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What's new in pulmonary and critical care medicine
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What's new in pulmonary and critical care medicine
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Dec 13, 2017.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ASTHMA

Exhaled nitric oxide analysis and chronic cough (October 2017)

An increase in the fraction of exhaled nitric oxide (FENO) is a marker of eosinophilic airway inflammation. A potential role for measuring FENO in the diagnosis of cough-variant asthma (associated with eosinophilic inflammation) and nonasthmatic eosinophilic bronchitis (NAEB) was examined in a systematic review of over 2000 patients, in which FENO performed better to "rule in" cough-variant asthma and NAEB (as determined by a response to inhaled corticosteroids) than to exclude them, and performance was better for patients with cough-variant asthma than chronic cough without asthma [1]. However, heterogeneity among studies was high, limiting the strength of the evidence. Further study is needed to clarify whether FENO measurement can help improve patient-important outcomes in chronic cough. (See "Exhaled nitric oxide analysis and applications", section on 'Cough variant asthma' and "Exhaled nitric oxide analysis and applications", section on 'Nonasthmatic eosinophilic bronchitis'.)

Global asthma mortality (October 2017)

Asthma ranks 32nd as a cause of death worldwide, but mortality varies among countries [2]. Based on World Health Organization (WHO) data, age-standardized death rates per 100,000 individuals aged 5 to 34 years range from 17.16 in India and 1.65 in China to 0.88 in the United States and 0.24 in the Netherlands. In an analysis of the WHO database, asthma mortality was essentially unchanged from 2006 to 2012, after decreasing substantially from 1993 to 2006 [3]. Lower mortality rates correlated with adoption of best practices and more widespread implementation of established asthma management strategies is needed. (See "Identifying patients at risk for fatal asthma", section on 'Mortality statistics'.)

Azithromycin in poorly controlled asthma (October 2017)

Macrolide antibiotics have both antimicrobial and anti-inflammatory actions, raising the possibility of benefit in severe asthma, but data are conflicting in terms of the asthma phenotypes likely to derive benefit. In the AMAZES trial, 420 adults with asthma that was poorly controlled despite therapy with an inhaled glucocorticoid and a long-acting beta agonist were assigned to add-on therapy with azithromycin 500 mg or placebo three times weekly for 48 weeks [4]. Azithromycin decreased the rate of exacerbations and improved asthma-related quality of life, with some suggestion that the treatment worked better in eosinophilic patients (as defined by sputum or blood eosinophilia). In contrast, an earlier study suggested benefit only in patients with noneosinophilic asthma. Based on the differing results, chronic azithromycin remains investigational for severe asthma. (See "Treatment of severe asthma in adolescents and adults", section on 'Macrolide antibiotics'.)

Tezepelumab for poorly controlled moderate-to-severe asthma (September 2017)

Tezepelumab, an investigational human monoclonal antibody to thymic stromal lymphopoietin (TSLP), appears to reduce asthma exacerbations. In a multicenter trial, 584 patients with asthma that was poorly controlled on medium to high doses of inhaled glucocorticoids and inhaled long-acting beta agonists (LABA) were assigned to one of three doses of tezepelumab or placebo administered subcutaneously every four weeks [5]. The annualized asthma exacerbation rates at one year were lower in the three tezepelumab-treated groups compared with the placebo group. These findings need confirmation in additional studies. (See "Investigational agents for asthma", section on 'Anti-thymic stromal lymphopoietin'.)

Mepolizumab for eosinophilic granulomatosis with polyangiitis (August 2017)

Mepolizumab is a monoclonal anti-interleukin-5 antibody that is approved for use in severe eosinophilic asthma. In a multicenter trial, 136 patients with relapsing or refractory eosinophilic granulomatosis with polyangiitis (EGPA) were randomly assigned to receive mepolizumab 300 mg (three times the US Food and Drug Administration-approved dose of 100 mg) or placebo subcutaneously every four weeks for 52 weeks [6]. Mepolizumab led to significantly more accrued weeks of remission and a lower frequency of relapse than placebo. Among mepolizumab-treated subjects, 44 percent were able to taper prednisolone to ≤4 mg/day, compared with 7 percent on placebo. While not all patients respond, high-dose mepolizumab may be an additional option for selected patients with EGPA. (See "Treatment and prognosis of eosinophilic granulomatosis with polyangiitis (Churg-Strauss)", section on 'Anti-IL-5 antibodies'.)

Benralizumab and glucocorticoid-sparing effect in severe asthma (June 2017)

Benralizumab, an investigational anti-IL-5 receptor alpha antibody, appears to have a glucocorticoid-sparing effect in patients requiring oral glucocorticoids to control severe asthma. In a multicenter trial, 220 patients who had ≥150 eosinophils/mL in peripheral blood AND required daily oral glucocorticoids for the previous six months were randomly assigned to one of two benralizumab treatment arms or placebo [7]. The oral glucocorticoid dose was reduced according to a predetermined program (2.5 to 5 mg every four weeks). After 28 weeks, the oral glucocorticoid dose decreased by 75 percent from baseline in the two benralizumab groups, compared with 25 percent in the placebo group. Exacerbation rates were lower in the benralizumab groups despite glucocorticoid tapering, and pulmonary function remained stable. (See "Investigational agents for asthma", section on 'Anti-IL-5 receptor alpha antibodies'.)

Tyrosine kinase inhibition and severe asthma (June 2017)

Mast cells are typically increased in asthmatic airways and are associated with greater bronchial hyperresponsiveness. The KIT tyrosine kinase inhibitor, imatinib, inhibits the major growth factor for mast cells, raising the possibility that imatinib may ameliorate severe asthma. In a proof-of-principle randomized trial, 62 adults with severe asthma were assigned to imatinib or placebo for six months [8]. Airway hyperresponsiveness, as determined by methacholine inhalation challenge, was decreased in the imatinib group, indicating a potential role for KIT-dependent processes and mast cells in severe asthma. Whether tyrosine kinase inhibition by imatinib or a related agent will prove to be a safe and effective treatment for severe asthma awaits further study. (See "Investigational agents for asthma", section on 'Tyrosine kinase inhibitors'.)

COPD

Tiotropium and minimally symptomatic COPD with low exacerbation risk (October 2017)

Current guidelines suggest the use of a bronchodilator in less symptomatic, low exacerbation-risk chronic obstructive pulmonary disease (COPD) patients, without specifying the use of a long-acting muscarinic agent (LAMA) [9]. A multicenter randomized trial of over 800 patents with minimally symptomatic COPD (forced expiratory volume in one second [FEV1] ≥50 percent predicted) compared tiotropium with placebo used once daily [10]. After 24 weeks, lung function and the rate of exacerbations were improved in the tiotropium group, although questions have been raised about the specific study patient population. Further study is needed with assessment of longer-term outcomes before expanding the role of LAMAs to include these patients. (See "Management of stable chronic obstructive pulmonary disease", section on 'Anticholinergics'.)

Mepolizumab and COPD (October 2017)

Mepolizumab is a monoclonal antibody against interleukin (IL)-5 used in the treatment of severe eosinophilic asthma. Its effectiveness for patients with chronic obstructive pulmonary disease (COPD) and an eosinophilic phenotype was investigated in two parallel randomized trials [11]. Over 450 patients with COPD, a blood eosinophil count ≥150 cells/mL, and a history of moderate or severe exacerbations despite triple inhaler therapy were assigned to mepolizumab (100 mg or 300 mg) or placebo, administered subcutaneously every four weeks. After one year, mepolizumab slightly reduced the rate of exacerbations compared with placebo. Additional study is needed to understand the role of eosinophils in COPD and whether therapeutic strategies directed against eosinophils are likely to be of benefit. (See "Management of stable chronic obstructive pulmonary disease", section on 'Future directions'.)

Chemical constituents released by heat-not-burn (HNB) tobacco cigarettes (August 2017)

Heat-not-burn (HNB) tobacco cigarettes use an electric blade to heat a tobacco stick to a temperature much below that at which traditional tobacco cigarettes burn. In a laboratory study, HNB tobacco cigarettes released lower amounts of harmful constituents (nicotine, polycyclic aromatic hydrocarbons, and carbon monoxide) than conventional tobacco cigarette smoke [12]. Whether this translates to lower health risks is uncertain. HNB products are not currently available in many countries, including the United States. (See "Patterns of tobacco use", section on 'Heat-not-burn tobacco cigarettes'.)

Nocturnal noninvasive ventilation and COPD (June 2017)

Nocturnal noninvasive ventilation (NIV) at home may reduce readmissions and improve survival in patients with hypercapnic chronic obstructive pulmonary disease (COPD). In a randomized trial, 116 patients who received NIV during a COPD exacerbation and had persistent hypercapnia (PaCO2 >53 mmHg) were assigned to nocturnal NIV or supplemental oxygen after discharge. Nocturnal NIV prolonged the median time to readmission or death compared with supplemental oxygen alone (4.3 versus 1.4 months, respectively) [13]. One reason for the success of NIV in this study may be the use of high inspiratory pressures (median 24 cm H2O) titrated to reduce transcutaneous carbon dioxide by ≥4 mmHg. (See "Nocturnal ventilatory support in COPD", section on 'Effects on hospitalization and mortality'.)

CRITICAL CARE

Potential harm with open lung ventilation in acute respiratory distress syndrome (October 2017)

Previous randomized trials of open lung ventilation (combining the strategies of low tidal volume ventilation and high positive end-expiratory pressure [PEEP]), have shown inconsistent mortality benefit in patients with acute respiratory distress syndrome (ARDS). However, a recent randomized trial reported that an open lung ventilation strategy, compared with a conventional ventilation strategy, resulted in higher mortality rates and an increased risk of clinically significant pneumothorax [14]. Based upon these data we now suggest not using open lung ventilation as an initial strategy in patients with ARDS. (See "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'Harm'.)

A systematic approach to ICU admission for patients with sepsis (October 2017)

A multicenter cluster randomized trial in critically ill elderly patients compared a systematic approach to intensive care unit (ICU) admission with standard practice to determine care location [15]. The systematic approach resulted in a doubling of the ICU admission rate and an increased risk of in-hospital death, but mortality was no different between the two approaches at six months. Several potential flaws, including a higher severity of illness in the intervention group, may have biased these results. We believe that the location of care should be individualized based upon patient characteristics, preferences for end-of-life care, available resources, and physician judgment. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Location of admission'.)

Immigrant status and end-of-life care in the intensive care unit (October 2017)

Immigration status may be a factor that impacts care at the end of life. In a population-based study from Ontario that examined location of death and intensity of care received in the last six months of life, immigrants (residents <30 years) were more likely to be admitted to the intensive care unit (ICU), die in the ICU, and receive more aggressive care (including mechanical ventilation, dialysis, and feeding tube placement) than long-standing residents [16]. Rates of ICU death varied among different nationalities but were highest in Southern Asians and lowest in Western and Northern Europeans. Further studies are required to understand the factors underlying this association, but they may include health literacy, cultural preferences, and communication barriers. (See "Palliative care: Issues in the intensive care unit in adults", section on 'Barriers' and "Palliative care: The last hours and days of life", section on 'Place of death'.)

Endotracheal tube introducer ("bougie") improves first pass success (October 2017)

The endotracheal tube introducer (ETI, often referred to as a "bougie") is an effective but sometimes underappreciated tool for emergency airway management. To date, studies of introducers have been performed almost exclusively in the operating room. However, in a recent observational study of over 500 consecutive intubations performed in a single, urban academic emergency department, use of an ETI was independently associated with greater first-pass success [17]. Clinicians responsible for emergency airway management should be familiar with this useful, inexpensive tool. (See "Endotracheal tube introducers (gum elastic bougie) for emergency intubation", section on 'Evidence of effectiveness'.)

Trends in incidence and mortality of sepsis in the US (September 2017)

In determining trends for incidence and mortality of sepsis in the United States, the source of data used to identify cases of sepsis appears to have a large impact on findings. In a recent study using electronic health record (EHR) clinical data from United States hospitals, hospital admission rates for sepsis between 2009 and 2014 were stable at 6 percent, while in-hospital mortality decreased by 3 percent [18]. In contrast, rates based on traditional claims-based analyses using ICD-9 codes indicated a 10 percent increase in incidence and 7 percent reduction in mortality. When compared with direct chart review (thought to be the most sensitive method of detecting incidence), it was estimated that EHR-based analyses missed 20 percent of sepsis cases, while claims-based analyses missed 40 percent. Whether United States incidence or mortality rates of sepsis between 2009 and 2014 were stable is thus uncertain. EHR-based analyses may be a more sensitive method than traditional claims-based analyses to follow future trends. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Incidence'.)

Guidelines on the use of noninvasive ventilation for acute respiratory failure (September 2017)

The European Respiratory Society/American Thoracic Society issued guidelines on the use of noninvasive ventilation (NIV) for patients with acute respiratory failure (ARF) [19]. Strong recommendations were made for the use of NIV in patients with acute exacerbations of chronic obstructive pulmonary disease who have hypercapnic acidosis and patients with acute cardiogenic pulmonary edema. Trials of NIV were suggested in other ARF populations, including patients who are immunocompromised, who have chest trauma, or who require palliative relief for dyspnea. These recommendations are consistent with previous UpToDate recommendations. (See "Noninvasive ventilation in acute respiratory failure in adults", section on 'Indications'.)

Lack of benefit of cytomegalovirus prophylaxis in critically ill patients (August 2017)

Cytomegalovirus (CMV) reactivation is common in critically ill immunocompetent patients and is associated with increased length of hospital and intensive care unit (ICU) stay, sepsis, and mortality. However, there is no evidence that antiviral prophylaxis in these patients leads to improved outcomes. In a placebo-controlled trial of CMV-seropositive immunocompetent patients with critical illness due to sepsis or trauma, prophylaxis with intravenous ganciclovir was associated with a reduced incidence of CMV reactivation. However, there was no difference between the groups in levels of the pro-inflammatory cytokine, interleukin-6 (the primary outcome), or in incidence of secondary bacteremia or fungemia, ICU length of stay, or mortality [20]. (See "Epidemiology, clinical manifestations, and treatment of cytomegalovirus infection in immunocompetent adults", section on 'Prophylaxis against reactivation'.)

Guidelines for mechanical ventilation in patients with ARDS (August 2017)

Guidelines were issued by the American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine for mechanical ventilation strategies in patients with acute respiratory distress syndrome (ARDS) [21]. Key aspects included recommendations in favor of the use of low tidal volume ventilation (all ARDS patients) and prone positioning (severe ARDS). They also promoted the use of high levels of positive end expiratory pressure (PEEP) and recruitment maneuvers in select patients and recommended against the use of high frequency oscillatory ventilation (HFOV). No recommendations were made on the use of extracorporeal membrane oxygenation. (See "Prone ventilation for adult patients with acute respiratory distress syndrome" and "High-frequency ventilation in adults" and "Extracorporeal membrane oxygenation (ECMO) in adults" and "Mechanical ventilation of adults in acute respiratory distress syndrome", section on 'Low tidal volume ventilation'.)

Angiotensin II as an investigational vasopressor agent in shock (August 2017)

A randomized trial investigated the safety and efficacy of angiotensin II as a vasopressor agent for patients with vasodilatory (mostly septic) shock [22]. For patients receiving high-dose norepinephrine, the trial compared the addition of angiotensin or placebo.The increase in mean arterial pressure (MAP) was greater in the angiotensin II group. As well, less norepinephrine was required in the angiotensin II group and there was no difference in serious adverse events between the groups. These results are encouraging, but further trials are indicated to determine the role of angiotensin II for the treatment of vasodilatory shock. (See "Use of vasopressors and inotropes", section on 'Angiotensin II'.)

Vasopressor blood pressure targets in critically ill patients with shock (July 2017)

Hemodynamic support with continuous infusion of a vasopressor agent may be necessary in patients with shock if administration of intravenous fluids fails to restore adequate blood pressure and/or tissue perfusion. In a systematic review of two randomized trials that included 894 critically ill adults with hypotension requiring vasopressor therapy, higher mean arterial pressure (MAP) target values (80 to 85 mmHg in one trial and 75 to 80 mmHg in the other) did not result in a mortality benefit and increased the risk of cardiac arrhythmias, compared with lower targets (65 to 70 mmHg and 60 to 65 mmHg) [23]. We suggest a target MAP of 65 to 70 mmHg, rather than a higher target, in critically ill adults with hypotension who require vasopressor support. Similar MAP target values were recommended in a recent guideline of the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCS-SSAI) [24]. (See "Intraoperative management of shock in adults", section on 'Initial interventions'.)

Confirmatory data on idarucizumab for dabigatran reversal (July 2017)

Idarucizumab (pronounced "I-dare-you-cizumab") is a monoclonal antibody fragment against dabigatran that can reverse the anticoagulant effect within minutes. A preliminary report suggested good efficacy in patients with dabigatran-associated bleeding or those undergoing emergency surgery. In a new report of over 500 patients treated with idarucizumab, most had cessation of bleeding or underwent surgery without abnormal bleeding [25]. We continue to suggest idarucizumab for clinically significant bleeding or emergency surgery in patients on dabigatran with a history or laboratory testing that suggest they are actively anticoagulated. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Dabigatran reversal'.)

New oral direct factor Xa inhibitor betrixaban approved (June 2017)

The US Food and Drug administration has approved a new oral direct factor Xa inhibitor, betrixaban, for venous thromboembolism prophylaxis in acutely ill medical patients [26]. Betrixaban (brand name Bevyxxa) is taken at a dose of 160 mg on day 1 followed by 80 mg once daily for the duration of thromboprophylaxis. In a trial in which over 7500 patients hospitalized for an acute medical illness were randomly assigned to receive betrixaban or the low molecular weight heparin enoxaparin for 35 to 42 days, betrixaban was associated with a trend towards greater efficacy and a similar risk of bleeding compared with enoxaparin. (See "Direct oral anticoagulants and parenteral direct thrombin inhibitors: Dosing and adverse effects" and "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults".)

Vitamin C and sepsis (June 2017)

New therapies are needed for sepsis. In a preliminary investigation, the effects of high-dose intravenous vitamin C in combination with thiamine and hydrocortisone in patients with sepsis or septic shock and a procalcitonin level >2 ng/mL were compared with historical controls [27]. The vitamin C regimen was associated with reduced in-hospital mortality, faster weaning off vasopressors, and a decrease in progressive organ dysfunction. These results suggest a possible benefit for vitamin C and justify a larger randomized trial to test its efficacy in sepsis. (See "Investigational and ineffective therapies for sepsis", section on 'Vitamin C, thiamine, and hydrocortisone combination'.)

Stress ulcer prophylaxis in critically ill patients (June 2017)

The benefits and harms of stress ulcer prophylaxis in critically ill patients have recently been questioned, with concerns about possible increased risk of pneumonia and Clostridium difficile infection associated with use of proton pump inhibitors (PPIs). A preliminary randomized trial in 91 patients reported no difference in the rate of upper gastrointestinal bleeding, pneumonia, or C. difficile infection in mechanically ventilated receiving pantoprazole (a PPI) or placebo [28]. Also included as part of the study was a meta-analysis of five trials comparing PPIs to placebo that reported no difference in the rates of bleeding, infections, or mortality. These data justify the feasibility of larger placebo-controlled trials to replicate these findings before revising recommendations for stress ulcer prophylaxis in critically ill patients. (See "Stress ulcer prophylaxis in the intensive care unit", section on 'Efficacy'.)

Time to treatment and mortality in sepsis (May 2017)

Timely administration of fluids and antibiotics is the cornerstone of therapy for patients with sepsis and septic shock. A recent database study of patients with sepsis reported increased mortality in association with the delayed administration of antibiotics (greater than three hours) but not with a longer time to completion of a fluid bolus (greater than six hours) [29]. This study further validates international guideline recommendations that antibiotics be administered within the first three hours, and preferably within the first hour after presentation in patients with sepsis and septic shock. We also continue to recommend infusion of intravenous fluids within the first three hours of presentation. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Initial resuscitative therapy'.)

INTERSTITIAL LUNG DISEASE

Consensus statement on granulomatous and lymphocytic interstitial lung disease (August 2017)

Granulomatous and lymphocytic interstitial lung disease (GLILD) is the most common cause of diffuse parenchymal lung disease in patients with common variable immunodeficiency, but the literature to date has been limited to case reports and small series. The British Lung Foundation and UK Primary Immunodeficiency Network published a consensus statement summarizing the experience of approximately 30 physicians caring for over 100 patients with GLILD [30]. It includes a proposed definition for the disorder, as well as several statements about diagnosis and first-line therapy, and is intended to provide preliminary guidance for care and future research. (See "Pulmonary complications of primary immunodeficiencies", section on 'Granulomatous and lymphocytic interstitial lung disease'.)

PULMONARY VASCULAR DISEASE

Evaluation for occult cancer in unprovoked venous thromboembolism (August 2017)

Whether patients with a diagnosis of unprovoked venous embolism (VTE) should be evaluated for occult cancer with an extensive or more limited strategy is controversial. In a meta-analysis of 10 prospective studies (over 2000 patients with unprovoked VTE), the prevalence of cancer at one year was 5 percent [31]. Extensive screening, performed in nearly 60 percent of patients, detected more cancer initially than limited evaluation, but the difference was not significant at one year. The effect on long-term mortality is unknown. Until the benefits of extensive evaluation strategies are proven, we suggest evaluating patients with a single episode of unprovoked VTE using a limited strategy (clinical examination, routine laboratory studies, chest radiography, and age-appropriate screening) for the detection of occult cancer. (See "Evaluating adult patients with established venous thromboembolism for acquired and inherited risk factors", section on 'First episode of uncomplicated unprovoked VTE'.)

YEARS algorithm for the diagnosis of pulmonary embolism (June 2017)

Algorithms that integrate pretest probability (PTP) assessment using Wells criteria with a fixed cutoff level for D-dimer (<500 ng/mL) are typically used to target which patients with suspected pulmonary embolism (PE) should undergo computed tomography pulmonary angiography (CTPA). Compared with this typical approach, an alternative strategy using the YEARS items (clinical signs of deep venous thrombosis, hemoptysis, and PE as the most likely diagnosis) together with varying cutoff levels of D-dimer resulted in a 14 percent reduction in the number of CTPA scans performed, without increasing the risk of PE during a three-month follow-up [32]. While encouraging, this algorithm requires further validation before it is routinely used in practice. (See "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism", section on 'D-dimer'.)

SLEEP MEDICINE

Risk of cognitive impairment in adults with sleep-disordered breathing (November 2017)

Obstructive sleep apnea (OSA) and other causes of sleep-disordered breathing are increasingly recognized as a risk factor for cognitive impairment and dementia, possibly through deleterious effects of hypoxemia or shared vascular risk factors. In a pooled analysis of prospective studies in over 200,000 adults, those with sleep-disordered breathing were 26 percent more likely to develop clinically relevant cognitive decline or dementia [33]. Further studies are needed to determine whether effective treatment of OSA can reduce the risk of dementia. (See "Risk factors for cognitive decline and dementia", section on 'Obstructive sleep apnea'.)

Unilateral phrenic nerve stimulation device for central sleep apnea (October 2017)

An implantable device that causes diaphragmatic contraction via unilateral transvenous phrenic nerve stimulation has been approved by the US Food and Drug Administration for treatment of moderate to severe central sleep apnea (CSA) [34]. In a randomized trial in which 151 patients with moderate to severe CSA underwent device implantation, those assigned to active stimulation for six months were more likely to achieve 50 percent or greater reduction in the apnea-hypopnea index than those assigned to no stimulation (51 versus 11 percent) [35]. Therapy-related discomfort was reported by over one-third of patients but resolved with device reprogramming in all but one. The one-year device complication rate was approximately 10 percent in both groups. Additional studies on cardiovascular outcomes and long-term safety are needed to determine the role of the device in relation to other less invasive therapies for CSA. (See "Central sleep apnea: Treatment", section on 'Phrenic nerve stimulation'.)

OTHER PULMONARY MEDICINE

Remission-induction in nonsevere systemic necrotizing vasculitis (December 2017)

Most patients with nonsevere systemic necrotizing vasculitides including eosinophilic granulomatosis with polyangiitis (EGPA, previously Churg-Strauss), microscopic polyangiitis (MPA), and non-hepatitis B virus-associated polyarteritis nodosa (PAN) achieve remission with glucocorticoids alone; however, approximately one-third of patients relapse within the first two years. A randomized trial in 95 patients with nonsevere disease (51 with EGPA, 25 with MPA, and 19 with PAN) found that the addition of azathioprine to standard daily oral glucocorticoids did not improve remission rates, lower relapse risk, spare steroids, or reduce the EGPA asthma/rhinosinusitis exacerbation rate when compared with placebo at two years [36]. More data are needed to guide optimal therapy with "steroid-sparing" agents for patients with these disorders. (See "Treatment and prognosis of polyarteritis nodosa", section on 'Disease resistant to treatment with glucocorticoids alone'.)

Comparison of influenza diagnostic tests (October 2017)

Conventional reverse-transcriptase polymerase chain reaction (RT-PCR) is currently the preferred test for influenza due to its high sensitivity and specificity. Newer tests include rapid molecular assays using nucleic acid amplification and digital immunoassays (DIAs) using automated antigen detection. Both provide results more quickly than conventional RT-PCR and have higher sensitivity than traditional antigen detection tests. In a meta-analysis that compared various influenza assays with conventional RT-PCR for influenza A, the pooled sensitivities of rapid molecular assays and DIAs were 92 and 80 percent, respectively [37]. Both had higher sensitivity than traditional rapid antigen tests (sensitivity 54 percent). If available, a rapid molecular assay can be used as an alternative to conventional RT-PCR. (See "Diagnosis of seasonal influenza in adults", section on 'Molecular assays' and "Diagnosis of seasonal influenza in adults", section on 'Choice of diagnostic test' and "Seasonal influenza in children: Clinical features and diagnosis", section on 'Approach to testing'.)

Postoperative surveillance for nonmetastatic NSCLC (September 2017)

Although surveillance for patients who have been treated for nonmetastatic lung cancer typically includes computed tomography (CT) scans, there are no data from randomized trials supporting this strategy. In preliminary results of a trial in which 1775 patients with early or locally advanced non-small cell lung cancer (NSCLC) were randomly assigned to postoperative surveillance with either clinical examination and chest x-ray or these measures plus CT scans, median overall survival was 8.2 versus 10.3 years, respectively, a difference that was not statistically significant [38]. Given the limited median follow-up in this study and pending longer follow-up, we continue to include CT scans as part of our surveillance strategy. (See "Management of stage I and stage II non-small cell lung cancer", section on 'Approach'.)

Lack of benefit with corticosteroid use for acute bronchitis (September 2017)

Corticosteroids are frequently used for symptom relief in patients with acute bronchitis, although no data support use for this indication. In a randomized trial comparing oral prednisolone with placebo in 401 adult outpatients with acute cough, symptomatic lower respiratory tract infection, and no indication for antibiotic treatment, there was no difference in symptom severity, duration of cough, or peak flow [39]. Patients with chronic lung disease or asthma were excluded. This study supports our advice to not prescribe corticosteroids in patients with acute bronchitis, apart from those with concurrent asthma or chronic obstructive pulmonary disease (COPD) exacerbations. (See "Acute bronchitis in adults", section on 'For cough'.)

Revised follow-up for a solitary pulmonary nodule (June 2017)

Fleischner Society guidelines have been updated to reflect the accumulating data on the malignancy risk of incidental pulmonary nodules and growth rates of lung cancer [40]. Important changes include guidance on identifying benign nodules with minimal follow-up imaging. For patients with a solid or subsolid (ground glass or part-solid) solitary pulmonary nodule measuring <6 mm, follow-up computed tomography (CT) is optional, but no longer required. A solitary pulmonary nodule that is solid and unchanged on serial CT over a two-year period, or subsolid and unchanged over a five-year period, is likely benign and does not need further diagnostic evaluation. Recommendations in UpToDate have been revised to reflect these new guidelines. (See "Diagnostic evaluation of the incidental pulmonary nodule", section on 'Management' and "Diagnostic evaluation of the incidental pulmonary nodule", section on 'Solid nodule ≤8 mm'.)

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