Latest in Pulmonary News

Latest in Pulmonary News2019-02-15T07:28:32-04:00

The Caveat to Inhaled Corticosteroids for Asthma

For the past several years, the trend has been to use inhaled corticosteroid(ICS) early and often for patients with asthma. And now the 2019 Global Initiative for Asthma (GINA) guidelines recommend using ICS as first-line therapy (step 1) as needed).[1] This change is sure to increase ICS use even more.
The logic behind using ICS early and often is sound, but when it comes to asthma, nothing is simple. The first problem is that asthma is overdiagnosed (some estimates put the rate as high as 30%-35%).[2] Even when the diagnosis is correct, up to 50% of patients with the disease will have a noneosinophilic, non-type 2 phenotype that is less likely to respond to ICS.[3] Both scenarios leave physicians chasing symptoms with higher and higher doses of ICS.

So what?” you might say. ICS is safe, and there is minimal systemic absorption. Better to ensure that all asthmatics have ICS on board and risk overtreating than to withhold therapy from someone who needs it. The problem is, ICS is not risk-free. Furthermore, the risk-benefit skews further toward adverse effects, even in those who benefit from treatment, as the dose is increased. A recent review estimates that over 90% of efficacy is achieved at the “lowest” ICS dose As the dose is increased, the incremental benefit is minimal, while side effects increase in a linear fashion.

Patients with mild disease are particularly problematic. They make up the majority (50%-75%) diagnosed with asthma, and they are the group most likely to be affected by the changes to step 1 in the GINA guidelines. A recent study found high rates of noneosinophilic asthma in this group and response to ICS that wasn’t better than to placebo.

The “early and often” approach to ICS is fine. It should come with an important caveat, though. If your patient isn’t responding and you find yourself escalating ICS dose for persistent symptoms, make sure you have the right diagnosis. Once you’ve confirmed you do, take a look at the patient’s serum eosinophil count and ensure that you have the right asthma phenotype. If in doubt, find a good pulmonologist to refer the patient to.

Author : Aaron B. Holley, MD
Source :

Obstructive sleep apnea: focus on myofunctional therapy


Orofacial myofunctional therapy (OMT) is a modality of treatment for children and adults with obstructive sleep apnea (OSA) to promote changes in the musculature of the upper airways. This review summarizes and discusses the effects of OMT on OSA, the therapeutic programs employed, and their possible mechanisms of action.


We conducted an online literature search using the databases MEDLINE/PubMed, EMBASE, and Web of Science. Search terms were “obstructive sleep apnea” in combination with “myofunctional therapy” OR “oropharyngeal exercises” OR “speech therapy”. We considered original articles in English and Portuguese containing a diagnosis of OSA based on polysomnography (PSG). The primary outcomes of interest for this review were objective measurement derived from PSG and subjective sleep symptoms. The secondary outcome was the evaluation of orofacial myofunctional status.


Eleven studies were included in this review. The studies reviewed reveal that several benefits of OMT were demonstrated in adults, which include significant decrease of apnea-hypopnea index (AHI), reduced arousal index, improvement in subjective symptoms of daytime sleepiness, sleep quality, and life quality. In children with residual apnea, OMT promoted a decrease of AHI, increase in oxygen saturation, and improvement of orofacial myofunctional status. Few of the studies reviewed reported the effects of OMT on the musculature.


The present review showed that OMT is effective for the treatment of adults in reducing the severity of OSA and snoring, and improving the quality of life. OMT is also successful for the treatment of children with residual apnea. In addition, OMT favors the adherence to continuous positive airway pressure. However, randomized and high-quality studies are still rare, and the effects of treatment should also be analyzed on a long-term basis, including measures showing if changes occurred in the musculature.

Author: de Felício CM, da Silva Dias FV, Trawitzki LVV


Obstructive sleep apnea: Who should be tested, and how?

Patients who have risk factors for obstructive sleep apnea (OSA) or who report symptoms of OSA should be screened for it, first with a complete sleep history and standardized questionnaire, and then by objective testing if indicated. The gold standard test for OSA is polysomnography performed overnight in a sleep laboratory. Home testing is an option in certain instances.

Common risk factors include obesity, resistant hypertension, retrognathia, large neck circumference (> 17 inches in men, > 16 inches in women), and history of stroke, atrial fibrillation, nocturnal arrhythmias, heart failure, and pulmonary hypertension. Screening is also recommended for any patient who is found on physical examination to have upper-airway narrowing or who reports symptoms such as loud snoring, observed episodes of apnea, gasping or choking at night, unrefreshing sleep, morning headaches, unexplained fatigue, and excessive tiredness during the day.

The American Academy of Sleep Medicine suggests three opportunities to screen for OSA1:

  • At routine health maintenance visits
  • If the patient reports clinical symptoms of OSA
  • If the patient has risk factors.


The prevalence of OSA in the United States is high, estimated to be 2% in women and 4% in men in the middle-aged work force,2 and even more in blacks, Asians, and older adults.3 Yet only 10% of people with OSA are diagnosed4—a dismal statistic considering the association of OSA with resistant hypertension5 and with a greater risk of stroke,6cardiovascular disease, and death.7


Untreated OSA is associated with a number of conditions7:

  • Hypertension. OSA is one of the most common conditions associated with resistant hypertension. Patients with severe OSA and resistant hypertension who comply with continuous positive airway pressure (CPAP) treatment have significant reductions in blood pressure.
  • Coronary artery disease. OSA is twice as common in people with coronary artery disease as in those with no coronary artery disease. In patients with coronary artery disease and OSA, CPAP may reduce the rate of nonfatal and fatal cardiovascular events.
  • Heart failure. OSA is common in patients with systolic dysfunction (11% to 37%). OSA also has been detected in more than 50% of patients with heart failure with preserved systolic function. CPAP treatment can improve ejection fraction in patients with systolic dysfunction.
  • Arrythmias. Atrial fibrillation, nonsustained ventricular tachycardia, and complex ventricular ectopy have been reported to be significantly more common in people with OSA.8 If the underlying cardiac conduction system is normal and there is no significant thyroid dysfunction, bradyarrhythmias and heart block may be treated effectively with CPAP.7 Treatment of OSA may decrease the incidence and severity of ventricular arrhythmias.7
  • Sudden cardiac death. OSA was independently associated with sudden cardiac death in a longitudinal study.9
  • Stroke. The Sleep Heart Health Study6 showed that OSA is 30% more common in patients who developed ischemic stroke. Long-term CPAP treatment in moderate to severe OSA and ischemic stroke is associated with a reduction in the mortality rate.10
  • Diabetes. The Sleep Heart Health Study showed that OSA is independently associated with glucose intolerance and insulin resistance and may lead to type 2 diabetes mellitus.11


If you suspect OSA, consider administering a sleep disorder questionnaire such as the Berlin,12 the Epworth Sleepiness Scale, or the STOP-Bang questionnaire (Table 1). The STOP-Bang questionnaire is an easy-to-use tool that expands on the STOP questionnaire (snoring, tiredness, observed apnea, high blood pressure) with the addition of body mass index, age, neck size, and gender. The Berlin questionnaire has been validated in the primary care setting.12 The STOP-Bang questionnaire has been validated in preoperative settings13 but not in the primary care setting (although it has been commonly used in primary care).


If the score on the questionnaire indicates a moderate or high risk of OSA, the patient should undergo objective testing with polysomnography or, in certain instances, home testing.1Polysomnography is the gold standard. Home testing costs less and is easier to arrange, but the American Academy of Sleep Medicine recommends it as an alternative to polysomnography, in conjunction with a comprehensive sleep evaluation, only in the following situations14:

  • If the patient has a high pretest probability of moderate to severe OSA
  • If immobility or critical illness makes polysomnography unfeasible
  • If direct monitoring of the response to non-CPAP treatments for sleep apnea is needed.

Home testing for OSA should not be used in the following situations:

  • If the patient has significant morbidity such as moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure
  • In evaluating a patient suspected of having comorbid sleep disorders such as central sleep apnea, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorder, or narcolepsy
  • In screening of asymptomatic patients.

Home testing has important drawbacks. It may underestimate the severity of sleep apnea. The rate of false-negative results may be as high as 17%. If the home test was thought to be technically inadequate or the results were inconsistent with those that were expected—ie, if the patient has a high pretest probability of OSA based on risk factors or symptoms but negative results on home testing—then the patient should undergo polysomnography.14


The diagnosis of OSA is confirmed if the number of apnea events per hour (ie, the apnea-hypopnea index) on polysomnography or home testing is more than 15, regardless of symptoms, or more than 5 in a patient who reports OSA symptoms. An apnea-hypopnea index of 5 to 14 indicates mild OSA, 15 to 30 indicates moderate OSA, and greater than 30 indicates severe OSA.


Treatment of OSA with CPAP reduces the 10-year risk of fatal and nonfatal motor vehicle accidents by 52%, the 10-year expected number of myocardial infarctions by 49%, and the 10-year risk of stroke by 31%.7 It has also been found to be cost-effective, for men and women of all ages with moderate to severe OSA.15

Lies, Damned Lies, and Asthma

Aminophylline suppositories, cocaine nasal packs, and potassium iodide were commonly prescribed for asthma in 1963 when Claude A. Frazier, MD, wrote a thoughtful essay on the do’s and don’ts in treating allergic asthma in Consultant.1 How times have changed! Dr Frazier left us with several clinical observations that are prophetic. He was correct in asserting in his introduction that “allergic asthma is a problem disease; its capricious nature defies control and keeps the health of the asthmatic always in a precarious state. And, improper treatment can make the asthma worse.” His wisdom preceded the proliferation of consensus guidelines, beginning with the National Institutes of Health National Asthma Education and Prevention Program (NIH-NAEPP) Expert Panel Report (EPR-1) in 1991.2 Here I offer an updated list of do’s and don’ts and a perspective from one clinician’s experience with difficult-to-control asthma since 1998 ……

Samuel Louie, MD
Professor of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine; and Director, UC Davis Asthma Network (UCAN) at UC Davis Health, Sacramento, California

Louie S. Lies, damned lies, and asthma. Consultant. 2018;58(12):336-342.


What exercises can help increase lung capacity?

The lungs are responsible for the exchange of oxygen and carbon dioxide that keep the brain, heart, and other parts of the body healthy. Age, smoking, inhaling pollutants, and other factors can affect lung function.
People cannot necessarily change their lung capacity in terms of how much oxygen their lungs can hold. However, they can perform exercises that may reduce shortness of breath when they have a lower lung function than is desirable. An example could be someone who has chronic obstructive pulmonary disease (COPD).

A person should always talk to their doctor before starting any exercise program, including breathing exercises. This is especially true if they have an underlying condition such as COPD.

Pursed lip breathing

Pursed lip breathing is an exercise that can help to keep the airways open for longer to help air flow. The exercise is easy to perform, and people can do it almost anywhere. To do pursed lip breathing:

  • Sit up straight. Practicing good posture can help promote better lung movement.
  • Breathe in deeply through your nose in a slow, controlled fashion.
  • Purse your lips, which is much like making a “kissing” face where your lips are almost, but not quite, touching.
  • Breathe out through your pursed lips, making a goal of breathing out twice as long as breathing in. Some people may find it beneficial to set a timer, such as focusing on breathing in for 5 seconds and exhaling for 10 seconds.

This exercise can be helpful for someone who is not as physically active as some others and may not be using their breathing muscles as frequently. Those with COPD can also benefit from performing this exercise.

Belly breathing

Belly breathing is an exercise that focuses on targeting and strengthening the diaphragm muscle that allows a person to take a deep breath. People can follow these steps to accomplish this exercise:

  • Rest your hand or another lightweight object on your stomach.
  • Breathe in slowly through your nose to note how your stomach rises and falls when breathing.
  • Breathe out through your mouth.
  • Breathe in through your nose again, this time trying to get your stomach to go up more than it did with the previous breath.
  • Try to exhale for a much longer time than when you inhale, such as two to three times as long.
  • Periodically, roll your shoulders forward and backward and move your head side to side to ensure you are not building tension in your upper body.

This exercise from the American Lung Association helps to improve the rate at which the lungs fill and empty air. A person can practice belly breathing and pursed lip breathing for about 5 to 10 minutes every day to enhance their lung function.

Interval training

For people who have problems with breathlessness and shortness of breath while exercising, interval training may be a better solution than steady-state exercise. Interval training involves alternating a more challenging exercise with a slower recovery period. Examples include walking at a very fast pace for 1 minute, then walking more slowly for 2 minutes. Similarly, a person may perform a weightlifting activity for 1 minute, such as bicep curls or lunges, then step to the side or walk at a gentle pace for 2 to 3 minutes. Interval training allows the lungs time to recover before challenging them again. Whenever a person is exercising and becomes short of breath, slowing down for a few minutes and performing pursed lip breathing can help. They can continue pursed lip breathing until feelings of breathlessness subside.

Tips for preserving lung health

While lung exercises cannot reverse damage already done to the lungs, they can help a person use their lungs to their best capacity. Exercises are not the only thing a person can do to improve or protect their lung health. Other steps people can take include:

  • refraining from smoking
  • drinking plenty of water
  • staying physically active

If a person has symptoms of poor lung health, such as shortness of breath during daily activities, pain when breathing, or a cough that will not go away, they should see their doctor. The earlier lung problems receive a diagnosis and treatment, the better the treatment outcome is likely to be.


Lung exercises can be beneficial to lung function. Pursed lip breathing and diaphragm breathing are two common focuses for people in pulmonary rehabilitation to improve their lung function.
Before starting any exercise program, including a lung exercise one, it is best to talk to a doctor to ensure there are not any restrictions or individual recommendations for best results.

Author : By Rachel Nall, RN, MSN
Source :

Thirty-Day Hospital Readmission Metric Linked to Increased Mortality for HF and Pneumonia

Physicians are at increased pressure to reduce readmissions for certain chronic diseases. A recent study found that implementation of the 30-day readmission rules has been associated with increased 30-day post-discharge mortality for those hospitalized for heart failure and pneumonia.

Post-discharge deaths have increased by 0.25% for patients hospitalized with heart failure and by 0.40% for patients with pneumonia since the implementation of the 30-day readmission rules.
There are approximately 8 million hospitalizations during the study period. Such small increases may account for a large number of deaths.

The findings, published online in JAMA, come from a retrospective cohort study that compared mortality rates among 8.3 million Medicare beneficiaries hospitalized for these common conditions before and after implementation of the Hospital Readmissions Reduction Program (HRRP). This early data should lead physicians to exercise caution in discharging patients prematurely.

Source: Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia. JAMA. 2018;320(24):2542-2552. doi:10.1001/jama.2018.19232

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