Evolving Concepts of Asthma in 2015

Dear Friends, in American Journal of Respiratory and Critical Care Medicine appeared new article on concepts of asthma!
Our understanding of asthma has evolved over time from a singular disease to a complex of various phenotypes, with varied natural histories, physiologies, and responses to treatment. Early therapies treated most patients with asthma similarly, with bronchodilators and corticosteroids, but these therapies had varying degrees of success. Similarly, despite initial studies that identified an underlying type 2 inflammation in the airways of patients with asthma, biologic therapies targeted toward these type 2 pathways were unsuccessful in all patients. These observations led to increased interest in phenotyping asthma. Clinical approaches, both biased and later unbiased/statistical approaches to large asthma patient cohorts, identified a variety of patient characteristics, but they also consistently identified the importance of age of onset of disease and the presence of eosinophils in determining clinically relevant phenotypes. These paralleled molecular approaches to phenotyping that developed an understanding that not all patients share a type 2 inflammatory pattern. Using biomarkers to select patients with type 2 inflammation, repeated trials of biologics directed toward type 2 cytokine pathways saw newfound success, confirming the importance of phenotyping in asthma. Further research is needed to clarify additional clinical and molecular phenotypes, validate predictive biomarkers, and identify new areas for possible interventions.

Read more: 
http://www.atsjournals.org/doi/abs/10.1164/rccm.201504-0763PP#.VhKqFitqqUl

2015 Current Understanding and Future Research Needs in Tobacco Control and Treatment by American Thoracic Society

Yesterday in Am J Respir Crit Care Med was published An Official American Thoracic Society Research Statement: Current Understanding and Future Research Needs in Tobacco Control and Treatment.

Introduction: Since the mid-20th century, the scientific community has substantially improved its understanding of the worldwide tobacco epidemic. Although significant progress has been made, the sheer enormity and scope of the global problem put it on track to take a billion lives this century. Curbing the epidemic will require maximizing the impact of proven tools as well as the development of new, breakthrough methods to help interrupt the spread of nicotine addiction and reduce the downstream morbidity.

Methods: Members of the Tobacco Action Committee of the American Thoracic Society queried bibliographic databases, including Medline, Embase, and the Cochrane Collaborative, to identify primary sources and reviews relevant to the epidemic. Exploded search terms were used to identify evidence, including tobacco, addiction, smoking, cigarettes, nicotine, and smoking cessation. Evidence was consolidated into three thematic areas: (1) determinants of risk, (2) maternal-fetal exposure, and (3) current tobacco users. Expert panel consensus regarding current gaps in understanding and recommendations for future research priorities was generated through iterative discussion.

Results: Although much has been accomplished, significant gaps in understanding remain. Implementation often lags well behind insight. This report identifies a number of investigative opportunities for significantly reducing the toll of tobacco use, including: (1) the need for novel, nonlinear models of population-based disease control; (2) refinement of “real-world” models of clinical intervention in trial design; and (3) understanding of mechanisms by which intrauterine smoke exposure may lead to persistent, tobacco-related chronic disease.

Discussion: In the coming era of tobacco research, pooled talent from multiple disciplines will be required to further illuminate the complex social, environmental and biological codeterminants of tobacco dependence.

Read More:  

http://www.atsjournals.org/doi/abs/10.1164/rccm.201506-1081ST#.Vc68j5cXyUk

30th anniversary of the first successful single-lung transplant

Dear Respiratory friends we are congratulating everybody with wonderful anniversary of the first successful lung transplant!!!

Last year alone, 1,754 lung transplants were performed throughout the U.S., according to the Organ Procurement and Transplantation Network. Yet not long ago, lung transplantation was regarded as one of thoracic surgery's great unsolved challenges. "It was thought that the bronchus might just be the Achilles' heel of transplantation, and it just was an insoluble problem," says Joel D. Cooper, MD, 74, from his office at the Perelman School of Medicine at the University of Pennsylvania.

Monica Assenheimer (from left), the second single-lung recipient, Tom Hall, the world’s first single-lung recipient, and Ann Harrison, the world’s first double-lung recipient. The University of Toronto will celebrate the 30th anniversary of the first successful lung transplant and honor Dr. Cooper at a ceremony Nov. 6.
Photo Courtesy of University of Toronto’s Living History project, livinghistory.med.utoronto.ca.

After participating in the 44th failed attempt in the late 1970s, Dr. Cooper retreated to his lab at University of Toronto. With the support of his colleagues and a number of research fellows from around the world, they conducted a series of wound-healing experiments in dogs that uncovered the culprit: high doses of the immunosuppressant drug prednisone interfered with the healing process. Using omentum and cyclosporin (both experimental at the time), Dr. Cooper and his team completed the first successful lung transplant in 1983 on a 58-year-old Canadian hardware executive and pulmonary fibrosis patient Tom Hall, and the procedure was reproducible.

"When everybody failed, Joel never gave up on making the dream of lung transplantation a reality," says Shaf Keshavjee, MD, surgeon in chief at (Toronto) University Heath Network and director of the Toronto Lung Transplant Program, which Dr. Cooper initiated. "Thousands of lung patients are alive because of Joel's contributions."

November marks the 30th anniversary of the first successful single-lung transplant, but it's hardly Dr. Cooper's only contribution to thoracic surgery and medicine. Dr. Cooper, a professor of surgery at Penn and an ATS member since 1976, directed the first successful double-lung transplants in 1986 and 1987, and later the bilateral, sequential, single-lung transplantation procedure to treat cystic fibrosis, emphysema and pulmonary hypertension.

When asked how he felt about his legacy of solving a great thoracic mystery, Dr. Cooper humbly answers, "We put the icing on the cake that other people had spent years and years baking. I think it was Isaac Newton coined the aphorism, 'if we see further, it's because we stand on the shoulders of giants.' Nothing, I think, typifies that more than the transplant."

Five Things Chest Physicians and Respiratory Patients Should Question

Dear Respiratory friends we are re-posting interesting questions and answers from American College of Chest Physicians and American Thoracic Society!

1

Don’t perform computed tomography (CT) surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines.

Clinical practice guidelines for pulmonary nodule evaluation (such as those issued by the Fleischner Society or the American College of Chest Physicians) suggest that intensity of surveillance should be guided by the likelihood of malignancy. In patients with no prior history of cancer, solid nodules that have not grown over a 2-year period have an extremely low risk of malignancy (although longer follow-up is suggested for ground-glass nodules). Similarly, intensive surveillance (e.g., repeating CT scans every 3 months for 2 years or more) has not been shown to improve outcomes such as lung cancer mortality. Meanwhile, extended or intensive surveillance exposes patients to increased radiation and prolonged uncertainty.

2

Don’t routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (Groups II or III pulmonary hypertension).

Evidence and clinical practice guidelines have not established benefits of vasoactive agents (e.g., prostanoids, phosphodiesterase inhibitors, endothelin antagonists) for patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases. Moreover, the use of these agents may cause harm in certain situations and incurs substantial cost and resource utilization. Patients should be carefully assessed (including at a minimum right heart catheterization, echocardiography, chest CT, six minute walk test and pulmonary function testing) to confirm that they have symptomatic pulmonary arterial hypertension prior to having approved agents initiated.

3

For patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, don’t renew the prescription without assessing the patient for ongoing hypoxemia.

Hypoxemia often resolves after recovery from an acute illness, and continued prescription of supplemental oxygen therapy incurs unnecessary cost and resource use. At the time that supplemental oxygen is initially prescribed, a plan should be established to re-assess the patient no later than 90 days after discharge. Medicare and evidence-based criteria should be followed to determine whether the patient meets criteria for supplemental oxygen.

4

Don’t perform chest computed tomography (CT angiography) to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay.

Clinical practice guidelines for pulmonary embolism indicate that the cost and potential harms of CT angiography (including radiation exposure and the possibility of detecting and treating clinically insignificant pulmonary emboli with anticoagulation) outweigh the benefits for patients with a low pre-test probability of pulmonary embolism. In patients with a low clinical prediction score (e.g., Wells or Geneva score) followed by a negative D-dimer measured with a high sensitivity test (e.g., ELISA), pulmonary embolism is effectively excluded and no further imaging is indicated for pulmonary embolism evaluation.

5

Don’t perform CT screening for lung cancer among patients at low risk for lung cancer.

Low dose chest CT screening for lung cancer has the potential to reduce lung cancer death in patients at high risk (i.e., individuals aged 55-74 with at least a 30-pack year history of tobacco use, who are either still smoking or quit within the past 15 years). However, CT screening for lung cancer also has the potential to cause a number of adverse effects (e.g., radiation exposure, high false positive rate, harms related to downstream evaluation of pulmonary nodules, overdiagnosis of indolent tumors). Thus, screening should be reserved for patients at high risk of lung cancer and should not be offered to individuals at low risk of lung cancer.

New 2013 Guidelines on Pulmonary Rehabilitation

A fresh guideline on pulmonary rehabilitation has been published this week, helping professionals, patients and the public understand what to expect from a pulmonary rehabilitation programme.

The new guideline, produced by the European Respiratory Society and the American Thoracic Society, supports the use of pulmonary rehabilitation as an essential part of the care offered to people with chronic obstructive pulmonary disease and other long-term lung conditions.

Link to 2013 Guidelines on Pulmonary Rehabilitation

For the first time, the European Lung Foundation has produced a patient version of this official ERS guideline. 

Link to this important Respiratory document

This document can be freely downloaded to help increase public understanding and awareness of pulmonary rehabilitation and what to expect from the programme.

Disparities in respiratory health

To address the global phenomenon of disparities in respiratory health, the American Thoracic Society and the European Respiratory Society have released an official policy statement in which each pledges its commitment to reducing health disparities between the lowest and highest socioeconomic groups by continuing or initiating work with leaders from governments, academia, and other organizations to promote scientific inquiry and training, disseminate medical information and best practices, and monitor and advocate for public respiratory health.

Klaus Rabe, MD, writing committee member and a past president of ERS, continued: "The effects of health disparities in Europe on respiratory disease are very pronounced. Individuals in lower social groups are not only more likely to have respiratory diseases, but, compared with other disorders, social inequality is associated with a larger proportion of deaths from these diseases."

The American Thoracic Society and European Respiratory Society pledge to frame their actions to reduce respiratory health disparities. The vision of the ATS and ERS is that all persons attain better and sustained respiratory health. They call on all their members and other societies to join in this commitment.