Clinical Pulmonary Medicine

Vaping-associated Lung Injury Successfully Treated With Pulse Dose Corticosteroids Electronic cigarettes were developed for the inhalation of flavored nicotine, tetrahydrocannabinol and cannabidiol via cannabis oil. Recently, there has been an outbreak of vaping-induced lung injuries ranging in severity. We report 3 previously healthy male patients, who presented with acute respiratory failure with a recent history of electronic cigarette use, ultimately diagnosed with lipoid pneumonia. All 3 patients received intravenous high-dose, pulse corticosteroids for short duration with dramatic improvement.

Corticosteroids for COVID-19-Associated ARDS Systemic corticosteroids have emerged as a possible therapy to mitigate lung injury in severe COVID-19 infection. Here, we provide historical context for corticosteroid administration in acute respiratory failure due to viral infection and review existing data for the use of systemic corticosteroids for SARS-CoV-2 infection. The results of these limited data consistently suggest a mortality benefit for patients with COVID-19-associated acute respiratory distress syndrome with no existing evidence to suggest harm.

The Complex Relationship Between Poor Sleep Quality and Chronic Obstructive Pulmonary Disease Sleep-related symptoms are prevalent among patients with chronic obstructive pulmonary disease (COPD). The disease process often manifests with nocturnal respiratory symptoms. Long-acting antimuscarinic medications improve nocturnal COPD symptoms, though their effect on sleep quality requires further investigation. Those with COPD often suffer from comorbidities that negatively impact sleep, including obstructive sleep apnea (OSA) and mood disorders such as anxiety and depression. Sleep quality is also predictive of COPD exacerbations. Patients with concurrent COPD and OSA suffer from overlap syndrome (OVS), characterized by a synergistic effect on poor health outcomes. The intersection of COPD and OSA offers the clinical pulmonary audience a useful lens for ongoing basic, clinical, and translational research. Patients with OVS experience higher mortality compared with either COPD or OSA alone. This observation is attributable to the compound effect each condition has on adverse cardiovascular events. A complex interplay exists between COPD, sleep symptoms, and OSA. COPD appears to influence important nonanatomical contributors to OSA. The presence of underlying COPD makes the definitive diagnosis of OSA a challenge. Chronic noninvasive ventilation (NIV) is the backbone of therapy for OVS, OSA, and hypercarbic COPD. NIV is additionally a well-established treatment for acute COPD exacerbations and emerging research demonstrates that NIV decreases mortality and hospitalizations in patients with hypercarbic COPD. Clinicians often need to individualize therapeutic interventions for patients with COPD, OSA, and OVS, balancing the benefits and adverse effects of such interventions. NIV can have unwanted impact on the quality of life for some patients with COPD. Certain medications used for COPD, such as corticosteroids, have adverse effects on sleep quality. Future therapeutic approaches are needed to improve the sleep symptoms and health outcomes of patients suffering from COPD and OVS.

Excessive Dynamic Airway Collapse: A COPD/Asthma Mimic or a Treatment-emergent Consequence of Inhaled Corticosteroid Therapy: Case Series and Brief Literature Review Excessive dynamic airway collapse (EDAC) is a clinical entity characterized by narrowing of larger airways during tidal breathing. Symptoms of EDAC can be similar to chronic obstructive airway disease (COPD)/asthma and EDAC can coexist with airway disease. More recently widespread use of inhaled corticosteroids (ICS) among patients with COPD/asthma has been implicated for the emergence of EDAC. In this report, we describe 6 adult patients presenting with chronic cough with a background diagnosis of either COPD or asthma on ICS, who were noted to have EDAC. We also made an attempt to briefly review the earlier published reports on EDAC. Our review suggested that EDAC is prevalent among patients with previous diagnosis of COPD/asthma and with ICS use. Female sex, older age, higher body mass index, and presence of gastroesophageal reflux disease (GORD), and chronic upper respiratory tract infections (URTI) may be a risk factor for EDAC. Chronic barking cough and shortness of breath are the common clinical presentation and acute presentation could be triggered by lower respiratory tract infection and episodic presentations can be related to chronic recurrent aspiration secondary to GORD or chronic URTI. Dynamic computed tomography of the chest and bronchoscopy are useful in the diagnosis. Pulmonary function tests could be variable, demonstrating normal, obstructive, or restrictive pattern. Management of EDAC with weight loss strategies, addressing GORD and URTI issues and antibiotics during acute lower respiratory tract infection may be helpful. Noninvasive positive pressure ventilation may be beneficial in some patients. ICS should be used wisely to prevent the emergence of EDAC among patients with chronic airway disease.

Immune-related Pulmonary Toxicity From Cancer Immunotherapy: A Systematic Approach Immune checkpoint inhibitors (ICIs) are one of the major advances in cancer treatment. ICIs have shown significant benefit in treating several types of cancer. Currently there are 6 ICIs available in the United States and multiple ICIs in the pipeline. Immune checkpoint signaling leads to immune tolerance of cancer cells through downregulation of T-cell activation. The reversal in tumor-tolerance and self-tolerance effected by ICIs likely drives both T-cell–mediated toxicity and immune-related adverse effects (irAEs); however, the exact mechanism remains not completely understood. Pulmonary irAEs are among the most feared high-grade irAEs leading to discontinuation of ICIs and, not uncommonly, treatment-related death. Because of the high degree of morbidity and mortality associated with pulmonary irAEs and the exponential growth of ICI use, clinicians must increasingly be facile in diagnosing and managing these irAEs.

The Diagnosis of Hypersensitivity Pneumonitis and the Role of Lung Biopsy Hypersensitivity pneumonitis (HP) refers to a collective noun of diffuse lung diseases encompassing some degree of bronchiolar and interstitial granulomatous inflammation that results from persistent inhalation exposure and consequent immune sensitization to a large potential diversity of (predominantly) organic antigens in predisposed individuals. In suspected cases of HP, forceps transbronchial lung biopsy (TBLB) has been traditionally performed on a case-by-case basis along with bronchoalveolar lavage. This option has been subject to some debate and its use is more restrained in the presence of a chronic fibrotic form of HP—where surgical lung biopsy is classically recommended in the face of the need for a more reliable differentiation from fibrotic idiopathic interstitial pneumonias. We intended to assess the diagnostic contribution of conventional TBLB in the combined multidisciplinary diagnosis of an HP patient cohort. A retrospective evaluation of all the diagnostic elements and level of confidence from all HP cases followed in an interstitial lung disease ILD outpatient clinic of a district hospital center (Centro Hospitalar do Baixo Vouga), from June 2015 to August 2019, and simultaneously evaluated in a multidisciplinary team discussion of the same hospital, comprising an interstitial lung disease dedicated lung physician, a chest radiologist, 2 rheumatologists, and a pathologist. We identified 78 patients (mean age: 70.5 y, interquartile range: 58.5 to 78.0) with a slight female predominance. Most of the patients (61.5%) had chronic/fibrotic HP. The most frequently identified inducing antigens were avian antigens in 59.0% of cases, followed by molds in 20.5%. Of the 72 patients who underwent bronchofibroscopy, 36.1% (n=26) conventional TBLB performed, predominantly in the segments of the right lower lobe with an average number of 3.9 biopsies (SD±1.4) accomplished per patient. In 50.0% of the cases submitted to TBLB, the biopsies showed representative material with histologic features (definite or supportive) which had some degree of contribution for the diagnostic discussion. Among the patients where TBLBs were not performed or whose results were found to be devoid of significant findings, 73.1% were still diagnosed as HP without the need for surgical video-assisted thoracoscopic lung biopsy/transbronchial lung cryobiopsy (VATS/TBLCB) on the grounds of other diagnostic elements; 15.4% of patients were diagnosed with HP after a VATS/TBLCB procedure. Lastly, around 11.5% of patients were considered to have an unacceptable risk for VATS/TBLCB but, on the basis of clinical, radiologic, and immunologic elements received a multidisciplinary provisional diagnosis still with a reasonable level of confidence. Regarding complications with TBLB, there were 2 cases of moderate bleeding (7.6%) and 1 pneumothorax (3.8%) that did not require drainage. Notwithstanding its limitations, TBLB can still have a role in the diagnostic workup of HP, namely in acute/inflammatory HP, adding definite or supportive histologic information for multidisciplinary discussion in up to 50% of cases. TBLB can augment diagnostic yield at the expense of only a minimal increase of risk, as it is a universally available technique that can be performed along with bronchoalveolar lavage. This has important implications, particularly in centers devoid of TBLCB, as a surgical biopsy can be avoided in approximately half of patients who are eventually diagnosed with HP.

Bronchoscopy in the COVID-19 Era Bronchoscopy is an aerosol-generating procedure with important diagnostic and therapeutic indications. However, in the era of the coronavirus disease 2019 (COVID-19) pandemic, airway procedures can put health care providers at an increased risk of exposure and transmission of COVID-19. We have reviewed and summarized guidelines from various societies of respiratory medicine to stratify the indications for bronchoscopy and optimize preprocedural, procedural, and postprocedural preparation. Appropriate measures can help decrease exposure to health care workers when performing this aerosol-generating procedure.

Is a Trial of Observation Safer Than Intervention With Spontaneous Pneumothorax? Synopsis: Modest evidence that a conservative approach to the treatment of primary spontaneous pneumothorax is noninferior to intervention.

Home, Hospice, or Hospital: Where Are Our Patients With Chronic Lung Disease Dying? Synopsis: This cross-sectional study examined the differences in place of death among patients with chronic lung disease living in the United States from 2003 to 2017. Overall, there was a shift toward home and hospice deaths and away from hospital or nursing facility deaths. However, important differences in race, education, and socioeconomic status indicate the pressing need for further research into how to best care for all patients with chronic lung disease at the end of their lives.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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