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What's new in pulmonary and critical care medicine
Official reprint from UpToDate® ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
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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: Sep 2017. | This topic last updated: Oct 18, 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.


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'.)


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'.)


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 [14]. 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'.)

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 [15]. 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 [16]. 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) [17]. 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 [18]. (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) [19]. 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 [20]. 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) [21]. 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) [22]. (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 [23]. 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 [24]. 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 [25]. 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 [26]. 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) [27]. 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'.)

Immunoassay for acetaminophen-induced liver injury (May 2017)

Establishing the diagnosis of acetaminophen (APAP) poisoning in patients who present greater than 24 hours to several days after ingestion, when a serum APAP level may no longer be detectable, can be difficult. However, a recent observational cohort study found excellent performance for a rapid immunoassay that measures serum APAP-protein adducts in identifying patients with APAP-induced acute liver injury (ALI) [28]. In this study, a point of care immunoassay (AcetaSTAT) had 100 percent sensitivity and 100 percent negative predictive value, compared with results of high performance liquid chromatography as a reference standard, for identifying patients with such injury. If these results are validated in future clinical trials, this assay may provide a rapid means to distinguish APAP-induced ALI from other causes, and to begin appropriate management quickly. (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and diagnosis", section on 'Evaluation following delayed presentation'.)

Routine prophylactic antibiotics do not improve clinically important outcomes in survivors of out-of-hospital cardiac arrest (April 2017)

Many survivors of out-of-hospital cardiac arrest (OHCA) go on to develop pneumonia, but the value of prophylactic antibiotics is unproven. In a single-center clinical trial involving 60 comatose OHCA patients without obvious evidence of tracheobronchial aspiration on admission, random assignment to prophylactic antibiotics versus clinically-driven antibiotic therapy reduced the number of positive broncho-alveolar lavage cultures on hospital day 3, but did not improve survival or other patient-important outcomes [29]. We do not suggest routine prophylactic treatment with antibiotics in these patients. (See "Post-cardiac arrest management in adults", section on 'Antibiotic therapy and prophylaxis'.)

2011 shortage of norepinephrine in the United States and septic shock outcome (April 2017)

The impact of a shortage of norepinephrine in the United States in 2011 on vasopressor agent selection was recently highlighted in a study of 28,000 patients with sepsis. When norepinephrine (first-line agent) was in short supply, phenylephrine was the most frequent alternative agent chosen, during which time mortality rates from septic shock also rose (36 to 40 percent) [30]. While there is little guidance for selecting a second-line vasopressor agent in patients with sepsis, phenylephrine should continue to be avoided, when feasible. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Vasopressors'.)


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 [31]. 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'.)


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 [32]. 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 patients with established venous thromboembolism for acquired and inherited risk factors", section on 'First episode of uncomplicated unprovoked VTE'.)

Rivaroxaban for treatment of superficial vein thrombosis (May 2017)

Short-term anticoagulation is recommended for treatment of superficial vein thrombosis (SVT) in patients at high risk for venous thromboembolism (VTE). The phase 3b SURPRISE trial randomly assigned over 400 patients with SVT to oral rivaroxaban (a direct factor Xa inhibitor) or subcutaneous fondaparinux and found that both groups had similar rates of symptomatic VTE, progression or recurrence of SVT, and all-cause mortality at 45 days [33]. There were no major bleeds in either group, but clinically relevant nonmajor bleeding occurred more often in the rivaroxaban group. Thus, rivaroxaban appears to be an effective anticoagulant for patients with SVT and may be a more convenient and less expensive option than subcutaneous therapy. (See "Phlebitis and thrombosis of the superficial lower extremity veins", section on 'Increased risk for thromboembolism'.)


Guideline on obstructive sleep apnea diagnosis and treatment in commercial drivers (May 2017)

The American Academy of Sleep Medicine (AASM) has released consensus-based recommendations on screening, diagnosis, and management of obstructive sleep apnea (OSA) in commercial drivers [34]. The AASM recommends that drivers meeting any of the following high-risk criteria be referred to a sleep medicine specialist for clinical sleep evaluation and diagnostic testing (table 1):

Body mass index (BMI) ≥40 kg/m2

Fatigue or sleepiness during the duty period or involvement in a sleepiness-related crash or accident

BMI ≥33 kg/m2 and either hypertension requiring two or more medications to control or type 2 diabetes

The document also provides guidance on determining when to restrict driving certification based on OSA severity, symptoms, and adherence with positive airway pressure therapy. (See "Drowsy driving: Risks, evaluation, and management", section on 'Special considerations in commercial drivers'.)

Adaptive servoventilation in adults with central sleep apnea and heart failure (April 2017)

A previous randomized trial (SERVE-HF) found that adaptive servoventilation (ASV), a modified method of positive airway pressure ventilation, increased cardiovascular mortality in patients with central sleep apnea (CSA) due to symptomatic heart failure with reduced ejection fraction. In the CAT-HF trial, 126 hospitalized patients with heart failure and moderate-to-severe CSA were randomly assigned to ASV plus optimized medical therapy or medical therapy alone [35]. While the trial showed no difference between the groups in a combined endpoint (death, cardiovascular hospitalizations, and timed walk distance), the confidence intervals were wide and there was a suggestion of increased harm in the ASV group (HR 1.06, 95% CI 0.75-1.51). The trial was stopped early, in part due to results of SERVE-HF. Although this limits interpretation of the CAT-HF results, we continue to recommend against use of ASV in patients with CSA and heart failure with reduced ejection fraction. (See "Sleep-disordered breathing in heart failure", section on 'Adaptive servoventilation' and "Central sleep apnea: Treatment", section on 'Patients with ejection fraction ≤45 percent'.)


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 [36]. 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 [37]. 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 [38]. 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 and management of the solitary pulmonary nodule", section on 'Management strategy' and "Diagnostic evaluation and management of the solitary pulmonary nodule", section on 'Solid nodules ≤8 mm'.)

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