Enhancing Recruitment and Retention of Minority Populations for Clinical Research in Pulmonary, Critical Care, and Sleep Medicine: An Official American Thoracic Society Research Statement

Background: Well-designed clinical research needs to obtain information that is applicable to the general population. However, most current studies fail to include substantial cohorts of racial/ethnic minority populations. Such underrepresentation may lead to delayed diagnosis or misdiagnosis of disease, wide application of approved interventions without appropriate knowledge of their usefulness in certain populations, and development of recommendations that are not broadly applicable.Goals: To develop best practices for recruitment and retention of racial/ethnic minorities for clinical research in pulmonary, critical care, and sleep medicine.Methods: The American Thoracic Society convened a workshop in May of 2019. This included an international interprofessional group from academia, industry, the NIH, and the U.S. Food and Drug Administration, with expertise ranging from clinical and biomedical research to community-based participatory research methods and patient advocacy. Workshop participants addressed historical and current mistrust of scientific research, systemic bias, and social and structural barriers to minority participation in clinical research. A literature search of PubMed and Google Scholar was performed to support conclusions. The search was not a systematic review of the literature.Results: Barriers at the individual, interpersonal, institutional, and federal/policy levels were identified as limiting to minority participation in clinical research. Through the use of a multilevel framework, workshop participants proposed evidence-based solutions to the identified barriers.Conclusions: To date, minority participation in clinical research is not representative of the U.S. and global populations. This American Thoracic Society research statement identifies potential evidence-based solutions by applying a multilevel framework that is anchored in community engagement methods and patient advocacy.

[Flexible bronchoscopy: contribution of the anesthesiologis]

The field of interventional pulmonology is expanding rapidly with increasingly complex endoscopic procedures. Pulmonologists and anesthesiologists are both airway specialists. When they cooperate in performing flexible bronchoscopies, they must share a common anatomical space. A close and dynamic collaboration helps to optimize patient management by enhancing safety, facilitating the procedures and improving patient satisfaction. Several challenges are to be taken up, notably managing frail and often polymorbid patients, working outside the usual operating-room area, and the need to be quickly available, given the frequently semi-urgent setting of these procedures. In this context, the optimization of collaborative procedures is essential.

Pediatric Airway Endoscopy: Recommendations of the Society for Pediatric Pneumology

For many decades, pediatric bronchoscopy has been an integral part of the diagnosis and treatment of acute and chronic pulmonary diseases in children. Rapid technical advances have continuously influenced the performance of the procedure. Over the years, the application of pediatric bronchoscopy has considerably expanded to a broad range of indications. In this comprehensive and up-to-date guideline, the Special Interest Group of the Society for Pediatric Pneumology reviewed the most recent literature on pediatric bronchoscopy and reached a consensus on a safe technical performance of the procedure.

Consensus-Statement der Österreichischen Gesellschaften für Pneumologie und Rheumatologie zur Definition, Evaluation und Therapie von progredient fibrosierenden interstitiellen Lungenerkrankungen (pfILD)

Interstitielle Lungenerkrankungen (ILD) sind eine heterogene Gruppe von Pathologien, die zunehmend als relevanter Faktor pulmonaler Morbidität und Mortalität erkannt werden. Verschiedene ILD wie die idiopathische Lungenfibrose (IPF), aber auch durch Autoimmunprozesse oder durch exogene Noxen bedingte ILD können zu progredienter, meist irreversibler Lungenfibrose führen. Die antifibrotischen Substanzen Nintedanib und Pirfenidon können den Krankheitsverlauf bei IPF-Patienten günstig beeinflussen. Dagegen werden ILD, die auf entzündlichen Prozessen wie z. B. rheumatologischen Grunderkrankungen oder exogen-allergischer Alveolitis beruhen, bis dato klassischerweise immunsuppressiv therapiert. Immer wieder kommt es aber trotz einer solchen Behandlung zu progredienter Fibrosierung. Eine positive Wirkung antifibrotischer Medikation auf progredient fibrosierende (pf)ILD abseits der IPF konnte in rezenten Studien demonstriert werden, auch wenn der Stellenwert der Antifibrotika in solchen Situationen noch nicht vollständig geklärt ist. Dieses Consensus-Statement beruht auf einem virtuellen, multidisziplinären Expertenmeeting von Rheumatologen, Pneumologen und Radiologen und wurde durch die jeweiligen ILD-Arbeitskreise der Österreichischen Gesellschaften für Pneumologie sowie Rheumatologie (ÖGP und ÖGR) akkordiert. Ziel war es, den aktuellen Stand von klinischer Praxis und wissenschaftlicher Datenlage zu Definition, Evaluation und Therapie von pfILD darzustellen. Zusammenfassend sollen ILD-Patienten einer standardisierten Abklärung unterzogen, in einem multidisziplinären ILD-Board diskutiert und dementsprechend therapiert werden. Kern dieser Empfehlungen ist, auch Non-IPF-Patienten mit dokumentiert progredient fibrosierendem ILD-Verlauf antifibrotisch zu behandeln, insbesondere wenn Honigwabenzysten oder eine bereits ausgedehnte Erkrankung vorliegen. Patienten mit fibrotischer ILD, die auf Basis der ILD-Board-Empfehlung primär keiner oder ausschließlich einer immunsuppressiven Therapie unterzogen werden, sollten engmaschig hinsichtlich eines progredienten Verlaufes überwacht werden.

Saudi experts' recommendation for RSV prophylaxis in the era of COVID-19: Consensus from the Saudi Pediatric Pulmonology Association

Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and viral pneumonia in pediatrics worldwide. In the Kingdom of Saudi Arabia (KSA), the prevalence of RSV is 23.5% in pediatric patients with acute lower respiratory tract illness. Coronavirus disease (COVID-19) poses critical public health and socioeconomic challenges in KSA. The Saudi Pediatric Pulmonology Association (SPPA), a subsidiary of the Saudi Thoracic Society (STS), developed a task force to determine the potential challenges and barriers to the RSV immunoprophylaxis program during the era of COVID-19 and to compose a practical, nationwide, and multidisciplinary approach to address these challenges. Some of the recommendations to manage these challenges include increasing the number of RSV immunoprophylaxis clinics, drive-thru visits, home-care services, and swift referrals to the RSV immunoprophylaxis program specialists. Additional training is required for healthcare personnel to add RSV immunoprophylaxis to the regular immunization schedule.

Spanish Society of Pulmonology and Thoracic Surgery positioning on the use of telemedine in sleep-disordered breathing and mechanical ventilation

The rapid introduction of new information and communication technologies into medical practice has prompted Spanish Society of Pulmonology and Thoracic SurgeryR to publish a position paper on sleep-disordered breathing, especially in relation to positive pressure treatment. It should be pointed out that the scientific literature is to some extent controversial due to a paucity of large randomized multicenter studies with long-term follow-up. Moreover, the telematics devices and systems on the market vary widely. As a result, the recommendations are based primarily on a consensus of expert professionals. Another very important aspect addressed extensively in this document is the obvious lack of regulations on legal matters and the operations of commercial companies. The most important recommendations included in this position paper are that telemedicine is primarily advocated in subjects with travel problems or who live far from the hospital, in patients with poor CPAP compliance, and in most cases treated with non-invasive mechanical ventilation. A key element is patient individualization. It is imperative that the relevant technical, legal and ethical requirements (medical device regulations, data protection, and informed consent) are met. Finally, expert professionals from our society must contribute to and become involved in spearheading this technological change.

Reactive oxygen species modulators in pulmonary medicine

Adapted to effectively capture oxygen from inhaled air and deliver it to all other parts of the body, the lungs constitute the organ with the largest surface area. This makes the lungs more susceptible to airborne pathogens and pollutants that mediate pathologies through generation of reactive oxygen species (ROS). One pathological consequence of excessive levels of ROS production is pulmonary diseases that account for a large number of mortality and morbidity in the world. Of the various mechanisms involved in pulmonary disease pathogenesis, mitochondrial dysfunction takes prominent importance. Herein, we briefly describe the significance of oxidative stress caused by ROS in pulmonary diseases and some possible therapeutic strategies.

Chronic obstructive pulmonary disease: diagnosis and treatment of stable phase of disease; personalized treatment approach using phenotype features of the disease Summary of the 2020-2021 Czech Pneumological and Phthiseological Society position paper

Chronic obstructive pulmonary disease (COPD) is a heterogenous condition affecting hundreds of millions of people worldwide. COPD is a major health problem associated with significant morbidity and mortality. In this review, the authors present the current concept of care for patients with COPD in the Czech Republic, along with a summary of treatment recommendations formulated by the expert group of the Czech Pneumological and Phthisiological Society. A more detailed version of the position paper was published in 2020. The aim of this work was to transform the most recent scientific knowledge into the context of daily practice in the Czech Republic. Our concept of care for patients with COPD uses a complex approach with special emphasis on individual phenotypic features of the disease. Maximal effort has been put into individualization of treatment according to the presence of certain clinical phenotypes/treatable traits with respect to current scientific knowledge.

[Comparison of the values of the YEARS algorithm and the simplified Wells combined with age-adjusted D-dimer algorithm in the evaluation of patients with suspected acute pulmonary embolism Wang Zhehua1, Zhou Hongbin2, Yuan Dong2, Li Gang3, Li Yaqing2. 1Zhejiang Hospital, Hangzhou 310030, China;2Department of Respiratory Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), Hangzhou 310014, China; 3Department of Emergency Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), Hangzhou 310014, China]

Objective: To compare the values of the YEARS algorithm and the simplified Wells combined with age-adjusted D-dimer (sWells-Age) algorithm in the evaluation of patients with suspected acute pulmonary embolism (APE). Methods: Patients with suspected APE receiving CT pulmonary angiography (CTPA) were enrolled from 2016 to 2017. With CTPA results as the gold standard, we evaluated and compared the performance of the two algorithms in the whole population and in symptom-onset site (in-hospital, out-of-hospital) subgroups. Results: Among the 285 patients included, APE was confirmed by CTPA in 80 patients (28.1%). The two algorithms had a high level of diagnostic agreement (κ=0.855, P<0.05). The evaluated performance of the YEARS algorithm and the sWells-Age algorithm was as follows: 21.8% and 17.2% for the efficiencies; 1.6% and 0.0% for the failure rates; 29.8% and 23.9% for the specificities(P<0.05); 98.8% and 100.0% for the sensitivities. The efficiencies and the specificities of the two algorithms differed in the subgroups divided by symptom-onset sites (in-hospital, out-of-hospital). For the patients with symptoms-onset outside the hospital, the YEARS algorithm and the sWells-Age algorithm showed efficiencies of 33.0% and 26.9%, respectively, and specificities of 44.7% and 37.1%, respectively, (P<0.05).For the patients with symptoms-onset in hospital, the YEARS algorithm and the sWells-Age algorithm showed efficiencies of 1.9% and 0.0%, respectively, and specificities of 2.7% and 0.0%, respectively. Conclusions: The YEARS algorithm and the sWells-Age algorithm had a good diagnostic agreement and low failure rates and both could safely rule out APE. More patients with suspected APE could be safely excluded by the YEARS algorithm than the sWells-Age algorithm, especially in those suspected APE patients with out-of-hospital symptom-onset. However, both two algorithms were not applicable to suspected APE patients with in-hospital symptom-onset.

Consensus Document on the Diagnosis and Treatment of Chronic Bronchial Infection in Chronic Obstructive Pulmonary Disease

Although the chronic presence of microorganisms in the airways of patients with stable chronic obstructive pulmonary disease (COPD) confers a poor outcome, no recommendations have been established in disease management guidelines on how to diagnose and treat these cases. In order to guide professionals, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has prepared a document which aims to answer questions on the clinical management of COPD patients in whom microorganisms are occasionally or habitually isolated. Since the available scientific evidence is too heterogeneous to use in the creation of a clinical practice guideline, we have drawn up a document based on existing scientific literature and clinical experience, addressing the definition of different clinical situations and their diagnosis and management. The text was drawn up by consensus and approved by a large group of respiratory medicine experts with extensive clinical and scientific experience in the field, and has been endorsed by the SEPAR Scientific Committee.

Sleep Breathing Disorders in the COVID-19 Era: Italian Thoracic Society Organizational Models for a Correct Approach to Diagnosis and Treatment

The attenuation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, at least in Italy, allows a gradual resumption of diagnostic and therapeutic activities for sleep respiratory disorders. The knowledge on this new disorder is growing fast, but our experience is still limited and when a physician cannot rely on evidence-based medicine, the experience of his peers can support the decision-making and operational process of reopening sleep laboratories. The aim of this paper is to focus on the safety of patients and operators accessing hospitals and the practice of diagnosing and treating sleep-related respiratory disorders. The whole process requires a careful plan, starting with a triage preceding the access to the facility, to minimize the risk of infection. Preparation of the medical record can be performed through standard questionnaires administered over the phone or by e-mail, including an assessment of the COVID-19 risk. The home sleep test should include single-patient sensors or easy-to-sanitize material. The use of nasal cannulas is discouraged in view of the risk of the virus colonizing the internal reading chamber, since no filter has been tested and certified to be used extensively for coronavirus due to its small size. The adaptation to positive airway pressure (PAP) treatment can also be performed mainly using telemedicine procedures. In the adaptation session, the mask should be new or correctly sanitized and the PAP device, without a humidifier, should be protected by an antibacterial/antiviral filter, then sanitized and reassigned after at least 4 days since SARS-CoV-2 was detected on some surfaces up to 72 h after. Identification of pressure should preferably be performed by telemedicine. The patient should be informed of the risk of spreading the disease in the family environment through droplets and how to reduce this risk. The follow-up phase can again be performed mainly by telemedicine both for problem solving and the collection of data. Public access to hospital should be minimized and granted to patients only. Constant monitoring of institutional communications will help in implementing the necessary recommendations.

Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement

Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as “unrepresented.” There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice.

Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting.

Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law.

Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient’s preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight.

Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.