Dana Zappetti

Pulmonary Nocardiosis in the Immunocompetent Host: Case Series.

Pulmonary nocardiosis is commonly recognized as an opportunistic infection in patients with predisposing immunosuppressive conditions. However, reports of pulmonary nocardiosis in the immunocompetent host are rare. Here, we report a case series of four patients with pulmonary nocardiosis without a predisposing condition.

High-flow Nasal Cannula is Superior to Conventional Oxygen Delivery After Extubation

Synopsis: In a multicenter randomized clinical trial, high-flow nasal cannula reduced the reintubation rate after extubation among intensive care unit patients considered to be at a low risk for reintubation compared with conventional oxygen therapy (4.9% vs. 12.2%, respectively). Source: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. JAMA. 2016, ahead of print.

Less is More: Do Patients With Copd and Moderate Resting or Exercise-induced Desaturation Benefit From Long-term Supplemental Oxygen Therapy?

Synopsis: Although long-term supplemental oxygen for patients with COPD and severe resting oxygen desaturation is associated with reduced mortality, it has remained unclear whether patients with moderate desaturation would derive a similar benefit. This large, randomized clinical trial demonstrated that long-term supplemental oxygen in patients with moderate resting or exercise-induced desaturations has neither reduced time to mortality nor time to first hospitalization for any cause. Furthermore, it provided no reduction in the incidence of COPD exacerbations and no improvement in lung function, quality of life, or functional status. These findings potentially alter practice patterns for this subset of patients with COPD. Source: The Long-Term Oxygen Treatment Trial Research Group. A randomized trial of long-term oxygen for COPD with moderate desaturation. N Engl J Med. 2016;375:1617–1627.

Are We Assessing Patients’ Experiences of Breathlessness Accurately During Spontaneous Breathing Trials?

on HRCT and intraprocedural confirmation of the absence of collateral ventilation. In the subgroup analysis of VENT patients with complete fissures on HRCT, an FEV1 improvement of 16.2% was seen at 6 months, which was markedly better when compared with the rest of the cohort. Despite this increase in the efficacy, the concern for adverse events continues to be a limiting factor in expanding the use of this technique. There were 6 additional cases of pneumothorax in the EBV group in this study, and overall the difference in major adverse events was trending toward significance in VENT (9 vs. 0, P = 0.06) and reached significance in this STELVIO trial. The selection of patients without collateral ventilation is perhaps a double-edged sword. Whereas these patients are more likely to respond to valve placement, perhaps their physiology also increases the risk for barotrauma and subsequent pneumothorax. An increase in the risk for COPD exacerbation requiring hospitalization and hemoptysis observed in VENT was not observed with STELVIO, although this could simply reflect the smaller patient population of STELVIO. Further larger trials using EBVs are needed before the risk and the benefit of this intervention are fully defined.

Do Smokers With Respiratory Symptoms but Preserved Lung Function Have a COPD-like Disease?

life indices compared with the LABA-ICS group. Although a previous study had revealed a possible mortality risk associated with Tiotropium monotherapy compared with combination Salmeterol-Fluticasone administration, the FLAME trial found no difference in the mortality between the LABALAMA and the LABA-ICS groups. Although this is only 1 trial, the results of the FLAME trial support a shift toward combination LABA-LAMA as the preferred therapy in GOLD class C or D disease. Current guidelines should still be followed, as additional studies over longer follow-up times are needed before making more definitive conclusions.

The Safety of Fluticasone-Salmeterol in Patients With Moderate to Severe Asthma

ing that investigators were unable to comment upon whether retreatment represented a relapse or reinfection with a different isolate. Lastly, rifampin was prescribed to a relatively small and highly selected patient population with few medical comorbidities and low risk of drug-drug interactions, which skews the analysis of discontinuation rates. Further studies of clofazimine-containing regimens are thus warranted as the data presented by Jarand et al suggest that they are at least as good as rifampin-containing regimens for the treatment of MAC lung disease. The current study was conducted in Canada, but in the United States, clofazamine is not commercially available and currently must be obtained from the Food and Drug Administration by submitting an Investigational New Drug application.

Apneic Oxygenation With a High-flow Nasal Cannula Does Not Improve Oxygen Saturation During Endotracheal Intubation in the Critically Ill

high-flow nasal cannula after extubation is associated with lower rates of persistent respiratory failure and also decreased reintubation rates in low-risk patients. Combined with the knowledge that noninvasive positive pressure ventilation has not been conclusively shown to reduce reintubation rates in general populations of critically ill patients, the results of this study raise the question of whether all patients without a diagnosis known to benefit from noninvasive positive pressure ventilation (ie, congestive heart failure, chronic obstructive pulmonary disease, postsurgical patients, or patients with hypercapnea during spontaneous breathing trial) should be extubated to high-flow nasal cannula regardless of the presumed risk of reintubation. This may be especially beneficial for those with copious secretions. Further studies are needed to determine the optimal duration of high-flow nasal oxygen after extubation and to answer remaining questions as to the superiority of noninvasive positive pressure ventilation or high-flow nasal cannula in various patient populations (eg, postsurgical or obese patients).

Discontinuation of Inhaled Corticosteroids May Reduce the Risk of Pneumonia in COPD Patients

defects seen on CTA may not represent the true PE, but may be treated as such, subjecting patients to the potential risks of anticoagulant therapy. The application of clinical prediction rules and the utilization of age-adjusted D-dimers may help increase the positive predictive value by selecting the appropriate patients for CTA. In addition, the combination of a negative lower-extremity Doppler ultrasound and an ageadjusted D-dimer may allow a clinician to safely observe patients who are found to have an isolated subsegmental PE without anticoagulation. Some small studies have shown that withholding anticoagulation in patients with inconclusive scans or those with isolated subsegmental PE may not result in adverse outcomes, although further investigation is needed. This study illustrates that the increased use of CTA will result in the detection of small subsegmental filling defects, some of which may not represent the true PE, and when treated, subject patients to the risks of anticoagulation, despite a lack of clear evidence that there is benefit to anticoagulation in these individuals.

Endobronchial Valve Placement: Too Much Risk for the Benefit?

Synopsis: the STELVIO trial randomized patients without collateral interlobar ventilation to receive endobronchial valves or standard care as a treatment for severe COPD. Although improvement in the lung function and the exercise capacity was observed in the valve group, a significant rate of pneumothorax was also observed. Source: Klooster K, Ten HAcken NHT, Hartman JE et al. Endobronchial valves for emphysema without interlobar collateral ventilation. NEJM. 2015; 373: 2325–35.

Can the Use of a Genomic Classifier Reduce the Need for Invasive Procedures to Diagnose Lung Cancer

Synopsis: This study evaluates the potential for a novel genetic classifier in patients with pulmonary nodules to increase the sensitivity and specificity of lung cancer screening and thereby reduce the number of patients being exposed to the harms of invasive diagnostic testing. Source: Vachani A, Whitney D, Parsons E, et al. Clinical utility of a bronchial genomic classifier in patients with suspected lung cancer. Chest. 2016;150(1):210–218.