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
What do you mean oxygen doesn t help? Current CMS coverage for supplemental oxygen PaO2 < 55 mm Hg or saturation < 88% PaO2 55-9 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; 375:1617-1627
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; 375:1617-1627
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; 375:1617-1627
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; 375:1617-1627
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; 375:1617-1627
Conservative v. Conventional Oxygen Therapy in the ICU Study groups: Conservative PaO2 70-100 mm Hg / saturation 94-98 % Conventional PaO2 Up to 150 mm Hg / saturation 97-100% 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, 1583-1588
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) 0.006 Liver failure 4 (1.9) 14 (6.4) 0.02 Bacteremia 11 (5.1) 22 (10.1) 0.049 Girardis M. JAMA 2016;316:15, 1583-1588
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
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
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
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
Cough and Short of breath.now what???
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-
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) 1257 1743 2229 304 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
Updated GOLD Guidelines
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
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
Classification to Guide Therapy
Treatment of Stable COPD 2017 Global Initiative for Chronic Obstructive Lung Disease
The Forgotten Therapy Smoking cessation Pulmonary rehabilitation Vaccination End of life counseling Co-morbidities Surgical therapies Oxygen
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):1627-1635
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):1627-1635
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
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
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
Who can I ignore potential of PE What I ll never know
Thank you! Johnson.Margaret2@mayo.edu (904) 953 2282