The edition · Pulmonology
FeNO thresholds can rule asthma in and out when spirometry is normal, and inhaled amikacin raised culture conversion in new MAC lung disease
A meta-analysis with a primary care validation cohort on exhaled nitric oxide for asthma diagnosis, a phase 3b trial of inhaled liposomal amikacin in untreated Mycobacterium avium complex disease, a randomised trial of cryobiopsy for peripheral lung lesions, and two smaller trials in children and in home ventilation.
The edition in brief
A meta-analysis of 30 studies (22 in adults, 7,141 patients; nine in children, 989) found fractional exhaled nitric oxide (FeNO) had good accuracy for airway hyper-responsiveness in adults with suspected asthma and normal spirometry (AUC 0.80, 95% CI 0.73 to 0.85), fair in children (0.75), and that blood eosinophils added nothing. At a primary care prevalence of 20%, FeNO of 65 ppb or more gave a positive predictive value of 80% and below 20 ppb a negative predictive value of 93%, missing 18% of cases; accuracy fell within two weeks of inhaled corticosteroids. A 123-patient primary care cohort replicated the findings. ENCORE randomised 425 adults with newly diagnosed Mycobacterium avium complex lung disease to inhaled liposomal amikacin or placebo added to azithromycin and ethambutol: culture conversion by month 13 was 82.4% against 55.6%, and the symptom score difference was 3.11 points. Cryo-RCT randomised 627 patients with peripheral lung lesions and found cryobiopsy raised histological yield (83% vs 75%) at the cost of more moderate bleeding (38% vs 19%) and pneumothorax. A 51-patient trial found home high-intensity interval training raised fitness in young people with post-infectious bronchiolitis obliterans, and a 75-patient trial found web education reduced non-invasive ventilation side effects. The pearl covers inhaler technique.
Inhaled liposomal amikacin added to standard therapy raised culture conversion in newly diagnosed MAC lung disease
Consider the ENCORE data when discussing add-on inhaled amikacin in newly diagnosed MAC lung disease, within guidelines and local availability.
Cryobiopsy raised diagnostic yield for peripheral lung lesions, with more bleeding
Consider cryobiopsy for peripheral lesions in experienced hands, accepting more bleeding and a small extra pneumothorax risk.
Remote high-intensity interval training improved fitness in young people with bronchiolitis obliterans
Consider a supervised exercise programme for young people with bronchiolitis obliterans, expecting fitness gains rather than lung function change.
Web-based education eased home ventilation side effects and insomnia in COPD
Consider structured education and an insomnia check for patients starting home ventilation.
Check inhaler technique at every visit
Watch the patient use the inhaler and correct errors before escalating treatment.
FeNO can rule asthma in or out in primary care when spirometry is normal, if inhaled steroids are accounted for
Consider FeNO with explicit rule-in and rule-out thresholds when diagnosing asthma with normal spirometry, and test before inhaled steroids are started.
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