Severe asthma in children: An official statement from Saudi Pediatric Pulmonology Association

In Saudi Arabia, the prevalence of pediatric asthma ranges between 8% and 25%. However, there are no sufficient data regarding severe asthma in childhood in Saudi Arabia. Therefore, a task force has been formed by the Saudi Pediatric Pulmonology Association which is a subsidiary group of the Saudi Thoracic Society and consists of Saudi experts with well-respected academic and clinical backgrounds in the fields of pediatric asthma as well as other respiratory diseases to write a consensus on definitions, phenotypes, and pathophysiology, evaluation, and management. To achieve this, the subject was divided into various sections, each of which was assigned to at least 2 experts. Without a central literature review, the authors searched the literature using their own strategies. To reach an agreement, the entire panel reviewed and voted on proposed findings and recommendations.

Objective structured clinical examinations (OSCEs) for students' training and assessment in the French respiratory medicine departments in 2021: An overview

BACKGROUND

Medical professional performances can be assessed by objective structured clinical examinations (OSCEs) where medical trainees go through a series of simulated clinical situations. OSCEs are now the gold standard for the assessment of medical students' competence during their training. In France, the first national OSCEs will take place in May 2024 and respiratory teachers will be involved in this reform and will use OSCEs for students' training and assessment in respiratory medicine. Students training regarding this final OSCE may vary across medical faculties and may impact students' results. Therefore, we aimed to provide a national overview of OSCE's training performed by respiratory teachers and their interest in developing a common French databank of OSCEs.

METHODS

We conducted a national anonymous online survey among the members of the French college of respiratory teachers (CEP), from 2021 February the 15th to 2021 June the 15th. The survey consisted of 32 questions.

RESULTS

Among 118 French pulmonologists teachers, 52 (45%) responded to the survey. We received a response from at least one of each of the French Medical Universities. Twenty-two (42%) had received specific training on how to conduct an OSCE. Twenty-eight (54%) of respondents used OSCEs for training purposes and 24 (46%) for assessment purposes, for less than 1 year in more than half of the participants. The average satisfaction scores out of 10 about OSCEs was 7.3 ± 1.7 for training and 7.4 ± 1.5 for students' assessment. Respondents were willing (8.9 ± 1.8 out of ten) to develop a common databank to share OSCEs subjects in respiratory medicine in France.

CONCLUSIONS

This survey confirms heterogeneity in the training and the use of OSCEs among French respiratory teachers. However, a common national databank could be a useful tool to reduce these disparities.

Current state and future potential of AI in occupational respiratory medicine

PURPOSE OF REVIEW

The COVID-19 pandemic has accelerated the pace of technological development relating to pulmonary diseases. The advent of newer technologies, such as Artificial Intelligence (AI), continues to be adapted for diagnostic purposes. AI offers comparable precision to trained physicians under certain circumstances, as well as the unique ability to process the information characteristic of Big Data. With respect to individual susceptibilities/pre-existing diseases, AI seems poised to integrate such individualized information and contribute to a greater implementation of precision medicine.

RECENT FINDINGS

AI can match trained clinicians in specific applications, but AI has limitations that require clearly defined questions and a high quality of data. Data collected for this purpose is predicted to increase both in quality and volume, as technology concerned with personal health (FitBit, Apple Watch) proliferates. However, the role of AI with respect to physicians in a clinical setting is still being debated. AI generally aims to increase objectivity through its correlational methodology.

SUMMARY

AI continues to be a proliferative field of study. It has defined strengths and weaknesses which, if accounted for, has the potential to increase healthcare access as well as the quality of care delivered.

The Diagnostic Contribution of Systematic Lung Ultrasonography in Patients Admitted to a Conventional Pulmonology Hospitalization Unit

OBJECTIVE

Although the evidence to date remains limited, we hypothesized that performing protocolized lung ultrasound (LUS) in patients, admitted to a conventional pulmonology hospitalization unit, could improve diagnostic precision. The main objectives of this study were to evaluate the diagnostic contribution and changes in the treatments administered after performing a protocolized LUS in patients hospitalized in a Pulmonology Department ward.

METHODOLOGY

This was a prospective, observational study, which included patients admitted from the Emergency Department to a conventional Pulmonology Department hospitalization unit, after first being evaluated by a pulmonologist. LUS was performed within the first 48 hours of admission. The diagnosis at the time of discharge was used as the reference diagnosis.

RESULTS

A total of 180 patients were included in this study. The admitting diagnoses were the decompensation of an underlying obstructive disease in 60 patients (33.3%), respiratory infection in 93 (51.7%), pulmonary thromboembolism (PE) in 9 (5%), exacerbation of an interstitial lung disease in 14 (7.8%), and other causes in 4 cases (2.2%). Ultrasonography provided new information, unsuspected at the patient's admission, in 117 (65%) of the patients by capturing images suggestive of infection in 63 patients (35%), 1 new case of ILD, 23 (12.7%) cases of cardiogenic edema, and pleural pathology in 19 (10.5%), as well as two tumors and indirect data related to a PE. The use of LUS resulted in the decision to change the already established treatment in 17.2% of the cases.

CONCLUSIONS

LUS provided additive information in more than half of patients that ended up reclassifying or potentially changing diagnosis or treatment. Thus, including LUS in management algorithms could reduce the need for other complementary tests or unnecessary treatments.

[French practical guidelines for the diagnosis and management of IPF - 2021 update, short version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

Establishing CREATE: lessons learned in setting up a training environment for early-career researchers in respiratory medicine

BACKGROUND

The purpose of the National Health and Medical Research Council Centre of Research Excellence in Pulmonary Fibrosis (CRE-PF) is to improve and extend the lives of patients living with pulmonary fibrosis through the development of a comprehensive and integrated program of basic and clinical research and education across Australia. A key objective of the CRE-PF was establishment of a unique national training scheme, CREATE, for early-career researchers (ECRs) in respiratory research. CREATE ECRs are broadly drawn from two main fields of researchers: clinicians and scientists, where clinicians tend to be involved in part-time translational research and scientists are involved in broad scientific research including laboratory or genetic research, health economics or population research.

METHODS

We describe the CREATE Program which, with limited budget and the assistance of key organisations, has provided funding opportunities (scholarships, fellowships, prizes, travel and collaboration grants), professional development (mentoring program, symposia, presentation opportunities and on-line training) and fostered a connected, supportive research community for respiratory ECRs.

RESULTS

The CREATE program has successfully fostered the development of the supported researchers, contributing substantially to the future of pulmonary fibrosis research in Australia. During the life of the program the CRE-PF has offered 10 PhD scholarships and five postdoctoral fellowships, awarded 13 travel grants and three grants to promote collaboration between ECRs from different institutes. A mentoring program has been established and CREATE Symposia have been held in association with key meetings. During COVID-19 restrictions, a series of virtual research meetings has offered 12 CREATE ECRs from seven universities the opportunity to present their research to a national audience. CREATE research-related achievements are impressive, including over 80 first-author publications by ECRs, and many conference presentations. Contributions to the research community, measured by committee membership, is also strong.

CONCLUSIONS

In spite of a very limited budget, wide geographic distribution of participants and the multi-disciplinary nature of the cohort, we have succeeded in providing a unique, supportive academic development environment for CREATE ECRs. Lessons learned in the process of developing this program include the importance of leveraging funding, being flexible, building networks and seeking and responding to ECR input.

Education and Use of Lung Ultrasound in Rheumatology and Pneumology in Spain: A SER-SEPAR Survey

INTRODUCTION

Lung ultrasound (LUS) is a clinical and research tool with great potential in the diagnosis and monitoring of diffuse interstitial lung disease (ILD) present in systemic autoimmune diseases (SAD). Appropriate training in LUS is essential for the correct and safe use of this technique.

OBJECTIVE

To document the current state of LUS education and use among Spanish rheumatologists and pneumologists.

MATERIAL AND METHODS

A national online survey was designed for members of the Spanish Society of Rheumatology and the ILD Area of the Spanish Society of Pneumology and Thoracic Surgery. The survey consisted of 22 questions on demographics, professional activity, performance and training in LUS.

RESULTS

One hundred and thirty-five (56.72% rheumatologists, 41.79% pneumologists) responded to the survey. Of these, 56.30% were part of an ILD Unit in their centre. LUS in clinical practice was performed by 35.82% but only 14.93% performed it in ILD, mainly for diagnostic purposes. Training in LUS of responders had been diverse in format, content and sponsors. The vast majority (87.79%) considered that the optimal model of education in LUS should be standardized and structured and consist of a combination of theoretical-practical courses and the conduct of a minimum number of supervised LUS examinations, with competency assessment.

CONCLUSIONS

The current lack of formal structured education in LUS is an opportunity to develop quality educational programmes in this emerging field.

Anesthesia for interventional pulmonology

PURPOSE OF REVIEW

Anesthesia for pulmonological interventions is a demanding challenge. This article discusses recent innovations and the implications for periinterventional anesthetic management.

RECENT FINDINGS

Interventional pulmonology is a rapidly expanding specialty with very complex diagnostic and therapeutic approaches that include oncological staging, treatment of obstructive and restrictive lung diseases, recanalization of endobronchial obstructions, and retrieval of foreign bodies. With the development of advanced diagnostic and therapeutic interventions, the application is extended to critically ill patients. Current evidence focusing on the anesthetic techniques is presented here.

SUMMARY

The development of new pulmonological methods requires a tailored anesthesiological approach. Their specific impact must be taken into account to ensure patient safety, goal-oriented outcome diagnostics and -quality, successful interventions, and patient comfort.

[Pulmonology 2021: year in review]

Among the new therapeutic developments in pulmonology during 2021, we have identified three topics of interest. A new biotherapy is now available for the management of severe uncontrolled non-Th2 asthma. In the field of pulmonary arterial hypertension, upfront triple therapy at the time of diagnosis is associated with a survival benefit in high-risk patients. Riociguat is a therapeutic option for patients that remain at intermediate risk despite treatment with iPDE5. Sotatercept, a promising new class of drug for treatment of group 1 PAH will soon be available. Finally, the use of transbronchial cryobiopsies as a valid alternative to surgical lung biopsy for the diagnosis of diffuse interstitial lung diseases will also be discussed in this review.

Do guidelines influence breathlessness management in advanced lung diseases? A multinational survey of respiratory medicine and palliative care physicians

BACKGROUND

Respiratory medicine (RM) and palliative care (PC) physicians' management of chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD), fibrotic interstitial lung disease (fILD) and lung cancer (LC), and the influence of practice guidelines was explored via an online survey.

METHODS

A voluntary, online survey was distributed to RM and PC physicians via society newsletter mailing lists.

RESULTS

450 evaluable questionnaires (348 (77%) RM and 102 (23%) PC) were analysed. Significantly more PC physicians indicated routine use (often/always) of opioids across conditions (COPD: 92% vs. 39%, fILD: 83% vs. 36%, LC: 95% vs. 76%; all p < 0.001) and significantly more PC physicians indicated routine use of benzodiazepines for COPD (33% vs. 10%) and fILD (25% vs. 12%) (both p < 0.001). Significantly more RM physicians reported routine use of a breathlessness score (62% vs. 13%, p < 0.001) and prioritised exercise training/rehabilitation for COPD (49% vs. 7%) and fILD (30% vs. 18%) (both p < 0.001). Overall, 40% of all respondents reported reading non-cancer palliative care guidelines (either carefully or looked at them briefly). Respondents who reported reading these guidelines were more likely to: routinely use a breathlessness score (χ2 = 13.8; p < 0.001), use opioids (χ2 = 12.58, p < 0.001) and refer to pulmonary rehabilitation (χ2 = 6.41, p = 0.011) in COPD; use antidepressants (χ2 = 6.25; p = 0.044) and refer to PC (χ2 = 5.83; p = 0.016) in fILD; and use a handheld fan in COPD (χ2 = 8.75, p = 0.003), fILD (χ2 = 4.85, p = 0.028) and LC (χ2 = 5.63; p = 0.018).

CONCLUSIONS

These findings suggest a need for improved dissemination and uptake of jointly developed breathlessness management guidelines in order to encourage appropriate use of existing, evidence-based therapies. The lack of opioid use by RM, and continued benzodiazepine use in PC, suggest that a wider range of acceptable therapies need to be developed and trialled.

[Annual review of interventional pulmonology (2021)]

In the last decade, interventional pulmonology has developed rapidly, and gradually become a mature subspecialty in modern respiratory medicine, playing a more and more important role in the diagnosis and treatment of respiratory diseases. Especially in recent years, with the development of the related technology, various new technologies of interventional pulmonology came out and are gradually applied to chronic respiratory diseases which were mainly treated with drugs before, greatly expanding the application field of interventional pulmonology. Here, we reviewed the new progress and up-to-date research achievements of interventional pulmonology from 2020 to 2021.

[Clinical update in critical care of pulmonary medicine 2021]

In this review, we outlined the clinical studies in critical care field of pulmonary medicine from November 1, 2020 to September 30, 2021. A Chinese retrospective study for critically ill patients with COVID-19 showed that corticosteroid therapy was associated with a reduced 28-day mortality in patients with the hyperinflammatory phenotype. In hospitalized patients with COVID-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization, and early sedation with dexmedetomidine exhibited a high probability of reduced 90-day mortality in older patients regardless of operative or non-operative cluster status. High-flow nasal cannula (HFNC) improved the prognosis compared with conventional oxygen therapy in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients with acute compensated hypercapnic respiratory failure. For COVID-19 patients suffering from acute respiratory failure with HFNC therapy, awake prone positioning reduces the incidence of treatment failure and the need for intubation. Compared with pressure-volume curve guiding positive end-expiratory pressure (PEEP) titration for acute respiratory distress syndrome (ARDS) patients, PEEP titration guided with EIT (Electrical impedance tomography) might be associated with improved driving pressure and survival rate. Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe ARDS patients, but the survival among ECMO-assisted patients with COVID-19 is strongly associated with a centre's experience in ECMO during the previous year and early ECMO management. Compared to conventional lung-protective mechanical ventilation (MV), neurally adjusted ventilatory assist (NAVA) decreased duration of MV. These findings also provide evidence for improving the clinical management in critical care of pulmonary medicine.

The role of interventional pulmonology in pleural disease diagnosis and management

PURPOSE OF REVIEW

Pleural disease guidelines have not been updated in a decade. Advances have been made in the diagnosis and management of pleural diseases since, with expanding evidence of the utility of medical thoracoscopy (MT) as a safe and effective tool.

RECENT FINDINGS

Although thoracic ultrasound has improved early determination of pleural disease etiology, thoracentesis remains limited, and pleural tissue is necessary for the diagnosis of undifferentiated exudative pleural effusions. Medical thoracoscopy has been shown to be superior to traditional closed pleural biopsy, and recent literature is focused on which technique is best. A recent randomized controlled trial (RCT) found rigid mini-thoracoscopy was not superior to semirigid thoracoscopy. Meta-analyses have not found pleural cyrobiopsy to be superior to forceps biopsies. As a therapeutic tool, meta-analysis suggests MT as a possible first-line tool for the treatment of complicated parapneumonic effusions (CPE) and early empyema. A RCT comparing MT to intrapleural fibrinolytic therapy demonstrated that the former technique is safe, effective, and may shorten hospital length of stay in patients with CPE/empyema.

SUMMARY

The implications of the recent findings in the medical literature are that medical thoracoscopy, particularly by trained Interventional Pulmonologists, will find an expanded role in future iteration of pleural disease guidelines.

Robotic bronchoscopy and future directions of interventional pulmonology

PURPOSE OF REVIEW

To describe the emerging field of robotic bronchoscopy within advanced diagnostic bronchoscopy. We review the literature available for these two novel platforms to highlight their differences and discuss the impact on future directions.

RECENT FINDINGS

There are two distinct technologies both known as robotic bronchoscopy. The Monarch robotic-assisted bronchoscopy is based on electromagnetic guidance whereas the Ion robotic-assisted bronchoscopy is founded on shape sensing technology. Although there is ongoing work to explore the capabilities of these systems, studies have shown that both are safe modalities. Furthermore, both hold promise to improve diagnostic yield and may eventually pave the way for therapeutic bronchoscopic ablation in the future.

SUMMARY

Although both platforms fall under the umbrella term of robotic-assisted bronchoscopy, the Monarch and Ion systems are quite unique in their technology. Thus far, both have demonstrated safety, and early data shows promising results for improved diagnostic yield compared to previously advanced bronchoscopy modalities, especially when combined with advanced confirmatory imaging. Future directions may include bronchoscopic ablation of peripheral lesions given the stability and reach of these platforms.

Effectiveness of Simulation-based Clinical Skills Training for Medical Students in Respiratory Medicine:<br /> A Pilot Study

OBJECTIVE

To assess the effectiveness of high-fidelity simulation-based medical education (HF-SBME) in teaching and learning respiratory clinical examination in medical students.

STUDY DESIGN

Quasi-experimental pilot study.

PLACE AND DURATION OF STUDY

The Aga Khan University, Karachi, from November 2018 to January 2020.   Methodology: This study was conducted amongst third year medical students at the University. Students were assigned to intervention (IG) or control groups (CG). The IG underwent training for the respiratory clinical examination on a high-fidelity simulator mannequin, while the CG received the conventional practice session on standardised patients. Students were assessed on their respiratory clinical examination skills in five domains, and each domain was scored between 1-3 points (poor=1, fair=2, good=3) for a maximum composite score of 15. Feedback on use of SBME was also obtained from students.

RESULTS

There were no statistically significant differences in demographics for the CG (n=41) and IG (n=40). Composite score for control and intervention groups was not significantly different (CG: 12.9 ± 1.89 vs. IG: 12.0 ± 2.35; p=0.067). However, a greater percentage of CG students were rated good in all five domains, with the difference being statistically significant for ability to correlate findings with clinical history (CG: 87.8% vs. IG: 67.5%; p=0.028).

CONCLUSION

Although medical students perceived HF-SBME as a beneficial teaching modality, it did not translate into improved performance. More research is required to determine the utility of HF-SBME in a developing country, like Pakistan. Key Words: Simulation, High-fidelity, Medical education, Developing country, Clinical skills.

Frequency of Osteoporosis among Chronic Obstructive Pulmonary Disease Patients Attending Respiratory Medicine Out Patient Department, BSMMU

Osteoporosis is an important systemic manifestation of Chronic Obstructive Pulmonary Disease (COPD). Osteoporosis is a systemic disease of bone which may present as low bone mass and micro-architectural disarray that increases the risk of fracture. The World Health Organization defines osteoporosis as bone density ≥2.5 standard deviations below the bone density of a normal young adult. Osteopenia, a less severe form of bone loss, is defined as a bone density between 1 and 2.5 standard deviations below that reference point. The aetiology of osteoporosis in COPD patients remain unclear, but several factors significantly correspond to reduced bone density in COPD, including older age, female sex and body mass index (BMI). However, the relationship to other factors, such as FEV₁, tobacco smoking, physical inactivity and corticosteroid therapy, are still an unresolved issue. This cross-sectional study was done in the Department of Respiratory Medicine, BSMMU from March 2018 to March 2019. A total of 86 patients of which prevalence of osteoporosis is 29.1%, osteopenia 50% and normal BMD in 20.9%, majority of them was belonging to age group 51-60 years. Male were predominant with male-female ratio of 3.5:1. The frequency of osteoporosis was 32.0%, 64.0% and 4.0% in moderate, severe and in very severe COPD patients, respectively. The frequency of osteopenia was 14.0% in mild, 53.5% in moderate, 20.9% in severe and 11.6% were in very severe COPD patients. The p value (p=0.018) was significant for prevalence osteoporosis and osteopenia with increase in severity of COPD. The prevalence of osteoporosis and osteopenia was high in COPD patients under study. The frequency of osteoporosis and osteopenia was more with severity of COPD.

Health outcomes: Towards the accreditation of respiratory medicine departments

National health systems must ensure compliance with conditions such as equity, efficiency, quality, and transparency. Since it is the right of society to know the health outcomes of its healthcare system, our aim was to develop a proposal for the accreditation of respiratory medicine departments in terms of care, teaching, and research, measuring health outcomes using quality of care indicators. The management tools proposed in this article should be implemented to improve outcomes and help us achieve our objectives. Promoting accreditation can serve as a stimulus to improve clinical management and enable professionals to take on greater leadership roles and take action to improve outcomes in patient care.

Recent Insights into the Measurement of Carbon Dioxide Concentrations for Clinical Practice in Respiratory Medicine

In the field of respiratory clinical practice, the importance of measuring carbon dioxide (CO2) concentrations cannot be overemphasized. Within the body, assessment of the arterial partial pressure of CO2 (PaCO2) has been the gold standard for many decades. Non-invasive assessments are usually predicated on the measurement of CO2 concentrations in the air, usually using an infrared analyzer, and these data are clearly important regarding climate changes as well as regulations of air quality in buildings to ascertain adequate ventilation. Measurements of CO2 production with oxygen consumption yield important indices such as the respiratory quotient and estimates of energy expenditure, which may be used for further investigation in the various fields of metabolism, obesity, sleep disorders, and lifestyle-related issues. Measures of PaCO2 are nowadays performed using the Severinghaus electrode in arterial blood or in arterialized capillary blood, while the same electrode system has been modified to enable relatively accurate non-invasive monitoring of the transcutaneous partial pressure of CO2 (PtcCO2). PtcCO2 monitoring during sleep can be helpful for evaluating sleep apnea syndrome, particularly in children. End-tidal PCO2 is inferior to PtcCO2 as far as accuracy, but it provides breath-by-breath estimates of respiratory gas exchange, while PtcCO2 reflects temporal trends in alveolar ventilation. The frequency of monitoring end-tidal PCO2 has markedly increased in light of its multiple applications (e.g., verify endotracheal intubation, anesthesia or mechanical ventilation, exercise testing, respiratory patterning during sleep, etc.).