CRD Editor's corner archive: October-December.

Ventilator dependence in neuromuscular disease – managing life’s basics …

December 21st, 2021 When people with neuromuscular disease become more dependent on round the clock non-invasive ventilation (NIV), the simple basics of life such as eating, drinking and talking become a significant challenge. In the journal this month, Kinnear and colleagues , observe how people manage these functions whilst using NIV. Importantly, they manage to do this safely for example by timing swallowing between ventilator breaths. Providing the right support in this situation may allow tube feeding to be avoided - an important consideration for many. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Management of pleural disease during the COVID-19 pandemic. Keeping the show on the road.

December 16th, 2021 A positive consequence of the pandemic has been the pace of innovation in the delivery of clinical services previously highly reliant on face to face patient contact. Ajmal and colleagues demonstrate nicely how this was achieved for the delivery of pleural services in a tertiary hospital by incorporating a triage process to direct cases to the most appropriate form of clinical-patient contact. It seems likely such innovations are here to stay – we look forward to seeing more data on impacts on clinical outcomes and the patient’s experience of their care. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Ventilatory support in Motor Neurone Disease. Evidence beyond RCTs.

December 2nd, 2021 The provision of ventilatory support in people with motor neurone disease is an intervention that therapists know can be effective but is supported by only limited clinical trial evidence. It would be difficult to undertake more trials now because withholding a standard care in a control group would be unethical. Judging effectiveness therefore requires different sources of evidence and in the journal this month Walsh et al. provide insightful data from a clinical cohort of patients treated in their centre. They demonstrate that successful initiation and adherence to NIV is associated with longer survival in patients with bulbar predominant disease. Of course there may be a variety of confounding factors affecting the causal link between the intervention and the outcome. However, from the clinical perspective, these data should drive the offer of treatment to those who might need it and in particular underpin the support of the wider multi-professional team in helping patients use the equipment consistently. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Achromobacter species in primary ciliary dyskinesia. How much should we worry?

December 2nd, 2021 The clinical importance of persistent bacterial colonisation of the lung in bronchiectasis and cystic fibrosis is increasingly recognised but there are fewer data in rare conditions such as PCD and the role of less common organisms also uncertain. In the journal this month, Holgerson et al. present data from a PCD registry documenting the longitudinal prevalence of Achromobacter species in sputum cultures and the associations with disease severity. Only around 5% of patients demonstrated positive cultures each year but the finding was associated with poorer lung function. The causality of this association cannot easily be ascertained and it remains difficult to be sure whether intensive antibiotic therapy in response to a positive culture is warranted. Prospective intervention studies would of course be desirable but we understand how difficult this would be for an uncommon microbiological event in a rare disease! Cohort studies such as the study of Holgerson and colleagues offer significant insight but we will continue to have to rely on clinical judgement and experience when advising patients. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Modified exercise training techniques – getting the patient’s view

November 25th, 2021 The pulmonary rehabilitation literature is littered with studies investigating novel training methodologies aimed at enhancing efficacy and/or comfort for people undertaking rehabilitation. In many cases the focus of such investigations is the clinical outcome of the intervention but in the journal this month, Pereira-Neto et al. provide a welcome insight into the patient and therapist perspective of one such methodology, blood flow restricted exercise. They highlight potential concerns about safety, supervision and location of treatment among patients with chronic respiratory disease. Given that many novel training interventions that have shown promise, have not ultimately become part of routine care, we suggest studies such as this should be a priority when rehabilitation innovation is tested. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Predicting mortality during hospitalisation for COPD. Should we count our BUNs?

November 21st, 2021

Identifying risk predictors for adverse outcomes of hospitalisation in COPD has become a commonplace topic of research – principally because admissions are common and mortality is high. In the journal this month Chen et al. provide us with more information on this, highlighting that high blood urea (BUN) is a predictive factor. Given that BUN is a predictor of outcome in other diseases, perhaps we should not be surprised by this finding but the association held true when adjusted for other indices of illness severity we wonder whether this provides a marker of overall systemic “stress” arising from the event. We await validation in other cohorts and studies to determine whether this adverse risk is modifiable with treatment.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Glucose intolerance in COPD … not sweetening the pill

November 19th, 2021

Diabetes and glucose intolerance is reaching epidemic proportions especially in parts of the developing world. We’ve known that prevalence is higher in people with COPD and this is emphasized by the work of Zulkifli and colleagues published in the journal this month. They demonstrate the high prevalence of glucose intolerance in a cohort of patients with COPD managed in a tertiary centre in Malaysia. The findings suggest the need to proactively monitor and treat diabetes and glucose intolerance in patients with chronic respiratory disease.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Recovery from Thoracic Surgery – a question of balance?

October 29th, 2021 For people diagnosed with lung cancer, attention quite rightly is focused on rapid assessment and access to curative surgery in eligible candidates. There has been less focus on recovery from surgery but as Tough and colleagues highlight in the journal this month, patients regard this as an important aspect of their treatment journey. The authors also report a high prevalence of impaired balance and reduced daily physical activity following surgery and importantly, conducted a qualitative investigation of patients’ experience of treatment finding that the provision of rehabilitation to assist recovery would be welcomed. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Relativism versus absolutism in physical activity measurement

October 27th, 2021 We’ve known for some time that physical activity (PA) is linked to health outcomes in people with COPD. Objective measurement of PA using wearable technology has become a standard of measurement but provides a measure of absolute movement (or lack thereof) over a specific period of time. For people with COPD, low intensity PA might actually incur significant energy cost because of truncated physical capacity and high respiratory effort. In the journal this month, Brito et al. account for this by comparing the readouts from two contemporaneously worn monitors providing information about time spent walking relative to energy expenditure during walking in a cohort of patients with COPD. They show that both time spent walking and energy expended during walking determine whether an individual is deemed “physically active” but energy expenditure (ie intensity) was more predictive. It’s not just what you do but how hard you do it ….. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Diagnosing asthma…an ongoing conundrum

October 23rd, 2021 For such a common condition, objective diagnosis of asthma remains challenging. In this month’s journal Almeshari et al. review the performance of novel airway function tests in the diagnosis of asthma, discussing the role of diagnostics such as multiple breath washout and forced oscillometry. As the authors point out – these are relatively easy to do, requiring only tidal breathing on the part of the subject (and presumably less aerosol generation – an important consideration in the age of COVID-19). Perhaps the intermittent nature of airflow obstruction and the wide range of phenotypic characteristics across the spectrum of asthma have impeded wider use of these tests in clinical practice – we await wider population studies to help us understand where to use them. -Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease.

Referral for PR in interstitial lung disease – Is the glass half full or half empty?

October 12th, 2021

Enhancing referral and access to PR for people with chronic respiratory disease should be the highest priority given that it’s the most effective intervention for improving breathlessness and quality of life. In the journal this month, Hoffman et al. report PR referral rates and patient experiences from a specialist Interstitial lung disease service. Around 40% of those deemed eligible were referred although we don’t know whether this was a lack of a PR offer from the healthcare team or offers being made but declined by patients. Room for improvement perhaps but these rates are better than those often reported for COPD. Perhaps the organisation of ILD care through specialist MDTs primarily aimed at providing standardised access to disease modifying therapy is having the knock-on effect of standardising and thereby increasing rates of PR referral. A lesson for the organisation of COPD care?

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease