The American Diabetes Association took advantage of the time between April 3, 2020, when it cancelled the live 

, originally scheduled for Chicago's McCormick Place, and the meeting's opening day which was--and still is--Friday, June 12, 2020.

The Virtual 80th Scientific Sessions will feature the entire program planned before the COVID-19 pandemic. Nearly all of the in-person presentations are still part of the virtual meeting, according to Jose C. Florez, MD, PhD, chair of the 80th Scientific Sessions Meeting Planning Committee. 

of scientific and educational sessions available, with an eye toward the clinical needs of primary care clinicians. Start here:

Slideshows

The American Diabetes Association kicks off its Virtual 80th Scientific Sessions on Friday, June 12, 2020. Here is our guide to top sessions. 

10 Essential Symposia for Primary Care at ADA 2020

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, and pulmonary rehabilitation has been shown to improve outcomes and reduce hospital readmissions among these patients. However, studies have shown that only a fraction of patients who need pulmonary rehabilitation actually receive it.

Disparities in access and the emergence of telehealth as a modality to more conveniently deliver pulmonary rehabilitation received significant attention during a session titled “Pulmonary Rehabilitation 2019” at the American Thoracic Society Meeting 2019 held May 17 – 22, 2019, in Dallas, Texas. Several studies were presented that revealed new insights into both areas of research. 

Carolyn Rochester, MD, Medical Director of the Yale COPD Program, Yale School of Medicine in New Haven, Connecticut, highlighted top research in pulmonary rehabilitation for 2018-2019. One 

 of particular interest highlighted significant problems with geographic access to hospital outpatient pulmonary rehabilitation programs, with a focus on rural areas. Published in the journal

 in April 2019, the study found that there were 1,776 counties in the United States lacking a hospital outpatient pulmonary rehabilitation program in a short-term acute care general medical or surgical hospital. The regions with the greatest disparities to access were in the South (for which only 39% of hospitals had a program) and West (for which only 35.5% had a program).

presented during the session that explored whether geographic variation in access to pulmonary rehabilitation could explain why rates of use are lower among African-American patients compared to whites.

Is geographic variation in access a factor?

 Using the hospital-referral region as a measure of geographic location, study researchers found that a median of 2% of Medicare beneficiaries (range, 0.5% – 7.1%) included in the analysis received pulmonary rehabilitation after hospital discharge for COPD exacerbation. This rate varied across hospital-referral region, with higher rates in the Midwest and hospital-referral regions with greater pulmonary rehabilitation program density.

However, the median rate of pulmonary rehabilitation was lower among African-Americans (1.2%; IQR, 1.1 – 1.2) compared to whites (2.1%; IQR, 1.5 – 2.9). Furthermore, while program density was associated with higher rates of pulmonary rehabilitation among white Medicare beneficiaries (P<.0001), no such association was seen among African-Americans. These findings suggest that the lower rates of pulmonary rehabilitation receipt among African-Americans cannot be explained by geographic differences.

“We need to add more [pulmonary rehabilitation] programs definitely, but adding more programs is not going to solve this disparity that we’re seeing,” said study presenter Kerry Spitzer, PhD, MPA, Institute for Healthcare Delivery and Population Science, Baystate Health, in Springfield, Massachusetts.
	 

Telehealth for pulmonary rehabilitation. 

Pulmonary rehabilitation not only has low uptake but also high dropout rates, and telehealth has emerged as a modality to help counteract this problem. In fact, Yale's Dr Rocheter highlighted a recently 

 showing pulmonary rehabilitation delivered via video-based telehealth could reduce 30-day hospital readmissions among patients with COPD.

Specifically, the all-cause remission rate was significantly lower among telehealth group participants compared to those in the standard of care group (6.2% vs 18.1%; P<.013). The acute exacerbation COPD readmission rate was also lower among the telehealth group (3.8% vs 11.9%; P=0.040).

 of a multicenter, randomized controlled trial conducted to determine if telehealth could deliver outcomes superior to conventional pulmonary rehabilitation among patients with advanced COPD. 

The trial enrolled 134 patients with severe and very severe COPD and randomly assigned them to either pulmonary tele-rehabilitation (n=67) or conventional pulmonary rehabilitation (n=67). The tele-rehabilitation intervention consisted of 60 minutes 3 times per week for 10 weeks, and the conventional pulmonary rehabilitation program consisted of 90 minutes 2 times a week for 10 weeks. The primary outcome was difference in 6-minute walk distance.

The study failed to showed superior 6-minute walk distance among patients in the tele-rehabilitation group or higher adherence rates compared to the conventional program group, but did show higher completion rates in the former (odds ratio=3.18; 95% CI, 1.37 – 7.35; P<.01).

Study authors note that tele-rehabilitation could potentially provide an equally effective alternative to conventional pulmonary rehabilitation but implementation would require evidence from a randomized controlled trial designed to explore noninferiority.

Articles

DALLAS--In a session at the American Thoracic Society meeting this week study authors reported on gaps in post-discharge care for COPD and on tele-rehabilitation as possible bridge. 

Can Telehealth Bridge Disparities in Access to Pulmonary Rehab? 

At the American Thoracic Society Meeting 2019 held May 17 – 22, 2019, in Dallas, Texas, several studies presented during a thematic poster session titled “Idiopathic Interstitial Pneumonia: Natural History” reported characteristics that could be used to help predict outcomes among patients with interstitial lung disease (ILD), including certain factors during mechanical ventilation, white blood cell (WBC) count, and weight loss.

Factors predict mortality during mechanical ventilation

Mechanical ventilation has been shown to be associated with high mortality rates among patients with fibrotic ILD (f-ILD) but there is a dearth of information on patient characteristics at hospital admission and procedural strategies that could improve outcomes. A retrospective study of patients intubated for acute respiratory failure (ARF) identified several factors during mechanical ventilation that predicted mortality in this patient population.

The study included 111 patients (38 with idiopathic pulmonary fibrosis [IPF] and 73 with non-IPF), for whom there were 114 admissions for ARF and placement on mechanical ventilation. Most patients (75%) died while in the hospital. Of the 25% of patients who survived to hospital discharge, 4.5% died within 30 days of discharge and 9% died within one year, leaving 11% who survived past 1 year.

An adjusted analysis revealed several statistically significant predictors of mortality, including P/F ratios within 3 and 48 hours of mechanical ventilation, initial fraction of inspired oxygen, initial mean airway pressure, and higher net volume status. The strongest predictors were vasopressor use (odds ratio [OR]=8.05; P=0.0001) and paralytic use (OR=17.9; P<.001) in the first 24 hours of mechanical ventilation.

White blood cell count associated with survival. 

In the abstract for this study, the authors note that inpatient status and elevated white blood cell count (WBC) have both been associated in the past with negative outcomes in IPF. Results of their single-center study of patients hospitalized with IPF found that increased WBC count, vs a low count, was associated with reduced survival. 

The study cohort included 56 IPF patients who were hospitalized at Inova Fairfax Hospital between 2009 and 2018. The cohort had a median WBC count of 11.2 X 10

 cells/L at hospital admission (range, 4.4 – 30.0 X 10

 cells/L), and this median was used to stratify patients as having a “low” (<11.2 X 10

 cells per liter) WBC count or a “high” (>11.2 X 10

A high WBC count was associated with a >20-month shorter transplant-free survival compared with a low WBC count (0.5 vs 21.5 months; P=0.005). The reason why high WBC is associated with worse survival is unclear. The study authors propose that an elevated white count could be a surrogate for infection and other inflammatory stressors that affect the disease course in patients with IPF.

The significance of weight loss in patients with ILD has not been studied. Authors of a single-center study presented during this poster session reported that weight loss was associated with decreased survival and pulmonary function among patients with ILD.

The study cohort had 224 patients with ILD, including subtypes such as IPF, connective tissue disease-associated-ILD, and chronic hypersensitivity pneumonitis. Only patients who had 2 or more pulmonary function tests conducted more than 90 days apart were included. Average body mass index (BMI) among patients was 28.2 and average annual decline in BMI, 0.1 kg/m

In an adjusted analysis, for each annual decline in BMI of 1%, there was a statistically significant increased risk of death (risk ratio [RR]=1.04; 95% CI, 1.01 - 1.08; P=0.005), but no increased risk of ≥10% decline in forced vital capacity (FVC) (RR=1.02; 95% CI, 0.99 - 1.05; P=0.16). Furthermore, the largest effect was seen in patients with at least a 5% annual decline in BMI where increased risk of death was more than 2-fold (RR=2.18; 95% CI, 1.23 - 3.89; P=0.008) and risk of FVC decline nearly 2-fold (RR=1.91; 95% CI, 1.15 - 3.16; P=0.012).

“BMI decline over time is prevalent among patients with ILD and is associated with an increased risk of disease progression, as measured by death and pulmonary function decline,” the study authors wrote.

DALLAS-Studies on 3 factors that may help guide intervention for patients with ILD were presented: factors during mechanical ventilation, WBC count, and weight loss.

From ATS 2019: Update on Factors that May Help Predict ILD Outcomes

New research on predicting outcomes in patients with chronic obstructive pulmonary disease (COPD) was presented in a session titled “COPD: Mortality and Risk Prediction” at the American Thoracic Society Meeting 2019 held May 17 – 22, 2019, in Dallas, Texas.

Here we highlight studies on the role of respiratory exacerbations; the predictive accuracy of a new machine learning tool; and, hemoglobin as a biomarker of clinical outcomes. 

Exacerbation frequency predicts mortality

, which included more than 10 000 current and former smokers with or without COPD, revealed possible predictors and causes of mortality in this patient population. Study authors posited that prediction and causality would depend on severity of airflow restriction. 

The most common causes of death among smokers without COPD fell into the miscellaneous category, Other (33%), followed by cardiovascular (25%) and lung cancer (10%). By contrast, the most common causes of death among smokers with GOLD stage 1 or stage 2 COPD were cardiovascular (22%) and respiratory (20%) and most smokers with GOLD stage 3 or stage 4 COPD died from respiratory disease (61%).

In an adjusted analysis, having at least 2 respiratory exacerbations during the past year was predictive of all-cause mortality for GOLD stage 1 or stage 2 COPD (hazard ratio [HR]=1.44; P=0.05) and GOLD stage 3 or 4 COPD (HR=1.61; P<.001), but not for smokers without COPD (HR=0.89; P=0.70).

Chronic bronchitis was predictive of all-cause mortality for smokers without COPD (HR=1.47; P=0.009) and smokers with GOLD stage 3 or stage 4 COPD (HR=1.35; P=0.003), but not for smokers with GOLD stage 1 or stage 2 COPD (HR=1.11; P=0.50).

“We affirmed that reducing the exacerbation rate remains an important clinical and research priority for patients with COPD,” said the study presenter Wassim Walid Labaki, MD, Division of Pulmonary and Critical Care Medicine, University of Michigan.

Results of this new study found that a machine learning algorithm combined with clinical and quantitative CT imaging features predicted mortality among COPD patients better than the traditionally used BODE (Body-mass index, airflow Obstruction, Dyspnea, and Exercise) index and other prognostic indices.

“While the BODE index may have some limitations, despite many people trying, no one has actually successfully outperformed the BODE index consistently,” said the study presenter Matthew Moll, MD, Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

To develop the machine learning model, patients with GOLD 2 to 4 COPD from the COPDGene and the 

 were used. Three-quarters of the COPDGene cohort (n=1,974) were used for the training set and the remaining quarter (n=658) were used for the testing set. The algorithm was then externally validated in the ECLIPSE cohort (n=1,645).

The most important predictors of mortality in the model were 6-minute walk distance, FEV1, and age. The machine learning model outperformed 4 other prognostic indices, including BODE, updated BODE, e-BODE, and ADO (age, dyspnea and FEV1), for both the testing set (P<.05) and externally validated set (P<.05).

“To put this in clinical context, if you use our model compared to BODE, for every 26 patients that you use our model in, 1 additional person would be predicted correctly to die at 5 years,” said Dr. Moll.

Among patients with COPD, anemia was independently associated with worse outcomes, including symptoms, quality of life, and functional performance, according to results of a cross-sectional 

“Because there are new therapies that are available for the treatment of chronic inflammation-related anemia, understanding hemoglobin as a biomarker across its continuous range is pretty important,” said study presenter Aparna Balasubramanian, MD, Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.

The cross-sectional study used data from the COPDGene cohort for which hemoglobin data were available. On the basis of hemoglobin level, patients were categorized as normal, anemic (Hgb <12 g/dL for females and Hgb <13 g/dL for males), or polycythemic (Hgb >16 g/dL for women, Hgb>16.5 g/dL for men).

In an adjusted analysis, compared with a normal hemoglobin level, anemia was associated with worse scores on St. George's Respiratory Questionnaire (which assesses quality of life), worse scores on the Short Form (36) Health Survey for physical and general function, and decreased distance on the 6-minute walk test, whereas polycythemia was not. Continuous analyses showed that the relationship between hemoglobin and COPD morbidity is likely nonlinear.

DALLAS--Results of 3 studies presented at the American Thoracic Society meeting this week focus on the predictive role of disease exacerbations, machine learning, and Hgb levels in COPD. 

ATS Highlights Advances in the Prediction of COPD Outcomes

In a session titled “Addicting a New Generation: Juuling, Vaping, Heat Not Burn, Flavorings, and the Evidence for Why We Should Be Very Concerned,” at the American Thoracic Society Meeting 2019 held May 17 – 22, 2019, in Dallas, Texas, experts described the alarming growth in the rate of e-cigarette use among teens and emerging data on the safety of the new electronic nicotine delivery systems. 

, 1 in 5 high school students were e-cigarette users in 2018, up from approximately 1 in 100 in 2011. Currently, more than 1 in 4 high school students use any tobacco or nicotine product. “Up until 2010, we had been conquering the tobacco epidemic. Tobacco use among youth in our population had been going down,” said Harold J. Farber, MD, MSPH, ATSF, Texas Children’s Hospital, Houston, Texas. “Now we’re starting to see this rise again.”

Contrary to common belief, the use of e-cigarettes is not necessarily associated with quitting or avoiding smoking tobacco, and may have the opposite effect. A 

and meta-analysis among adolescents and young adults found that e-cigarette users had a more than three times greater risk of starting cigarette smoking than those who had never used e-cigarettes.

There are dozens of e-cigarette brands on the market, but one causing particular alarm is the JUUL, which entered the market in 2015 and by November of 2018 had secured 76% of the e-cigarette market. “[JUUL is] very small, very discrete, and amazingly addictive,” said Dr. Farber. JUUL uses a patented nicotine salt-nicotine benzoate-that increases the rate of nicotine uptake and has less adverse effects than freebase nicotine, often found in traditional tobacco cigarettes. “You find kids saying it gives them a better buzz,” he said.

The US Food and Drug Administration gained the authority to regulate e-cigarettes in 2016, but data about safety of the products is needed in order to decide how best to regulate them.  A primary problem, however, is that these products have only been on the market for a few years and the market is constantly changing, explained Ilona Jaspers, PhD, University of North Carolina at Chapel Hill. “We are always chasing and always behind on the products, in terms of testing their toxicity,” she said.

A feature of e-cigarettes that especially worries Dr. Jaspers when it comes to safety is the flavorings used; while the natural flavors are recognized as safe when used as a food product, that safety cannot be assumed when the route of exposure is changed to inhalation. Of particular concern are the aromatic aldehyde compounds, which include the cinnamon flavor (cinnamaldehyde), almond flavor (benzaldehyde), and vanilla flavor (vanillin and ethyl vanillin). Other aromatic aldehydes, such as formaldehyde, are known to be toxic when inhaled, and cinnamaldehyde 

 to inhibit the function of immune cells, including macrophages, neutrophils, and natural killer cells. “Why do we think that [these flavors] actually could be safe when we inhale them?” she asked rhetorically. 

Studies also have shown that e-cigarettes appear to have different effects on the body than conventional cigarettes. For instance, a mid-2018 

 that airways among e-cigarette users were inflamed whereas the airways of cigarette smokers and nonsmokers were not. 

 found e-cigarette users to have more gene expression changes than combustible cigarette smokers and to have an overall immune suppressive phenotype. 

reported at the American Thoracic Society meeting went a step further and showed a reduced antiviral response within the respiratory tract among e-cigarette users compared with non-users.

Although there is no conclusive evidence to date, Dr. Jaspers speculated that it is possible new diseases may emerge among e-cigarette users. For example, a 2018 

described an 18-year-old female who developed hypersensitivity pneumonitis and acute respiratory distress syndrome after e-cigarette use.

“We may not be seeing [chronic obstructive pulmonary disease], but we may be seeing an uptick in new diseases and new clinical phenotypes,” she said.

DALLAS-At the American Thoracic Society meeting thought leaders cited disturbing trends in e-cigarette use by teens and warned of health dangers, known and unknown.

E-Cigarettes: The New Addiction and Why Physicians Must be Concerned 

Supplemental oxygen has been shown in clinical trials to help patients with lung conditions, such as chronic obstructive pulmonary disease (COPD) and interstitial lung disease, but being dependent on supplemental oxygen day-to-day can be a challenge. In a session titled “Rethinking Oxygen: Getting the Right Oxygen to the Right Patient,” at the American Thoracic Society Meeting 2019 held May 17 – 22, 2019, in Dallas, Texas, the trials and tribulations of using supplemental oxygen were discussed by physicians, patients, and caregivers.

Jerry A. Krishnan, MD, PhD, Professor of Medicine and Public Health at the University of Illinois Hospital & Health Sciences System noted that when patients are on clinical trials, and particularly trials that have shown the benefit of supplemental oxygen, they also benefit from support not available to patients not involved in clinical research.

For example, COPD patients who received supplemental oxygen in the Nocturnal Oxygen Therapy 

 had home visits from nurse practitioners every week and a clinic visit every month for the trial’s first 6 months. After that home visits were scheduled every month and a clinic visit every 3 months. “This is a problem with implementation in the United States,” Dr Krishan told the audience, “that sometimes we take the evidence that's been published and then we strip away all the supports.”


	Heather Kagel was diagnosed with familial pulmonary fibrosis in February 2013 and provided her first-hand experience as a supplemental oxygen user. She described 3 common challenges that supplemental oxygen users face: traveling with oxygen, using oxygen at home, and exercising with oxygen.


	To travel by air, patients are required to use a portable oxygen concentrator (PCO), and most PCOs have little to no continuous flow options. “If you are a user that relies on a continuous flow, as opposed to a pulse flow, you really are very restricted in your air travel,” said Heather. To travel long distance by car, a patient must notify a supplier in advance in the destination city to be able to rent equipment and may need to stop along the way to change out oxygen tanks, making sure to arrive within a company’s normal business hours-typically 9 am to 6 pm, Monday through Friday.

Travel with supplemental oxygen can be costly, as well. Renting a portable oxygen concentrator, arriving without enough advanced notice, or dropping off equipment outside of normal business hours all come with additional fees. “It’s not just the access to the equipment itself," that can be a problem, Heather said. "It's [also] the financial means to be able to have that access.”


	As for using supplemental oxygen at home, some patients use tanks, which can be very heavy and to refill them may require either a home fill machine or delivery of new tanks. If tank delivery is required, Heather explained, patients often have to stay home all day, “hoping” that the company shows up.

Heather, like some patients, uses a portable oxygen concentrator at home, which for her is an out-of-pocket cost of several thousand dollars. But having the concentrator at home can be a financial risk; it may not be used for very long because of disease progression. “There are people who pay several thousand dollars and get very little use out of that machine,” she said. “So, it can be a gamble.”


	Finally, while exercise is encouraged for people with lung disease, supplemental oxygen demands vary and they may require different types of oxygen. “[It’s] difficult to find the right machines at the right time with the right output,” Heather said. In addition, insurance companies require detailed explanation of why a patient may need various supplemental oxygen devices. “You have to really be a patient advocate for yourself,” she said.

Caregivers also feel the burdens of supplemental oxygen use, explained Jeffrey Swigris, DO, MS, Associate Professor, Department of Medicine at National Jewish Health in Denver, Colorado. “When we prescribe supplemental oxygen, it’s a really big deal,” he said. “When oxygen comes into the house, it disrupts the whole homeostasis of that house, and potentially disrupts the homeostasis of the relationship between patients and caregivers.”

DALLAS--Supplemental oxygen helps patients with lung disease manage better day-to-day, but according to speakers gathered at the ATS meeting in Dallas this week, it can also add to disease burden.

Rethinking Supplemental Oxygen: Physicians, Patients, and Caregivers Weigh In

-At the American Thoracic Society Meeting 2019 held May 17 – 22, 2019, in Dallas, Texas, physicians gathered on Monday morning, May 20th, to debate controversial issues that arise when caring for patients with interstitial lung disease (ILD) during a session titled 

“When There is No Right Answer: A Pro/con Debate on Controversies in ILD.” 

 Two specific topics were discussed: First, whether antifibrotic therapy is warranted in all patients with idiopathic pulmonary fibrosis (IPF) and, second, whether patients with rapidly progressive ILD should be offered extracorporeal membrane oxygenation (ECMO), a device used to oxygenate a patient’s blood. There were pros and cons and some caveats.

Who should receive antifibrotic therapy? 


	There are two antifibrotic therapies- Esbriet® (pirfenidone) and Ofev® (nintedanib)-indicated for IPF, but currently, approximately half of patients with IPF aren’t on any treatment and the outcomes are dismal. The median survival among untreated patients is 3 years, and by 5 years after diagnosis, fewer than 1 in 5 patients remain alive.

Toby Maher, MD, MSc, PhD, Imperial College London, explained that antifibrotic therapy should be discussed with all patients with IPF because the drugs help preserve lung function and improve survival. “[IPF] is a disease where the lung becomes destroyed, and once it's destroyed, there’s no recovering it,” Dr. Maher said. He encouraged physicians to go into every clinic visit planning to offer antifibrotic therapy so the patient can be informed.

“To me it makes no sense to send a patient off to get worse before you initiate treatment.”

Steven Nathan, MD, Inova Fairfax Hospital, Falls Church, Virginia, argued that while antifibrotic therapy should be considered for all patients with IPF, not all patients with IPF warrant such treatment. He emphaiszed that factors such as older age, asymptomatic disease, and stable disease may be reasons to not initiate antifibrotic therapy.


	Whether patients with rapidly progressing ILD should be offered ECMO is a highly controversial area of medicine.

 Daniel Brodie, MD, Columbia University Medical Center, New York, argued that ECMO should be offered to patients as a bridge to lung transplantation, to recovery, or to some other goal, such as obtaining a diagnosis. In fact, a 

 by Dr. Brodie and his colleagues showed that among 121 patients with end-stage lung disease who began using ECMO as a bridge to lung transplantation, more than half (59%) were successfully bridged to transplant.

Even when these bridged patients were matched to lung transplant patients who were not bridged, the outcomes were the same despite differences in the lung allocation score. Dr. Brodie concluded that this study shows that ECMO is a “very viable option” for patients awaiting lung transplantation. However, he said, “When lung transplant is not an option, then ECMO has to be a bridge to recovery, or it's going to be a bridge to nowhere.”

James Walter, MD, Northwestern University, Chicago, Illinois, cautioned against the use of ECMO and gave 4 main reasons for this view.

The cohort of patients with rapidly progressing ILD is very poorly defined and a uniform definition is needed before the utility of ECMO can be assessed.

 High-quality data (ie, randomized clinical trials) are lacking to support the use of ECMO.

 Immunocompromised patients, common among those with rapidly progressing ILD, do not have good survival outcomes when they are placed on ECMO.

 Use of ECMO can set perilous (unrealistic) expectations among patients and their families.

Dr. Walter emphasized the critical need for clear expectation setting when discussing ECMO as an option. “When patients and families misunderstand what the goal of ECMO is, that’s when ethical issues come up, especially in the setting where ECMO becomes a bridge to nowhere,” he said.

DALLAS--Which patients are candidates for antifibrotic therapy? Is extracorporeal membrane oxygenation appropriate for all ILD patients? The topics were hotly debated on Monday at the American Thoracic Society meeting. 

A Pro-Con Debate on How to Care for Patients With Interstitial Lung Disease

In this short slide show, pick up a compact review of what the patient at risk for type 2 diabetes looks like metabolically, how often you should screen patients you know are at high risk for progressive hyperglycemia, and ADA-recommended cut offs for diagnosis of type 2 diabetes. This slide show first appeared as part of the Patient Care "Type 2 Diabetes Back-to-Basics" Special Report.

Who is at risk for T2DM? How often should you screen? What are the cut offs for Dx? Revisit the basics in 5 minutes or less.

Type 2 Diabetes: Clinical Suspicion and Diagnosis 

Dorothy is a 55-year-old woman, who was well until about a year ago, when she first noticed some dyspnea carrying groceries up the front steps. This has progressed to where she now notes dyspnea even walking on level ground with her friends or at work. She recently had a hernia repair, and the preoperative chest xray showed increased interstitial markings. She was told to follow up with her physician, which is why she came into see you today. She denies cough and is a lifelong nonsmoker. She has no chest pain or any history of heart disease. She works as an accountant in Manhattan. She states that her office is old and dusty but knows of no mold problems at work or at home. She has no pets. She notes some back and neck arthritis but has no history of joint swelling, dry eyes or mouth, skin rashes, muscle pain, or change in color of digits in cold. Her only medications are an ACE inhibitor for hypertension, and occasional ibuprofen.

1. What possibilities are you considering for her shortness of breath and her radiographic findings?

 Interstitial lung disease (ILD) associated with connective tissue disease
	
	

 ILD associated with occupational exposure (pneumoconiosis)

Please click below for answer, discussion, and continuation of case .

Actually, all of those conditions are reasonable possibilities. In fact, I would say that if you kept those 5 categories in mind, you would rarely miss a diagnosis in your approach to the patient with ILD. In this case, Dorothy is on the youngish side for IPF, but it is not unheard of for this to develop in a patient in his or her 50s. Most of my patients receive a diagnosis between the ages of 60 and 80, so when I see a patient below this age range, my radar for the other entities goes up. Dorothy denies any occupational exposure and is not taking any medications associated with ILD, so I would be concerned that she might have an undiagnosed connective tissue disease or hypersensitivity pneumonitis.

 Bibasilar crackles, positive inspiratory squeak
	
	

No cyanosis, clubbing, or edema. No arthritic deformities, joint swelling or tenderness

2. Did the physical exam provide any further clues?

Definitely! The bibasilar crackles are consistent with the diagnosis of ILD. The inspiratory squeaks suggest a small airways problem, which really should point you to a specific category of disease, but I don’t want to give things away yet


	You obtain spirometry, screening bloodwork for collagen vascular disease, and a hypersensitivity pneumonitis panel; the results are shown in the 

 below. You also walk the patient around your office, and she desaturates from 98% to 91%.
	 

This is consistent with moderate restrictive disease, although you make a mental note to send the patient to a pulmonologist for full pulmonary function tests (PFTs), including lung volumes and diffusing capacity, to confirm.

Serologies for collagen vascular disease are negative. A hypersensitivity pneumonitis panel comes back positive for pigeon serum precipitating antibodies.

You then send the patient for a CT scan of the chest. A representative image is shown at right, above (please click image to enlarge).

Note the diffuse increased ground glass opacities throughout both lung fields. In addition, there are areas of relative sparing bilaterally as well, representing air trapping in the small airways. If expiratory films were obtained, these areas would become more pronounced, confirming this finding.
	 

ILD associated with collagen vascular disease

Please click below for answer and discussion.

 It turns out that Dorothy had found some abandoned, injured baby pigeons in her yard, and had brought them into her basement for rehabilitation, where they have been staying over the past year. When asked why she didn’t tell you this in the first place, Dorothy said she didn’t consider them pets, and she also didn’t want to admit that she had them, because in retrospect, she recognized that when she went into the basement to tend to the birds, her symptoms would acutely worsen. (This is a history that I have seen repeatedly in my practice. Patients will routinely deny that they have pets, and specifically have to be asked about birds in the house, in the garage, etc.)

Dorothy was able to give her pigeons to a local wildlife center. She was referred to a local pulmonologist, who treated her with steroids for 3 months, and her symptoms rapidly improved.

Hypersensitivity pneumonitis is a relatively common form of ILD, which usually presents with progressive dyspnea, exposure to mold or other antigen, restriction on PFTs, and a CT scan with characteristic early findings of air trapping and centrilobular ground glass opacities. Left untreated, it can progress to end-stage lung disease, so it is important to recognize this entity early, where removal of the offending antigen and, if necessary, treatment with steroids can markedly improve outcome.

Dorothy is 55-years-old, has never smoked, and was well until 1 year ago when she first noticed mild dyspnea on exertion; it has gotten progressively worse.

A Non-smoker with Progressive Dyspnea, No Cough 

This brief report will summarize the common questions I get from colleagues and students about COPD exacerbations. Guidelines will be relied on for answers, but I will introduce my own personal approaches and biases as well!

When should a patient be admitted with a COPD exacerbation?

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest the following potential indicators for hospitalization:

 Severe symptoms such as sudden worsening of resting dyspnea, high respiratory rate, desaturation, drowsiness, or confusion

. Onset of new physical signs such as cyanosis or peripheral edema

These criteria are mostly subjective. My basic approach is if my patient has failed outpatient therapy, or is in the emergency department and "looks bad” after initial treatment, it’s time to be admitted to the hospital.

Very simple question, but a very hard one to answer! The guidelines are generally useless in this regard. The GOLD guidelines suggest a duration of 5 to 7 days but don’t really state what to choose. The American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines state that antibiotic choice should depend on local pathogens and resistance patterns. My go-to antibiotics of the past decade were macrolides for mild to moderate exacerbations, and quinolones for moderate to severe exacerbations. However, both classes of medications have come under fire lately: macrolides for prolongation of the QT interval, and quinolones for QT prolongation, and association with tendon rupture and 

. infection. In my hospital, many of my colleagues have replaced macrolides with doxycycline, and quinolones with either cephalosporins or Augmentin. However, my feeling is that the evidence for the use of doxycycline is lacking in COPD exacerbations. In fact, a recent, large, double-blind study showed no added efficacy of doxycycline vs placebo in a large cohort of COPD exacerbations. Thus, I generally favor the use of Augmentin for almost all severe outpatient exacerbations, and I use Augmentin or cephalosporins for inpatient exacerbations. I still use quinolones when I suspect 

 infection, and I still use macrolides for milder outpatient exacerbations or penicillin allergies.

Again, not an easy question to answer, although the GOLD guidelines are rather emphatic and recommend 40 mg of prednisone or the equivalent for 5 days and then stop, for both inpatients and outpatients. The ATS/ERS guidelines recommend oral steroids for 9 to 14 days with a dose not specified for outpatient exacerbations, and oral steroids at an unspecified dose or duration for inpatient exacerbations. My own practice has been to reduce both the amount and duration of steroids I have been using in my patients, since recent literature comparing higher dose or duration treatment to lower has shown no differences. For outpatient exacerbations, I generally treat with prednisone 40 mg from 5 to 14 days, depending on the intensity of the exacerbation as well as the response of the patient to treatment. For inpatients, I generally start with intravenous steroids for a few days, usually at a dose of 40 mg of Solu-Medrol twice daily, and then change to prednisone 40 mg on day 3 and continue for a total of 7 to 14 days. Unless I plan on continuing steroids for more than 2 weeks, I no longer taper steroids.

My patient is taking Spiriva and Advair. Should I leave him on them while he gets short-acting bronchodilators by nebulizer in the hospital for his exacerbation?

Surprisingly, there are no data on this question. The GOLD guidelines acknowledge this but recommend that patients be kept on their long-acting bronchodilators. My practice is to discontinue them, then change the patient to prn nebulizers toward the end of the hospitalization, and reinstitute the maintenance medications at that point.

Next: Should I use noninvasive ventilation? (please click below) 

Should I use noninvasive ventilation (NIV) for COPD exacerbations?

Finally, an easy question! The answer is an unequivocal yes!  For patients with COPD exacerbations who have acute or chronic respiratory failure, patients on NIV had a lower mortality and shorter hospitalization, and were less likely to need intubation. Note that patients with a high aspiration risk, facial deformities, inability to cooperate, or severe change in mental status were often excluded from these studies and should also be excluded in real life from NIV. The exact device, duration, and settings for NIV varied tremendously in the pivotal studies, and also vary tremendously among treating physicians across the country; thus, it is hard to give specific recommendations on settings and duration of therapy.

What should I do to prevent readmission to the hospital within 30 days?

Literally, the million-dollar question! Hospitals are under tremendous financial pressure to ensure that patients with certain condition, including COPD, are not readmitted within 30 days of discharge. I was put in charge of an emergency task force at my hospital to try to address this issue. Some of the changes our group implemented included:

 Implementation and “marketing” of a COPD exacerbation standardized order set
	
	

 Ensure that patients had follow-up appointments with a physician within a week of discharge
	
	

 Calls by a specialized nurse to a physician whose patient’s length of stay exceeded 7 days
	
	

Emails to all pulmonary physicians showing the length of stay and readmission rate of the competing pulmonary groups monthly


	Were any of these changes evidence based? 

. Did they improve quality or patient-centered outcomes?

. However, our length of stay in the hospital decreased after the above changes were implemented.The effect on 30-day readmission was less clear; however, we stayed under national averages and were recently commended for our COPD treatment by a national magazine (

) and a national grading organization (Healthgrades).
	 

COPD exacerbations have a major health care cost to patient and a large economical cost to society. I hope I have answered some of your more common questions regarding the treatment of this condition.

Works Cited
	Global Initiative for Chronic Obstructive Lung Disease. Gold Guidelines. www.goldcopd.org Accessed August 11, 2017

Wedzicha JA ERS Co-Chair, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3).

A pulmonologist answers some of the most common questions he hears from colleagues and students about COPD exacerbations and their management.

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