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Hot off the breath: a big step forward for idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive interstitial lung disease of unknown etiology1 with a median survival of 3 years from the time of diagnosis.2 The recent decade has seen a tremendous investment in IPF clinical research, and as a result, we have moved beyond traditional treatment approaches (prednisone and other immunomodulatory therapies) toward clinical trials of potential antifibrotic therapies.3 As recently as 2011, however, an international guideline committee concluded that there remained insufficient evidence to support the regular use of any IPF pharmacotherapy.1 Because of this, there has been no consensus standard of care for IPF patients. This will likely change with the recent publication of three landmark studies.4–6 Two novel therapies, p...

The early origins of COPD in severe asthma: the one thing that leads to another or the two things that come together?

Chronic obstructive pulmonary disease (COPD) is diagnosed during middle to late adult life, when significant airflow limitation has already developed by the time the disease is recognised. What if the origins of COPD occurred much earlier? If this were true, it would have major implications for detection (screening) and prevention of COPD. Convincing evidence is hard to obtain, because it requires exceptionally long follow-up, such as half a life span, a period that is often longer than the average career of a researcher! Williams and McNichol established such a longitudinal asthma study from a 1957 birth cohort, and now Tai et al1 evaluate for an association between childhood asthma and adult COPD. They followed-up a cohort of 6–7-year-old children over more than four decades, of wh...

Trials of home mechanical ventilation in COPD: what have we learnt?

15639226_sChronic respiratory failure following an acute exacerbation of COPD is associated with excess morbidity and mortality and, empirically, the use of long-term non-invasive ventilation (NIV) to treat the chronic respiratory failure to improve outcome is a rational therapeutic option.

Although detailed physiological studies have demonstrated a reduction in the arterial pCO2 by managing sleep disordered breathing and enhancing sleep quality, previous randomised controlled trials have failed to translate physiological improvement into a clinical benefit.

Despite the lack of clinical trial evidence supporting the addition of NIV to standard treatment, including long-term oxygen therapy, there has remained widespread clinical enthusiasm in the UK and Europe for the use of home mechani...

5 versus 14 days of prednisone for acute COPD exacerbations

In this multicentre, double-blind, randomised control trial, a shorter 5-day course of glucocorticoids was compared with a 14-day course to assess non-inferiority. Patients received an initial dose of IV methylprednisone, then 4 days of oral prednisone, followed by further prednisone or a placebo.

This study confirms that further steroids seem neither to do more harm nor more good...

Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure: a randomised, controlled, parallel-group study

The effectiveness of non-invasive positive pressure ventilation (NIV) in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure (ARF) remains unclear. We investigated if nocturnal NIV in these patients prolongs the time to readmission for respiratory causes or death (primary endpoint) in the following 12 months. Methods : 201 COPD patients admitted to hospital with ARF and prolonged hypercapnia >48 h after termination of ventilatory support were randomised to NIV or standard treatment. Secondary outcomes were daytime arterial blood gasses, transcutaneous PCO2 during the night, lung function, health-related quality-of-life (HRQL), mood state, daily activities and dyspnoea. Results : 1 year after discharge, 65% versus 64% of patients (NIV vs standard treatment) were readmitted to hospital for respiratory causes or had died; time to event was not different (p=0.85). Daytime PaCO2 was significantly improved in NIV versus standard treatment (PaCO2 0.5 kPa (95% CI 0.04 to 0.90, p=0.03)) as was transcutaneous PCO2 during the night. HRQL showed a trend (p=0.054, Severe Respiratory Insufficiency questionnaire) in favour of NIV. Number of exacerbations, lung function, mood state, daily activity levels or dyspnoea was not significantly different. Discussions : We could not demonstrate an improvement in time to readmission or death by adding NIV for 1 year in patients with prolonged hypercapnia after an episode of NIV for ARF. There is no reason to believe the NIV was not effective since daytime PaCO2 and night-time PCO2 improved. The trend for improvement in HRQL favouring NIV we believe nevertheless should be explored further.

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