The edition · Pulmonology
ATS comes down firmly for high-flow oxygen in hypoxaemic respiratory failure
A new American Thoracic Society guideline settles modality choice across acute respiratory failure, astegolimab cuts COPD exacerbations by 15% irrespective of eosinophils, and dupilumab reduces emergency attendances by 38% in eosinophilic COPD.
The edition in brief
The American Thoracic Society has published its first comprehensive guideline on non-invasive respiratory support across acute respiratory failure, using GRADE. For acute hypoxaemic failure: a strong recommendation for high-flow nasal cannula, a conditional one for non-invasive ventilation or CPAP, with close monitoring for escalation. For acute hypercapnic failure: a strong recommendation for non-invasive ventilation to reduce mortality and intubation, with high-flow reserved conditionally for milder hypercapnia and pH above 7.25 where escalation is immediately available. A strong recommendation for high-flow or non-invasive ventilation as preoxygenation before intubation. After extubation, high-flow for low-risk and non-invasive ventilation for high-risk patients. Pooled data from ALIENTO and ARNASA, 2,682 participants with COPD and frequent exacerbations, show astegolimab every two weeks reduced moderate or severe exacerbations by 15% (rate ratio 0.85, 95% CI 0.76 to 0.96) and severe exacerbations by 32% (0.68, 0.52 to 0.87). Participants were enrolled irrespective of blood eosinophil count. A pooled analysis of BOREAS and NOTUS, 1,874 patients with eosinophilic COPD, found dupilumab cut emergency department visits and hospital admissions by 38% (rate ratio 0.62, 0.43 to 0.90) and systemic corticosteroid courses for severe exacerbations by 42%. AZIMUNE, a mechanism study in 40 adults with uncontrolled asthma, found azithromycin increased rhinovirus-induced interferon beta and lambda in bronchial epithelial cells and reduced interleukin-33, without significant clinical differences. Today's pearl: in hypercapnic failure, high-flow is a decision that needs a pH and a plan.
The ATS settles which non-invasive support to use, and when
Use high-flow nasal cannula first in acute hypoxaemic failure and non-invasive ventilation first in hypercapnic failure — and preoxygenate every intubation with one of the two.
Astegolimab cuts COPD exacerbations regardless of eosinophil count
Astegolimab reduces COPD exacerbations by about 15% in patients with frequent exacerbations regardless of eosinophil count — a modest effect, but in a group with no current biologic option.
Dupilumab in eosinophilic COPD: fewer emergency attendances, less steroid exposure
In COPD with eosinophils at or above 300 cells per microlitre, dupilumab reduces emergency attendances by 38% and systemic steroid courses by up to 42% — so measure the eosinophil count.
High-flow in hypercapnia needs a pH, a clock and a plan
Before starting high-flow in a hypercapnic patient, check the pH, set a one to two hour reassessment with a repeat gas, and confirm non-invasive ventilation can actually be started if it fails.
AZIMUNE: how azithromycin actually protects asthmatic airways
Azithromycin appears to work in asthma by restoring epithelial antiviral interferon responses and lowering interleukin-33 — an explanation for an established effect, not a reason to widen prescribing.
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