What s New in the Pulmonary Medicine Literature. 24 March 2017 Boca Raton Florida

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1 What s New in the Pulmonary Medicine Literature MARGARET M JOHNSON, MD ASSOCIATE PROFESSOR OF MEDICINE CHAIR, DIVISION OF PULMONARY MEDICINE JOHNSON.MARGARE T2@MAY O.E DU 24 March 2017 Boca Raton Florida

2 What do you mean oxygen doesn t help? Current CMS coverage for supplemental oxygen PaO2 < 55 mm Hg or saturation < 88% PaO mm Hg or saturation 89% with: CHF Cor pulmonale HCT > 56% Original design Resting saturation 89-93% Changed after 7 months and 34 subjects Subsequent design During 6 MW, > 80% * 5 minutes and < 90% * 10 seconds Long-Term Oxygen Treatment Trial Group, NEJM 2016; 375:

3 Subjects 738 patients randomized 368 received supplemental oxygen 220-oxygen 24/7 148-use during sleep/exercise Followed for 1-6 years Median 18 months Long-Term Oxygen Treatment Trial Group, NEJM 2016; 375:

4 No difference between. Time to death First hospitalization Time to first exacerbation Time to first hospitalization for COPD exacerbation Rate of all hospitalization Rate of all COPD exacerbations Quality of life Anxiety Depression Functional status Long-Term Oxygen Treatment Trial Group, NEJM 2016; 375:

5 Nadir in 6 MW No supplemental oxygen (n= 370) Supplemental oxygen < 86% 29% 29% 86-88% 36% 36% > 88% 35% 35% Long-Term Oxygen Treatment Trial Group, NEJM 2016; 375:

6 Comments Odd definition of hypoxemia < 90% * 10 seconds Study-design-patient selection Only 1/3 below 86% Compliance with use Reported mean 15 hrs/day (24 hour group) 11 hrs/day (exercise/sleep group) Reluctance for enrollment You can t deny me oxygen Long-Term Oxygen Treatment Trial Group, NEJM 2016; 375:

7 Conservative v. Conventional Oxygen Therapy in the ICU Study groups: Conservative PaO mm Hg / saturation % Conventional PaO2 Up to 150 mm Hg / saturation % 2/3 were on mechanical ventilation COPD patients with acute exacerbation excluded Primary outcome: ICU mortality (Fairly) well matched at baseline Both MICU (1/3) and SICU (2/3) patients Girardis M. JAMA 2016;316:15,

8 Better Outcomes with Conservative Oxygen Therapy Conservative # (%) Conventional # (%) ICU mortality 25 (11.6) 44 (20.2) 0.01 P Shock 8 (3.7) 23 (10.6) Liver failure 4 (1.9) 14 (6.4) 0.02 Bacteremia 11 (5.1) 22 (10.1) Girardis M. JAMA 2016;316:15,

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10 What caused syncope? Adult patients with first episode of syncope who required hospital admission Excluded those on anticoagulation Completed protocol within 48 hours Evaluation for etiology followed algorithm Prandoni P. NEJM 2016; 375:1524

11 PE Evaluation Negative d-dimer and Unlikely simplified Well s score assumed not to have clot Simplified Well s 7 component scoring system < 4 Unlikely Well validated approach Either positive d-dimer or Likely Wells score lead to imaging CTA in most; VQ if CTA contraindicated Prandoni P. NEJM 2016; 375:1524

12 Results 560 patients who required admission Did not capture those who were discharged from ED 330 excluded by d-dimer/well s score 230 included 97/230 ( 42.2%) + PE Entire cohort 97/560 (17.3%) Prandoni P. NEJM 2016; 375:1524

13 Comments Of 355 patients with an alternative explanation, 45 (13%) still had PE 25% of those with PE had no clinical findings to suggest VTE 40% did not have large clot on imaging Prandoni P. NEJM 2016; 375:1524

14 Cough and Short of breath.now what???

15 Cryobiopsy Lung Biopsy for ILD Retrospective observational study 33 patients Diffuse interstitial lung disease not felt to be probable UIP Performed via bronchoscope Propofol anesthesia Endotracheal tube in place Outpatient Hernandez-Gonzalez F. Arch Bronconeumol 2015;51:261-

16 Cryobiopsy Lung Biopsy for ILD Diagnostic yield 26/33 (79%) VATS (No admission) VATS 24 hr stay VATS 49=8 hr stay Cryobiopsy Outpatient Cost/pt (E) Complication Number (%) Mild bleeding 3 (9%) Moderate bleeding Severe bleeding 0 7 (21%) PTX 4 (12%) Hernandez-Gonzalez F. Arch Bronconeumol 2015;51:261-7

17 Updated GOLD Guidelines

18 What remains Emphasis on preventable nature Focus on treatment for present control of symptoms and future complications (exacerbations/death) Maintain recommendations for therapy based on grouping (A-D) What s new Absence of spirometry in severity grading De-escalation recommendations

19 The Alphabet Soup LABA-long acting beta agonist Formoterol, salmeterol, indacterol LAMA-long acting anti-muscarinic Tiotropium, umecldinium ICS-inhaled corticosteroid LAMA and LABA combination Umecldinium + vilanterol Indacaterol/glycopyrroium

20 Classification to Guide Therapy

21 Treatment of Stable COPD 2017 Global Initiative for Chronic Obstructive Lung Disease

22 The Forgotten Therapy Smoking cessation Pulmonary rehabilitation Vaccination End of life counseling Co-morbidities Surgical therapies Oxygen

23 Is IVC Filter Additive to Anticoagulation Symptomatic PE + DVT Anticoagulation * 6 months with or without IVC filter Similar characteristics at baseline with exception of known chronic respiratory disease Higher in filter group (17% v. 9%) Similarities: Active cancer (15%) Signs of RV dysfunction (65%) Prior VTE (35%) Mismetti P. JAMA 2015;313(16):

24 Is IVC Filter Additive to Anticoagulation No difference in: 3 month recurrence 6 month recurrence Symptomatic DVT Major bleeding Death (3 months) Death (6 months). Mismetti P. JAMA 2015;313(16):

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29 Sleep Duration and Quality: Impact on Lifestyle Behaviors and Cardiometabolic Health Sleep and cardiometabolic relationship is not limited to sleep disordered breathing Short and long sleep duration associated with: Coronary disease Obesity Insulin resistance HTN Public health campaign advocated to promote importance of sleep and screening for sleep duration AHA Scientific Statement Circulation 2016; 134:e367-e386

30 What I think I know Some is good does not equate to more is better Super-oxygenation is likely harmful I won't invest in an oxygen bar IVC filter has a very limited role Remove those that are not longer indicated Don t let an attorney s phone call remind me of those I left behind Cryobiopsy offers a safe and effective alternative to TBBX and OLBx in diffuse lung disease Sleep is good

31 What I am still unsure of When should I prescribe supplemental oxygen in patients with COPD How to individualize drug therapy in COPD How to get more sleep

32 Who can I ignore potential of PE What I ll never know

33 Thank you! (904)