The edition · Pulmonology
A bacterial lysate fails to prevent preschool wheeze, and one low eosinophil count is not enough
ORBEX found no reduction in wheezing illness with OM-85 in 822 high-risk toddlers; pooled mepolizumab data show intermittently raised eosinophils identify a treatable COPD phenotype; and tezepelumab cut exacerbations by 70% in a real-world severe asthma population.
The edition in brief
ORBEX randomised 822 children aged 6 to 18 months at increased risk of asthma to the bacterial lysate OM-85 3.5 mg or placebo for 10 days a month over 24 months, then followed them for 36 months off treatment. Time to first wheezing lower respiratory illness did not differ: 71 of 342 (21%) on OM-85 against 61 of 339 (18%) on placebo, hazard ratio 1.16 (95% CI 0.82 to 1.64), log-rank p = 0.35. Adverse events were no different. Pooled data from METREX, METREO and MATINEE examined mepolizumab in COPD by blood eosinophil pattern. Exacerbations fell, or trended down, in patients with counts of at least 300 cells/µL at any point before randomisation (21% reduction), in those persistently raised (12 to 27%) and in those whose counts varied over time (22 to 36%). From 150 cells/µL upwards, mepolizumab reduced exacerbations needing emergency attendance or admission. Patients persistently below 150 cells/µL derived no benefit. In PASSAGE, a phase 4 single-arm study of 286 US patients with severe uncontrolled asthma, the annualised exacerbation rate fell 70% (95% CI 63 to 75) from 2.88 to 0.87, with gains across eosinophil-low and eosinophil-high phenotypes, and pre-bronchodilator FEV1 up 0.122 L at 52 weeks. Thirteen studies of ECG-based AI for obstructive sleep apnoea pooled to sensitivity 0.88 and specificity 0.89. A meta-analysis of robotic bronchoscopy against CT-guided needle biopsy found equal yield and a quarter the rate of pneumothorax needing intervention, on retrospective data from one health system.
OM-85 did not prevent wheezing illness in high-risk toddlers
Stop recommending OM-85 for preventing wheeze in high-risk toddlers, and tell families already using it that the evidence does not support it.
Tezepelumab worked across phenotypes in a real-world severe asthma population
A low eosinophil count or a smoking history should not by itself rule a severe asthma patient out of tezepelumab.
ECG-based AI detects sleep apnoea by reading the autonomic response
Use ECG-based apnoea algorithms to prioritise the waiting list, not to make the diagnosis.
Robotic bronchoscopy matched CT-guided biopsy with fewer pneumothoraces
Where both are available, robotic bronchoscopy offers similar yield with fewer pneumothoraces needing intervention — but choose by lesion characteristics, not by this evidence alone.
Watch the inhaler before you change it
Watch a dose being taken with the patient's own inhaler before stepping up treatment.
One low eosinophil count does not rule out an eosinophilic COPD phenotype
Check historical blood counts and repeat a borderline result before ruling out an eosinophilic phenotype in COPD.
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