Secondary outcomes will evaluate the efficacy of telerehabilitation on 6-min walk distance, endurance cycle time during a constant work rate test, physical activity and quality of life. Adherence to pulmonary rehabilitation between the two models will be compared. A full economic analysis from a societal perspective will be undertaken to determine the cost-effectiveness of telerehabilitation compared to centre-based pulmonary rehabilitation. Discussion(s): Alternative models of pulmonary rehabilitation are required to improve both equity of access and patient-related outcomes. T

The 6-minute walk test (6MWT) is recommended to be performed twice to accurately assess exercise performance in stable chronic obstructive pulmonary disease (COPD) due to the presence of a learning effect. It is unknown whether a learning effect exists when the 6MWT is performed during hospitalisation for acute exacerbation of COPD (AECOPD). This study investigated whether repeat 6MWTs are necessary when conducted in inpatients with AECOPD. Pooled analysis was undertaken of data from two studies (Australia and Brazil) involving 46 participants (25 males, mean age 67.2 years, FEV1 43% predicted) admitted with AECOPD. Two 6MWTs, separated by >=20 minutes, were performed on the day of discharge. Six-minute walk distance (6MWD; primary outcome), perceived dyspnoea (Borg scale), heart rate and oxyhaemoglobin saturation were recorded. 6MWD data from tests one (T1) and two (T2) were analysed via visual inspection of Bland-Altman plots. Factors associated with test improvement or decline were explored. Mean 6MWD difference between T1 and T2 was 6.2 m, however limits of agreement were wide (-92.2 m to 104.5 m). 32 (70%) participants improved (by any distance) from T1 to T2 by a mean (+/- standard deviation) of 32 m +/- 28 m. Of these, 14 (30%) improved by a distance > 30 m. Fourteen (30%) participants recorded poorer 6MWD at T2 by a mean of 52 m +/- 36 m. No factors were able to identify participants who improved or declined upon repeat testing. When performed in patients admitted to hospital with AECOPD, the 6MWT needs to be conducted twice in order to better estimate 6MWD.Copyright © 2016 Taylor & Francis Group, LLC.

Langerhans cell histiocytosis (LCH) is a rare disorder which frequently involves the lungs of affected adults. Recent evidence suggests it is a clonal neoplastic disorder. Prognosis in this disease is variable, but in its multisystem form or when associated with progressive respiratory dysfunction, prognosis is poor. Recent case reports and a phase II trial of the antimonocyte drug 2-chlorodeoxyadenosine (2CDA) have described success in treating LCH. We used 2CDA to treat a young Australian man with LCH involving lungs and bone. A complete symptomatic remission was achieved with no evidence of recurrence some 5 years after completion of chemotherapy.

Aim: To determine whether COPD patients who do not fulfil criteria for long term oxygen therapy benefit from ambulatory, domiciliary oxygen. Design(s): 12 week randomised, placebo-controlled trial of intranasal oxygen. Method(s): Patients underwent baseline lung function measurements including inspiratory capacity. Other baseline measures included 6 minute walk distance and measures of dyspnoea and quality of life. Patients were randomly allocated to use intranasal air or oxygen via nasal prongs at 6L/minute for 12 weeks during any activity which might induce breathlessness. Data were analysed on an intention to treat basis, p<0.05. Result(s): 143 subjects (44 female) mean age 71.8+/- 9.8yrs, FEV1 1.16+/-0.51L, PaO2 71.4+/-8.5mmHg were randomised. Sixty five percent of the patients desaturated to <=88% during baseline exercise testing. After treatment, no significant differences were found between groups receiving air or oxygen for any outcome. Secondary analyses did not find any benefit in the subgroup who desaturated during exercise. In both the air and oxygen groups, statistically significant improvements in dyspnoea, depression and 6 minute walk distance were observed over the 12 week trial. Conclusion(s): In breathless patients with COPD who do not fulfil criteria for long term continuous oxygen therapy, ambulatory oxygen confers no benefits in terms of exercise capacity, dyspnoea or quality of life. A statistically significant placebo effect of intranasal gas (both air and oxygen) was observed. Desaturation during exercise was not predictive of any improvement in function.

Background: Patients with chronic obstructive pulmonary disease (COPD) who are not severely hypoxaemic at rest may experience significant breathlessness on exertion, and ambulatory oxygen is often prescribed in this circumstance despite a lack of conclusive evidence for benefit. This study aimed to determine whether such patients benefit from domiciliary ambulatory oxygen and, if so, which factors may be associated with benefit. Method(s): This was a 12 week, parallel, double-blinded, randomised, placebo-controlled trial of cylinder air versus cylinder oxygen, provided at 6 l/min intranasally, for use during any activity provoking breathlessness. Patients underwent baseline measurements of arterial blood gases and lung function. Outcome measures assessed dyspnoea, health-related quality of life, mood disturbance, functional status and cylinder utilisation. Data were analysed on an intention-to-treat basis, p<=0.05. Result(s): 143 subjects (44 female), mean+/-SD age 71.8+/-9.8 years, forced expiratory volume in 1 s (FEV1) 1.16+/-0.51 lites, PaO2 9.5+/-1.1 kPa (71.4+/-8.5 mm Hg) were randomised, including 50 patients with exertional desaturation to <=88%. No significant differences in any outcome were found between groups receiving air or oxygen. Statistically significant but clinically small improvements in dyspnoea and depression were observed in the whole study group over the 12 weeks of the study. Conclusion(s): In breathless patients with COPD who do not have severe resting hypoxaemia, domiciliary ambulatory oxygen confers no benefits in terms of dyspnoea, quality of life or function. Exertional desaturation is not predictive of outcome. Intranasal gas (either air or oxygen) may provide a placebo benefit. Clinical trial number: ACTRN12605000457640.

Rationale: Respiratory function tests (RFT) are integral in the diagnosis and treatment of respiratory disease. Substantial efforts have been made to standardise methods and instrumentation with the aim of reducing inter-laboratory variation. However, there are little data on the reliability of interpretation of test results, despite its potential to affect patient outcomes. This study describes the degree of variability in interpretation of RFTs across a wide cross-section of Australian and New Zealand respiratory laboratories Methods: A test set of 10 RFTs(spirometry+/-bronchodilator and DLCO) were selected to cover a broad range of commonly encountered values, presented in a standardised format and distributed to respiratory laboratories. Staff who considered themselves able to interpret RFTs were invited to participate. Participants completed a questionnaire to document their professional grouping, reporting experience, qualifications and public/private lab status. Result(s): 84 people participated comprising 61% physicians, 21% scientists and 14% registrars. RFT reporting experience was 12.6(9.5) years and average number of reports/week was 26(22) (mean(SD)). Raw agreement for major reporting categories are shown in the table for the 10 test RFTS. Substantial variations in the interpretation of volume effects on DLCO was seen. (Table Presented) mixed. Conclusion(s): Substantial inter-rater variations in all areas of RFT interpretation were observed, although the degree of variation varied markedly across the different test results. These results provide a benchmark against which future efforts to improve RFT reporting reliability may be compared.

Respiratory tract involvement with amyloid is rare. We report eight cases of lower respiratory tract amyloidosis including a case of isolated pulmonary interstitial amyloidosis treated with chemotherapy, two cases of recurrent endobronchial amyloid with airway obstruction successfully treated with laser therapy and three cases of localized nodular pulmonary amyloidosis. The subjects with endobronchial and nodular amyloid demonstrated good long-term survival, while those with systemic or interstitial pulmonary amyloid had progressive disease and poor survival. Circulating monoclonal immunoglobulins were identified in five of the eight cases as the likely cause of the amyloid.

Rationale Lung function tests (LFT) are integral in the diagnosis and treatment of respiratory disease. Although substantial efforts have been made to standardise methods and instrumentation, there are very few data on the reliability of interpretation of test results, despite the potential to affect patient outcomes. This study describes the degree of variability in interpretation of LFTs in a cross-section of Australian and New Zealand respiratory laboratories. Method(s): Ten LFTs (spirometry +/- BD and TLCO) covering a range of values and presented in a standard format were distributed for interpretative comment. Participants also completed a questionnaire to document their profession, reporting experience, qualifications and public/private lab status. Result(s): Eighty-four reporters participated (61% physicians, 21% scientists, 14% registrars). The table demonstrates wide variation in agreement for major reporting categories. Percent raw agreement is calculated as the largest proportion of raters with a common interpretation. There was also substantial variation seen in the interpretation of volume effects on TLCO. (Table presented) Conclusion(s): Significant inter-rater variation in all areas of LFT interpretation was observed, although the degree of variation depended upon the pattern of LFT values. These results provide a reference against which future efforts to improve LFT reporting reliability may be compared.

PURPOSE: Precise, inexpensive tools for measuring physical activity levels are important for developing strategies to improve symptoms and enhance quality of life in chronic obstructive pulmonary disease (COPD). Self-report questionnaires and diaries have been used in many populations with variable results. The pedometer is widely recognized as a valid and reliable objective measurement tool, but it has not been well tested in COPD. This study aimed to determine the relationship between free-living physical activity recorded in a daily diary and that measured by using a pedometer in patients with COPD. METHODS: Participants with COPD (n = 80) recorded physical activity over 7 days. Cumulative pedometer readings and diary records of 4 activity categories for each 0.5 hour were compared. RESULTS: Participants (n = 76) with complete data sets were included in the analysis. The diary was more reliably completed. Mean pedometer reading per week was 23,129 (SD = 17,083) "step" counts (range, 1,725-66,454). Mean diary-recorded standing and walking time per week was 98.9 (SD = 10.4) hours (range, 73-119.5). The relationship between these measures was moderate and statistically significant (r = 0.37, P = .001). CONCLUSIONS: A daily diary record appears to offer more promise than the pedometer as a tool for measuring free-living physical activity in patients with COPD. Further research is required to assess the value of the 2 methods as discriminative, evaluative, and predictive tools in COPD populations.