Pulmonary and Critical Care Year in Review

Transcription

1 Pulmonary and Critical Care Year in Review Heath E Latham, MD Assistant Professor University of Kansas Dept of Internal Medicine Division of Pulmonary and Critical Care

2 None Disclosure

3 Lung Cancer Screening Reduced Lung-Cancer Mortality with Low- Dose CT Screening NEJM 2011;365:395. The National Lung Screening Trial (NLST)

4 Lung Cancer Screening Background Lung cancer leading cause of cancer death >150,000 deaths in 2011 Screening efforts in lung cancer unsuccessful CXR CT imaging Low-Dose CT imaging Allowed early detection with less radiation

5 Lung Cancer Screening Study Protocol 53,454 patients at 33 US medical centers Age range High risk for lung cancer >30 pack years Active smoker Non-smokers < 15 years Annual Low-Dose CT vs CXR for 3 years Followed for 8 years

6 Lung Cancer Screening Study Findings Positive nodules identified 39.1% of CT group with 1060 Lung CA diagnosed 16% of CXR group with 941 Lung CA diagnosed 90% of positive tests lead to diagnostic studies False positives 96.4% in CT group 94.5% in CXR group

7 Lung Cancer Screening Rate of Death from Lung Cancer 247 per 100,000 person years in CT group 309 per 100,000 person years in CXR group Relative Risk Reduction with CT 20% with p=0.004 Absolute Mortality Reduction with CT 6.7% with p=0.02 Number Needed to Screen 320

8 Lung Cancer Screening Author s Conclusion Low Dose CT screening reduces mortality from lung cancer

9 Lung Cancer Screening Caution/Consideration Unknown cost Unknown duration Unknown radiation effects Requires dedicated administration to run the screening program similar to mammography Guidelines Being Developed by Societies ATS/ACCP/ASCO NCCN

10 Lung Cancer Screening Conclusion Referral and screen at dedicated centers Expect cost analysis soon Development of non-invasive diagnostics Blood and Breath tests Smoking cessation

11 Azithromycin in COPD Azithromycin for Prevention of Exacerbations in COPD NEJM 2011;365:689. Multicenter US study

12 Azithromycin in COPD Background COPD 4 th leading cause of death Exacerbations effect patient and community Significant increase in 30 day mortality Rapid decline in lung function Reduce quality of life Economic burden Lost work Care provided Further study needed in prevention

13 Azithromycin in COPD Study Protocol 1 year Randomized placebo controlled Azithromycin 250mg daily vs placebo Standard COPD diagnostic criteria History of exacerbations or O2 dependent Excluded Tachycardia QT Prolongation or Drugs causing QT prolongation Hearing impairment

14 Azithromycin in COPD Study Sample 75% were severe and very severe COPD >80% were receiving ICS >80% were on long-acting bronchodilators 60% were on O2 therapy 20% active smokers

15 Azithromycin in COPD Study Findings Reduced risk of AECOPD Extended time to first AECOPD 266 days in Az group 174 days in placebo NNT = 2.86

16 Azithromycin in COPD Adverse Events No difference in death rate No difference in cardiovascular events Increased hearing decrement 25% vs 20% (p=0.04)

17 Azithromycin in COPD Additional Outcomes Reduced Colonization 12% vs 31% developed colonization Macrolide Resistance No difference if colonized at enrollment 81% vs 41% resistance if developed colonization No difference in rate of pneumonia

18 Azithromycin in COPD Author s Conclusion Azithromycin reduces exacerbations in select COPD patients when taken daily for one year. Additional Considerations Reduced exacerbations over standard of care appears additive.

19 Azithromycin in COPD Conclusion Clear additive benefit Effect via reduced colonization and inflammation Select patients Duration of therapy? Effect of reduced dose?

20 Tiotropium in Asthma Tiotropium in Asthma Poorly Controlled with Standard Combination Therapy NEJM DOI: /NEJMoa European study Pharma sponsored

21 Tiotropium in Asthma Background Poorly controlled asthma despite LABA/ICS Increased risk of exacerbations Lost work and school days High health care costs Small studies support addition of tiotropium Reduce symptoms Reduce exacerbations

22 Tiotropium in Asthma Study Protocol Randomized, double-blind, placebo-controlled Parallel group replicate trials Asthma diagnosed prior to age of 40 Persistent airflow obstruction Symptomatic by Asthma Control Questionaire All on ICS/LABA Non-smokers At least one exacerbation

23 Study Results Tiotropium in Asthma Peak FEV1 Improved Trial 1 86mL & 73mL Trial 2 154mL & 152mL Baseline FEV1 Improved Trial 1 89mL & 94mL Trial 2 111mL & 92mL Reduced exacerbation RR 21% Side effects equal No deaths NNT = 15

24 Tiotropium in Asthma Author s Conclusion Adding tiotropium to inhaled steroids and LABAs in poorly controlled asthma delayed first exacerbation and improved lung function. Additional Consideration No added side effects Essentially one year study Pharma sponsored

25 Tiotropium in Asthma Conclusion Ensure adherence to ICS/LABA Examine triggers and avoid Safe addition to poorly controlled asthma Fixed obstruction and frequent exacerbations

26 Pulmonary Embolism Moderate Pulmonary Embolism Treated with Thrombolysis (MOPETT) Presented American College of Cardiology 3/27/ US Pilot study

27 Pulmonary Embolism Background Acute PE carries high potential for mortality Little change in treatment for submassive PE Thrombolytics reserved for hemodynamically unstable ACCP and AHA guidelines

28 Pulmonary Embolism Study Protocol Open labeled randomized controlled trial ½ dose TPA plus reduced anticoagulation vs full anticoagulation without TPA. Single center 121 patients Submassive PE with RV dysfunction and PAP over 40 mmhg (avg PAP 50 mmhg) Endpoint reduced pulmonary HTN

29 Pulmonary Embolism Study Results 48 Hour PA pressures 16 mmhg reduction in TPA group 5 mmhg reduction in control 28 Month PA pressures 28 mmhg avg pressure in TPA group 43 mmhg avg pressure in control Reduced hospital stay 2.2 days in TPA group 4.9 days in control No acute bleeding in study

30 Pulmonary Embolism Author s Conclusion Reduced TPA regimen safely treats pulmonary embolism

31 Pulmonary Embolism Conclusion Pilot study Larger study needed to confirm findings 2 similar studies currently in progress No change in practice currently Follow ACCP or AHA guidelines Prepare for another debate