Topical Steroid Withdrawal is a Targetable Excess of Mitochondrial NAD.

Background: Topical corticosteroids (TCS) are first-line therapies for numerous skin conditions. Topical Steroid Withdrawal (TSW) is a controversial diagnosis advocated by patients with prolonged TCS exposure who report severe systemic reactions upon treatment cessation. However, to date there have been no systematic clinical or mechanistic studies to distinguish TSW from other eczematous disorders. Methods: A re-analysis of a previous survey with eczematous skin disease was performed to evaluate potential TSW distinguishing symptoms. We subsequently conducted a pilot study of 16 patients fitting the proposed diagnostic criteria. We then performed: tissue metabolomics, transcriptomics, and immunostaining on skin biopsies; serum metabolomics and cytokine assessments; shotgun metagenomics on microbiome skin swabs; genome sequencing; followed by functional, mechanistic studies using human skin cell lines and mice. Results: Clinically distinct TSW symptoms included burning, flushing, and thermodysregulation. Metabolomics and transcriptomics both implicated elevated NAD+ oxidation stemming from increased expression of mitochondrial complex I and conversion of tryptophan into kynurenine metabolites. These abnormalities were induced by glucocorticoid exposure both in vitro and in a cohort of healthy controls (N=19) exposed to TCS. Targeting complex I via either metformin or the herbal compound berberine improved outcomes in both cell culture and in an open-label case series for patients with TSW. Conclusion: Taken together, our results suggest that TSW has a distinct dermatopathology. While future studies are needed to validate these results in larger cohorts, this work provides the first mechanistic evaluation into TSW pathology, and offers insights into clinical identification, pharmacogenomic candidates, and directed therapeutic strategies.

Efficacy and Safety of Systemic Corticosteroids for Urticaria: A systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Short courses of adjunctive systemic corticosteroids are commonly used to treat acute urticaria and chronic urticaria flares (both with or without mast cell-mediated angioedema), but their benefits and harms are unclear. OBJECTIVE: To evaluate the efficacy and safety of treating acute urticaria or chronic urticaria flares with versus without systemic corticosteroids. METHODS: We searched MEDLINE, EMBASE, CENTRAL, CNKI, VIP, Wanfang, and CBM databases from inception to July 8, 2023 for randomized controlled trials of treating urticaria with versus without systemic corticosteroids. Paired reviewers independently screened records, extracted data, and appraised risk of bias with the Cochrane 2.0 tool. We did random effects meta-analyses of urticaria activity, itch severity and adverse events. We assessed certainty of the evidence using the GRADE approach. RESULTS: We identified 12 randomized trials enrolling 944 patients. For patients with low or moderate probability (17.5% to 64%) to improve with antihistamines alone, add-on systemic corticosteroids likely improve urticaria activity by a 14% to 15% absolute difference (odds ratio [OR] 2.17, 95%CI 1.43-3.31; Number needed to treat [NNT] 7; Moderate certainty). Among patients with a high chance (95.8%) for urticaria to improve with antihistamines alone, add-on systemic corticosteroids likely improved urticaria activity by a 2.2% absolute difference (NNT, 45; Moderate certainty). Corticosteroids may improve itch severity (OR, 2.44; 95%CI 0.87-6.83; Risk difference, 9%; NNT, 11; Low certainty). Systemic corticosteroids also likely increase adverse events (OR, 2.76; 95%CI 1.00-7.62; Risk difference, 15%; number needed to harm [NNH], 9; Moderate certainty). CONCLUSION: Systemic corticosteroids for acute urticaria or chronic urticaria exacerbations likely improve urticaria, depending on antihistamine-responsiveness, but also likely increase adverse effects in approximately 15% more.

Executive Summary of Clinical Practice Guideline on Immunotherapy for Inhalant Allergy.

OBJECTIVE: Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. PURPOSE: The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS: The guideline development group made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The guideline development group made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitization, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The guideline development group offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

Plain Language Summary: Immunotherapy for Inhalant Allergy.

The plain language summary explains allergen immunotherapy to patients, families, and caregivers. The summary is for patients aged 5 years and older who are experiencing symptoms from inhalant allergies and are considering immunotherapy as a treatment option. It is based on the 2024 "Clinical Practice Guideline: Immunotherapy for Inhalant Allergy." This plain language summary is a companion publication to the full guideline, which provides greater detail for health care providers. Guidelines and their recommendations may not apply to every patient, but they can be used to find best practices and quality improvement opportunities.

Clinical Practice Guideline: Immunotherapy for Inhalant Allergy.

OBJECTIVE: Allergen immunotherapy (AIT) is the therapeutic exposure to an allergen or allergens selected by clinical assessment and allergy testing to decrease allergic symptoms and induce immunologic tolerance. Inhalant AIT is administered to millions of patients for allergic rhinitis (AR) and allergic asthma (AA) and is most commonly delivered as subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT). Despite its widespread use, there is variability in the initiation and delivery of safe and effective immunotherapy, and there are opportunities for evidence-based recommendations for improved patient care. PURPOSE: The purpose of this clinical practice guideline (CPG) is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the management of inhaled allergies with immunotherapy. Specific goals of the guideline are to optimize patient care, promote safe and effective therapy, reduce unjustified variations in care, and reduce the risk of harm. The target patients for the guideline are any individuals aged 5 years and older with AR, with or without AA, who are either candidates for immunotherapy or treated with immunotherapy for their inhalant allergies. The target audience is all clinicians involved in the administration of immunotherapy. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of inhaled allergies with immunotherapy. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS: The GDG made a strong recommendation that (Key Action Statement [KAS] 10) the clinician performing allergy skin testing or administering AIT must be able to diagnose and manage anaphylaxis. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should offer or refer to a clinician who can offer immunotherapy for patients with AR with or without AA if their patients' symptoms are inadequately controlled with medical therapy, allergen avoidance, or both, or have a preference for immunomodulation. (KAS 2A) Clinicians should not initiate AIT for patients who are pregnant, have uncontrolled asthma, or are unable to tolerate injectable epinephrine. (KAS 3) Clinicians should evaluate the patient or refer the patient to a clinician who can evaluate for signs and symptoms of asthma before initiating AIT and for signs and symptoms of uncontrolled asthma before administering subsequent AIT. (KAS 4) Clinicians should educate patients who are immunotherapy candidates regarding the differences between SCIT and SLIT (aqueous and tablet) including risks, benefits, convenience, and costs. (KAS 5) Clinicians should educate patients about the potential benefits of AIT in (1) preventing new allergen sensitizations, (2) reducing the risk of developing AA, and (3) altering the natural history of the disease with continued benefit after discontinuation of therapy. (KAS 6) Clinicians who administer SLIT to patients with seasonal AR should offer pre- and co-seasonal immunotherapy. (KAS 7) Clinicians prescribing AIT should limit treatment to only those clinically relevant allergens that correlate with the patient's history and are confirmed by testing. (KAS 9) Clinicians administering AIT should continue escalation or maintenance dosing when patients have local reactions (LRs) to AIT. (KAS 11) Clinicians should avoid repeat allergy testing as an assessment of the efficacy of ongoing AIT unless there is a change in environmental exposures or a loss of control of symptoms. (KAS 12) For patients who are experiencing symptomatic control from AIT, clinicians should treat for a minimum duration of 3 years, with ongoing treatment duration based on patient response to treatment. The GDG offered the following KASs as options: (KAS 2B) Clinicians may choose not to initiate AIT for patients who use concomitant beta-blockers, have a history of anaphylaxis, have systemic immunosuppression, or have eosinophilic esophagitis (SLIT only). (KAS 8) Clinicians may treat polysensitized patients with a limited number of allergens.

Changing high-risk asthma in Memphis through partnership: Results from the CHAMP program.

BACKGROUND: Children in metro Shelby County, Tennessee, have disproportionally high asthma-related health care resource use (HRU) compared with those in other regions in Tennessee. OBJECTIVE: To describe the goals, logistics, and outcomes of the Changing High-Risk Asthma in Memphis through Partnership (CHAMP) program implemented to improve pediatric asthma care in Shelby County. METHODS: CHAMP established a multidisciplinary team with dedicated medical staff and community health workers, implemented a 24/7 call line to improve access to care, established a patient data registry to address fragmented care, assigned community health educators to improve asthma education and social needs, and partnered with services to address environmental triggers and social determinants of health. Patients eligible for CHAMP are Shelby County residents aged 2 to 18 years with high-risk asthma enrolled in Tennessee's Medicaid managed care program. Health care resource use outcomes 1-year pre- and post-CHAMP enrollment were analyzed for patients who had completed 1 year of CHAMP between January 2013 and December 2022. The 24/7 call line data between November 2013 and December 2022 were analyzed. RESULTS: CHAMP has enrolled 1348 children; 945 have completed 1 year (63% male; 90% identified as Black). At 1-year post-CHAMP enrollment, patients had 58%, 68%, 42%, and 53% reductions in emergency department visits, inpatient and observation visits, urgent care visits, and total asthma exacerbations, respectively. The number of asthma exacerbations per patient significantly decreased from 2.97 to 1.40 at 1-year post-CHAMP enrollment. Of the calls made to the 24/7 call line, 58% occurred after hours and 52% led to issue resolution without a medical facility visit. CONCLUSION: CHAMP successfully decreased asthma HRU in children with high-risk asthma in Shelby County by implementing initiatives that targeted barriers to asthma care.

Real-world use and perceptions of shared decision-making for allergy and asthma care in a US population.

Background: Shared decision-making (SDM), the process of engaging patients in their healthcare decisions, is an integral component of personalized medicine. The use of SDM in real-world allergy and asthma care in the United States (US) is unknown. Cross-sectional surveys of allergists and patients in a US population were conducted to assess the use and perceptions of SDM and SDM tools in real-world allergy and asthma care. Methods: Allergists (N = 101) who were members of the American College of Allergy Asthma & Immunology (ACAAI) and who were also Dynata (a marketing research firm) research partners or in the Allergy & Asthma Network customer database completed an online survey from February-March 2022. Adult patients (N = 110) with asthma, allergy, and/or eczema in the United States who were participants of online research panels hosted by Dynata completed on online survey from February 1-7, 2022. Results: Based on their own definition, 98% of the allergists reported familiarity with SDM, and 79% reported using it frequently. Allergists reported using SDM with an average of 44% of their patients. The most commonly used tool was the Immunotherapy SDM toolkit (40%); 43% had not used any SDM tool. Among allergists not using SDM or using it infrequently (n = 19), 42% considered it too time-consuming and 37% believed their patients have low health literacy. Of the surveyed patients, 25% reported their provider used SDM "frequently" or "occasionally" when being treated for allergies, asthma, or eczema, and 22% reported using SDM tools with their provider at some point. The most commonly used tool was the Asthma and Allergy Symptom Test (60%). Among patients whose allergists used SDM infrequently or never (n = 56), 70% reported they would be likely to ask their allergist to use SDM more often. Conclusion: Survey responses revealed a disconnect between allergists and patients regarding SDM use. Barriers to SDM are consistent with those across the healthcare industry. Patients clearly expressed their desire for SDM.

Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials.

BACKGROUND: Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects. OBJECTIVE: We sought to systematically synthesize the benefits and harms of AD prescription topical treatments. METHODS: For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s). RESULTS: The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus. CONCLUSIONS: For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.

Systemic treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials.

BACKGROUND: Atopic dermatitis (AD) is an inflammatory skin condition with multiple systemic treatments and uncertainty regarding their comparative impact on AD outcomes. OBJECTIVE: We sought to systematically synthesize the benefits and harms of AD systemic treatments. METHODS: For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, Web of Science, and GREAT databases from inception to November 29, 2022, for randomized trials addressing systemic treatments and phototherapy for AD. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. This review is registered in the Open Science Framework (https://osf.io/e5sna). RESULTS: The 149 included trials (28,686 patients with moderate-to-severe AD) evaluated 75 interventions. With high-certainty evidence, high-dose upadacitinib was among the most effective for 5 of 6 patient-important outcomes; high-dose abrocitinib and low-dose upadacitinib were among the most effective for 2 outcomes. These Janus kinase inhibitors were among the most harmful in increasing adverse events. With high-certainty evidence, dupilumab, lebrikizumab, and tralokinumab were of intermediate effectiveness and among the safest, modestly increasing conjunctivitis. Low-dose baricitinib was among the least effective. Efficacy and safety of azathioprine, oral corticosteroids, cyclosporine, methotrexate, mycophenolate, phototherapy, and many novel agents are less certain. CONCLUSIONS: Among individuals with moderate-to-severe AD, high-certainty evidence demonstrates that high-dose upadacitinib is among the most effective in addressing multiple patient-important outcomes, but also is among the most harmful. High-dose abrocitinib and low-dose upadacitinib are effective, but also among the most harmful. Dupilumab, lebrikizumab, and tralokinumab are of intermediate effectiveness and have favorable safety.

Asthma innovations from the first International Collaborative Asthma Network forum.

Background: Many patients have uncontrolled asthma despite available treatments. Most of the new asthma therapies have focused on type 2 (T2) inflammation, leaving an unmet need for innovative research into mechanisms of asthma beyond T2 and immunity. An international group of investigators developed the International Collaborative Asthma Network (ICAN) with the goal of sharing innovative research on disease mechanisms, developing new technologies and therapies, organising pilot studies and engaging early-stage career investigators from across the world. This report describes the purpose, development and outcomes of the first ICAN forum. Methods: Abstracts were solicited from interdisciplinary early-stage career investigators with innovative ideas beyond T2 inflammation for asthma and were selected for presentation at the forum. Breakout sessions were conducted to discuss innovation, collaboration and research translation. Results: The abstracts were categorised into: 1) general omics and big data analysis; 2) lung-brain axis and airway neurology; 3) sex differences; 4) paediatric asthma; 5) new therapeutic targets inspired by airway epithelial biology; 6) new therapeutics targeting airway and circulating immune mediators; and 7) lung anatomy, physiology and imaging. Discussions revealed that research groups are looking for opportunities to further their findings using larger scale collaboration and the ability to translate their in vitro findings into clinical treatment. Conclusions: Through ICAN, teams that included interdisciplinary early-stage career investigators discussed innovation, collaboration and translation in asthma and severe asthma research. With a combination of fresh ideas and energetic, collaborative, global participation, ICAN has laid a firm foundation and model for future collaborative global asthma research.

An Electronic Shared Decision-Making App to Improve Asthma Outcomes: A Randomized Controlled Trial.

BACKGROUND: Shared decision-making (SDM) incorporates patient values and preferences to optimize asthma management decisions. Available asthma SDM aids primarily focus on medication selection. OBJECTIVE: To assess the usability, acceptability, and preliminary effectiveness of an electronic SDM application, the ACTION (Active Conversation in asthma Treatment shared decisION-making) app, that addressed medication, nonmedication, and COVID-19 concerns for asthma. METHODS: In this pilot study, 81 participants with asthma were randomized into the control arm or ACTION app intervention. The ACTION app was completed 1 week before a clinic visit, and responses were shared with the medical provider. The primary outcomes were patient satisfaction and SDM quality. Next, ACTION app users (n = 9) and providers (n = 5) provided feedback through separate virtual focus groups. Sessions were coded by comparative analysis. RESULTS: The ACTION app group scored higher agreement that providers adequately addressed COVID-19 concerns compared with the control group (4.4 vs 3.7, P = .03). Although the ACTION app group had a higher total 9-item Shared Decision-Making Questionnaire score, this did not reach statistical significance (87.1 vs 83.3, P = .2). However, the ACTION app group demonstrated stronger agreement that their physician knew exactly how they wanted to be involved in decision-making (4.3 vs 3.8, P = .05), providers asked about preferences (4.3 vs 3.8, P = .05), and that different options were thoroughly weighed (4.3 vs 3.8, P = .03). Major focus group themes included that the ACTION app was practical and established a patient-centered agenda. CONCLUSION: An electronic asthma SDM app that incorporates patient preferences regarding nonmedication-related, medication-related, and COVID-19-related concerns is well accepted and can improve patient satisfaction and SDM.

"Black People Like Me": A virtual conference series to engage underserved patients with asthma in patient centered outcomes research.

BACKGROUND: In response to racial inequity in asthma, asthma-related research among diverse patients is vital. However, people from historically marginalized groups are underrepresented in clinical and patient-centered outcomes research (PCOR). The "Black People Like Me" (BPLM) virtual conference series was developed to: (1) engage Black patients with asthma and their caregivers in education and discussions about asthma, and (2) encourage involvement in PCOR. Education about COVID-19 and COVID-19 vaccination was also incorporated. METHODS: The Project Advisory Group consisting of Black patients, clergy, physicians, and a program evaluator met monthly to develop BPLM. The program consisted of free one-hour virtual sessions held monthly for 6 months. BPLM was promoted through the Allergy & Asthma Network website, emails, social media, and personal contacts with a recruitment goal of ≥ 100 Black patients with asthma or caregivers. Program evaluations, interactive polling questions during each session, and participant pre- and post-session tests were conducted. RESULTS: Sessions averaged 658 participants including Black patients, family members, caregivers, Black clergy, health care providers, and other concerned community. Overall, 77% of participants strongly agreed with satisfaction with the sessions. Pre- and post-tests demonstrated that participants exhibited growth in knowledge regarding asthma risk, PCOR, and PCOR research opportunities for patients, exhibited preexisting and sustained knowledge regarding COVID-19 vaccination and side effects, and demonstrated an increased sense of empowerment during healthcare visits. CONCLUSIONS: BPLM demonstrated that a virtual platform can successfully engage Black communities. Incorporating clergy and religious organizations was critical in developing the trust of the Black community towards BPLM.

Development of a Pulmonary Workshop for Organ Recovery Coordinators' Continuing Medical Education.

Organ recovery coordinators (ORCs) have varied professional education backgrounds; however, based on their specialized education, their training may not have included in-depth mechanical ventilation and pulmonary management. An 8-hour pulmonary workshop was developed in collaboration between an organ procurement organization and a university-based respiratory care department. The workshop focused on pulmonary management and hands-on laboratory exercises using mechanical ventilators. A program assessment questionnaire was completed by participants following the workshop, which requested their self-reported comfort/familiarity with pulmonary management skills before and after the workshop on a 5-point Likert scale. Following the pulmonary workshop, the mean ORC comfort/familiarity for all pulmonary management skills increased significantly (P < .01). This program suggests ORCs can develop a greater awareness and comfort with pulmonary management by participating in a continuing education pulmonary workshop. Continuing education initiatives focused on pulmonary management of donor patients using hands-on competencies should be part of the ORCs practice improvement efforts.

The Use of Bronchoscopy During the Coronavirus Disease 2019 Pandemic: CHEST/AABIP Guideline and Expert Panel Report.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has swept the globe and is causing significant morbidity and mortality. Given that the virus is transmitted via droplets, open airway procedures such as bronchoscopy pose a significant risk to health-care workers (HCWs). The goal of this guideline was to examine the current evidence on the role of bronchoscopy during the COVID-19 pandemic and the optimal protection of patients and HCWs. STUDY DESIGN AND METHODS: A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that addressed specific topics on bronchoscopy related to COVID-19 infection and transmission. MEDLINE (via PubMed) was systematically searched for relevant literature and references were screened for inclusion. Validated evaluation tools were used to assess the quality of studies and to grade the level of evidence to support each recommendation. When evidence did not exist, suggestions were developed based on consensus using the modified Delphi process. RESULTS: The systematic review and critical analysis of the literature based on six PICO questions resulted in six statements: one evidence-based graded recommendation and 5 ungraded consensus-based statements. INTERPRETATION: The evidence on the role of bronchoscopy during the COVID-19 pandemic is sparse. To maximize protection of patients and HCWs, bronchoscopy should be used sparingly in the evaluation and management of patients with suspected or confirmed COVID-19 infections. In an area where community transmission of COVID-19 infection is present, bronchoscopy should be deferred for nonurgent indications, and if necessary to perform, HCWs should wear personal protective equipment while performing the procedure even on asymptomatic patients.

Adherence to an Oxygen-Weaning Protocol in Mechanically Ventilated Adults in the Medical ICU.

BACKGROUND: Patients undergoing mechanical ventilation in the ICU often receive supplemental oxygen. If not closely monitored, this may lead to hyperoxia. The use of an oxygen-weaning protocol may reduce this risk by pacing the titration of oxygen therapy to patient needs. ICU protocols are correlated with decreased mortality and length of stay and have great potential for cost savings. The goals of this study were to determine whether the oxygen-weaning protocol at a university-affiliated hospital was followed and to measure the length of time respiratory therapists took to wean patients once the oxygen-weaning parameters were met. METHODS: This was a retrospective chart review of subjects > 18 y of age admitted to the medical ICU who underwent intubation and mechanical ventilation and were placed on an oxygen therapy protocol. The following data were collected: demographics, arterial blood gases, the length of time to change [Formula: see text] after meeting weaning parameters, and the percent change in [Formula: see text]. RESULTS: Data were collected from 30 subjects. The most common oxygen saturation parameter measured via pulse oximetry ([Formula: see text]) used to initiate weaning oxygen was 92%. The mean ± SD [Formula: see text] administered to subjects was 39.6 ± 15.3% prior to extubation. The majority of subjects exhibited adequate oxygenation prior to extubation (mean ± SD): [Formula: see text] 99.3 ± 6.7 mm Hg, [Formula: see text] 95.1 ± 26.9%. The mean ± SD length of time to the first change in [Formula: see text] from the time a subject met the weaning criteria was 9.1 ± 10.6 h (range 1-39 h; interquartile range 2-13 h). CONCLUSIONS: Subjects admitted to the medical ICU who were intubated, mechanically ventilated, and placed on the oxygen therapy protocol experienced a significant delay in oxygen weaning. Closer monitoring and adherence to the oxygen-weaning protocol should be considered to reduce the potential risk for hyperoxia.

Endotracheal cuff pressures in the PICU: Incidence of underinflation and overinflation.

BACKGROUND: While uncuffed endotracheal tubes have been traditionally used in the pediatric intensive care unit (PICU) population, evidence suggests cuffed endotracheal tubes (ETTs) are also safe to use within this population. Nevertheless, risks related to the use of cuffed ETTs increase when guidelines for safe and appropriate use are not followed. The primary goal of this study was to measure the cuff pressure (CP) using a cuff pressure manometer in a group of intubated pediatric subjects and determine the rate of cuff underinflation (<20 cm H20) or overinflation (>30 cm H20). The secondary aim was to determine whether CP was associated to gender, age, ETT size, and PICU length of stay prior to CP measurement. METHODS: This was a prospective observational study conducted in an urban PICU. Pediatric subjects intubated with cuffed ETTs from 1 April 2017 to 1 May 2017 were included in the study. ETT CPs were measured daily to determine degree of inflation and compared according to gender, age, ETT size, and number of days intubated prior to CP measurement. Descriptive data are expressed as means and standard deviations. A two-sample t test was used to compare groups according to age, gender, and number of days present. And significance was considered with a P < 0.05. Pearson chi test was used to evaluate correlation between CPs and size of the ETT, number of days intubated prior to CP measurement, gender, and age. RESULTS: Twenty pediatric subjects admitted during the study period were included for analysis. Eleven cuff measurements were found to be within normal limits, while 9 cuff measurements were found to be underinflated. No cases of overinflation were found. There were no significant associations between CP and size of the ETT (r = -0.08), number of days intubated prior to CP measurement (r = 0.19), gender (r = 0.09), and age (r = 0.12). CONCLUSIONS: Our study suggests that endotracheal cuff underinflation occurs often in the PICU population. Strategies to ensure appropriate ETT CPs are maintained are essential in the intubated pediatric population. Additional studies are necessary to develop interventions and training focused on the use of a cuff pressure manometer to measure CPs in the PICU by respiratory therapists and ensure consistent measurement using inter rater evaluation processes are needed.

Effect of heliox on end-tidal CO2 measurement in healthy adults.

BACKGROUND: Therapeutic gases and other modalities delivered by inhalation may affect the accuracy of capnographic measurements in 2 ways. First is the specificity of the measurement of CO2 within the device, and second is the dilution effect of supplemental gases in the ambient air during CO2 sampling by the device. Our goal was to determine if variables such as inhaled gas composition, gas flows delivered via non-rebreather mask, and mouth open or closed affect measurements of end-tidal CO2 pressure (PETCO2) measured with the Capnostream 20 capnograph. METHODS: We measured PETCO2 and breathing frequency by capnography in 20 adult normal subjects, with coaching to maintain respiratory frequency between 10 and 20 breaths/min. SpO2 was monitored to detect hypoxemia. A 6 min wash-out period occurred between each 6 min level of testing. RESULTS: A mixed models analysis revealed that the mean ± SD PETCO2 for all subjects and flows while breathing heliox (37 ± 5 mm Hg) was not different (P = .50) from the value while breathing room air (36 ± 5 mm Hg). Repeated measurements with given subjects over 6 min periods of breathing spontaneously 0 L/min, with 10 L/min, and with 15 L/min of either air or heliox showed no difference in PETCO2 related to flow: P = .97 for 0 L/min vs 10 L/min, P = .87 for 0 L/min vs. 15 L/min. CONCLUSIONS: In normal subjects, PETCO2 measurements with the Capnostream 20 were not affected by heliox or gas flow at 10 or 15 L/min through a non-rebreathing mask.

Critical-thinking ability in respiratory care students and its correlation with age, educational background, and performance on national board examinations.

BACKGROUND: Critical thinking is an important characteristic to develop in respiratory care students. METHODS: We used the short-form Watson-Glaser Critical Thinking Appraisal instrument to measure critical-thinking ability in 55 senior respiratory care students in a baccalaureate respiratory care program. We calculated the Pearson correlation coefficient to assess the relationships between critical-thinking score, age, and student performance on the clinical-simulation component of the national respiratory care boards examination. We used chi-square analysis to assess the association between critical-thinking score and educational background. RESULTS: There was no significant relationship between critical-thinking score and age, or between critical-thinking score and student performance on the clinical-simulation component. There was a significant (P = .04) positive association between a strong science-course background and critical-thinking score, which might be useful in predicting a student's ability to perform in areas where critical thinking is of paramount importance, such as clinical competencies, and to guide candidate-selection for respiratory care programs.

A randomized, controlled study to evaluate the role of an in-home asthma disease management program provided by respiratory therapists in improving outcomes and reducing the cost of care.

BACKGROUND AND PURPOSE: Asthma management programs (AMP) may reduce costs and improve outcomes in patients with moderate to severe asthma. However, it is not known which personnel are best able to deliver such interventions and what settings are most effective. The purpose of this study was to compare the effects of an in-home AMP provided by respiratory therapists (RTs) to an AMP provided by nurses (RNs) and to usual care (UC) provided in physician offices or clinics. METHODS: Subjects (age 18-64) who had been admitted to the emergency department (ED) or hospital for acute asthma exacerbation were randomized to three groups: AMP-RT, AMP-RN or UC. The AMP groups received five (5) weekly home visits to provide assessment and instruction; the UC group was instructed to return to their physician for routine follow-up. Outcomes assessed at 6 months included hospitalizations, in patient days, hospitalization cost, ED visits and cost, clinic visits, pulmonary function, symptoms, health related quality of life (HRQOL), asthma episode self-management score (AESM), environmental assessment, and patient satisfaction (PS). Variables were compared using ANOVA with a Neuman-Keuls follow-up for multiple comparisons using an intent-to-treat approach. RESULTS: Upon enrollment, (n = 159) there were no differences (p > .05) between groups for age, gender, pulmonary function or HRQOL (SF-36 and St. Georges Respiratory Questionnaire - SGRQ). At 6 months, both AMP groups (AMP-RN n = 54; AMP-RT n = 46) had significantly fewer (p < 0.05) hospitalizations and in-patient days, lower hospitalization costs, and greater HRQOL physical component summary change scores (PCS) and PS than UC (n = 59). AMP-RT also had greater PEFR, SGRQ Total and SGRQ Symptoms change scores when compared to UC and significantly better AESM and PS scores as compared to AMP-RN and UC. CONCLUSIONS: An in-home asthma management program can be effectively delivered by respiratory therapists and may reduce hospitalizations, in-patient days, cost and improve measures of HRQOL and PS in a population prone to asthma exacerbation.