Correction
Davidson AC, Banham S, Elliott M, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 2016;71 Suppl 2:ii1–35. doi: 10.1136/thoraxjnl-2015-208209. The British Thoracic Society wishes to clarify reference to the definition of hypercapnia in relation to the BTS/ICS Guidelines for the ventilatory management of acute hypercapnic respiratory failure (2016). The British Thoracic Society recognises the definition of hypercapnia as a PaCO2 ≥6 kPa as used in the BTS Standards of Care document on non invasive ventilation in acute respiratory failure (ref1) a...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Tags: Miscellaneous Source Type: research

What's hot that the other lot got
Rivaroxaban or aspirin for extended treatment of venous thromboembolism Many patients with venous thromboembolism (VTE) require extended treatment beyond the standard 6 months if they are felt to be at high risk of recurrence. It remains uncertain as to whether full or lower intensity anticoagulation is required. This randomised, double-blind, phase III trial (Weitz et al. N Engl J Med 2017;376:1211–22) compared once daily rivaroxaban at 20 mg or 10 mg doses with 100 mg of aspirin. Each patient had already completed 6–12 months of treatment dose anticoagulation therapy. A total of 3365 ...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Soar, B. Tags: Chest clinic Source Type: research

Pulmonary endarterectomy for calcified amorphous tumour-related pulmonary hypertension
A 42-year-old patient presenting with exertional dyspnoea was diagnosed with functional class II pulmonary hypertension (PH) with severe tricuspid valve insufficiency due to cardiac and pulmonary artery obstruction by calcified amorphous tumour (paCAT). Bilateral (sub)segmental perfusion defects were seen on ventilation/perfusion scan (see online ), while the CT angiogram showed large amounts of calcified radio-opaque material in absence of radiological characteristics of chronic thromboembolic pulmonary hypertension (CTEPH), such as webs, stenosis or pouches (figure 1A, C). After multi-institutional (Amsterdam, NL and Pap...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Bonta, P. I., Bogaard, H. J., van den Berk, I., Niessen, H. W. M., van der Wal, A., Symersky, P. Tags: Images in Thorax, Screening (oncology), Pulmonary hypertension Chest clinic Source Type: research

What causes occupational asthma in cleaners?
Epidemiological studies have consistently found cleaners to be at increased risk of new-onset asthma,1 2 the risk seems to be particularly high in domestic cleaners using spray bleaches.2 Due to the large numbers employed in cleaning, they constitute a significant proportion of the population attributable risk of occupational asthma. It has, however, been very difficult to identify the precise cause of domestic cleaners' asthma from specific inhalation challenge (SIC) tests. Chlorine-based substances form the basis of many domestic (sodium hypochlorite) and healthcare (sodium dichloroisocyanurate) cleaning agents. Approxim...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Moore, V. C., Burge, P. S., Robertson, A. S., Walters, G. I. Tags: Chest clinic Source Type: research

Metalworking fluids: a new cause of occupational non-asthmatic eosinophilic bronchitis
Ruth E Wiggans (REW): A 52-year-old man was referred with chronic cough of increasing severity over the last 4 years. The cough was productive of green sputum and he experienced coughing attacks weekly. He reported no other respiratory symptoms. He had a sore throat following coughing bouts but denied other upper airway complaints. He was otherwise well with no systemic symptoms. His cough had improved following a 2-week summer holiday, and subsequently deteriorated following his return to work. A chest X-ray organised in primary care was normal. Three years earlier, his general practitioner increased his lansoprazole...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Wiggans, R. E., Barber, C. M. Tags: Open access, General practice / family medicine, TB and other respiratory infections, Asthma, Bronchitis, Interstitial lung disease, Radiology (diagnostics) Chest clinic Source Type: research

Choking on a foreign body: a physiological study of the effectiveness of abdominal thrust manoeuvres to increase thoracic pressure
The Heimlich manoeuvre is a well-known intervention for the management of choking due to foreign body airway occlusion, but the evidence base for guidance on this topic is limited and guidelines differ. We measured pressures during abdominal thrusts in healthy volunteers. The angle at which thrusts were performed (upthrust vs circumferential) did not affect intrathoracic pressure. Self-administered abdominal thrusts produced similar pressures to those performed by another person. Chair thrusts, where the subject pushed their upper abdomen against a chair back, produced higher pressures than other manoeuvres. Both approache...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Pavitt, M. J., Swanton, L. L., Hind, M., Apps, M., Polkey, M. I., Green, M., Hopkinson, N. S. Tags: Open access Research letter Source Type: research

The impact of HIV and antiretroviral therapy on TB risk in children: a systematic review and meta-analysis
Background Children (
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Dodd, P. J., Prendergast, A. J., Beecroft, C., Kampmann, B., Seddon, J. A. Tags: Open access Tuberculosis Source Type: research

Chronotherapy for hypertension in obstructive sleep apnoea (CHOSA): a randomised, double-blind, placebo-controlled crossover trial
Conclusions Our findings support combining OSA treatment with morning administration of antihypertensives. Unlike in essential hypertension, our results do not support evening administration of antihypertensives, at least with perindopril. Further research is required before this strategy can be widely adopted into hypertension guidelines and clinical practice. Trial registration number ACTRN12611000216910, Results. (Source: Thorax)
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Serinel, Y., Yee, B. J., Grunstein, R. R., Wong, K. H., Cistulli, P. A., Arima, H., Phillips, C. L. Tags: Sleep Source Type: research

{alpha}-Tocopherol transfer protein mediates protective hypercapnia in murine ventilator-induced lung injury
Conclusions Inspired CO2 upregulates αTTP which increases lung α-tocopherol levels and inhibits synthesis of a pathogenic chemoattractant. (Source: Thorax)
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Otulakowski, G., Engelberts, D., Arima, H., Hirate, H., Bayir, H., Post, M., Kavanagh, B. P. Tags: Respiratory physiology Source Type: research

Socioeconomic deprivation and the outcome of pulmonary rehabilitation in England and Wales
Background Pulmonary rehabilitation (PR) improves exercise capacity and health status in patients with COPD, but many patients assessed for PR do not complete therapy. It is unknown whether socioeconomic deprivation associates with rates of completion of PR or the magnitude of clinical benefits bequeathed by PR. Methods PR services across England and Wales enrolled patients to the National PR audit in 2015. Deprivation was assessed using Index of Multiple Deprivation (IMD) derived from postcodes. Study outcomes were completion of therapy and change in measures of exercise performance and health status. Univariate and mult...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Steiner, M. C., Lowe, D., Beckford, K., Blakey, J., Bolton, C. E., Elkin, S., Man, W. D. -C., Roberts, C. M., Sewell, L., Walker, P., Singh, S. J. Tags: Open access Rehabilitation Source Type: research

Deficient retinoid-driven angiogenesis may contribute to failure of adult human lung regeneration in emphysema
Conclusions RA regulates lung microvascular angiogenesis; the endothelium produces CYP26A1 which is increased in emphysema, possibly leading to reduced RA availability. These data highlight a role for RA in maintenance of the human pulmonary microvascular endothelium. (Source: Thorax)
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Ng-Blichfeldt, J.-P., Alcada, J., Montero, M. A., Dean, C. H., Griesenbach, U., Griffiths, M. J., Hind, M. Tags: Chronic obstructive pulmonary disease Source Type: research

Fruit and vegetable consumption and risk of COPD: a prospective cohort study of men
Background Antioxidants present in fruits and vegetables may protect the lung from oxidative damage and prevent COPD. Aims To determine the association between fruit and vegetable consumption and risk of COPD by smoking status in men. Methods The population-based prospective Cohort of Swedish Men included 44 335 men, aged 45–79 years, with no history of COPD at baseline. Fruit and vegetable consumption was assessed with a self-administered questionnaire. Results During a mean follow-up of 13.2 years, 1918 incident cases of COPD were ascertained. A strong inverse association between total fruit and vegeta...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Kaluza, J., Larsson, S. C., Orsini, N., Linden, A., Wolk, A. Tags: Press releases Chronic obstructive pulmonary disease Source Type: research

British Thoracic Society Oxygen Guidelines: another clinical brick in the wall
The world's first evidence-based guideline for emergency oxygen therapy was published by the British Thoracic Society (BTS) in 2008 and endorsed by 21 other societies and colleges.1 The key message in the guideline was very simple: clinicians were advised to avoid hypoxaemia and hyperoxaemia by prescribing a normal or near-normal target oxygen saturation of 94%–98% for most acutely unwell patients and to prescribe a lower range (usually 88%–92%) for patients at risk of hypercapnia, and to use high-concentration oxygen for some conditions such as carbon monoxide poisoning or the immediate management of critical ...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: O'Driscoll, B. R. Tags: Editorial Source Type: research

Occupational pesticide exposure and respiratory health: a large-scale cross-sectional study in three commercial farming systems in Ethiopia
Rationale In the last decade, due to expansion of greenhouses and irrigated farms, the use of pesticides in Ethiopia has increased 6–13-fold leading to potential health risks. Objective To investigate if occupational exposure to pesticides is associated with respiratory health effects in farmers and farm workers from commercial farming systems. Methods We performed two cross-sectional surveys comprising different farming systems. In the first survey we studied respiratory symptoms among 1104 subjects of which 601 were occupationally exposed to pesticides (ie, 256 pesticide applicators, 345 re-entry workers) and 503...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Negatu, B., Kromhout, H., Mekonnen, Y., Vermeulen, R. Tags: Epidemiologic studies, Editor's choice, Airway biology, Lung function, Occupational and environmental medicine Occupational lung disease Source Type: research

Do patients with obstructive sleep apnoea deserve new dedicated antihypertensive strategies?
Hypertension affects 25% of the adult population and remains a leading cause of cardiovascular mortality, accounting for 13.5% of all deaths. Half of all strokes and ischaemic heart disease events are attributed to hypertension.1 2 Most patients exhibit grade I hypertension (systolic blood pressure of 140–159 mm Hg and/or diastolic blood pressure of 90–99 mm Hg) without coexisting cardiovascular disease. Effective reduction of blood pressure in this population significantly reduces stroke and death.3 Obstructive sleep apnoea (OSA) is now recognised as a risk factor for the development of hyp...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Tamisier, R., Levy, P., Pepin, J.-L. Tags: Editorial Source Type: research

Turning a challenge into an opportunity: pulmonary rehabilitation and socioeconomic deprivation
The efficacy of pulmonary rehabilitation has been established for people with COPD such that the addition of further controlled clinical trials comparing pulmonary rehabilitation with usual care is considered unnecessary.1 2 How well the degree of health benefit reported within clinical trials of pulmonary rehabilitation translates into real-life settings is more difficult to ascertain. In real-world clinical environments, the effectiveness of pulmonary rehabilitation for people with COPD is likely to be confounded by heterogeneity in national healthcare systems, structure and staffing of rehabilitation programmes and part...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Johnston, K. N., Williams, M. T. Tags: Editorial Source Type: research

Could a healthy diet attenuate COPD risk in smokers?
Let food be thy medicine and medicine be thy food. Hippocrates The predominant risk factor for COPD in high-income countries is cigarette smoking,1 but not all smokers develop COPD.2 It has been hypothesised that a diet rich in antioxidants may counteract the deleterious oxidant effects of smoking and hence prevent COPD.3 Although most studies that have linked dietary antioxidant foods and nutrients to COPD have been cross-sectional,3 a few cohort studies have also reported associations between higher intake and a slower decline of lung function or a lower incidence of COPD.4–7 In Thorax,8 using longitudinal data fro...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Varraso, R., Shaheen, S. O. Tags: Press releases Editorial Source Type: research

Occupational exposure to pesticides: time to nip it in the bud?
In Thorax, Negatu et al describe two cross-sectional studies exploring the effects of exposure to pesticides on lung health in commercial farming systems in Ethiopia.1 They found a markedly increased risk of chronic cough and shortness of breath and impaired ventilatory function in exposed versus unexposed groups. These studies are the largest of their kind conducted in Ethiopia or the wider sub-Saharan Africa.2 The finding that exposure to pesticides is associated with an increased risk of respiratory symptoms, airways disease and impaired ventilator function is, however, not new. Mamane et al2 published a review of the l...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: Mortimer, K., Feary, J. Tags: Editorial Source Type: research

Highlights from this issue
On 8 June, this year, voters in the United Kingdom will select their members of parliament (MPs) for 650 constituencies–lets hope they choose wisely. In this edition of Airwaves, we offer you an election special of politically themed recommendations from Thorax. We hope these are informative, challenging and a welcome antidote to pre election and post election punditry. Agricultural Revolution Farms in Ethiopia have experienced a dramatic increase in their use of pesticides in recent years. This has given rise to understandable concerns that agricultural workers may suffer ill effects from occupational exposure to th...
Source: Thorax - May 15, 2017 Category: Respiratory Medicine Authors: The Triumvirate Tags: Airwaves election special Source Type: research

What is hot ...
This study by Vestjens et al (http://dx.doi.org/10.1111/resp.12996) sought to see if elevated troponin is a prognostic marker in patients admitted with community-acquired pneumonia (CAP).The study looked at cTnT levels on admission in 295 patients admitted with CAP. Levels were elevated (>14 ng/L) in 45%. Short-term (30 days) and long-term (up to 4.1 years) mortality were significantly higher in those with elevated cTnT. Elevated cTNT>28 ng/L was found to be a strong independent risk factor for mortality both short-term (OR 21.9, 95% CI 4.7 to 101.4) and long-term (OR 10.7,... (Source: Thorax)
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Batalla-Duran, E. Tags: Chest clinic Source Type: research

An oesophageal and pulmonary association not to forget
A 45-year-old Indian man with a history of achalasia presented with fevers, cough and fatigue. He had undergone endoscopic dilatation for achalasia several years prior. Chest radiograph revealed a dilated oesophagus and a left perihilar opacity (figure 1). He was treated for community-acquired pneumonia with a course of clarithromycin but had persistent cough, fatigue and weight loss with non-resolving radiographic infiltrates. A 3-week course of amoxicillin clavulanate was prescribed for suspected aspiration with little clinical improvement, and a chest CT was performed (figure 2). The patient had never smoked and had mov...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Sunwoo, B. Y. Tags: Images in Thorax Chest clinic Source Type: research

Lung Gene Expression Analysis (LGEA): an integrative web portal for comprehensive gene expression data analysis in lung development
‘LungGENS’, our previously developed web tool for mapping single-cell gene expression in the developing lung, has been well received by the pulmonary research community. With continued support from the ‘LungMAP’ consortium, we extended the scope of the LungGENS database to accommodate transcriptomics data from pulmonary tissues and cells from human and mouse at different stages of lung development. Lung Gene Expression Analysis (LGEA) web portal is an extended version of LungGENS useful for the analysis, display and interpretation of gene expression patterns obtained from single cells, sorted cell p...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Du, Y., Kitzmiller, J. A., Sridharan, A., Perl, A. K., Bridges, J. P., Misra, R. S., Pryhuber, G. S., Mariani, T. J., Bhattacharya, S., Guo, M., Potter, S. S., Dexheimer, P., Aronow, B., Jobe, A. H., Whitsett, J. A., Xu, Y. Tags: Open access Chest clinic Source Type: research

A case for the therapeutic use of perfluorocarbon in pulmonary atelectasis
This is a case report formatted as a clinical handover discussion between a junior ward paediatrician (SB) and senior paediatric intensive care consultant (AD) and cardiology consultant (GM). SB: I have been handed over a 3-year-old patient from the paediatric intensive care unit (PICU). She has a complex medical history and spent the first year of her life in PICU. She had a repair of a hypoplastic-aortic-arch and a tracheo-oesophageal fistula as a neonate but remained ventilator dependent for months with left main bronchus (LMB) compression. Separation from the ventilator was eventually achieved, after a failed aortopexy...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Bali, S., Morgan, G., Nyman, A., Turcu, S., Durward, A. Tags: Chest clinic Source Type: research

MRI ventilation abnormalities predict quality-of-life and lung function changes in mild-to-moderate COPD: longitudinal TINCan study
COPD biomarkers are urgently required for clinical trials of new therapies. We evaluated the longitudinal change and relationship of MRI and CT biomarkers of COPD with St. George's Respiratory Questionnaire (SGRO) and FEV1 worsening over 30 months. Among imaging biomarkers, only the longitudinal change in MRI ventilation defect percent (VDP) was greater in ever-smoker (n=34/p
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Kirby, M., Eddy, R. L., Pike, D., Svenningsen, S., Coxson, H. O., Sin, D. D., McCormack, D. G., Parraga, G., for the Canadian Respiratory Research Network Tags: Research letters Source Type: research

Cholesterol, lipoproteins and subclinical interstitial lung disease: the MESA study
We investigated associations of plasma lipoproteins with subclinical interstitial lung disease (ILD) by measuring high attenuation areas (HAA: lung voxels between –600 and –250 Hounsfield units) in 6700 adults and serum MMP-7 and SP-A in 1216 adults age 45–84 without clinical cardiovascular disease in Multi-Ethnic Study of Atherosclerosis. In cross-sectional analyses, each SD decrement in high density lipoprotein cholesterol (HDL-C) was associated with a 2.12% HAA increment (95% CI 1.44% to 2.79%), a 3.53% MMP-7 increment (95% CI 0.93% to 6.07%) and a 6.37% SP-A increment (95% CI 1.35% to 11.13%), in...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Podolanczuk, A. J., Raghu, G., Tsai, M. Y., Kawut, S. M., Peterson, E., Sonti, R., Rabinowitz, D., Johnson, C., Barr, R. G., Hinckley Stukovsky, K., Hoffman, E. A., Carr, J. J., Ahmed, F. S., Jacobs, D. R., Watson, K., Shea, S. J., Lederer, D. J. Tags: Research letters Source Type: research

Role of acid sphingomyelinase and IL-6 as mediators of endotoxin-induced pulmonary vascular dysfunction
Conclusions Our data indicate that aSMase and IL-6 are not simply biomarkers of poor outcomes but pathogenic mediators of pulmonary vascular dysfunction in ARDS secondary to Gram-negative infections. (Source: Thorax)
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Pandolfi, R., Barreira, B., Moreno, E., Lara-Acedo, V., Morales-Cano, D., Martinez-Ramas, A., de Olaiz Navarro, B., Herrero, R., Lorente, J. A., Cogolludo, A., Perez-Vizcaino, F., Moreno, L. Tags: Respiratory research Source Type: research

Inhaled resveratrol treatments slow ageing-related degenerative changes in mouse lung
Background Lung ageing, a significant risk factor for chronic human lung diseases such as COPD and emphysema, is characterised by airspace enlargement and decreasing lung function. Likewise, in prematurely ageing telomerase null (terc–/–) mice, p53 stabilisation within diminishing numbers of alveolar epithelial type 2 cells (AEC2) accompanies reduced lung function. Resveratrol (RSL) is a plant phytoalexin that has previously showed efficacy in enhancing invertebrate longevity and supporting mammalian muscle metabolism when delivered orally. Here, we tested whether inhaled RSL could protect young, terc–/&n...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Navarro, S., Reddy, R., Lee, J., Warburton, D., Driscoll, B. Tags: Editor's choice Respiratory research Source Type: research

Determinants of early-life lung function in African infants
Conclusion We identified several factors including infant size, sex, maternal smoking, maternal alcohol, maternal HIV and household benzene associated with altered early lung function, many of which are factors amenable to public health interventions. Long-term study of lung function and respiratory disease in these children is a priority to develop strategies to strengthen child health. (Source: Thorax)
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Gray, D., Willemse, L., Visagie, A., Czövek, D., Nduru, P., Vanker, A., Stein, D. J., Koen, N., Sly, P. D., Hantos, Z., Hall, G. L., Zar, H. J. Tags: Open access, Drugs: infectious diseases, HIV/AIDS, TB and other respiratory infections, Child health, Infant health, Airway biology, Lung function, Environmental issues, Health education, Smoking, Tobacco use, Tobacco use (youth) Paediatric lung disease Source Type: research

A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome
Conclusions In newly diagnosed severe OHS, Bi-level PAP and CPAP resulted in similar improvements in ventilatory failure, HRQoL and adherence. Baseline PaCO2 predicted persistent ventilatory failure on treatment. Long-term studies are required to determine whether these treatments have different cost-effectiveness or impact on mortality. Trial registration number ACTRN12611000874910, results. (Source: Thorax)
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Howard, M. E., Piper, A. J., Stevens, B., Holland, A. E., Yee, B. J., Dabscheck, E., Mortimer, D., Burge, A. T., Flunt, D., Buchan, C., Rautela, L., Sheers, N., Hillman, D., Berlowitz, D. J. Tags: Clinical trials (epidemiology), Epidemiologic studies, Health education, Obesity (public health) Non-invasive ventilation Source Type: research

Socio-economic inequalities in stage at diagnosis, and in time intervals on the lung cancer pathway from first symptom to treatment: systematic review and meta-analysis
Cancer diagnosis at an early stage increases the chance of curative treatment and of survival. It has been suggested that delays on the pathway from first symptom to diagnosis and treatment may be socio-economically patterned, and contribute to socio-economic differences in receipt of treatment and in cancer survival. This review aimed to assess the published evidence for socio-economic inequalities in stage at diagnosis of lung cancer, and in the length of time spent on the lung cancer pathway. MEDLINE, EMBASE and CINAHL databases were searched to locate cohort studies of adults with a primary diagnosis of lung cancer, wh...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Forrest, L. F., Sowden, S., Rubin, G., White, M., Adams, J. Tags: Lung neoplasms, Epidemiologic studies, Lung cancer (oncology), Lung cancer (respiratory medicine), Internet Source Type: research

The use of pretest probability increases the value of high-resolution CT in diagnosing usual interstitial pneumonia
Conclusions A possible UIP pattern on HRCT has high specificity for UIP on surgical lung biopsy, but PPV is highly dependent on underlying prevalence. Adding clinical and radiographic features to possible UIP pattern on HRCT may provide sufficient probability of histopathological UIP across prevalence ranges to change clinical decision-making. (Source: Thorax)
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Brownell, R., Moua, T., Henry, T. S., Elicker, B. M., White, D., Vittinghoff, E., Jones, K. D., Urisman, A., Aravena, C., Johannson, K. A., Golden, J. A., King, T. E., Wolters, P. J., Collard, H. R., Ley, B. Tags: Interstitial lung disease Source Type: research

Physical activity is increased by a 12-week semiautomated telecoaching programme in patients with COPD: a multicentre randomised controlled trial
Rationale Reduced physical activity (PA) in patients with COPD is associated with a poor prognosis. Increasing PA is a key therapeutic target, but thus far few strategies have been found effective in this patient group. Objectives To investigate the effectiveness of a 12-week semiautomated telecoaching intervention on PA in patients with COPD in a multicentre European randomised controlled trial. Methods 343 patients from six centres, encompassing a wide spectrum of disease severity, were randomly allocated to either a usual care group (UCG) or a telecoaching intervention group (IG) between June and December 2014. This 1...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Demeyer, H., Louvaris, Z., Frei, A., Rabinovich, R. A., de Jong, C., Gimeno-Santos, E., Loeckx, M., Buttery, S. C., Rubio, N., Van der Molen, T., Hopkinson, N. S., Vogiatzis, I., Puhan, M. A., Garcia-Aymerich, J., Polkey, M. I., Troosters, T., on behalf o Tags: Open access Chronic obstructive pulmonary disease Source Type: research

Biomechanical CT metrics are associated with patient outcomes in COPD
Background Traditional metrics of lung disease such as those derived from spirometry and static single-volume CT images are used to explain respiratory morbidity in patients with COPD, but are insufficient. We hypothesised that the mean Jacobian determinant, a measure of local lung expansion and contraction with respiration, would contribute independently to clinically relevant functional outcomes. Methods We applied image registration techniques to paired inspiratory-expiratory CT scans and derived the Jacobian determinant of the deformation field between the two lung volumes to map local volume change with respiration. ...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Bodduluri, S., Bhatt, S. P., Hoffman, E. A., Newell, J. D., Martinez, C. H., Dransfield, M. T., Han, M. K., Reinhardt, J. M., for the COPDGene Investigators Tags: Chronic obstructive pulmonary disease Source Type: research

Genetic variants affecting cross-sectional lung function in adults show little or no effect on longitudinal lung function decline
Conclusions Previously identified genetic variants jointly have a strong effect on cross-sectional lung function in adults but little or no effect on the rate of decline of lung function. It is possible that they influence COPD risk through lung development. Although no genetic variants have yet been associated with lung function decline at stringent genome-wide significance, longitudinal change in lung function is heritable suggesting that there is scope for future discoveries. (Source: Thorax)
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: John, C., Soler Artigas, M., Hui, J., Nielsen, S. F., Rafaels, N., Pare, P. D., Hansel, N. N., Shrine, N., Kilty, I., Malarstig, A., Jelinsky, S. A., Vedel-Krogh, S., Barnes, K., Hall, I. P., Beilby, J., Musk, A. W., Nordestgaard, B. G., James, A., Wain, Tags: Open access Chronic obstructive pulmonary disease Source Type: research

CPAP or non-invasive ventilation in obesity hypoventilation syndrome: does it matter which one you start with?
In recent decades, the prevalence of obesity and severe obesity has increased significantly around the globe.1 2 As a consequence, it is likely that the prevalence of obesity-associated comorbidities such as obesity hypoventilation syndrome (OHS) will follow the same trend.3 OHS is the most severe form of respiratory compromise induced by obesity, leading to increased mortality and a wide array of comorbidities such as pulmonary hypertension, right heart failure and increased risk of hospitalisation due to acute-on-chronic hypercapnic respiratory failure.4–6 Unfortunately, OHS remains frequently unrecognised or misdi...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Noda, J. R., Masa, J. F., Mokhlesi, B. Tags: Editorials Source Type: research

Pulmonary hypertension in ARDS: inflammation matters!
The recognition of pulmonary vascular complications in acute respiratory distress syndrome (ARDS) spans more than 40 years. Pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure of ≥25 mm Hg at right heart catheterisation. PH is a recognised consequence of ARDS, with a high prevalence in early studies. The pathogenesis of PH in ARDS is likely to be multifactorial and disease stage-dependent. Further to the modifiable effects of positive pressure ventilation,1 potential underlying mechanisms of PH in ARDS include vessel obliteration, microthrombosis and pulmonary vasoconstriction due t...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Price, L. C., Wort, S. J. Tags: Editorials Source Type: research

Socioeconomic position and delays in lung cancer diagnosis: should we target the more deprived?
Lung cancer incidence and mortality increase with all measures of socioeconomic deprivation primarily because of the fact that smoking rates also increase with the same measures. This powerful association means that we see double the number of people with lung cancer in the most deprived quintile compared with the least deprived. Socioeconomic deprivation is associated with reduced survival, more early deaths (within 30 or 90 days) and lower treatment rates.1–3 Possible explanations include a failure to present and seek help from doctors early and less effective primary healthcare in deprived communities, both f...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Baldwin, D. R. Tags: Editorials Source Type: research

Diagnosing idiopathic pulmonary fibrosis without a lung biopsy: honeycombing not required
Nearly 50 years ago, idiopathic interstitial pneumonias (IIPs) were defined by Liebow and Carrington based on the histological pattern present in the lung.1 2 Today, we consider histological patterns in the context of clinical and radiological information in order to diagnose a specific IIP, a paradigm shift initially introduced by a Consensus Statement published by the American Thoracic Society and European Respiratory Society in 2002 and developed further in 2011.3 With regard to idiopathic pulmonary fibrosis (IPF), this approach requires the presence of a usual interstitial pneumonia pattern (UIP), either on high r...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Homer, R., Lederer, D. J. Tags: Editorials Source Type: research

Progress in disease progression genetics: dissecting the genetic origins of lung function decline in COPD
Lung function is a heritable trait. Heritability estimates posit that approximately30%–50% of the phenotypic variation in FEV1 is explained by genetics,1–3 and genome-wide association studies (GWAS) of lung function4–11 have discovered multiple genetic variants that are associated with cross-sectional measurements in adults of FEV1, FVC and FEV1/FVC ratio at genome-wide significance levels. Many of these same loci have also been implicated in GWAS of COPD. Additional work is required to link these loci to pathophysiology. Functional studies on GWAS loci involving HHIP,12 13 FAM13A,14 HTR4,15 AGER16 and IR...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Busch, R., Cho, M. H., Silverman, E. K. Tags: Editorials Source Type: research

Highlights from this issue
Jacob's Creek Bodduluri and the COPDGene Investigators investigated the relationship between CT derived local lung expansion and contraction (Jacobian determinant) and functional outcome in COPD (see page 409). The deformation field between the two lung volumes, mapping local volume change with respiration, was associated with health related quality of life, exercise capacity and mortality. Will this be part of lung functioning testing going forward? Shiraz only knows. The ‘Cristal’ Maze John and colleagues are not using a crystal ball to try and see the future but genome-wide data (see page 400). They enrolled...
Source: Thorax - April 10, 2017 Category: Respiratory Medicine Authors: Triumvirate, T. Tags: Airwaves Source Type: research

What's hot that the other's got
Updating the definition of bronchopulmonary dysplasia This retrospective cohort study (JAMA Paeditr. Published Online First: 23 Jan 2017. http://dx.doi.org/10.1001/jamapediatrics.2016.4141) included 80% of neonates born in Canada at less than 29 weeks gestation from January 2010 to September 2011. The aim was find out which of six definitions of bronchopulmonary dysplasia are most predictive of respiratory morbidity or neurosensory deficit, as measured at 18–21 months corrected age. The group then analysed at what gestational age application of the definition would be most accurate. They showed that the exi...
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Higginson, J. Tags: Chest clinic Source Type: research

A bloody bronchoscopy
A 42-year-old male non-smoker presented to the emergency department with a 1-month history of fever. He had no medical history. He was treated with oral antibiotics for a presumed chest infection. Initial chest radiograph (CXR) is shown in figure 1A. Two weeks later, he was seen in outpatients with fever, progressive dyspnoea and haemoptysis. Repeat CXR (figure 1B) was performed in addition to a chest CT (figure 1C). He underwent urgent bronchoscopy and bronchoalveolar lavage (BAL). After the procedure, he was admitted due to persistent hypoxia. Bedside observations: temperature 36.4°C, oxygen saturation 95% with Fio2 ...
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Srikanthan, K., Shabeeh, H., De Souza, A., Shah, P. Tags: Chest clinic Source Type: research

Bagpipe lung; a new type of interstitial lung disease?
Background Hypersensitivity pneumonitis (HP) is an inflammatory lung disease mediated by an immunological response to an inhaled antigen and can progress to disabling or fatal lung disease. It is related to occupational or other environmental exposures. In a significant proportion of patients, the antigen is often difficult to identify from the clinical history.1 This case highlights the importance of a careful clinical history including hobbies, because in this case, playing the bagpipes, we feel, was very relevant to the development of HP. We were able to isolate various fungal species from the bagpipes. There have been ...
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: King, J., Richardson, M., Quinn, A.-M., Holme, J., Chaudhuri, N. Tags: Press releases, Pneumonia (infectious disease), TB and other respiratory infections, Interstitial lung disease, Pneumonia (respiratory medicine), Radiology (diagnostics) Chest clinic Source Type: research

Adults miscoded and misdiagnosed as having pneumonia: results from the British Thoracic Society pneumonia audit
A key objective of the British Thoracic Society national community-acquired pneumonia (CAP) audit was to determine the clinical characteristics and outcomes of hospitalised adults given a primary discharge code of pneumonia but who did not fulfil accepted diagnostic criteria for pneumonia. Adults miscoded as having pneumonia (n=1251) were older compared with adults with CAP (n=6660) (median 80 vs 78 years, p
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Daniel, P., Bewick, T., Welham, S., Mckeever, T. M., Lim, W. S., for the British Thoracic Society Tags: Chest clinic Source Type: research

Change in pulmonary mechanics and the effect on breathing pattern of high flow oxygen therapy in stable hypercapnic COPD
We studied the effects of high flow oxygen therapy (HFOT) versus non-invasive ventilation (NIV) on inspiratory effort, as assessed by measuring transdiaphragmatic pressure, breathing pattern and gas exchange. Fourteen patients with hypercapnic COPD underwent five 30-min trials: HFOT at two flow rates, both with open and closed mouth, and NIV, applied in random order. After each trial standard oxygen therapy was reinstituted for 10 min. Compared with baseline, HFOT and NIV significantly improved breathing pattern, although to different extents, and reduced inspiratory effort; however, arterial carbon dioxide oxygen ten...
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Pisani, L., Fasano, L., Corcione, N., Comellini, V., Musti, M. A., Brandao, M., Bottone, D., Calderini, E., Navalesi, P., Nava, S. Tags: Research letter Source Type: research

Assessing bronchodilator response in preschool children using spirometry
Conclusions A negative BDR in a child suspected of having asthma makes a diagnosis of asthma less likely. (Source: Thorax)
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Busi, L. E., Restuccia, S., Tourres, R., Sly, P. D. Tags: Child health, Asthma, Drugs: respiratory system Respiratory research Source Type: research

Respiratory symptoms in people living with HIV and the effect of antiretroviral therapy: a systematic review and meta-analysis
Conclusions Respiratory symptoms are more common in PLWH than controls. This association persists although at a reduced level in populations with access to ART. (Source: Thorax)
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Brown, J., Roy, A., Harris, R., Filson, S., Johnson, M., Abubakar, I., Lipman, M. Tags: Open access, Drugs: infectious diseases, HIV/AIDS, Internet Respiratory epidemiology Source Type: research

STAAR: a randomised controlled trial of electronic adherence monitoring with reminder alarms and feedback to improve clinical outcomes for children with asthma
Conclusions The results indicate that electronic adherence monitoring with feedback is likely to be of significant benefit in the routine management of poorly controlled asthmatic subjects. Trial registration number NCT02451709; pre-result. (Source: Thorax)
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Morton, R. W., Elphick, H. E., Rigby, A. S., Daw, W. J., King, D. A., Smith, L. J., Everard, M. L. Tags: Clinical trials (epidemiology), Epidemiologic studies, Child health, Asthma, Drugs: respiratory system Paediatric lung disease Source Type: research

Nintedanib in patients with idiopathic pulmonary fibrosis and preserved lung volume
Conclusions Patients with IPF and preserved lung volume (FVC>90% predicted) have the same rate of FVC decline and receive the same benefit from nintedanib as patients with more impaired lung volume. Trial registration number NCT01335464 and NCT01335477. (Source: Thorax)
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Kolb, M., Richeldi, L., Behr, J., Maher, T. M., Tang, W., Stowasser, S., Hallmann, C., du Bois, R. M. Tags: Open access, Interstitial lung disease Source Type: research

Long-term clinical outcomes of 'Prairie Epidemic Strain Pseudomonas aeruginosa infection in adults with cystic fibrosis
Rationale Epidemic Pseudomonas aeruginosa (PA) plays an important role in cystic fibrosis (CF) lung disease. A novel strain, the ‘Prairie Epidemic Strain’ (PES), has been identified in up to 30% of patients in Prairie-based Canadian CF centres. Objective To determine the incidence, prevalence and long-term clinical impact of PES infection. Methods A cohort of adults with CF was followed from 1980 to 2014 where bacteria isolated from clinical encounters were prospectively collected. Strain typing was performed using pulse-field gel electrophoresis and multilocus sequence typing. Patients were divided into one ...
Source: Thorax - March 16, 2017 Category: Respiratory Medicine Authors: Somayaji, R., Lam, J. C., Surette, M. G., Waddell, B., Rabin, H. R., Sibley, C. D., Purighalla, S., Parkins, M. D. Tags: Epidemiologic studies, Cystic fibrosis, Cardiothoracic surgery, Transplantation Source Type: research