Introduction There is interest in the use of macrolide antibiotics in asthma. Macrolides have been shown to improve airway hyper-responsiveness (AHR) and measures of airway inflammation.1 The degree of AHR may relate to the microbiota present in the airways,2 with a recent study reporting that patients with asthma with a significant improvement in AHR following treatment with clarithromycin had a higher bacterial diversity prior to treatment.3 To our knowledge, the impact on the asthmatic airway microbiota of an antibiotic has not been reported and we therefore set out to establish if macrolide therapy was associated with a change in airway microbiota in asthma. Methods Five adult patients with moderate/severe asthma (British Thoracic Society step 4–5) (see online supplementary table...

Conclusions Our results suggest that roflumilast only provides a net benefit to patients at a high risk of severe exacerbations. Guideline developers should consider different recommendations for patients with COPD at different baseline risks for exacerbations. (Source: Thorax)

In the ASTER study, mediastinal staging was more accurate for patients randomised to combined endobronchial and endoscopic ultrasound, followed by surgical staging if endoscopy was negative, versus surgical staging alone. Here, we report survival, quality of life and cost effectiveness up to 6 months, for the UK, The Netherlands and Belgium, separately. Survival in the two arms of the study was similar. In all three countries, the endosonography strategy had slightly higher quality-adjusted life years over 6 months, and was cheaper. Therefore, based on clinical accuracy and cost effectiveness, we conclude that mediastinal staging should commence with endosonography. (Source: Thorax)

The human and societal burden of COPD is alarming. Despite large reductions in smoking rates across industrialised nations, COPD mortality has increased by 60% over the past 20 years, making it the second leading cause of morbidity and mortality in the USA and elsewhere.1 Most of the COPD-related deaths occur during or shortly following acute exacerbations (or ‘lung attacks’). Unfortunately, severe lung attacks are common, with one in six patients requiring hospitalisation for urgent care each year.2 Despite best therapy, 1 in 12 of these patients will succumb to their disease in hospital.3 Even those who survive will experience persistent morbidity from their recent lung attack and never regain their lost health status. Furthermore, one in three patients will have another...