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What's new in pulmonary, critical care, and sleep medicine

Last literature review version 17.3: September 2009  |  This topic last updated: October 16, 2009   (More)

The following represent additions to UpToDate since the last version that were considered by the authors and editors to be of particular interest. The new material described below represents a small subset of the updating that has been performed, since approximately 40 percent of the topic reviews are updated during each four-month cycle.

ASTHMA

Churg-Strauss syndrome (CSS) has been reported in patients receiving omalizumab for treatment of severe asthma. The timing of onset of symptoms suggests that CSS preceded treatment with omalizumab or coincided with tapering of glucocorticoids after initiation of omalizumab [1]. (See "Churg-Strauss syndrome (allergic granulomatosis and angiitis)", section on 'Association with medications'.)

Nitric oxide levels in expired air (eNO) are typically higher in subjects with asthma than those without, and eNO generally rises in association with increasing airway inflammation. Isocyanates, found in polyurethane foam and paints, can be added to the list of irritant and allergenic inhalational agents that increase eNO [2]. (See "Exhaled nitric oxide analysis", section on 'Use in asthma'.)

COPD

Roflumilast is a phosphodiesterase-4 inhibitor that is being studied for use in COPD. A 52-week randomized trial of 3091 patients with COPD found that roflumilast improved the prebronchodilator forced expiratory volume in one second (FEV1) and decreased the rate of moderate to severe exacerbations [3]. Similarly, in two 24-week trials, roflumilast improved the prebronchodilator FEV1 in patients with moderate to severe COPD when added to either salmeterol or tiotropium [4]. (See "Management of stable chronic obstructive pulmonary disease", section on 'Future directions'.)

The risk of pneumonia was not increased by inhaled budesonide in a meta-analysis of 7042 patients with COPD [5]. (See "Role of inhaled glucocorticoid therapy in stable COPD", section on 'Adverse effects'.)

COUGH

Premature ventricular contractions (PVCs) may be a rare cause of chronic cough. In a series of 120 patients referred to an electrophysiology center for evaluation of PVCs, six patients had a chronic cough that was believed to be partially or entirely caused by the PVCs [6]. Treatment of the arrhythmia led to marked improvement in the cough in five of the six. (See "Evaluation of subacute and chronic cough in adults", section on 'Rare causes'.)

CRITICAL CARE

In a multicenter, double-blind trial, 193 patients with septic shock who were still vasopressor-dependent at the end of a standard 96-hour infusion of recombinant human activated protein C (rhAPC) were randomly assigned to receive additional rhAPC or placebo by continuous infusion for 72 hours [7]. Extending the duration of the rhAPC infusion did not improve clinical outcomes. (See "Management of severe sepsis and septic shock in adults", section on 'Recombinant human activated protein C'.)

A retrospective analysis of data from an earlier randomized trial found that the rate of serious bleeding events (intracranial hemorrhage, retinal hemorrhage, hemarthrosis, spinal hemorrhage, or other life threatening bleeding) was not increased among those who received heparin venous thromboembolism prophylaxis during rhAPC infusion, although total bleeding complications were increased [8]. (See "Management of severe sepsis and septic shock in adults", section on 'VTE prophylaxis during infusion'.)

In a meta-analysis of six randomized trials (1953 adults), patients who received glucocorticoid therapy had a reduction in the rate of postextubation stridor (6.1 versus 15 percent, relative risk 0.47, 95% CI 0.22-0.99) and a nonstatistically significant decrease in the rate of reintubation (2.7 versus 4.7 percent, relative risk 0.48, 95% CI 0.19-1.22) [9]. (See "Extubation management", section on 'Glucocorticoids'.)

A pooled analysis of nine studies (2231 patients) found that the absence of a cuff leak predicts post-extubation stridor with a sensitivity and specificity of 56 and 92 percent, respectively [10]. (See "Extubation management", section on 'Cuff leak'.)

A nonrandomized trial found that there is no consensus among surrogate decision-makers about whether clinicians should provide a recommendation regarding life support decisions during end-of-life discussions [11]. (See "Communication in the ICU: Holding a family meeting", section on 'Discussion'.)

INTERSTITIAL LUNG DISEASE

In a series of 19 patients with non-small cell lung cancer, induction chemotherapy with carboplatin and gemcitabine followed by radiation therapy was associated with high-grade radiation pneumonitis in 32 percent [12]. (See "Radiation-induced lung injury", section on 'Induction chemotherapy'.)

Although it has been assumed that patients with lymphangioleiomyomatosis (LAM) would be at increased risk for spontaneous pneumothorax during air travel, this has not been confirmed. In a series of 299 patients with LAM, the risk of a new pneumothorax was 3 percent, compared to less than 2 percent for those who traveled by land [13]. (See "Pulmonary lymphangioleiomyomatosis", section on 'Air travel'.)

Among patients with systemic sclerosis (SSc) and interstitial lung disease (ILD), centrilobular fibrosis is a rare pattern on high resolution computed tomography (HRCT) that shows patchy ground glass or consolidative opacities with a central distribution. In a series of 28 patients with SSc-ILD, six had centrilobular fibrosis on biopsy that was associated with pathologic evidence of recurrent aspiration [14]. (See "Clinical manifestations of systemic sclerosis (scleroderma) lung disease", section on 'Imaging'.)

INTERVENTIONAL PULMONOLOGY

A trial randomly assigned 50 patients with suspected sarcoidosis to undergo real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) or blind transbronchial needle aspiration (TBNA) [15]. EBUS-TBNA diagnosed sarcoidosis with a sensitivity and specificity of 83 and 100 percent, respectively, while blind TBNA diagnosed sarcoidosis with a sensitivity and specificity of 61 and 100 percent, respectively. The prevalence of sarcoidosis in the population studied was 94 percent. (See "Endobronchial ultrasound: Indications, advantages, and complications", section on 'Mediastinal lesions'.)

In an observational study, 48 patients who had undergone photodynamic therapy (PDT) to treat endobronchial squamous cell cancer were followed for a median of five years [16]. There were 11 deaths during the study. Only one death was due to the original malignancy, while six were due to metachronous or synchronous primary lung cancers. (See "Photodynamic therapy of lung cancer", section on 'Efficacy'.)

LUNG CANCER

A trial randomly assigned 189 patients with newly diagnosed or suspected non-small cell lung cancer (NSCLC) to undergo either conventional staging plus integrated computed tomography (CT)/positron emission tomography (PET) or conventional staging alone [17]. Patients who underwent conventional staging plus integrated CT/PET were less likely to be offered surgical therapy. Among those who were in the conventional staging plus integrated CT/PET group and not offered surgery, approximately one-third had been deemed inoperable on the basis of the integrated CT/PET. In addition, thoracotomy was less likely to be futile among those who received conventional staging plus integrated CT/PET (35 versus 58 percent). (See "Role of imaging in the staging of non-small cell lung cancer", section on 'Integrated PET/CT'.)

PULMONARY VASCULAR DISEASE

The Proceedings of the 4th World Symposium on Pulmonary Hypertension were published, which included changes to the definition, classification, and management of pulmonary hypertension [18-21]. (See "Overview of pulmonary hypertension" and "Diagnostic evaluation of pulmonary hypertension" and "Treatment of pulmonary hypertension".)

Unfractionated heparin (UFH) products manufactured in the United States after October 8, 2009 will be approximately 10 percent less potent [22]. This is a consequence of a new United States Pharmacopeia (USP) reference standard, which will lessen the potential for contamination and calibrate new material relative to the international standard issued by the World Health Organization. Since the clinical impact of this change is uncertain, it is advisable to closely monitor the aPTT in any patient receiving UFH. (See "Anticoagulation in acute pulmonary embolism", section on 'Potency change'.)

A meta-analysis of 21 randomized trials (3140 patients with pulmonary arterial hypertension) found that therapy with a prostanoid, an endothelin receptor antagonist, or a phosphodiesterase-5 inhibitor decreases mortality compared to controls (1.5 versus 3.8 percent, relative risk 0.57, 95% CI 0.35 - 0.92) [23]. (See "Overview of pulmonary hypertension", section on 'Outcome'.)

A trial randomly assigned 405 patients with group 1 pulmonary arterial hypertension (PAH) to receive tadalafil or placebo once daily for 16 weeks [24]. Tadalafil (40 mg) significantly increased the six-minute walk distance and the time to clinical worsening, while decreasing the incidence of clinical worsening and improving health related quality of life. (See "Treatment of pulmonary hypertension", section on 'PDE5 inhibitors'.)

SLEEP MEDICINE

The American Academy of Sleep Medicine released its clinical practice guidelines for the evaluation, management, and long-term care of adults with obstructive sleep apnea (OSA) [25]. (See "Overview of obstructive sleep apnea in adults" and "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Management of obstructive sleep apnea in adults".)

A trial that administered continuous positive airway pressure (CPAP) to 96 patients with an ischemic stroke and an apnea hypopnea index (AHI) of ≥20 events per hour found that 5-year mortality was lower among those who tolerated CPAP therapy than among those who did not (50 versus 68 percent) [26]. (See "Sleep related breathing disorders and stroke", section on 'Diagnosis and treatment'.)

A prospective cohort study estimated that 7 percent of adults develop insomnia each year and 30 percent develop some symptoms of insomnia [27]. Variables associated with the onset of insomnia included a previous episode of insomnia, a family history of insomnia, a predisposition toward being more arousable, poorer self-rated health, and more body pain. (See "Overview of insomnia", section on 'Risk factors'.)

A meta-analysis of eight randomized trials (3786 patients) found that patients taking eszopiclone for insomnia were at higher risk for infection than patients taking placebo (20 versus 11 percent, relative risk 1.48, 95% CI 1.25-1.74) [28]. A similar meta-analysis of ten randomized trials (2935 patients) found that patients taking zolpidem were also at higher risk for infection than patients taking placebo (5 versus 3 percent, relative risk 1.99, 95% CI 1.21-3.26) (see "Treatment of insomnia", section on 'Adverse effects'.

In a retrospective cohort study of 63 patients who underwent uvulopalatopharyngoplasty (UPPP) for OSA (mean AHI of 62 events per hour of sleep), only 15 patients (24 percent) achieved a surgical cure, which was defined as a postoperative AHI of <5 events per hour of sleep [29]. (See "Management of obstructive sleep apnea in adults", section on 'Surgery'.)

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REFERENCES

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  2. Ferrazzoni, S, Scarpa, MC, Guarnieri, G, et al. Exhaled nitric oxide and breath condensate ph in asthmatic reactions induced by isocyanates. Chest 2009; 136:155.
  3. Calverley, PM, Rabe, KF, Goehring, UM, et al. Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials. Lancet 2009; 374:685.
  4. Fabbri, LM, Calverley, PM, Izquierdo-Alonso, JL, et al. Roflumilast in moderate-to-severe chronic obstructive pulmonary disease treated with longacting bronchodilators: two randomised clinical trials. Lancet 2009; 374:695.
  5. Sin, DD, Tashkin, D, Zhang, X, et al. Budesonide and the risk of pneumonia: a meta-analysis of individual patient data. Lancet 2009; 374:712.
  6. Stec, SM, Grabczak, EM, Bielicki, P, et al. Diagnosis and management of premature ventricular complexes-associated chronic cough. Chest 2009; 135:1535.
  7. Dhainaut, JF, Antonelli, M, Wright, P, et al. Extended drotrecogin alfa (activated) treatment in patients with prolonged septic shock. Intensive Care Med 2009; 35:1187.
  8. Levy, M, Levi, M, Williams, MD, et al. Comprehensive safety analysis of concomitant drotrecogin alfa (activated) and prophylactic heparin use in patients with severe sepsis. Intensive Care Med 2009; 35:1196.
  9. Khemani, RG, Randolph, A, Markovitz, B. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev 2009; :CD001000.
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  11. White, DB, Evans, LR, Bautista, CA, et al. Are physicians' recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med 2009; 180:320.
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  13. Taveira-DaSilva, AM, Burstein, D, Hathaway, OM, et al. Pneumothorax after air travel in lymphangioleiomyomatosis, idiopathic pulmonary fibrosis, and sarcoidosis. Chest 2009; 136:665.
  14. de Souza, RB, Borges, CT, Capelozzi, VL, et al. Centrilobular fibrosis: an underrecognized pattern in systemic sclerosis. Respiration 2009; 77:389.
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  17. Fischer, B, Lassen, U, Mortensen, J, et al. Preoperative staging of lung cancer with combined PET-CT. N Engl J Med 2009; 361:32.
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UpToDate performs a continuous review of over 430 journals and other resources. Updates are added as important new information is published. The literature review for version 17.3 is current through September 2009; this topic was last changed on October 16, 2009. The next version of UpToDate (18.1) will be released in March 2010.

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