Thoracic Society of Australia and New Zealand position statement: The safe clinical use of sputum induction for bio-sampling of the lower airways in children and adults

Sputum induction is widely used in clinical settings for collection of biological samples from the lower airways. However, in recent years sputum induction has been associated with serious adverse events and even death. This position statement was commissioned by the Thoracic Society of Australia and New Zealand to address major adverse events of two deaths associated with sputum induction that have occurred in Australia in 2021, and outlines best practice for the safe use of sputum induction. The statement resulted from systematic literature searches by a multi-disciplinary group including respiratory physicians, nurses and physiotherapists (paediatric and adults focused). Consumers had input to an advanced draft of the position statement. The position statement covers indications for sputum induction, informed consent, scope of practice of personnel administering the procedure, infection control considerations, details about the sputum induction procedure, safety considerations and risk assessment in clinical settings.

Alignment of Doctors' Understanding of Treatment Burden Priorities and Chronic Heart Failure Patients' Experiences: A Nominal Group Technique Consultation

PURPOSE

To identify and rank areas of treatment burden in chronic heart failure (CHF), including solutions, that should be discussed during the clinical encounter from a patient, and doctors' perspective.

PATIENTS AND METHODS

Patients with CHF and clinicians managing heart failure were invited. Nominal group technique sessions held either face to face or online in 2021-2022, with individual identification of priorities and voting on ranking.

RESULTS

Four patient groups (N=22) and one doctor group (N=5) were held. For patients with heart failure, in descending order of priority Doctor-patient communication, Inefficiencies of the healthcare system, Healthcare access issues, Cost implications of treatment, Psychosocial impacts on patients and their families, and Impact of treatment work were the most important treatment burdens. Priorities independently identified by the doctors aligned with the patients' but ranking differed. Patient solutions ranged from involvement of nurses or pharmacists to enhance understanding of discharge planning, through to linkage between health information systems, and maintaining strong family or social support networks. Doctors' solutions covered timing medicines with activities of daily living, patient education on the importance of compliance, medication reviews to overcome clinical inertia, and routine clinical audits.

CONCLUSION

The top treatment burden priorities for CHF patients were related to interaction with clinicians and health system inefficiencies, whereas doctors were generally aware of patients' treatment burden but tended to focus on the complexity of the direct treatment work. Addressing the priority issues identified here can commence with clinicians becoming aware of the issues that matter to patients and proactively discussing feasible immediate and longer-term solutions during clinical encounters.

In tobacco smokers with respiratory symptoms, a dual bronchodilator did not reduce symptoms at 12 wk

Han MK, Ye W, Wang D, et al. Bronchodilators in tobacco-exposed persons with symptoms and preserved lung function. N Engl J Med. 2022;387:1173-84. 36066078.

Patient and physician perspectives on treatment burden in end-stage kidney disease: a nominal group technique study

OBJECTIVES

The treatment workload associated with end-stage kidney disease (ESKD) is high. The treatment burdens experienced by patients with ESKD are not well understood. In this study, we aimed to elucidate the most important areas of treatment burden for discussion in a clinical encounter from the perspectives of patients with ESKD and nephrologists. We sought to explore possible solutions to these high priority treatment burden challenges.

DESIGN

Nominal group technique (NGT) sessions.

SETTING AND PARTICIPANTS

Three in-person NGT sessions were conducted with 19 patients with dialysis-dependent ESKD from one tertiary treatment centre (mean age 64 years; range 47-82). All patients were either retired or on a disability pension; 74% perceived moderate or severe treatment burden; and 90% spent more than 11 hours on treatment-related activities per week (range 11-30). One online NGT session was conducted with six nephrologists from two Australian states.

MAIN OUTCOME MEASURES

The primary outcome was a ranked list of treatment burden priorities. The secondary outcome was potential solutions to these treatment burden challenges.

RESULTS

Every patient group ranked health system issues as the most important treatment burden priority. This encompassed lack of continuity and coordination of care, dissatisfaction with frequent healthcare encounters and challenges around healthcare access. Psychosocial burdens on patients and families were perceived to be the most important area of treatment burden by physicians, and were ranked the second highest priority by patients.

CONCLUSIONS

Discussing treatment burden in a clinical encounter may lead to a better understanding of patients' capacity to cope with their treatment workload. This could facilitate tailored care, improve health outcomes, treatment sustainability and patients' overall quality of life.

Treatment Burden Discussion in Clinical Encounters: Priorities of COPD Patients, Carers and Physicians

Purpose

Many people with chronic obstructive pulmonary disease (COPD) feel overburdened with the treatment and management of their illness. Although research has begun to shed light on how COPD patients experience treatment burden, most of what we know is limited to personal experiences of patients. The aim of this study is to identify and prioritise areas of treatment burden that should be discussed during the clinical encounter from the perspectives of COPD patients, carers, and respiratory physicians.

Patients and Methods

Data were collected from participants using the nominal group technique. Five nominal group sessions were conducted in total (n = 31); three sessions with patients (n = 18), one with carers (n = 7) and another with respiratory physicians (pulmonologists or chest physicians) (n = 6). Each session was recorded and analyzed using thematic analysis.

Results

Going beyond understanding patients’ and carers’ experiences of treatment burden, this study offers a practical viewpoint of what should be discussed in a clinical encounter. Each group of participants contextualized treatment burden issues for discussion from their own perspectives. There was strong agreement, however, across the groups that difficulties accessing healthcare, lack of education and information, and worry about COPD treatment and prognosis were the most important treatment burden priorities for discussion.

Conclusion

Understanding and creating opportunities to discuss these issues in a clinical encounter is important in not only reducing treatment burden but also improving health outcomes and quality of life for COPD patients and their carers.

Paths of Emergency Department Care: Development of a Decision Aid to Facilitate Shared Decision Making in Goals of Care Discussions in the Acute Setting

Background

Goals of care (GOC) conversations in the emergency department (ED) are often a brief discussion of code status rather than a patient-oriented dialogue. We aimed to develop a guide to facilitate conversations between ED clinicians and patients to elicit patient values and establish goals for end-of-life care, while maintaining ED efficiency. Paths of ED Care, a conversation guide, is the product of this work.

Design

A multidisciplinary/multispecialty group used recommended practices to adapt a GOC conversation guide for ED patients. ED clinicians used the guide and provided feedback on content, design, and usability. Patient-clinician interactions were recorded for discussion analysis, and both were surveyed to inform iterative refinement. A series of discussions with patient representatives, multidisciplinary clinicians, bioethicists, and health care designers yielded feedback. We used a process similar to the International Patient Decision Aid Standards and provide comparison to these.

Results

A conversation guide, eight pages with each page 6 by 6 inches in dimension, uses patient-oriented prompts and includes seven sections: 1) evaluation of patient/family understanding of disease, 2) explanation of possible trajectories, 3) introduction to different pathways of care, 4) explanation of pathways, 5) assessment of understanding and concerns, 6) code status, and 7) personalized summary.

Limitations

Recruitment of sufficient number of patients/providers to the project was the primary limitation. Methods are limited to qualitative analysis of guide creation and feasibility without quantitative analysis.

Conclusions

Paths of ED Care is a guide to facilitate patient-centered shared decision making for ED patients, families, and clinicians regarding GOC. This may ensure care concordant with patients’ values and preferences. Use of the guide was well-received and facilitated meaningful conversations between patients and providers.

Screening for Tuberculosis in Migrants: A Survey by the Global Tuberculosis Network

Tuberculosis (TB) does not respect borders, and migration confounds global TB control and elimination. Systematic screening of immigrants from TB high burden settings and-to a lesser degree TB infection (TBI)-is recommended in most countries with a low incidence of TB. The aim of the study was to evaluate the views of a diverse group of international health professionals on TB management among migrants. Participants expressed their level of agreement using a six-point Likert scale with different statements in an online survey available in English, French, Mandarin, Spanish, Portuguese and Russian. The survey consisted of eight sections, covering TB and TBI screening and treatment in migrants. A total of 1055 respondents from 80 countries and territories participated between November 2019 and April 2020. The largest professional groups were pulmonologists (16.8%), other clinicians (30.4%), and nurses (11.8%). Participants generally supported infection control and TB surveillance established practices (administrative interventions, personal protection, etc.), while they disagreed on how to diagnose and manage both TB and TBI, particularly on which TBI regimens to use and when patients should be hospitalised. The results of this first knowledge, attitude and practice study on TB screening and treatment in migrants will inform public health policy and educational resources.

Disease definitions in respiratory and sleep medicine: changes in diagnostic criteria and categories over time and clinical implications

The latest issue of Breathe focuses on disease definitions in respiratory and sleep medicine: read the introductory editorial by Chief Editor @ClaudiaCDobler https://bit.ly/3A7CeYj.

Preventing adverse cardiac events (PACE) in chronic obstructive pulmonary disease (COPD): study protocol for a double-blind, placebo controlled, randomised controlled trial of bisoprolol in COPD

INTRODUCTION

Heart disease in chronic obstructive pulmonary disease (COPD) is a common but neglected comorbidity. Patients with COPD are frequently excluded from clinical trials of treatments aimed at reducing cardiac morbidity and mortality, which has led to undertreatment of cardiovascular disease in patients with COPD. A particular concern in COPD is the underuse of beta (β)-blockers. There is observational evidence that cardioselective β-blockers are safe and may even reduce mortality risk in COPD, although some evidence is conflicting. There is an urgent need to answer the research question: Are cardioselective β-blockers safe and of benefit in people with moderately severe COPD? The proposed study will investigate whether cardioselective β-blocker treatment in patients with COPD reduces mortality and cardiac and respiratory morbidity.

METHODS AND ANALYSES

This is a double-blind, randomised controlled trial to be conducted in approximately 26 sites in Australia, New Zealand, India, Sri Lanka and other countries as required. Participants with COPD will be randomised to either bisoprolol once daily (range 1.25-5 mg, dependent on tolerated dose) or matched placebo, in addition to receiving usual care for their COPD over the study duration of 24 months.The study will enrol 1164 participants with moderate to severe COPD, aged 40-85 years. Participants will be symptomatic from their COPD and have a postbronchodilator forced expiratory volume in 1 s (FEV₁) ≥30% and ≤70% predicted and a history of at least one exacerbation requiring systemic corticosteroids, antibiotics or both in the prior 24 months.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Sydney Local Health District Human Research Ethics Committee at The Concord Repatriation General Hospital.

TRIAL REGISTRATION NUMBERS

NCT03917914; CTRI/2020/08/027322.

A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review

PURPOSE

This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable.

MATERIALS AND METHODS

Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation.

RESULTS

Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care.

CONCLUSIONS

This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.

Users' Guide to Medical Decision Analysis

Clinicians regularly have to trade benefits and harms to choose between testing and treatment strategies. This process is often done by making global and implicit judgments. A decision analysis is an analytic method that makes this process more explicit, reproducible, and evidence-based. While clinicians are unlikely to conduct their own decision analysis, they will read publications of such analyses or use guidelines based on them. This review outlines the anatomy of a decision tree and provides clinicians with the tools to critically appraise a decision analysis and apply its results to medical decision making. Clinicians reading about a decision analysis can make two judgments. The first judgment is about the credibility of the methods, such as whether the decision analysis addressed a relevant clinical question, included all important outcomes, used the current best evidence to derive variables in the model, and adopted the appropriate time horizon. The second judgment is about rating confidence in the preferred course of action by determining the certainty in the model variables, whether the results are robust in sensitivity analyses and if the results are applicable to a specific patient. Results from a valid and robust decision analysis can inform both guideline panels and the patient-clinician dyad engaged in shared decision-making.

Adherence to treatment

As clinicians, we are aware that prescribing a treatment is one thing, patients taking the treatment as prescribed is quite another. Adherence, which describes “the extent to which a patient correctly follows medical instructions” [1] is generally poor for long-term therapy for chronic illnesses. A systematic review of 37 studies in patients with COPD found that nonadherence to treatment ranged from 22 to 93% [2]. In young adults aged 15–30 years with asthma a meta-analysis of 16 studies demonstrated a pooled adherence to inhaled corticosteroid treatment of only 28% (95% CI 20–38%; p<0.001), with rates ranging from 6 to 58% [3].

The latest issue of Breathe focuses on adherence to treatment: read the introductory editorial by Chief Editor @ClaudiaCDoblerhttps://bit.ly/3vVRjKU

Treatment burden experienced by patients with obstructive sleep apnoea using continuous positive airway pressure therapy

BACKGROUND

Little is known about the treatment burden experienced by patients with obstructive sleep apnoea (OSA) who use continuous positive airway pressure (CPAP) therapy.

PARTICIPANTS

18 patients (33.3% males, mean age 59.7±11.8 years) with OSA who use CPAP therapy were interviewed.

METHODS

Patients treated with CPAP for OSA at a tertiary hospital outpatient clinic in Sydney, Australia, were invited to participate in an interview in person or via phone. Semi-structured interviews were used to explore the treatment burden associated with using CPAP. The interviews were recorded, transcribed, and analysed using NVivo 12 qualitative analysis software.

RESULTS

Four categories of OSA-specific treatment burden were identified: healthcare tasks, consequences of healthcare tasks, exacerbating and alleviating factors of treatment burden. Participants reported a significant burden associated with using CPAP, independently of how frequently they used their device. Common sources of their treatment burden included attending healthcare appointments, the financial cost of treatment, lifestyle changes, treatment-related side effects and general discomfort.

CONCLUSIONS

This study demonstrated that there is a significant treatment burden associated with the use of CPAP, and that treatment non-adherence is not the only consequence of treatment burden. Other consequences include relationship burden, stigma and financial burden. It is important for physicians to identify other negative impacts of treatment burden in order to optimise the patient experience.

Treatment burden associated with the intake of thickened fluids

The implementation of thickened fluids in patients with dysphagia is widely considered an effective strategy for safe and physiologically improved swallow. However, there is limited evidence to suggest that this intervention reduces the risk of dysphagia-related complications including aspiration pneumonia. In addition, there is growing evidence that this approach is associated with adverse clinical effects including dehydration, malnutrition and reduced health-related quality of life. This review summarises the rationale for thickened fluids, the evidence base (or lack thereof) underpinning their use, and current guideline recommendations.

Educational aims

To review the evidence base for thickened fluids in the management of dysphagia.To examine the evidence that thickened fluids reduce aspiration pneumonia.To provide an overview of the advantages and disadvantages of thickened fluids in the management of dysphagia.

Comparison of seroprevalence of SARS-CoV-2 infections with cumulative and imputed COVID-19 cases: Systematic review

BACKGROUND

Accurate seroprevalence estimates of SARS-CoV-2 in different populations could clarify the extent to which current testing strategies are identifying all active infection, and hence the true magnitude and spread of the infection. Our primary objective was to identify valid seroprevalence studies of SARS-CoV-2 infection and compare their estimates with the reported, and imputed, COVID-19 case rates within the same population at the same time point.

METHODS

We searched PubMed, Embase, the Cochrane COVID-19 trials, and Europe-PMC for published studies and pre-prints that reported anti-SARS-CoV-2 IgG, IgM and/or IgA antibodies for serosurveys of the general community from 1 Jan to 12 Aug 2020.

RESULTS

Of the 2199 studies identified, 170 were assessed for full text and 17 studies representing 15 regions and 118,297 subjects were includable. The seroprevalence proportions in 8 studies ranged between 1%-10%, with 5 studies under 1%, and 4 over 10%-from the notably hard-hit regions of Gangelt, Germany; Northwest Iran; Buenos Aires, Argentina; and Stockholm, Sweden. For seropositive cases who were not previously identified as COVID-19 cases, the majority had prior COVID-like symptoms. The estimated seroprevalences ranged from 0.56-717 times greater than the number of reported cumulative cases-half of the studies reported greater than 10 times more SARS-CoV-2 infections than the cumulative number of cases.

CONCLUSIONS

The findings show SARS-CoV-2 seroprevalence is well below "herd immunity" in all countries studied. The estimated number of infections, however, were much greater than the number of reported cases and deaths in almost all locations. The majority of seropositive people reported prior COVID-like symptoms, suggesting that undertesting of symptomatic people may be causing a substantial under-ascertainment of SARS-CoV-2 infections.

Treatment burden is important to patients but often overlooked by clinicians

The latest issue of Breathe focuses on "treatment burden" and the effects of this workload on patients: read the introductory editorial by Chief Editor @ClaudiaCDobler https://bit.ly/3djgNeO.

What pulmonologists need to know about extrapulmonary tuberculosis

Extrapulmonary tuberculosis (EPT) can affect all organs. Its diagnosis is often challenging, especially when the lung is not involved. Some EPT locations, such as when the central nervous system is involved, are a medical emergency, and some have implications for treatment options and length. This review describes clinical features of EPT, diagnostic tests and treatment regimens.

Extrapulmonary tuberculosis can affect any organ, can be potentially life threatening or disabling, poses diagnostic difficulties and may change the type and length of treatment. Looking for concomitant pulmonary tuberculosis is essential.https://bit.ly/2YEaRVb

Treatment burden experienced by patients with lung cancer

INTRODUCTION

Patients' burden from lung cancer treatment is not well researched, but this understanding can facilitate a patient-centred treatment approach. Current models of treatment burden suggest it is influenced by a patient's perception of their disease and treatment and their capacity to do the work required to treat their disease.

METHODS

Sixteen patients and 1 carer who were undergoing or had completed conventional or stereotactic ablative radiotherapy, chemotherapy or immunotherapy for lung cancer in the last 6 months participated in a semi-structured interview. A treatment burden framework was used with three main themes: a) treatment work, b) consequences of treatment and c) psychosocial factors affecting treatment burden.

RESULTS

The majority of patients did not feel unduly burdened by treatment tasks, despite having a large treatment-associated workload. Many saw treatment as a priority, causing them to restructure their life to accommodate for it. Patients wished that they would have been better informed about the lifestyle changes that they would have to make before treatment for lung cancer commenced and that the health service would provide services to assist them with this task.

DISCUSSION

While there was a large burden associated with lung cancer treatment, patients felt motivated and equipped to manage the workload because the disease was considered severe and life-threatening, and the treatment was seen as beneficial. Before initiating treatment for lung cancer, patients should be informed about lifestyle changes they likely have to make and should be offered assistance.

Conservative versus interventional treatment for spontaneous pneumothorax

For a primary spontaneous pneumothorax (PSP) (in a person with no underlying lung disease) with a visible rim of >2 cm between the lung margin and the chest wall (at the level of the hilum) on a chest radiograph, current guidelines recommend aspiration with a 16–18-gauge cannula and insertion of a small-bore chest drain (8–14 French) if the pneumothorax size cannot successfully be reduced below the 2 cm rim or the patient remains breathless [1]. As interventional management of PSP is associated with potential complications and a patient with a chest drain needs to be admitted to hospital, evaluation of conservative management as a potential alternative to interventional management of larger PSPs is desirable. Before the current trial, there were a few observational studies suggesting that moderate to large sized PSPs can potentially be successfully managed without intervention but evidence from randomised trials was lacking [2]. The PSP trial aimed to determine whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large PSP [3].

Conservative management (with a treatment escalation plan in case the patient deteriorates) is a safe alternative to interventional management of a primary spontaneous pneumothoraxhttps://bit.ly/3fIN4uh

Systemic diseases involving the lung

The December issue of Breathe focuses on systemic diseases involving the lung: read the introductory editorial by Chief Editor @ClaudiaCDoblerhttps://bit.ly/2JtC6NG

Discovery and validation of a personalized risk predictor for incident tuberculosis in low transmission settings

The risk of tuberculosis (TB) is variable among individuals with latent Mycobacterium tuberculosis infection (LTBI), but validated estimates of personalized risk are lacking. In pooled data from 18 systematically identified cohort studies from 20 countries, including 80,468 individuals tested for LTBI, 5-year cumulative incident TB risk among people with untreated LTBI was 15.6% (95% confidence interval (CI), 8.0-29.2%) among child contacts, 4.8% (95% CI, 3.0-7.7%) among adult contacts, 5.0% (95% CI, 1.6-14.5%) among migrants and 4.8% (95% CI, 1.5-14.3%) among immunocompromised groups. We confirmed highly variable estimates within risk groups, necessitating an individualized approach to risk stratification. Therefore, we developed a personalized risk predictor for incident TB (PERISKOPE-TB) that combines a quantitative measure of T cell sensitization and clinical covariates. Internal-external cross-validation of the model demonstrated a random effects meta-analysis C-statistic of 0.88 (95% CI, 0.82-0.93) for incident TB. In decision curve analysis, the model demonstrated clinical utility for targeting preventative treatment, compared to treating all, or no, people with LTBI. We challenge the current crude approach to TB risk estimation among people with LTBI in favor of our evidence-based and patient-centered method, in settings aiming for pre-elimination worldwide.

Models of healthcare in respiratory diseases

Increasing healthcare cost and utilisation of health services have sparked an interest in new models of care, especially those that allow provision of traditional inpatient care in a community setting. COVID-19 has accelerated the implementation of telehealth, the delivery of medical care via phone or digital communication.

The September issue of Breathe focuses on models of healthcare in respiratory diseases: read the introductory editorial by Chief Editor @ClaudiaCDoblerhttps://bit.ly/2YTcI8V

Electronic cigarettes: A position statement from the Thoracic Society of Australia and New Zealand

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.

Tuberculosis in migrants - screening, surveillance and ethics

Tuberculosis (TB) is the leading infectious cause of human mortality and is responsible for nearly 2 million deaths every year. It is often regarded as a ‘silent killer’ because it predominantly affects the poor and marginalized, and disease outbreaks occur in ‘slow motion’ compared to Ebola or coronavirus 2 (COVID-19). In low incidence countries, TB is predominantly an imported disease and TB control in migrants is pivotal for countries to progress towards TB elimination in accordance with the World Health Organisations (WHO’s) End TB strategy. This review provides a brief overview of the different screening approaches and surveillance processes that are in place in low TB incidence countries. It also includes a detailed discussion of the ethical issues related to TB screening of migrants in these settings and the different interests that need to be balanced. Given recognition that a holistic approach that recognizes and respects basic human rights is required to end TB, the review considers the complexities that require consideration in low-incidence countries that are aiming for TB elimination.

Social stigma in the time of coronavirus disease 2019

The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the lives of people around the globe since it appeared in Wuhan, China, at the beginning of December 2019. The burden of disease and its death toll have had an unprecedented impact on the healthcare, economic and financial systems of low-, middle- and high-income countries [1–3]. Peoples’ lives have been disrupted and negatively impacted by COVID-19-related suffering and lockdowns at community and household level.

Addressing COVID-19-related stigmahttps://bit.ly/2CPuxO1

Ability of the LACE index to predict 30-day hospital readmissions in patients with community-acquired pneumonia

Background and objective

Hospital readmissions within 30 days are used as an indicator of quality of hospital care. We aimed to evaluate the ability of the LACE (Length of stay, Acuity of admission, Comorbidities based on Charlson comorbidity score and number of Emergency visits in the last 6 months) index to predict the risk of 30-day readmissions in patients hospitalised for community-acquired pneumonia (CAP).

Methods

In this retrospective cohort study a LACE index score was calculated for patients with a principal diagnosis of CAP admitted to a tertiary hospital in Sydney, Australia. The predictive ability of the LACE score for 30-day readmissions was assessed using receiver operator characteristic curves with C-statistic.

Results

Of 3996 patients admitted to hospital for CAP at least once, 8.0% (n=327) died in hospital and 14.6% (n=584) were readmitted within 30 days. 17.8% (113 of 636) of all 30-day readmissions were again due to CAP, followed by readmissions for chronic obstructive pulmonary disease, heart failure and chest pain. The LACE index had moderate discriminative ability to predict 30-day readmission (C-statistic=0.6395) but performed poorly for the prediction of 30-day readmissions due to CAP (C-statistic=0.5760).

Conclusions

The ability of the LACE index to predict all-cause 30-day hospital readmissions is comparable to more complex pneumonia-specific indices with moderate discrimination. For the prediction of 30-day readmissions due to CAP, the performance of the LACE index and modified risk prediction models using readily available variables (sex, age, specific comorbidities, after-hours, weekend, winter or summer admission) is insufficient.

The LACE index is easy to use and its ability to predict all-cause 30-day hospital readmissions for patients hospitalised with community-acquired pneumonia is comparable to more complex pneumonia-specific indices with moderate discriminationhttps://bit.ly/2SYkxam

Poor quality research and clinical practice during COVID-19

The COVID-19 pandemic has turned our lives upside down. Health services have adapted to the challenges posed by the pandemic at eye-watering speed. Telemedicine has seen a rapid uptake in order for patient–physician encounters to comply with social distancing regulations. Elective surgeries have been put on hold to make room in hospitals for patients with COVID-19 and save valuable personal protective equipment. Many pre-pandemic research projects have been put on hold, and legions of medical researchers are now dedicated to researching COVID-19.

Breathe Chief Editor @ClaudiaCDobler on how #COVID19 amplifies flaws in clinical research and practicehttps://bit.ly/3cX0jpO

Nonpharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-Analysis

OBJECTIVE

To evaluate the effectiveness and adverse events of nonpharmacologic interventions in patients with exacerbation of chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

We searched Embase, MEDLINE, Cochrane databases, Scopus, and clinicaltrials.gov from database inception to January 2, 2019, for randomized controlled trials that enrolled adults with exacerbation of COPD and evaluated the effect of nonpharmacologic interventions on clinical outcomes and/or lung function.

RESULTS

We included 30 randomized controlled trials with 2643 participants. Improvement in 6-minute walking test distance was associated with resistance training (weighted mean difference [WMD], 74.42; 95% CI, 46.85 to 101.99), pulmonary rehabilitation (WMD, 20.02; 95% CI, 12.06 to 28.67), whole body vibration (WMD, 89.42; 95% CI, 45.18 to 133.66), and transcutaneous electrical nerve stimulation (WMD, 64.54; 95% CI, 53.76 to 75.32). Improvement in quality of life was associated with resistance training (WMD, 18.7; 95% CI, 5.06 to 32.34), combined breathing technique and range of motion exercises (WMD, 14.89; 95% CI, 5.30 to 24.50), whole body vibration (WMD, -12.02; 95% CI, -21.41 to -2.63), and intramuscular vitamin D (WMD, -4.67; 95% CI, -6.00 to -3.35 at the longest follow-up). Oxygen titration with a target oxygen saturation range of 88% to 92% was associated with reduced mortality compared with high flow oxygen (odds ratio, 0.36; 95% CI, 0.14 to 0.88). All findings were based on low strength of evidence.

CONCLUSION

In patients hospitalized for exacerbation of COPD, exercise interventions and pulmonary rehabilitation programs may ameliorate functional decline. Oxygen should be titrated with a target oxygen saturation of 88% to 92% in these patients.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42018111609.

Screening and surveillance in respiratory medicine

We are already a couple of months into 2020 and I hope you had a good start to the new year. I wish you, our readers, reviewers, authors and editors, happiness, success and health in this new decade.

The March issue of Breathe focuses on screening and surveillance in respiratory medicine: read the introductory editorial by Chief Editor @ClaudiaCDoblerhttp://bit.ly/2Ol8e5G

Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by frequent exacerbations.

PURPOSE

To evaluate the comparative effectiveness and adverse events (AEs) of pharmacologic interventions for adults with exacerbation of COPD.

DATA SOURCES

English-language searches of several bibliographic sources from database inception to 2 January 2019.

STUDY SELECTION

68 randomized controlled trials that enrolled adults with exacerbation of COPD treated in out- or inpatient settings other than intensive care and compared pharmacologic therapies with placebo, "usual care," or other pharmacologic interventions.

DATA EXTRACTION

Two reviewers independently extracted data and rated study quality and strength of evidence (SOE).

DATA SYNTHESIS

Compared with placebo or management without antibiotics, antibiotics given for 3 to 14 days were associated with increased exacerbation resolution at the end of the intervention (odds ratio [OR], 2.03 [95% CI, 1.47 to 2.80]; moderate SOE) and less treatment failure at the end of the intervention (OR, 0.54 [CI, 0.34 to 0.86]; moderate SOE), independent of severity of exacerbations in out- and inpatients. Compared with placebo in out- and inpatients, systemic corticosteroids given for 9 to 56 days were associated with less treatment failure at the end of the intervention (OR, 0.01 [CI, 0.00 to 0.13]; low SOE) but also with a higher number of total and endocrine-related AEs. Compared with placebo or usual care in inpatients, other pharmacologic interventions (aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, and short-acting bronchodilators) had insufficient evidence, showing either no or inconclusive effects (with the exception of the mucolytic erdosteine) or improvement only in lung function.

LIMITATION

Scant evidence for many interventions; several studies had unclear or high risk of bias and inadequate reporting of AEs.

CONCLUSION

Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42018111609).

Diagnosis and treatment of lung disease associated with alpha one-antitrypsin deficiency: A position statement from the Thoracic Society of Australia and New Zealand

AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD-associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD-related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD-related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non-pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand.

Association of Home Noninvasive Positive Pressure Ventilation With Clinical Outcomes in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis

IMPORTANCE

The association of home noninvasive positive pressure ventilation (NIPPV) with outcomes in chronic obstructive pulmonary disease (COPD) and hypercapnia is uncertain.

OBJECTIVE

To evaluate the association of home NIPPV via bilevel positive airway pressure (BPAP) devices and noninvasive home mechanical ventilator (HMV) devices with clinical outcomes and adverse events in patients with COPD and hypercapnia.

DATA SOURCES

Search of MEDLINE, EMBASE, SCOPUS, Cochrane Central Registrar of Controlled Trials, Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, and Scopus for English-language articles published from January 1, 1995, to November 6, 2019.

STUDY SELECTION

Randomized clinical trials (RCTs) and comparative observational studies that enrolled adults with COPD with hypercapnia who used home NIPPV for more than 1 month were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction was completed by independent pairs of reviewers. Risk of bias was evaluated using the Cochrane Collaboration risk of bias tool for RCTs and select items from the Newcastle-Ottawa Scale for nonrandomized studies.

MAIN OUTCOMES AND MEASURES

Primary outcomes were mortality, all-cause hospital admissions, need for intubation, and quality of life at the longest follow-up.

RESULTS

A total of 21 RCTs and 12 observational studies evaluating 51 085 patients (mean [SD] age, 65.7 [2.1] years; 43% women) were included, among whom there were 434 deaths and 27 patients who underwent intubation. BPAP compared with no device was significantly associated with lower risk of mortality (22.31% vs 28.57%; risk difference [RD], -5.53% [95% CI, -10.29% to -0.76%]; odds ratio [OR], 0.66 [95% CI, 0.51-0.87]; P = .003; 13 studies; 1423 patients; strength of evidence [SOE], moderate), fewer patients with all-cause hospital admissions (39.74% vs 75.00%; RD, -35.26% [95% CI, -49.39% to -21.12%]; OR, 0.22 [95% CI, 0.11-0.43]; P < .001; 1 study; 166 patients; SOE, low), and lower need for intubation (5.34% vs 14.71%; RD, -8.02% [95% CI, -14.77% to -1.28%]; OR, 0.34 [95% CI, 0.14-0.83]; P = .02; 3 studies; 267 patients; SOE, moderate). There was no significant difference in the total number of all-cause hospital admissions (rate ratio, 0.91 [95% CI, 0.71-1.17]; P = .47; 5 studies; 326 patients; SOE, low) or quality of life (standardized mean difference, 0.16 [95% CI, -0.06 to 0.39]; P = .15; 9 studies; 833 patients; SOE, insufficient). Noninvasive HMV use compared with no device was significantly associated with fewer all-cause hospital admissions (rate ratio, 0.50 [95% CI, 0.35-0.71]; P < .001; 1 study; 93 patients; SOE, low), but not mortality (21.84% vs 34.09%; RD, -11.99% [95% CI, -24.77% to 0.79%]; OR, 0.56 [95% CI, 0.29-1.08]; P = .49; 2 studies; 175 patients; SOE, insufficient). There was no statistically significant difference in the total number of adverse events in patients using NIPPV compared with no device (0.18 vs 0.17 per patient; P = .84; 6 studies; 414 patients).

CONCLUSIONS AND RELEVANCE

In this meta-analysis of patients with COPD and hypercapnia, home BPAP, compared with no device, was associated with lower risk of mortality, all-cause hospital admission, and intubation, but no significant difference in quality of life. Noninvasive HMV, compared with no device, was significantly associated with lower risk of hospital admission, but there was no significant difference in mortality risk. However, the evidence was low to moderate in quality, the evidence on quality of life was insufficient, and the analyses for some outcomes were based on small numbers of studies.

High-Flow Nasal Cannula Oxygen in Patients with Acute Respiratory Failure and Do-Not-Intubate or Do-Not-Resuscitate Orders: A Systematic Review

BACKGROUND AND OBJECTIVES

High-flow nasal cannula (HFNC) oxygen may provide tailored benefits in patients with preset treatment limitations. The objective of this study was to assess the effectiveness of HFNC oxygen in patients with do-not-intubate (DNI) and/or do-not-resuscitate (DNR) orders.

METHODS

We conducted a systematic review of interventional and observational studies. A search was performed using MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science, from inception to October 15, 2018.

RESULTS

We included six studies evaluating 293 patients. All studies had a high risk of bias. The hospital mortality rates of patients with DNI and/or DNR orders receiving HFNC oxygen were variable and ranged from 40% to 87%. In two before and after studies, the initiation of HFNC oxygen was associated with improved oxygenation and reduced respiratory rates. One comparative study found no difference in dyspnea reduction or morphine doses between patients using HFNC oxygen versus conventional oxygen. No studies evaluated quality of life in survivors or quality of death in nonsurvivors. HFNC was generally well tolerated with few adverse events identified.

CONCLUSIONS

While HFNC oxygen remains a viable treatment option for hospitalized patients who have acute respiratory failure and a DNI and/or DNR order, there is a paucity of high-quality, comparative, effectiveness data to guide the usage of HFNC oxygen compared with other treatments, such as noninvasive ventilation, conventional oxygen, and palliative opioids.

Biomarkers in respiratory diseases

The December issue of Breathe focuses on biomarkers in respiratory diseases: read the introductory editorial by Chief Editor @ClaudiaCDobler http://bit.ly/36nzAiW.

Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis

PURPOSE

To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.

METHODS

We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019.

RESULTS

Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate.

CONCLUSIONS

One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.

Changing conversations in primary care for patients living with chronic conditions: pilot and feasibility study of the ICAN Discussion Aid

PURPOSE

To pilot test the impact of the ICAN Discussion Aid on clinical encounters.

METHODS

A pre-post study involving 11 clinicians and 100 patients was conducted at two primary care clinics within a single health system in the Midwest. The study examined clinicians' perceptions about ICAN feasibility, patients' and clinicians' perceptions about encounter success, videographic differences in encounter topics, and medication adherence 6 months after an ICAN encounter.

RESULTS

39/40 control encounters and 45/60 ICAN encounters yielded usable data. Clinicians reported ICAN use was feasible. In ICAN encounters, patients discussed diet, being active and taking medications more. Clinicians scored themselves poorer regarding visit success than their patients scored them; this effect was more pronounced in ICAN encounters. ICAN did not improve 6-month medication adherence or lengthen visits.

CONCLUSION

This pilot study suggests that using ICAN in primary care is feasible, efficient and capable of modifying conversations. With lessons learned in this pilot, we are conducting a randomised trial of ICAN versus usual care in diverse clinical settings.

TRIAL REGISTRATION NUMBER

NCT02390570.

Oxygen

Oxygen is on the World Health Organization's List of Essential Medicines, which includes the most efficacious, safe and cost-effective medicines for priority conditions. It is one of the most commonly used treatments in hospitalised patients, yet the evidence on its optimal use to improve clinical outcomes and reduce possible harm is relatively sparse. Oxygen should be prescribed like any other medication, for a specific indication, with a specific dose and with monitoring of the therapeutic response, but prescribing practices are often poor, increasing the risk of an adverse outcome.

The September issue of Breathe focuses on medical oxygenhttp://bit.ly/2M83NLo

Patient-Clinician Decision Making for Stable Angina: The Role of Health Literacy

BACKGROUND

Stable angina patients have difficulty understanding the tradeoffs between treatment alternatives. In this analysis, we assessed treatment planning conversations for stable angina to determine whether inadequate health literacy acts as a barrier to communication that may partially explain this difficulty.

METHODS

We conducted a descriptive analysis of patient questionnaire data from the PCI Choice Trial. The main outcomes were the responses to the Decisional Conflict Scale and the proportion of correct responses to knowledge questions about stable angina. We also conducted a qualitative analysis on recordings of patient-clinician discussions about treatment planning. The recordings were coded with the OPTION12 instrument for shared decision-making. Two analysts independently assessed the number and types of patient questions and expressions of preferences.

RESULTS

Patient engagement did not differ by health literacy level and was generally low for all patients with respect to OPTION12 scores and the number of questions related to clinical aspects of treatment. Patients with inadequate health literacy had significantly higher decisional conflict. However, the proportion of knowledge questions answered correctly did not differ significantly by health literacy level.

CONCLUSIONS

Patients with inadequate health literacy had greater decisional conflict but no difference in knowledge compared to patients with adequate health literacy. Inadequate health literacy may act as a barrier to communication, but gaps were found in patient engagement and knowledge for patients of all health literacy levels. The recorded patient-clinician encounters and the health literacy measure were valuable resources for conducting research on care delivery.

Implementation strategies for interventions to improve the management of chronic kidney disease (CKD) by primary care clinicians: protocol for a systematic review

INTRODUCTION

There is a considerable implementation gap in managing early stage chronic kidney disease (CKD) in primary care despite the high prevalence and risk for increased morbidity and mortality associated with CKD. This systematic review aims to synthesise the evidence of efficacy of implementation interventions aimed at primary care practitioners (PCPs) to improve CKD identification and management. We further aim to describe the interventions' behavioural change components.

METHODS AND ANALYSIS

We will conduct a systematic review of studies from 2000 to October 2017 that evaluate implementation interventions targeting PCPs and which include at least one clinically meaningful CKD outcome. We will search several electronic data bases and conduct reference mining of related systematic reviews and publications. An interdisciplinary team will independently and in duplicate, screen publications, extract data and assess the risk of bias. Clinical outcomes will include all clinically meaningful medical management outcomes relevant to CKD management in primary care such as blood pressure, chronic heart disease and diabetes target achievements. Quantitative evidence synthesis will be performed, where possible. Planned subgroup analyses include by (1) study design, (2) length of follow-up, (3) type of intervention, (4) type of implementation strategy, (5) whether a behavioural or implementation theory was used to guide study, (6) baseline CKD severity, (7) patient minority status, (8) study location and (9) academic setting or not.

ETHICS AND DISSEMINATION

Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will inform a future trial of an intervention to promote uptake of CKD diagnosis and treatment guidelines in our primary care setting and the development of complementary tools to support its successful adoption and implementation. We will publish our findings in a peer-reviewed journal and develop accessible summaries of the results.

PROSPERO REGISTRATION NUMBER

CRD42018102441.

Living well with a chronic respiratory disease

Many patients we see as respiratory clinicians have a chronic respiratory condition and will therefore require long-term treatment and healthcare support with the main goal of care focusing on reducing symptoms and improving quality of life.

The June issue of Breathe focuses on living well with a chronic respiratory diseasehttp://bit.ly/2Vo3iBV

Treatment of stable chronic obstructive pulmonary disease: protocol for a systematic review and evidence map

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease, usually caused by tobacco smoking, but other important risk factors include exposures to combustion products of biomass fuels and environmental pollution. The introduction of several new (combination) inhaler therapies, increasing uncertainty about the role of inhaled corticosteroids and a rapid proliferation of the literature on management of stable COPD in general, call for novel ways of evidence synthesis in this area. A systematic review and evidence map can provide the basis for shared decision-making tools and help to establish a future research agenda.

METHODS AND ANALYSIS

This systematic review will follow an umbrella systematic review design (also called overview of reviews). We plan to conduct a comprehensive literature search of Ovid MEDLINE (including epub ahead of print, in process and other non-indexed citations), Ovid Embase, Ovid Cochrane Database of Systematic Reviews and Scopus from database inception to the present. We will include systematic reviews that assessed the effectiveness of any pharmacological or non-pharmacological intervention on one or more patient-important outcomes and/or lung function in patients with stable COPD. For every intervention/outcome pair, one systematic review will be included. An a priori protocol will guide, which systematic reviews will be chosen, how their credibility will be evaluated, and how the quality of the body of evidence will be rated. Data will be synthesised into an evidence map that will present a matrix that depicts each available treatment for stable COPD with a quantitative estimate on symptoms/outcomes from the patient perspective, along with an indication of the size and certainty in the evidence.

ETHICS AND DISSEMINATION

Approval by a research ethics committee is not required since the review will only include published data. The systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018095079.

Use of the terms "overdiagnosis" and "misdiagnosis" in the COPD literature: a rapid review

Challenges in the diagnostic process of chronic obstructive pulmonary disease (COPD) can result in diagnostic misclassifications, including overdiagnosis. The term "overdiagnosis" in general has been associated with variable definitions. In connection with efforts to reduce low-value care, "overdiagnosis" has been defined as a true positive diagnosis of a condition that is not associated with any harm in the diagnosed person. It is, however, unclear how the term "overdiagnosis" is used in the COPD literature. We conducted a rapid review of the literature to explore how the terms "overdiagnosis" and "misdiagnosis" are used in the context of COPD. Electronic searches of Medline were conducted from inception to October 2018, to identify primary studies that reported on over- and/or misdiagnosis of COPD using these terms. 28 articles were included in this review. Overdiagnosis and misdiagnosis in COPD were found to be used to describe five main concepts: 1) physician COPD diagnosis despite normal spirometry (14 studies); 2) discordant results for COPD diagnosis based on different spirometry-based definitions for airflow obstruction (10 studies); 3) COPD diagnosis based on pre-bronchodilator spirometry results (three studies); 4) comorbidities (e.g. heart failure or asthma) that affect spirometry and have clinical features which overlap with COPD (two studies); and 5) normalisation of abnormal (post-bronchodilator) spirometry at follow-up (one study). The terms "overdiagnosis" and "misdiagnosis" were often used interchangeably and almost always referred to a false positive diagnosis. Performing (technically correct) spirometry with correct interpretation of the results could probably reduce misdiagnosis in a large proportion of the misdiagnosed cases of COPD. In addition, guidelines need to provide a more acceptable consensus spirometric definition of airflow obstruction.

Key points

In the COPD literature, the terms "overdiagnosis" and "misdiagnosis" are often used interchangeably and almost always refer to a false positive diagnosis.Use of spirometry with correct interpretation of the results can avoid a substantial proportion of cases of misdiagnosis of COPD.

Educational aims

To explore the use of the terms "overdiagnosis" and "misdiagnosis" in the COPD literature.To identify the main sources of overdiagnosis and misdiagnosis in COPD.

Prevalence of Disagreement About Appropriateness of Treatment Between ICU Patients/Surrogates and Clinicians

BACKGROUND

ICU patients/surrogates may experience adverse outcomes related to perceived inappropriate treatment. The objective was to determine the prevalence of patient/surrogate-reported perceived inappropriate treatment, its impact on adverse outcomes, and discordance with clinicians.

METHODS

We conducted a multicenter, prospective, observational study of adult ICU patients.

RESULTS

For 151 patients, 1,332 patient, surrogate, nurse, and physician surveys were collected. Disagreement between patients/surrogates and clinicians regarding "too much" treatment being administered occurred in 26% of patients. Disagreement regarding "too little" treatment occurred in 10% of patients. Disagreement about perceived inappropriate treatment was associated with prognostic discordance (P = .02) and lower patient/surrogate satisfaction (Likert scale 1-5 of 4 vs 5; P = .02). Patient/surrogate respondents reported "too much" treatment in 8% of patients and "too little" treatment in 6% of patients. Perceived inappropriate treatment was associated with moderate or high respondent distress for 55% of patient/surrogate respondents and 35% of physician/nurse respondents (P = .30). Patient/surrogate perception of inappropriate treatment was associated with lower satisfaction (Family Satisfaction in the ICU Questionnaire-24, 69.9 vs 86.6; P = .002) and lower trust in the clinical team (Likert scale 1-5 of 4 vs 5; P = .007), but no statistically significant differences in depression (Patient Health Questionnaire-2 of 2 vs 1; P = .06) or anxiety (Generalized Anxiety Disorder-7 Scale of 7 vs 4; P = .18).

CONCLUSIONS

For approximately one-third of ICU patients, there is disagreement between clinicians and patients/surrogates about the appropriateness of treatment. Disagreement about appropriateness of treatment was associated with prognostic discordance and lower patient/surrogate satisfaction. Patients/surrogates who reported inappropriate treatment also reported lower satisfaction and trust in the ICU team.

Too much or too little medicine? Overdiagnosis, underdiagnosis, overtreatment and undertreatment in respiratory diseases

At a time when technical possibilities for medical investigations are plentiful and ever expanding, there is growing awareness that more is not always better and that “too much medicine” may be harmful. In recent years, the global Choosing Wisely educational campaign has aimed to bring attention to unnecessary healthcare. Unnecessary healthcare includes overtesting, overdiagnosis and overtreatment [1]. The March issue of Breathe aims to challenge us to rethink our clinical practice, to reflect on the evidence, and to identify potential cognitive biases that might influence us to provide “too much” or “too little” medicine [2].

The March issue of Breathe focuses on overdiagnosis, underdiagnosis, overtreatment and undertreatment in respiratory diseaseshttp://ow.ly/63OW30ntCeu

Overdiagnosis of pulmonary embolism: definition, causes and implications

Overuse of computed tomography pulmonary angiography to diagnose pulmonary embolism in people who have only a low pre-test probability of pulmonary embolism has received significant attention in the past. The issue of overdiagnosis of pulmonary embolism, a potential consequence of overtesting, has been less explored. The term “overdiagnosis”, used in a narrow sense, describes a correct (true positive) diagnosis in a person but without any associated harm. The aim of this review is to summarise literature on the topic of overdiagnosis of pulmonary embolism and translate this epidemiological concept into the clinical practice of respiratory professionals. The review concludes that the location of pulmonary embolism at a subsegmental level, rather than whether a diagnosis was made incidentally or following an investigation for suspected pulmonary embolism, is the best predictor for situations in which anticoagulation may not be necessary. In the absence of strong evidence of the optimal management of subsegmental pulmonary embolism, treatment decisions should be made case by case, taking into account the patient's situation and preference.

A suggested definition of overdiagnosis of pulmonary embolism: a diagnosis of pulmonary embolism that, if left untreated, would not lead to more harm than if it were treated with anticoagulation therapy, independent of symptomshttp://ow.ly/wgAK30nr5IV

Breathe: surgical interventions in pulmonary diseases

This is my first issue of Breathe as the new Chief Editor and I would like to take the opportunity to thank Renata Riha, the outgoing Chief Editor, for the outstanding work she has done over the past 3 years. Under her leadership, Breathe established a strong online presence, introduced new features such as the Physiology masterclass and the Radiology corner, and strengthened the journal's collaboration with the European Respiratory Society Early Career Members Committee. Today, Breathe is a leader in providing practice-focused educational content to respiratory professionals.

The December issue of Breathe focuses on surgical interventions in pulmonary diseaseshttp://ow.ly/iGEa30mlZuw

The IMPACT of triple versus dual single-inhaler therapy on exacerbations of COPD

For a long time, the combination of an inhaled corticosteroid (ICS) and a long-acting β-agonist (LABA) inhaler agent was considered the mainstay of treating chronic obstructive pulmonary disease (COPD) patients with severe airflow obstruction and frequent exacerbations. More recently, the role of ICS in the treatment paradigm of patients with severe COPD and frequent exacerbations has been challenged. This is mainly driven by: 1) the growing evidence of an increased risk of pneumonia associated with ICS [1]; 2) the introduction of combined dual long-acting bronchodilator inhalation therapy with a long-acting muscarinic antagonist (LAMA) and a LABA therapy as a plausible and likely superior treatment alternative [2]; and 3) the recognition that probably not all COPD exacerbation phenotypes stand to equally benefit from ICS therapy, e.g. patients with high blood eosinophil counts probably stand to benefit more from ICS therapy than those with low eosinophil counts [3]. The Informing the Pathway of COPD Treatment (IMPACT) study aimed to address the question of whether ICS in addition to dual therapy with LAMA/LABA can reduce moderate and severe acute exacerbations of COPD (AECOPD) compared with LAMA/LABA therapy alone [4].

In the IMPACT trial, triple inhalation therapy resulted in a lower rate of moderate or severe COPD exacerbations compared with either dual therapy with ICS/LABA or LAMA/LABA, but pneumonia rates were increased.http://ow.ly/pYJn30mgpFp