Showing papers in "Breathe in 2019"

Under- and over-diagnosis of COPD: a global perspective

Abstract: Globally, chronic obstructive pulmonary disease (COPD) is the fourth major cause of mortality and morbidity and projected to rise to third within a decade as our efforts to prevent, identify, diagnose and treat patients at a global population level have been insufficient. The European Respiratory Society and American Thoracic Society, along with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document, have highlighted key pathological risk factors and suggested clinical treatment strategies in order to reduce the mortality and morbidity associated with COPD. This review focuses solely on issues related to the under- and over-diagnosis of COPD across the main geographical regions of the world and highlights some of the associated risk factors. Prevalence of COPD obtained mainly from epidemiological studies varies greatly depending on the clinical and spirometric criteria used to diagnose COPD, i.e. forced expiratory volume in 1 s to forced vital capacity ratio Key points Globally, there is large variation in the prevalence of COPD, with 10–95% under-diagnosis and 5–60% over-diagnosis (table 1) due to differences in the definition of diagnosis used, and the unavailability of spirometry in rural areas of low- and middle-income countries where the prevalence of COPD is likely to be high. In order to be diagnosed with COPD, patients must have a combination of symptoms with irreversible airflow obstruction defined by a post-bronchodilator FEV1/FVC ratio of Not performing spirometry is the strongest predictor for an incorrect diagnosis of COPD; however, additional factors, such as age, gender, ethnicity, self-perception of symptoms, co-existent asthma, and educational awareness of risk factor by patients and their physician, are also important. COPD can be associated with inhalation of noxious particles other than smoking tobacco. Educational aims To summarise the global prevalence of over- and under-diagnosis of COPD. To highlight the risk factors associated with the under- and over-diagnosis of COPD. To update readers on the key changes in the recent progress made regarding the correct diagnosis of COPD.

Music and dance in chronic lung disease

Abstract: Arts in Health interventions show potential to improve the quality of life of people with chronic lung disease. Listening to music, making music, and dance have accepted and established roles in the lives of people without chronic disease. However, their potential utility in chronic disease management is infrequently considered by medical professionals. The aim of this review is to examine the use of music and dance in the treatment and self-management of chronic lung disease. Although the evidence base is currently limited, existing research suggests a range of biopsychosocial benefits. As personalised medicine and social prescribing become more prominent, further research is required to establish the role of arts interventions in chronic lung disease.

Post-intensive care syndrome: impact, prevention, and management

Abstract: Post-intensive care syndrome (PICS): inpatient prevention and outpatient recognition are essential http://bit.ly/2GCgz1q.

Over- and under-diagnosis in asthma.

Abstract: Asthma is extremely common with a prevalence of approximately 10% in Europe. It presents with symptoms which have a broad differential diagnosis and examination can be entirely normal. There is no agreed gold standard to diagnose asthma, and the objective tests that can aid diagnosis are often poorly available to primary care physicians. There is evidence that asthma is widely misdiagnosed. Overdiagnosis leads to unnecessary treatment and a delay in making an alternative diagnosis. Underdiagnosis risks daily symptoms, (potentially serious) exacerbations and long-term airway remodelling. An agreed standardised approach to diagnosis, with inclusion of objective measurements prior to treatment, is required to reduce misdiagnosis of asthma. Key points Asthma presents with common respiratory symptoms and physical examination is often normal; in addition, the most widely available tests (peak flow and spirometry) can be normal unless the patient is exacerbating. Treating asthma prior to carrying out objective tests decreases their sensitivity and can make confirmation of the diagnosis difficult. There is no single gold standard test to diagnose asthma, and there are significant differences between the suggested algorithms in commonly used guidelines. Both under- and over-diagnosis are widespread and lead to significant risks to patients.

Oxygen devices and delivery systems.

Abstract: Oxygen use has extended from inpatient to outpatient settings for patients with chronic pulmonary diseases and complications of hypoxaemia. This article presents an overview of oxygen devices (oxygen concentrators, compressed gas cylinders and liquid oxygen) and delivery systems (high- and low-flow). The indications, advantages and disadvantages of each device and delivery system are presented, aiming to offer updated knowledge to the multidisciplinary team members managing patients with respiratory failure, and therefore allowing appropriate selection of devices and delivery systems that are tailored to the needs of each patient.

Improving the quality of life of people with advanced respiratory disease and severe breathlessness.

Abstract: Advanced respiratory disease imposes a greater symptom burden than many cancers but not does have comparable recognition of the need for supportive and palliative care or the infrastructure for its systematic delivery. Consequently, many people with advanced respiratory disease (and those closest to them) have a poor quality of life, disabled by chronic breathlessness, fatigue and other symptoms. They are socially isolated by the consequences of long-term illness and are often financially impoverished. The past decade has seen an increasing realisation that care for this group must improve and that symptom management must be prioritised. Clinical guidelines recommend person-centred care, including access to supportive and palliative care as needed, as part of standard medical practice. Advanced lung disease clinics and specialist breathlessness services (pioneered within palliative care) are developing within respiratory medicine services but are provided inconsistently. This review covers the comprehensive assessment of the patient with advanced respiratory disease, the importance of supporting carers and the current best practice in the management of breathlessness, fatigue and cough. It also suggests ways to incorporate person-centred care into the general respiratory clinic, assisted by better liaison with specialist palliative and primary care. Emerging evidence shows that excellent symptom management leads to better clinical outcomes and reduces inappropriate use of emergency medical services. Key points People living with advanced respiratory disease and severe chronic breathlessness (and those closest to them) have a poor quality of life. Chronic breathlessness is a disabling symptom, and acute-on-chronic/episodic breathlessness is frightening to experience and observe. Chronic breathlessness imposes profound physical limitations and psychosocial burdens on those suffering from it or living with someone experiencing it. Fatigue and cough are two other cardinal symptoms of advanced respiratory disease, with very detrimental effects on quality of life. The impact of all these symptoms can be alleviated to a variable extent by a predominantly non-drug complex intervention. Many of the interventions are delivered primarily by allied health or nursing professionals. Doctors, nurses and other health professionals also need to play an active part in promoting quality of life as part of excellent medical care. A person-centred, psychologically informed approach is needed by all clinicians treating patients with advanced respiratory disease. Educational aims To give specialist respiratory clinicians practical clinical tools to help improve the quality of life of their patients with advanced respiratory disease and chronic breathlessness. To outline the evidence base for these interventions with reference to definitive sources. To highlight the importance of person-centred care in people with respiratory disease at all stages of illness.

Overdiagnosis of pulmonary embolism: definition, causes and implications

Abstract: Overuse of computed tomography pulmonary angiography to diagnose pulmonary embolism in people who have only a low pre-test probability of pulmonary embolism has received significant attention in the past. The issue of overdiagnosis of pulmonary embolism, a potential consequence of overtesting, has been less explored. The term “overdiagnosis”, used in a narrow sense, describes a correct (true positive) diagnosis in a person but without any associated harm. The aim of this review is to summarise literature on the topic of overdiagnosis of pulmonary embolism and translate this epidemiological concept into the clinical practice of respiratory professionals. The review concludes that the location of pulmonary embolism at a subsegmental level, rather than whether a diagnosis was made incidentally or following an investigation for suspected pulmonary embolism, is the best predictor for situations in which anticoagulation may not be necessary. In the absence of strong evidence of the optimal management of subsegmental pulmonary embolism, treatment decisions should be made case by case, taking into account the patient9s situation and preference. Key points Since the introduction of computed tomography pulmonary angiography in 1998, there has been a steep increase in the diagnosis of pulmonary embolism (PE). An increased incidence of PE diagnoses, but an almost stable mortality from PE in the population, together with a decreased case fatality, point towards overdiagnosis (in the absence of more effective treatment). Whether PE is diagnosed as an incidental finding or following an investigation for suspected PE does not appear to influence the need for anticoagulation therapy. An isolated subsegmental PE may not require anticoagulation therapy, and treatment decisions should be made case by case, taking into account the patient9s situation and preference. A suggested definition of overdiagnosis of PE: a diagnosis of PE that, if left untreated, would not lead to more harm than if it were treated with anticoagulation therapy, independent of symptoms. Educational aims To understand the term “overdiagnosis” based on its narrow definition and be able to apply it to PE. To outline the diagnostic approach to PE. To summarise what is known about the treatment of incidentally detected PE. To summarise what is known about the treatment of subsegmental PE. To understand in which situations anticoagulation therapy for PE may not be beneficial.

Evidence for lifestyle interventions in asthma

Abstract: Asthma is a chronic inflammatory airways disease, estimated to affect 300 million people worldwide. Asthma management plans focus on optimisation of asthma pharmacotherapy. Lifestyle interventions also hold great promise for asthma sufferers as they are accessible, low cost and have minimal side-effects, thus making adherence more likely. This review explores lifestyle interventions that have been tested in asthma, including improving nutrition, increasing physical activity and introduction of relaxation therapies such as yoga and massage therapy. Available evidence suggests a protective effect of increasing fruit, vegetable and wholegrain intake and increasing physical activity levels in asthma. Weight loss is recommended for obese asthmatic patients, as just 5–10% weight loss has been found to improve quality of life and asthma control in most obese asthmatic patients. Other lifestyle interventions such as meditation, yoga and massage therapy show promise, with positive effects on asthma seen in some studies. However, the study protocols are highly variable and the results are inconsistent. Additional research is needed to further develop and refine recommendations regarding lifestyle modifications that can be implemented to improve asthma. Key points Improving diet quality, by increasing fruit, vegetable and wholegrain intake and reducing saturated fat intake, should be recommended in asthma, as there is evidence suggesting that this leads to improvements in airway inflammation, asthma control and exacerbation risk. Regular physical activity should be promoted for people with asthma, as it can improve quality of life and lung function, as well as general health. In obese asthmatic patients, weight loss should be recommended, as it leads to numerous health benefits, including improvements in asthma. Even small amounts of weight loss in adults (5–10% body weight) have been shown to improve asthma quality of life and asthma control in the majority of people with asthma. There is some evidence of benefit of meditation, yoga and breathing exercises for adults with asthma, while massage therapy shows promise in children with asthma. However, the evidence is inconsistent and more research is needed to make definitive recommendations. Educational aims To summarise current knowledge on lifestyle interventions in asthma. To improve awareness of how lifestyle modification can be used in asthma management. To identify areas for future research on lifestyle interventions in asthma.

How to validate a diagnosis recorded in electronic health records.

Abstract: Systematic measurement errors in electronic health record databases can lead to large inferential errors. Validation techniques can help determine the degree of these errors and therefore aid in the interpretation of findings. http://ow.ly/iHQ630np4xU.

Living well with severe asthma

Abstract: Living well with severe asthma can be challenging. People with severe asthma can be refractory to treatment, can experience poor symptom control and are at a heightened risk of death. Patients experience symptoms of shortness of breath, chest tightness, cough and wheeze. These symptoms influence many aspects of an individual9s life, resulting in emotional, financial, functional and medication-related burdens that negatively impact quality of life. Quality of life is known to be influenced by individual levels of satisfaction that stem from real-life treatment experiences. This experience is portrayed through the lens of the patient, which is commonly referred to as the patient perspective. The patient perspective is only one element of the patient experience. It influences health status, which, in severe asthma, is commonly assessed using validated health-related quality of life measures. A positive patient perspective may be achieved with implementation of management strategies tailored to individual needs. Management strategies developed in partnership between the patient, the severe asthma multidisciplinary team and the general practitioner may minimise disease-related impairment, allowing patients to live well with severe asthma. Key points Despite advances in treatment over the past decade, the experience of living with severe asthma has not significantly improved, with high levels of burden influencing the patient perspective. The impact of severe disease is not only restricted to asthma symptoms and acute attacks. It causes significant emotional, financial, functional and medication-related burdens, leading to impaired health-related quality of life. Clinical outcomes should not be stand-alone measures in severe asthma. Nonclinical measures should also be considered when evaluating health-related quality of life. Disease burden may be minimised and quality of life improved via self-management strategies, including education sessions, written asthma action plans, symptom monitoring, breathing exercises, physical activity and psychotherapeutic interventions. Educational aims To demonstrate the importance of the patient perspective in severe asthma. To identify the significant levels of disease burden associated with severe asthma. To discuss quality of life in severe asthma. To outline strategies that increase well-being in severe asthma.

Procalcitonin in respiratory disease: use as a biomarker for diagnosis and guiding antibiotic therapy.

Abstract: Procalcitonin (PCT) is a peptide measurable in serum which becomes elevated in response to bacterial infection. Multiple trials have explored the safety and efficacy of using PCT as a biomarker to guide decisions about starting or stopping antibiotic therapy in a wide variety of situations, and PCT assays have recently been approved by the Federal Drug Administration (FDA) in the US for use in both sepsis and respiratory tract infections. While there have been a number of promising results particularly in acute respiratory tract infections and intensive care unit settings, problems including adherence to protocol, cost of the assay and improved antimicrobial stewardship more generally, have limited more widespread adoption. This educational article summarises the evidence for the use of procalcitonin as a biomarker of bacterial infection across the spectrum of respiratory disease and reviews how the use of procalcitonin-guided antibiotic therapy is reflected in current major international guidelines. Key points Procalcitonin has been widely investigated as a biomarker of bacterial infection to aid diagnosis and decisions to start or stop antibiotics in a range of conditions, including in diseases of the lower respiratory tract. Meta-analysis suggests that the use of procalcitonin to guide antibiotic therapy in acute respiratory tract infections can reduce duration of antibiotic therapy and hospital admission without adversely affecting outcomes – however, there was significant heterogeneity in methodology and population in the included studies, and more recent studies have failed to show such significant benefits. The use of procalcitonin to guide stopping or shortening antibiotic therapy in sepsis/septic shock is suggested in the international guidelines for the management of sepsis (2016), but this is a “weak” recommendation, with a low quality of evidence recognised. Major international guidelines do not support a role for procalcitonin in the management of acute exacerbations of COPD, bronchiectasis, interstitial lung disease or pleural infection. Regardless of situation, decisions on initiating, altering, or discontinuing antimicrobial therapy should never be made solely on the basis of changes in any biomarker – while biomarkers such as procalcitonin may provide supportive information, they should only be used alongside regular and robust clinical assessment. Educational aims To understand the principles of using procalcitonin to guide decisions regarding antibiotic use (procalcitonin-guided antibiotic therapy). To review important research studies into the use of procalcitonin as a biomarker of bacterial infection across the spectrum of diseases of the lower respiratory tract. To understand the current international guidelines regarding procalcitonin use in disease of the lower respiratory tract.

Introduction of the harmonised respiratory physiotherapy curriculum.

Abstract: Building on the core syllabus for postgraduate training in respiratory physiotherapy, published in 2014, the European Respiratory Society (ERS) respiratory physiotherapy task force has developed a harmonised and structured postgraduate curriculum for respiratory physiotherapy training. The curriculum outlines the knowledge, skills and attitudes which must be mastered by a respiratory physiotherapist working with adult or paediatric patients, together with guidance for minimal clinical exposures, and forms of learning and assessment. This article presents the rationale, methodology and content of the ERS respiratory physiotherapy curriculum. The full curriculum can be found in the supplementary material.

Hot topics and current controversies in community-acquired pneumonia

Abstract: Community-acquired pneumonia (CAP) is one of the most common infectious diseases, as well as a major cause of death both in developed and developing countries, and it remains a challenge for physicians around the world. Several guidelines have been published to guide clinicians in how to diagnose and take care of patients with CAP. However, there are still many areas of debate and uncertainty where research is needed to advance patient care and improve clinical outcomes. In this review we highlight current hot topics in CAP and present updated evidence around these areas of controversy.

EOLIA trial: the future of extracorporeal membrane oxygenation in acute respiratory distress syndrome therapy?

Abstract: In the EOLIA trial, early use of ECMO did not significantly improve mortality at 60 days in patients with severe ARDS, but when used as a rescue modality ECMO might help improve survivalhttp://bit.ly/2XOjwSE

Clinical utility of exhaled nitric oxide fraction in the management of asthma and COPD

Abstract: Exhaled nitric oxide fraction (FENO) values can be easily measured using portable analysers and are a surrogate marker of airway eosinophilia. FENO may be useful in diagnosing and monitoring conditions characterised by airway eosinophilia, i.e. asthma and possibly COPD. Many factors other than asthma and COPD affect FENO, especially atopy, which is associated with elevated FENO. One guideline recommends that FENO should be used as part of the diagnostic pathway for asthma diagnosis in adults and children aged >5 years. The role of FENO in monitoring asthma is even less clear, and most guidelines do not recommend its use outside of specialist asthma clinics. Currently, FENO is not recommended for diagnosis or monitoring of COPD. Although FENO is starting to find a place in the management of asthma in children and adults, considerably more research is required before the potential of FENO as an objective measurement in asthma and COPD can be realised. Key points For individuals aged ≥12 years, FENO is not recommended by all guidelines as a test to diagnose asthma (recommended only by the UK National Institute for Health and Care Excellence guideline for asthma symptoms, which are likely to respond to corticosteroid treatment). FENO may be used in conjunction with other investigations to diagnose asthma in 5–16-year-olds where there is diagnostic uncertainty, but further evidence is required. FENO is not recommended as a routine test to monitor all patients with asthma or to titrate asthma treatment. FENO is not recommended for routine clinical testing in adults with COPD. FENO may be useful to identify patients with COPD who could benefit from the use of inhaled corticosteroids (asthma–COPD overlap). Educational aims To understand what factors other than asthma and COPD affect FENO To understand the current controversies in the application of FENO to diagnosis and management of asthma in children To understand the current controversies in the application of FENO to diagnosis and management of asthma and COPD in adults

The electronic nose: emerging biomarkers in lung cancer diagnostics

Abstract: Lung cancer is very common and the most common cause of cancer death worldwide. Despite recent progress in the systemic treatment of lung cancer (checkpoint inhibitors and tyrosine kinase inhibitors), each year, >1.5 million people die due to this disease. Most lung cancer patients already have advanced disease at the time of diagnosis. Computed tomography screening of high-risk individuals can detect lung cancer at an earlier stage but at a cost of false-positive findings. Biomarkers could lead towards a reduction of these false-positive findings and earlier lung cancer diagnosis, and have the potential to improve outcomes and treatment monitoring. To date, there is a lack of such biomarkers for lung cancer and other thoracic malignancies, although electronic nose (e-nose)-derived biomarkers are of interest. E-nose techniques using exhaled breath component measurements can detect lung cancer with a sensitivity ranging from 71% to 96% and specificity from 33 to 100%. In some case series, such results have been validated but this is mostly using internal validation and hence, more work is needed. Furthermore, standardised sampling and analysis methods are lacking, impeding interstudy comparison and clinical implementation. In this narrative review, we provide an overview of the currently available data on E-nose technology for lung cancer detection.

COPD treatment choices based on blood eosinophils: are we there yet?

Abstract: Eosinophils are increasingly being recognised as an important characteristic feature of COPD. Patients with COPD and eosinophilic inflammation tend to respond to steroid therapy; however, many questions remain regarding the optimum measurement. Eosinophilic inflammation may be defined based on various sampling techniques, including eosinophil levels in blood, sputum, bronchoalveolar lavage or biopsy, which leads to inconsistencies in its definition. Blood eosinophils may increase in conjunction with sputum eosinophils during COPD exacerbations and therefore may be a good surrogate marker of airway eosinophilic inflammation. However, the timing of the blood eosinophil measurement, the stability of the eosinophil count and the threshold used in different studies are variable. The use of blood eosinophil count to direct biological therapies in COPD has also had variable outcomes. Eosinophilic inflammation has an important role in COPD management; however, its use as the optimum biomarker still needs further investigation. Key points Eosinophilia may play a significant role in the pathogenesis of COPD. Eosinophilic inflammation in COPD can be steroid responsive; however, eosinophilic inflammation is variable, and caution needs to be taken with measurements and the thresholds used. The long-term effects of reducing eosinophil levels in COPD is unclear. Educational aims To explore current knowledge of eosinophils in COPD. To explore the relationship between eosinophilia and corticosteroid use. To understand the limitations of assessing and using eosinophilia in COPD.

The role of cognitive behavioural therapy in living well with COPD

Abstract: Psychological ill health is very common in COPD; CBT may be a key step towards improving the care of COPD patients http://ow.ly/fb8j30onfPj.

Does aggressive management of solitary pulmonary nodules pay off

Abstract: Indeterminate solitary pulmonary nodules (SPNs), measuring up to 3 cm in diameter, are incidental radiological findings. The ever-growing use of modern imaging has increased their detection. The majority of those nodules are benign; however, the possibility of diagnosing early-stage lung cancer still stands. Guidelines for the management of SPNs have never been validated in prospective comparative studies. Positron emission tomography (PET) is a useful tool to provide functional information on SPNs. However, overall sensitivity and specificity of PET in detecting malignant SPNs of at least 10 mm in diameter are about 90% and false-negative results are reported. The development of video-assisted thoracic surgery has provided minimally invasive diagnosis and treatment of SPNs. In our series, 105 patients underwent surgery based on combined increased 18F-labelled 2-fluoro-2-deoxy-d-glucose (FDG) uptake on PET computed tomography and radiological features (morphology and density) without prior histological confirmation. We detected 26 false negatives (24.8%) and only nine false positives (8.57%). Therefore, our minimally invasive surgical approach prevented 25% of patients with lung cancer from a delayed treatment versus only 9% undergoing “overtreatment”. In our monocentric cohort, patients with SPNs with large diameter, irregular outline, no calcifications, central location, increased FDG uptake and/or subsolid aspect benefited from a primary surgical resection.

Hot topics and current controversies in non-cystic fibrosis bronchiectasis

Abstract: Non-cystic fibrosis bronchiectasis (NCFB) is a neglected and orphan disease with poor advances through the 20th century. However, its prevalence is rising and with this come new challenges for physicians. Few guidelines are available to guide clinicians on how to diagnose and manage patients with NCFB. Many areas of debate persist, and there is lack of consensus about research priorities most needed to advance patient care and improve clinical outcomes. In this review, we highlight the current hot topics in NCFB and present updated evidence to inform the critical areas of controversy. Key points Postural drainage, active cycle of breathing techniques and pulmonary rehabilitation are non-pharmacological treatment options that should be offered to all patients with non-cystic fibrosis bronchiectasis (NCFB). Eradication of Pseudomonas aeruginosa (PA) colonisation in patients without an acute exacerbation remains debatable. Sputum cultures are the leading and most readily available tool to detect patients with chronic colonisation by PA and should be performed in all patients with NCFB. Antibacterial monoclonal antibodies and vaccine studies have shown promising results in the prevention of chronic colonisation with PA and should stimulate new studies in NCFB. NCFB patients colonised with PA are at more risk of a rapid decline in lung function, worsening quality of life and more hospital admissions. Dual therapy is a promising option for the management of patients with PA-related exacerbations. Patients with PA-related exacerbations benefit from prolonged courses of antibiotics (i.e. 14 days) but emerging and future studies, including dual therapy, may show promising results with shorter courses. Endophenotyping bronchiectasis to address its inherent heterogeneity is a promising avenue for future investment and research.

Use of the terms “overdiagnosis” and “misdiagnosis” in the COPD literature: a rapid review

Abstract: Challenges in the diagnostic process of chronic obstructive pulmonary disease (COPD) can result in diagnostic misclassifications, including overdiagnosis. The term “overdiagnosis” in general has been associated with variable definitions. In connection with efforts to reduce low-value care, “overdiagnosis” has been defined as a true positive diagnosis of a condition that is not associated with any harm in the diagnosed person. It is, however, unclear how the term “overdiagnosis” is used in the COPD literature. We conducted a rapid review of the literature to explore how the terms “overdiagnosis” and “misdiagnosis” are used in the context of COPD. Electronic searches of Medline were conducted from inception to October 2018, to identify primary studies that reported on over- and/or misdiagnosis of COPD using these terms. 28 articles were included in this review. Overdiagnosis and misdiagnosis in COPD were found to be used to describe five main concepts: 1) physician COPD diagnosis despite normal spirometry (14 studies); 2) discordant results for COPD diagnosis based on different spirometry-based definitions for airflow obstruction (10 studies); 3) COPD diagnosis based on pre-bronchodilator spirometry results (three studies); 4) comorbidities (e.g. heart failure or asthma) that affect spirometry and have clinical features which overlap with COPD (two studies); and 5) normalisation of abnormal (post-bronchodilator) spirometry at follow-up (one study). The terms “overdiagnosis” and “misdiagnosis” were often used interchangeably and almost always referred to a false positive diagnosis. Performing (technically correct) spirometry with correct interpretation of the results could probably reduce misdiagnosis in a large proportion of the misdiagnosed cases of COPD. In addition, guidelines need to provide a more acceptable consensus spirometric definition of airflow obstruction. Key points In the COPD literature, the terms “overdiagnosis” and “misdiagnosis” are often used interchangeably and almost always refer to a false positive diagnosis. Use of spirometry with correct interpretation of the results can avoid a substantial proportion of cases of misdiagnosis of COPD. Educational aims To explore the use of the terms “overdiagnosis” and “misdiagnosis” in the COPD literature. To identify the main sources of overdiagnosis and misdiagnosis in COPD.

Con: should asymptomatic patients with moderate-to-severe OSA be treated?

Abstract: In a large proportion of patients with moderate-severe OSA who do not report daytime sleepiness there is no convincing evidence at present that CPAP or similar treatments provide benefit for associated medical disorders, such as hypertension and diabetes http://ow.ly/qqqi30nok4d.

Protracted bacterial bronchitis is a precursor for bronchiectasis in children: Myth or maxim?

Abstract: Recognising the link between protracted bacterial bronchitis and bronchiectasis creates an opportunity to understand the pathobiology of early suppurative endobronchial lung disease and prospects for the development of effective and early interventions http://bit.ly/2K3ikI6.

Biomarkers in respiratory diseases.

Abstract: The December issue of Breathe focuses on biomarkers in respiratory diseases: read the introductory editorial by Chief Editor @ClaudiaCDoblerhttp://bit.ly/36nzAiW

Transfer coefficient of the lung for carbon monoxide and the accessible alveolar volume: clinically useful if used wisely.

Abstract: Transfer coefficient of the lung for carbon monoxide (KCO) and alveolar volume (VA) increase the yield of clinical information obtained from transfer factor of the lung for carbon monoxide (TLCO) measurements in clinical practicehttp://ow.ly/AVgu30na1vu

Pro: should asymptomatic patients with moderate-to-severe OSA be treated?

Abstract: Substantial evidence points to a benefit with CPAP on cardiovascular and metabolic outcomes in asymptomatic patients with moderate-to-severe obstructive sleep apnoea http://ow.ly/FUxN30nkTqU.

Pregnant pause: should we screen for sleep disordered breathing in pregnancy?

Abstract: Physiological and hormonal changes in pregnancy can contribute towards sleep disordered breathing in pregnant women (SDBP). When present, SDBP increases the risk of several adverse maternal and fetal outcomes independent of factors such as age, weight and pre-existing maternal comorbidities. SDBP is underdiagnosed and may be hard to recognise because the presentation can be difficult to differentiate from normal pregnancy and the severity may change over the course of gestation. Timely intervention seems likely to help reduce adverse outcomes, but the relative benefits of intervention are still unclear. The definition of what constitutes a sleep-related breathing “disorder” in pregnancy may be different to the general population and so traditional thresholds for intervention may not be relevant in pregnancy. Any modifications to the disease definition in this group, or implementation of more intensive screening, may result in overdiagnosis. Further research is needed to help clinicians evaluate the balance of benefits and harms in this process. Until this is clearer there is a strong imperative for shared decision making in screening and treatment decisions, and screening programmes should be monitored to assess whether improved outcomes can be achieved at the healthcare system level. Key points Untreated sleep disordered breathing in pregnancy poses risks to maternal and fetal wellbeing, but it is underdiagnosed. Careful approaches to screening could improve rates of diagnosis, but thresholds for and benefits of intervention are unclear. Clinical guidelines and screening programmes for sleep disordered breathing in pregnancy need to consider the potential harms of overdiagnosis and should involve shared decision making and careful monitoring of outcomes relevant to the individual. Educational aims Explore current knowledge of the prevalence of sleep disordered breathing in the pregnant population. Explore the relationship between sleep disordered breathing and adverse outcomes. Understand the approaches to diagnosis and management of sleep disordered breathing in pregnancy. Explore issues around screening, underdiagnosis and overdiagnosis in the context of sleep disordered breathing in pregnancy.

Low-dose computed tomography instead of radiography in suspected pneumonia

Abstract: Overdiagnosis, as well as (to a lesser extent) underdiagnosis, of pneumonia on chest radiographs is common. Low-dose CT chest can potentially be helpful, especially in cases of intermediate probability of pneumonia on chest radiography. http://ow.ly/265z30n1Mox.

Assessing the effects of inspiratory muscle training in a patient with unilateral diaphragm dysfunction.

Abstract: Patients with diaphragm dysfunction experience exertional dyspnoea. Respiratory muscle function assessments can identify breathing abnormalities and IMT might help to reduce symptoms (mostly via improvements in non-diaphragmatic muscles). http://bit.ly/2QdxNFP.

Workplace-based assessment: how to use case-based discussion as a formative assessment

Abstract: Workplace-based assessments are increasingly used as a way of gaining insight into clinician performance in real-life situations. Although some can be used to inform a summative (pass/fail) assessment, many have a much greater role in the formative assessment of trainees, and can be used as tools for teaching and training and in identifying the development needs of trainees. There is considerable variation between different European countries in the use of formative, workplace-based assessment, such as a structured case-based discussion (CbD), during training. This article gives an overview of how to use CbD as a formative assessment for higher specialist trainees, and gives access to a downloadable record form which can be used by trainers.