European Respiratory Journal, European Respiratory Review, ERJ Open Research, Breathe, the ERS Monograph and ERS Handbooks, and European Lung White Book
Wheezy infants do not respond to bronchodilators despite evidence of functioning β-adrenoceptors. This is because the predominant aetiology, bronchiolitis, is characterised by small airway oedema and increased mucus, for which β2-agonists are ineffective.
In intubated ARDS patients, prone positioning reduces mortality. On spontaneously breathing patients, oxygenation improved during awake prone positioning. Relevant data on clinical outcomes are expected, especially on
#COVID19
patients.
Pulmonary thrombosis appears to be common in
#COVID19
pneumonia and takes two forms, proximal pulmonary emboli and/or distal thrombosis. The possible mechanisms and clinical implications are discussed.
Guideline statements for the diagnosis of hypersensitivity pneumonitis have recently been published by the ATS/JRS/ALAT and CHEST. This review examines differences in the two guideline statements and discusses current management options.
Evidence-based guidelines for the treatment of sarcoidosis: a major factor in treating patients is the risk of loss of organ function or impairment of quality of life
Home-based pulmonary rehabilitation is as effective as centre-based in improving exercise capacity and quality of life, and is an option for people with COPD whose access to pulmonary rehabilitation centres is difficult.
Long-term e-cigarette exposure may result in pulmonary inflammation and reduced resistance to respiratory infections, which partially reflects the established effects of cigarette exposure, due to a combination of nicotine exposure and oxidative stress.
Bronchiectasis, due to its highly heterogenous nature, requires an individualised approach to therapy. Treatment targets symptoms and exacerbations by aiming to improve mucociliary clearance and to reduce airway inflammation and airway infection.
The ERS guidelines for the management of
#COVID19
make recommendations in favour of corticosteroids, thromboprophylaxis, anti-IL-6 and noninvasive ventilatory support. These guidelines will be regularly updated as further evidence becomes available.
Nitrofurantoin is a cause of drug-induced pneumonitis and can result in clinically significant respiratory symptoms manifesting as interstitial lung disease on chest CT, even if the patient has been taking the drug chronically without side-effects
Chronic or recurrent use of systemic corticosteroids before SARS-CoV-2 infection is a major risk factor of worst COVID-19 severity and survival in asthmatics as opposed to ICS and biological therapy which seems to be safe.
European Respiratory Journal: 1-year DLCO decline was a better indicator of mortality than 1-year FVC decline in patients with >10% emphysema. In non-CPFE IPF patients, 1-year FVC declines >5% and >10% showed comparable mortality associations.
Pneumomediastinum in severe
#COVID19
presentations could be due to a lung parenchymal retractive process generated by intense inflammation as in acute exacerbation of idiopathic pulmonary fibrosis or MDA-5 acute interstitial lung disease
Asthma diagnosis in adults still remains a challenge with over- and under-diagnosis. Spirometry with reversibility testing is essential. Nitric oxide, peak expiratory flow variability and bronchial challenge testing should also be considered.
In discharged survivors with
#COVID19
, impairment of diffusion capacity is the most common abnormality of lung function, followed by restrictive ventilatory defects, which are both associated with the severity of the disease
Prednisolone given universally for COPD exacerbations causes harm without any benefit. Patients deserve blood eosinophil-guided prednisolone treatment for COPD exacerbations.
The large randomised, double-blind, placebo-controlled AMAZES trial observed that azithromycin 500 mg given 3-times a week for 48 weeks in adults with persistent uncontrolled asthma decreased asthma exacerbations and improved asthma-related quality of life
Smokers and those with COPD have increased airway expression of ACE-2, which is the entry receptor for the COVID-19 virus. This may explain the increased risk of severe COVID-19 in these subpopulations and highlight the importance of smoking cessation.
The diagnosis of cryptogenic organising pneumonia requires the clinician to be prudent in eliminating several clinical conditions including: environmental factors, medications, systematic disease, aspiration pneumonia and infection, including COVID-19
Asthma is a heterogenous disease. Targeted therapies have been developed based on the pathophysiology of type 2 inflammation. These therapies offer hope for improved management of type 2 inflammatory airway diseases.
We are pleased to announce new Journal Impact Factors of 16.7 (third in the respiratory field) for the European Respiratory Journal and 8.8 (eighth in the field) for the European Respiratory Review. Congratulations to the editorial boards of both publications.
High-flow nasal cannula or NIV oxygen treatment does not lead to an increase in aerosol dispersal compared to the use of low-flow nasal cannula oxygen. For a coughing patient, using dual-limb NIV may reduce the risk of aerosol spread.
Overdiagnosis in the COPD literature generally refers to a false positive diagnosis (misdiagnosis). Misdiagnosis can be significantly reduced by performing spirometry in every patient with suspected COPD.
Spirometry is used to diagnose and manage airway disease such as asthma and COPD, but relates poorly to symptoms, lacks sensitivity and is effort dependent. FOT and MBNW are emerging clinical lung function tests that help us dismantle disease mechanisms.
A complication of
#COVID19
, PASC-pulmonary fibrosis, has potential to become a global respiratory health crisis. Dedicated surveillance, mechanistic understanding and clinical and research efforts are needed to confront this emerging sequela of COVID-19.
ERR: Bronchiectasis is an underdiagnosed and heterogeneous disorder. Inflammation is a key driver of bronchiectasis and represents a therapeutic target for current and new treatments.
ERJOR: Oral prednisone did not show any advantage in patients with COPD exacerbation in primary care. Significantly higher respiratory-related treatment failure in the prednisone group warns against the use of corticosteroids in this setting.
New ERS guideline on chronic cough details the paradigm shift in our understanding. In adults, cough hypersensitivity has become the overarching diagnosis, and in children, persistent bacterial bronchitis explains most wet cough, changing treatment advice.
Since the proposal of the research entity interstitial pneumonia with autoimmune features (IPAF) in 2015, many questions remain unanswered and challenges remain in its definition
In patients with interstitial lung abnormalities (ILA), monitoring of those at risk of progression is currently recommended, and pulmonary physicians should pursue an early diagnosis when ILA become clinically significant to facilitate timely treatment
The 2021 Journal Impact Factors for ERS Publications are: ERJ, 33.795; ERR, 9.533; and ERJ Open Research, 4.239. Congratulations to our chief editors and their editorial boards!
Improving quality of life in people with chronic breathlessness, with a combination of (mostly) non-drug and drug interventions, improves clinical outcomes and reduces patient/carer suffering and futile use of medical services
#COVID19
pulmonary sequelae are unknown. The Swiss COVID-19 lung study reports on initial follow-up findings. Severe or critical COVID-19 was associated with significant functional impairment and radiological abnormalities after 4 months.
ERR: Asthma and COPD are complex inflammatory diseases of the airways. Targeted treatments have drastically improved severe asthma outcomes, but in COPD no targeted treatments have at present demonstrated great improvement.
Review of viral ARDS pathogenesis, how it informs evolving models of
#COVID19
, and how hallmarks of ageing explain the age-related morbidity and mortality of severe COVID-19
ERR: Pulmonary rehabilitation that includes individualised exercise training is effective in patients with stable COPD and those who have suffered an exacerbation. Remaining challenges are to increase uptake and access to and personalisation of programmes.
Breathe: Guidelines recommend FENO as a second-line test for diagnosing asthma in children. FENO-guided treatment is associated with reduced odds of exacerbation, but it is unclear how FENO should be incorporated into pathways of asthma care.
Breathlessness is a major cause of suffering across populations that relates strongly to increased healthcare utilisation and major adverse health including shorter survival
@MJJohnson_HYMS
E-cigarette use, particularly with nicotine-containing vapour, is a harmful alternative to tobacco smoking. Nicotine-containing e-cig vapour increases pulmonary endothelial permeability, induces inflammation and causes airway and parenchymal alterations.
The prevalence of comorbidities in asthma is high. Untreated, these conditions can worsen asthma control, leading to reflexive escalation of therapy. Systematic assessment and management of these entities in severe asthma is of paramount importance.
Hypercytokinaemic immune dysregulation in
#COVID19
is known as cytokine storm syndrome. Interleukin-6 levels ≥80 pg/mL predict an increased risk of respiratory failure and death, and immunomodulatory therapy is an area of urgent investigation.
Long-term use of inhaled corticosteroids in COPD is associated with a significantly increased risk of side-effects, especially oral candidiasis, dysphonia, pneumonia, mycobacterial disease, diabetes and fractures
Nailfold capillaroscopy by smartphone-dermatoscope is a safe, feasible tool that may improve the identification of connective tissue disease associated with interstitial lung disease beyond routine clinical assessment
European Respiratory Journal: IPCs are not superior to chest drain and pleurodesis at improving quality of life in patients with malignant pleural effusion
Cardiopulmonary exercise testing has been increasingly recognised as a complementary and indispensable tool to assess the functional status, the response to interventions and the prognosis of patients with chronic respiratory and cardiac diseases
ICS-naïve COPD patients who start ICS and whose most recent blood eosinophil count is <150 cells/µL have a 15% higher risk of future exacerbation compared to those with a count ≥150 cells/µL. ICS should be reserved for those with higher blood eosinophils.
ERJ: Nicotine vaping is associated with acute and chronic lung cellular, structural and functional changes that can be expected to have significant short- and long-term consequences for consumers’ respiratory health
3 months post-COVID-19, most patients have at least one organ function impairment. All patients have some degree of cognitive impairment and abnormal dyspnoea symptom scores. Abnormal HRCT and impaired DLCO are predominately found in inpatients.
#longCOVID
Inducible laryngeal obstruction and breathing pattern disorder are common causes of breathlessness. Multidisciplinary assessment can prevent unnecessary medication use, hospital admissions and facilitate effective management of these complex conditions.
Endothelial cell dysfunction and impaired microcirculatory function contribute markedly to life-threatening complications of
#COVID19
, such as venous thromboembolic disease and multiple organ involvement
Asthma is frequently misdiagnosed. Both over- and under-diagnosis are associated with inappropriate treatment and potential patient harm. Although no gold standard diagnostic test is available, objective testing can improve diagnostic accuracy.
High-dose prednisolone may not be superior to a low-dose 6-week regimen in improving clinical, physiological and radiological outcomes, or health-related quality of life, in patients with symptomatic post-
#COVID19
diffuse parenchymal lung abnormalities
The respiratory microbiome encompasses bacterial, fungal and viral communities. In health, it is a dynamic structure and dysbiotic in disease. Dysbiosis can be related to disease severity and may be utilised to predict patients at clinical risk.
The ERS/ATS Task Force makes recommendations on the use of novel therapies for severe asthma, specifically biologicals for type 2 high asthma, and antimuscarinic agents and macrolides, as well as on biomarkers for predicting treatment response
ERJ: High-dose (40 mg/day initial dose) prednisolone was not superior to a lower dose (20 mg/day initial dose) in improving outcomes or the HRQoL in sarcoidosis and was associated with similar adverse effects.
Sarcoidosis-associated pulmonary hypertension is a significant cause of morbidity and mortality. A guide to screening, diagnosis and treatment has been developed by a team of experts.
Chronic refractory cough is frequently characterised by cough hypersensitivity and laryngeal dysfunction. An interdisciplinary team approach that includes laryngeal evaluation can identify laryngeal hypersensitivity along with other cough aetiologies.
#COVID19
pneumonia can be life-threatening. Given the unprecedented burden placed on ICU resources by the epidemic, avoiding intubation is a major issue. This study suggests that CPAP can achieve this objective.
CT total airway count (TAC) predicts incident COPD in at-risk smokers, indicating that smokers exhibit early airway remodelling prior to abnormal spirometry and that CT TAC is a potential tool to help identify smokers at increased risk of COPD
Early pulmonary rehabilitation shortly after
#AECOPD
leads to a faster recovery in physical performance than initiated in the stable phase. Adherence to rehabilitation is significantly higher when initiated shortly after an exacerbation.
Pulmonary surfactant is a crucial structure for lung function and gas exchange. Recent studies have documented pulmonary surfactant abnormalities in most chronic lung diseases, participating in disease pathology and symptoms.
Cluster analysis based on extrapulmonary treatable traits in people with moderate-to-severe asthma indicates that physical inactivity, higher levels of sedentary time, symptoms of anxiety and depression, and obesity are associated with worse outcomes.
Continuation of antifibrotic treatment during waiting time for lung transplantation proved to be safe. Pirfenidone did not appear to have a beneficial effect in bronchiolitis obliterans syndrome; results of antifibrotic therapy in RAS are eagerly awaited.
Pulmonary rehabilitation has evolved from an “art” to “science” over the past decades thanks to the contributions of Prof Casaburi. His priorities for the future are: 1) access, 2) access, and 3) access!
This ERS/ESICM statement outlines a review of the literature and practice concerning prevalence, clinical significance, diagnosis and management of dyspnoea, one of the most distressing experiences, in critically ill mechanically ventilated adult patients
Pneumomediastinum is more frequent in
#COVID19
patients with ARDS despite the use of a protective ventilatory approach. Lung frailty, and not barotrauma, appears to be the main cause of this finding.
The FORZA trial investigated beclomethasone–formoterol versus placebo in bronchiectasis without asthma or COPD. There were no signs of benefit and more adverse events, which warrants caution for the prescription of ICS/LABA therapy in bronchiectasis.
CRP-guided antibiotic treatment (cut-off ≥50 mg/L) in patients with acute exacerbations of COPD admitted to hospital significantly reduces antibiotic consumption without an increase in adverse events
SARS-CoV-2 infection itself may cause damage to the respiratory muscles and may contribute to the acute and persistent dyspnoea in patients with COVID-19. Respiratory muscle testing and training appear to be important for patients with COVID-19.
α1-antitrypsin deficiency is a heterogeneous disease driven by aberrant protease activity in the presence of low α1-AT levels. Understanding mechanisms driving pathological processes in α1-ATD phenotypes could identify novel therapeutic targets.
Respiratory physiotherapists have a key role within the integrated care continuum of patients with respiratory diseases. The current review highlights the diversity of the profession and addresses future research directions in respiratory physiotherapy.
Breathe: Pulmonary renal syndrome is the combination of rapidly progressive glomerulonephritis (RPGN) and diffuse alveolar haemorrhage (DAH). Morbidity and mortality are high so prompt diagnosis and intervention are key for the respiratory physician.
Asthma is a complex, heterogeneous disease, which currently has no cure; this review explores the disease-modifying potential of asthma therapies and the direction future research may take to achieve disease remission or prevention.
Mycobacterium marinum can cause pulmonary infection and can grow at ≤32°C. Physicians should consider M. marinum when examining patients with pulmonary infection and low body temperature or anorexia nervosa, and grow the specimen at ≤32°C.
The use of the 6-min walk test as a primary end-point in interstitial lung disease clinical trials should depend upon the study population, the degree of disease progression expected and how this might be impacted by the study treatment
ERJ: Rituximab plus MMF is associated with benefits in lung function and progression-free survival compared with MMF plus placebo after 24 weeks of treatment. The safety profile of rituximab plus MMF was similar to that of MMF plus placebo.
Treatment of obstructive sleep apnoea in adults is evolving, from a “one treatment fits all” to a more individualised approach. Proper patient selection and use of specific criteria are crucial for a beneficial outcome.
Multimorbidity is common in COPD and is a global health priority. Using novel approaches to understand the complex mechanisms underlying multimorbidity is key to developing targeted, patient-centred management strategies to improve outcomes.
Low-dose azithromycin is effective therapy for persistent asthma. AMAZES supports AZM as a treatment option for patients with severe asthma. Long-term, low-dose AZM reduces asthma exacerbations and improves quality of life in patients with severe asthma.
Studies of the microbiome in bronchiectasis demonstrate an association between Pseudomonas, Haemophilus and other genera with exacerbations. Lower microbiome diversity correlates with greater disease severity. Larger studies are needed.
European Respiratory Journal: Sputum colour is a simple non-invasive marker of airway inflammation that identifies patients with bronchiectasis at higher risk of exacerbation, hospitalisation and mortality
The minute ventilation/CO2 production ratio is useful when evaluating exercise responses. This review describes the physiology of the minute ventilation/CO2 production ratio and the ratio response in endurance athletes, asthma and obesity.
Exposure to air pollution induces airway epithelial barrier dysfunction through several mechanisms including increased oxidative stress, exaggerated cytokine responses and impaired host defence, which contributes to development of asthma and COPD.
Bronchiectasis is a chronic progressive condition with significant disease burden and frequent exacerbations for which the diagnosis relies on cross-sectional imaging
Pulmonary hypertension complicates various forms of ILD and carries a poor prognosis. Diagnosis requires clinical suspicion and right heart catheterisation. Treatment remains limited, although results of the INCREASE study show promise.
Dyspnoea and fatigue are common in chronic lung disease and are associated with decreased exercise capacity, muscle weakness and physical inactivity.
#pulmonaryrehab
is effective at targeting these extrapulmonary features, but is underused.
@burtin_chris
Bilateral endobronchial valves treatment can lead to additional significant benefits in patients who respond to the first procedure and have a clear target lobe on both lungs but increases the rate of complications
CPAP can be successfully used in a number of
#COVID19
patients with hypoxaemic respiratory failure and gas exchange and radiological findings similar to those generally considered to be indications for invasive mechanical ventilation