The edition · Pulmonology
With normal spirometry, FeNO of 65 ppb or more pointed strongly to asthma and below 20 ppb made it unlikely
A 30-study meta-analysis with prospective validation gives primary care usable FeNO thresholds, WHO-commissioned data define who is at risk from influenza, and dupilumab cut COPD emergency visits and admissions by 38%.
The edition in brief
A meta-analysis of 30 studies (8,130 patients) with suspected asthma and normal spirometry found FeNO had good accuracy for airway hyper-responsiveness in adults (AUC 0.80) and fair accuracy in children (0.75). At primary care prevalence, FeNO of 65 ppb or more gave a positive predictive value of 80%, and below 20 ppb a negative predictive value of 93%, though 18% of diagnoses were missed. Blood eosinophils performed poorly and added nothing. A prospective primary care cohort of 123 adults replicated the thresholds, and accuracy fell within 2 weeks of inhaled corticosteroid use. A WHO-commissioned meta-analysis of 63 studies (2.15 million patients) identified cardiovascular disease, immunosuppression, neurological and chronic respiratory disease, pregnancy, diabetes and older age as risk factors for influenza admission, and secondary bacterial infection, malnutrition, sepsis and acute kidney injury as the strongest risk factors for death in severe influenza. In pooled BOREAS and NOTUS data (1,874 patients with eosinophilic COPD), dupilumab reduced ED visits or admissions by 38% and systemic steroid use for exacerbations. A UK cohort of 206,381 obese adults with type 2 diabetes found GLP-1 receptor agonists were not associated with less incident sleep apnoea diagnosis than DPP-4 inhibitors (HR 1.07, 0.93 to 1.23).
Influenza: WHO-commissioned review grades the risk factors for admission and death
Give early antivirals to influenza patients with chronic disease, immunosuppression or pregnancy, and escalate when bacterial infection, sepsis or kidney injury appears.
Dupilumab reduced emergency visits, admissions and steroid courses in eosinophilic COPD
In exacerbating COPD with eosinophils ≥300 despite triple therapy, dupilumab reduces admissions and steroid courses.
GLP-1 agonists were not associated with less new sleep apnoea than DPP-4 inhibitors in obese type 2 diabetes
Keep screening obese people with diabetes for sleep apnoea even when they are on a GLP-1 agonist.
Start oseltamivir in high-risk or admitted influenza patients even after 48 hours
Start oseltamivir in admitted or high-risk patients with suspected influenza, whatever the duration of symptoms.
FeNO gives primary care usable rule-in and rule-out thresholds for asthma when spirometry is normal
When spirometry is normal, measure FeNO before any inhaled steroid: ≥65 ppb rules asthma in, <20 ppb makes it unlikely in adults.
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