The edition · Pulmonology
Asthma symptom scores predicted attacks poorly; eosinophils and FeNO did better
A patient-level analysis of 7161 people argues for biomarkers, not symptoms alone, to guide escalation. Also: ATS guidance on high-flow and non-invasive ventilation, astegolimab in COPD, gabapentin for IPF cough, and exacerbation risk in bronchiectasis.
The edition in brief
A patient-level meta-analysis drawing on ORACLE2 and four other datasets (7161 participants) found the ACQ-5 symptom score had little relation to lung function or inflammation and only modest value for predicting severe asthma attacks: rate ratio 1.09 per 0.5 points. Blood eosinophils and FeNO better identified patients at risk and those who would respond to anti-inflammatory treatment. The ATS has issued a guideline on non-invasive respiratory support: a strong recommendation for high-flow nasal oxygen in acute hypoxaemic failure, NIV for hypercapnic failure, high-flow or NIV for preoxygenation, and risk-based post-extubation support. Pooled ALIENTO and ARNASA data (2682 patients) showed astegolimab every 2 weeks reduced moderate or severe COPD exacerbations by 15%. A single-centre Chinese trial of 68 patients found gabapentin up to 900 mg/day relieved IPF cough in 73.5% against 26.5% with placebo, with more drowsiness. In 19,324 EMBARC patients with bronchiectasis, each previous exacerbation raised future risk stepwise, and one hospital admission roughly quadrupled the risk of another. Today's pearl: record the number of exacerbations and admissions in the past year at every bronchiectasis and COPD review.
ATS guideline: matching high-flow, CPAP and NIV to the type of respiratory failure
Choose non-invasive support by the type of failure: high-flow for hypoxaemic, NIV for hypercapnic, and set a time to reassess for escalation.
Astegolimab reduced COPD exacerbations regardless of eosinophil count
Astegolimab modestly reduced COPD exacerbations in patients not selected by eosinophils, but it is not yet an available option; optimise standard care first.
Gabapentin relieved cough in idiopathic pulmonary fibrosis in a small trial
For troublesome cough in IPF, consider a cautious trial of gabapentin up to 900 mg a day, watching for sedation and falls.
In bronchiectasis, every past exacerbation raises future risk, with no safe threshold
In bronchiectasis, treat even one or two exacerbations, and any admission, as reason to intensify prevention rather than waiting for three.
Count last year's exacerbations and admissions at every airway review
At every airway disease review, record the number of exacerbations and admissions in the past year; they predict the next one and guide escalation.
Use eosinophils and FeNO, not symptom scores alone, to decide asthma escalation
Before stepping up asthma treatment for symptoms, check blood eosinophils and FeNO; high symptoms with low biomarkers call for a search for other causes.
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