Respiratory GURU: Genuinely Useful Respiratory Updates

Welcome back to the next instalment of respiratory GURU, this time we delve into two RCTs investigating rescue therapy for patients with CTD ILD. The EVER ILD study looks at MMF vs MMF plus rituximab, and the RECITAL study looks at rituximab vs cyclophosphamide. 2 very useful studies and I was thrilled to be joined by two national experts in the field, Dr Anjali Crawshaw and Dr Emma Derrett-Smith. Hopefully, this will make you feel more well-prepared for ILD MDTs, and give you a real insight into how these two experts view the recent literature in the context of their day-to-day practice. Here are the pubmed links for the two papers, the INBUILD study which we discuss briefly, and the American College of Rheumatology guidelines, which apparently is where most of the guidance we need regarding CTD ILD (for now) sits. Enjoy listening, thank you for being patient with the podcast releases whilst I birthed and raised my second child, and fingers crossed no more career interruptions!! Mankikian J et al. Rituximab and mycophenolate mofetil combination in patients with interstitial lung disease (EVER-ILD): a double-blind, randomised, placebo-controlled trial. Eur Respir J. 2023 Jun 8;61(6):2202071. doi: 10.1183/13993003.02071-2022. PMID: 37230499. Maher TM et al. Rituximab versus intravenous cyclophosphamide in patients with connective tissue disease-associated interstitial lung disease in the UK (RECITAL): a double-blind, double-dummy, randomised, controlled, phase 2b trial. Lancet Respir Med. 2023 Jan;11(1):45-54. doi: 10.1016/S2213-2600(22)00359-9. Epub 2022 Nov 11. PMID: 36375479. interstitial-lung-disease-guideline-summary-treatment-2023.pdf (contentstack.io) Support the show

A vibrant discussion with our two regional leads for occupational lung disease and a specialised solicitor dealing with OLD claims into how to drill down into the details of an occupational lung disease, how to refer, how to write your clinical letters and how to direct patients towards compensation if it's right for them. Support the show

A perfect introduction to series 2, a COPD podcast with Professor Turner and Dr LJ Smith where we jump into MART for COPD, the new P2X3 receptor agonist Filapixant, antihyperglycaemic drugs preventing COPD exacerbations and much more. Happy listening! Studies discussed: Association of the Use of Novel Antihyperglycemic Drugs With Prevention of COPD Exacerbations Among Patients With Type 2 Diabetes BMJ. 2022 Nov 1;379:e071380. doi: 10.1136/bmj-2022-071380. PMID: 36318979; Budesonide/Formoterol Maintenance and Reliever Therapy vs Fluticasone/Salmeterol Fixed-Dose Treatment in Patients With COPD Thorax. 2023 May;78(5):451-458. doi: 10.1136/thorax-2022-219620. Epub 2023 Feb 1. PMID: 36725331. The P2X3 receptor antagonist filapixant in patients with refractory chronic cough: a randomized controlled trial Respir Res. 2023 Apr 11;24(1):109. doi: 10.1186/s12931-023-02384-8. PMID: 37041539; Prospective Detection of Early Lung Cancer in Patients With COPD in Regular Care by Electronic Nose Analysis of Exhaled Breath Chest. 2023 May 19:S0012-3692(23)00754-7. doi: 10.1016/j.chest.2023.04.050. Epub ahead of print. PMID: 37209772. Support the show

This fascinating episode delivers pragmatic advice and recommendations for how to identify and manage patients with inducible laryngeal obstruction (ILO)-the new phrase for vocal cord dysfunction, GORD and breathing pattern disorders-the new phrase for dysfunctional breathing. This will make so much difference to how you do your consults with your breathless patients who have one of these disorders, how to reassure them, treat them and not feel a deep heart sink when you read your last letter about them before calling them into your consultation room. The quality of this podcast recording is not at the highest standard I strive to achieve, so bear with me, and turn up the volume a little when prof is speaking, you won't want to miss a word! Support the show

Next instalment of the aspergillosis podcast, where we move on to talk about chronic pulmonary aspergillosis and invasive aspergillosis. Hope you've had time to digest part 1, part 2 is filled with useful content about diagnostics again, including the utility or lack of as it might be of galactomannans and Beta D Glucans in aspergillosis. Thank you again to Dr Chris Kosmidis. Support the show

An interview with Dr Chris Kosmidis, Clinical Senior Lecturer at Wythenshawe Hospital and Aspergillosis centre about aspergillosis. Divided into two parts, the first part of our discussion covers ABPA for the generalist, and is a goldmine of information for diagnosing, treating and monitoring response in these patients. I now feel comfortable interpreting the serology, prescribing antifungals where appropriate and how to look out for a relapse which is a long way from where I started! References for this podcast include: Kosmidis C, Denning DW. The clinical spectrum of pulmonary aspergillosis. Thorax. 2015 Mar;70(3):270-7. doi: 10.1136/thoraxjnl-2014-206291. Epub 2014 Oct 29. PMID: 25354514. Godet et al. Nebulised liposomal amphotericin-B as maintenance therapy in allergic bronchopulmonary aspergillosis: a randomised, multicentre trial. Eur Respir J. 2022 Jun 16;59(6):2102218. doi: 10.1183/13993003.02218-2021. PMID: 34764182. Agarwal R, Muthu V, Sehgal IS, Dhooria S, Prasad KT, Garg M, Aggarwal AN, Chakrabarti A. A randomised trial of prednisolone versus prednisolone and itraconazole in acute-stage allergic bronchopulmonary aspergillosis complicating asthma. Eur Respir J. 2021 Sep 9;59(4):2101787. doi: 10.1183/13993003.01787-2021. PMID: 34503983. How do we treat aspergillosis? - Dr Chris Kosmidis - YouTube Support the show

This month's episode dives into progressive fibrosing ILD, previously a disadvantaged set of patients who have a progressive ILD but as they weren't specifically UIP they were not entitled to antifibrotic treatment. So thank goodness for the INBUILD trial back in 2020 and it's extension and NICE technological appraisal for injecting pragmastism not only in to the types of patients now referrable for antifibrotics, but also the referral criteria. This has moved away from FVC and towards radiological classification and gas transfer which we all know are useful parameters of parenchymal health. We also talk about post COVID fibrosis, anti-reflux medication and anti-cough medication. I am joined by two regional experts in the field, Dr Chris Huntley and Dr Gareth Walters. References are below: Pirfenidone in patients with idiopathic pulmonary fibrosis (CAPACITY): two randomised trials PMID: 21571362 A Phase 3 Trial of Pirfenidone in Patients with Idiopathic Pulmonary Fibrosis DOI: 10.1056/NEJMoa1402582 Efficacy and Safety of Nintedanib in Idiopathic Pulmonary Fibrosis DOI: 10.1056/NEJMoa1402584 Efficacy of a Tyrosine Kinase Inhibitor in Idiopathic Pulmonary Fibrosis DOI: 10.1056/NEJMoa1103690 Pirfenidone in patients with progressive fibrotic interstitial lung diseases other than idiopathic pulmonary fibrosis (RELIEF): a double-blind, randomised, placebo-controlled, phase 2b trial PMID: 33798455 Nintedanib in Progressive Fibrosing Interstitial Lung Diseases DOI: 10.1056/NEJMoa1908681 Phase 2B Study of Inhaled RVT-1601 for Chronic Cough in Idiopathic Pulmonary Fibrosis: A Multicenter, Randomized, Placebo-controlled Study (SCENIC Trial) PMID: 35050837 Effect of anti-reflux therapy on pulmonary function in idiopathic pulmonary fibrosis: a systematic review and meta-analysis. PMID: 34795926 Post COVID PFT and CT systematic review: PMID: 35642193 Support the show

Finally it's here, the pleural podcast! Ever wondered why you can't get a straight answer about suction, talc and fibrinolytics? That's because the evidence until recently has been poor and we're still using guidelines written 12 years ago. But with the assistance of two excellent pleural specialists we pull apart the latest studies to discuss all your usual pleural conundrums to help you manage 90% of pleural disease within your local hospital, minimise the time spent in a hospital bed and reduce the need for a surgeon getting involved. Studies discussed include: MARS 2: PMID: 32873681 Conservative versus Interventional Treatment for Spontaneous Pneumothorax: PMID: 31995686 Ambulant treatment with a digital chest tube for prolonged air leak is safe and effective: PMID: 35070365 The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial: PMID: 31711990 Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): A Pilot Randomized Clinical Trial PMID: 35081010 Efficacy of sonographic and biological pleurodesis indicators of malignant pleural effusion (SIMPLE): protocol of a randomised controlled trial PMID: 29225889 Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions: A Randomized Clinical Trial PMID: 31804680 The bacteriology of pleural infection (TORPIDS): an exploratory metagenomics analysis through next generation sequencing DOI:https://doi.org/10.1016/S2666-5247(21)00327-X Support the show

This month's episode is all about COPD, and I am joined by the brilliantly intelligent Professor Alice Turner. Her knowledge of the research in this field is remarkably in-depth, yet she is generous with her experience and answers the questions you want to ask but may not feel comfortable exposing the chasms in your knowledge like I did! 40 minute podcast, strap in for a detailed, transformative and revelatory podcast with an international COPD leader. Studies discussed include: Prevalence and Impact of Pulmonary Bacterial Colonisation in Stable State Chronic Obstructive Pulmonary Disease (COPD). PMID: 35052762 Pye A, Hill SL, Bharadwa P, Stockley RA. Effect of storage and postage on recovery and quantitation of bacteria in sputum samples. PMID: 17893120 Prevalence, Pattern, Risks Factors and Consequences of Antibiotic Resistance in COPD: PMID: 35016569. https://www.nice.org.uk/guidance/ng115 Home Non-Invasive Ventilation in COPD: A Global Systematic Review. PMID: 35259290. Effect of Home Noninvasive Ventilation With Oxygen Therapy vs Oxygen Therapy Alone on Hospital Readmission or Death After an Acute COPD Exacerbation: A Randomized Clinical Trial. PMID: 28528348 Long-Term Risk of Mortality Associated with Isolation of Pseudomonas aeruginosa in COPD: A Systematic Review and Meta-Analysis. PMID: 35210766 Effect of Inhaled Corticosteroid Withdrawal on Chronic Obstructive Pulmonary Disease Exacerbations in Patients Taking Triple Therapy at Baseline. PMID: 33204084 Long-term cost and utility consequences of short-term clinically important deterioration in patients with chronic obstructive pulmonary disease: results from the TORCH study PMID: 31190781 Blood eosinophils to guide inhaled maintenance therapy in a primary care COPD population. PMID: 35141324 Effect of Theophylline as Adjunct to Inhaled Corticosteroids on Exacerbations in Patients With COPD: A Randomized Clinical Trial. PMID: 30326124 Support the show

A vibrant discussion with Dr Sarb Clare MBE and author of Ultrasound for the Generalist about point of care lung USS and how we can use lung USS to achieve rapid diagnoses, without needing to wheel down to imaging. No more distinctly average portable CXRs, USS offer us the ability to do bedside serial imaging on our unwell respiratory patients and to see with our own eyes what is going on inside when we don't quite believe the CXR or our vocal resonance examination. Resources discussed include: https://www.generalistultrasound.com/book/ https://www.generalistultrasound.com/ Díaz-Gómez JL, Mayo PH, Koenig SJ. Point-of-Care Ultrasonography. N Engl J Med. 2021 Oct 21;385(17):1593-1602. doi: 10.1056/NEJMra1916062. PMID: 34670045. Support the show

A great discussion of the recent MDR TB Clinical Advice Service Annual Report, and a complex MDR TB case as a great demonstration of the intricacies of it's management. Dr Guy Hagan is our local TB lead and an encyclopaedia of TB treatments, and we talk about a tricky pericardial TB patient and his clinical journey. I learnt so much about the group A, B and C selection of medications for MDR TB, how to use the clinical advice service and look out for the rare side effects. Discussed link are below: https://www.brit-thoracic.org.uk/quality-improvement/lung-disease-registries/bts-mdr-tb-clinical-advice-service/ https://www.who.int/publications/i/item/9789240007048 https://clinicaltrials.gov/ct2/show/NCT03086486 Oelofse S, Esmail A, Diacon AH, Conradie F, Olayanju O, Ngubane N, Howell P, Everitt D, Crook AM, Mendel CM, Wills GH, Olugbosi M, Del Parigi A, Sun E, Calatroni A, Spigelman M, Dheda K. Pretomanid with bedaquiline and linezolid for drug-resistant TB: a comparison of prospective cohorts. Int J Tuberc Lung Dis. 2021 Jun 1;25(6):453-460. doi: 10.5588/ijtld.21.0035. PMID: 34049607; PMCID: PMC8171246. Support the show

Discussion with Professor Adel Mansur who is the lead for the Birmingham Regional Asthma Service about the 4 main current biologics in the asthma NICE guidelines together with discussion of three more novel agents in development that have recently been published. A must listen for anyone reviewing asthma patients, Adel gives a great summary of the underlying mechanisms for these agents, their current use in clinical practice and importantly...how to pronounce them! Papers reviewed are as follows: Dupilumab https://www.nice.org.uk/guidance/TA751 Mepolizumab https://www.nice.org.uk/guidance/TA671 Benralizumab https://www.nice.org.uk/guidance/TA565 Reslizumab https://www.nice.org.uk/guidance/TA479 Brightling CE, Nair P, Cousins DJ, Louis R, Singh D. Risankizumab in Severe Asthma - A Phase 2a, Placebo-Controlled Trial. N Engl J Med. 2021 Oct 28;385(18):1669-1679. doi: 10.1056/NEJMoa2030880. PMID: 34706172. Wechsler ME, Ruddy MK, Pavord ID, Israel E, Rabe KF, Ford LB, Maspero JF, Abdulai RM, Hu CC, Martincova R, Jessel A, Nivens MC, Amin N, Weinreich DM, Yancopoulos GD, Goulaouic H. Efficacy and Safety of Itepekimab in Patients with Moderate-to-Severe Asthma. N Engl J Med. 2021 Oct 28;385(18):1656-1668. doi: 10.1056/NEJMoa2024257. PMID: 34706171. Menzies-Gow A, Corren J, Bourdin A, Chupp G, Israel E, Wechsler ME, Brightling CE, Griffiths JM, Hellqvist Å, Bowen K, Kaur P, Almqvist G, Ponnarambil S, Colice G. Tezepelumab in Adults and Adolescents with Severe, Uncontrolled Asthma. N Engl J Med. 2021 May 13;384(19):1800-1809. doi: 10.1056/NEJMoa2034975. PMID: 33979488. Support the show

This Christmas present is a summary of the recently updated guidelines for Sarcoidosis and asthma. 20 minute summary of the guidelines to listen to whilst munching on a mince pie and a glass of something festive. You're welcome. Sarcoidosis guidelines https://erj.ersjournals.com/content/58/6/2004079.long GINA asthma guidelines https://ginasthma.org/gina-reports/ Support the show

November's summary of clinical respiratory updates; 30 min podcast to listen to on the way to work or any kind of multitasking so you can keep up to date without even trying. This month's papers and guidelines are: Single-case metanalysis of fat embolism syndrome https://pubmed.ncbi.nlm.nih.gov/34743891 Clinical and pathophysiological characteristics of valproate-induced pleural effusion https://pubmed.ncbi.nlm.nih.gov/34259092 Randomised trial of the P2X 3 receptor antagonist sivopixant for refractory chronic cough https://pubmed.ncbi.nlm.nih.gov/34649978 Eliapixant (BAY 1817080), a P2X3 receptor antagonist, in refractory chronic cough: a randomised, placebo-controlled, crossover phase 2a study https://pubmed.ncbi.nlm.nih.gov/33986030/ Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s https://pubmed.ncbi.nlm.nih.gov/33740390 Effect of Continuous Positive Airway Pressure on Weight and Local Adiposity in Adults with Obstructive Sleep Apnea: A Meta Analysis https://pubmed.ncbi.nlm.nih.gov/34495549 Integrated disease management interventions for patients with chronic obstructive pulmonary disease https://www.nice.org.uk/guidance/ng202 Support the show

October's summary of clinically relevant respiratory publications released in the past month. 10 studies, and 2 interviews, your CPD for keeping up to date in just 52 minutes. List of studies discussed below 1. Evaluation of multi-component interventions for prevention of nosocomial pneumonia in older adults: a randomized, controlled trial. Eur Geriatr Med. 2021 PMID34081314 2. Management and Treatment of Patients With Obstructive Sleep Apnea Using an Intelligent Monitoring System Based on Machine Learning Aiming to Improve Continuous Positive Airway Pressure Treatment Compliance: Randomized Controlled Trial. J Med Internet Res. 2021 Oct. PMID34661550 3. A weight-loss Mediterranean diet/lifestyle intervention ameliorates inflammation and oxidative stress in patients with obstructive sleep apnea: results of the "MIMOSA" randomized clinical trial. Eur J Nutr. 2021 Oct. PMID33839919 4. Effectiveness of a motivational intervention based on spirometry results to achieve smoking cessation in primary healthcare patients: randomised, parallel, controlled multicentre study. J Epidemiol Community Health. 2021 Oct PMID33883199 5. Pragmatic Randomized Controlled Trial for Stepping Down Asthma Controller Treatment in Patients Controlled with Low-Dose Inhaled Corticosteroid and Long-Acting β2-Agonist: Step-Down of Intervention and Grade in Moderate Asthma Study. J Allergy Clin Immunol Pract. 2021 Oct PMID33940213 6. Efficacy of erlotinib and its effects on the quality of life of older patients with epidermal growth factor receptor-mutant non-small cell lung cancer: A prospective, multicenter, dose-modification study. Geriatr Gerontol Int. 2021 Oct PMID34378299 7. Exploratory composite endpoint demonstrates benefit of trilaciclib across multiple clinically meaningful components of myeloprotection in patients with small cell lung cancer. Int J Cancer. 2021 Oct PMID34109630 8. Comparing the outcomes of intrapleural fibrinolytic and DNase therapy versus intrapleural fibrinolytic or DNase therapy: A systematic review and meta-analysis. Pulm Pharmacol Ther. 2021 Sep PMID34571093 9. Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis. Thorax. 2021 Sep PMID34497138 10. Effect of Prophylactic Subcutaneous Scopolamine Butylbromide on Death Rattle in Patients at the End of Life: The SILENCE Randomized Clinical Trial. JAMA. 2021 Oct PMID34609452 Support the show