Bronchoalveolar Lavage Lymphocytes in the Diagnosis of Hypersensitivity Pneumonitis among Patients with Interstitial Lung Disease: A Systematic Review

RATIONALE: Hypersensitivity Pneumonitis (HP) is an interstitial lung disease (ILD) characterized by inflammation and/or fibrosis in response to an inhalational exposure. OBJECTIVE: To determine the value of bronchoalveolar lavage (BAL) fluid lymphocyte cellular analysis in the detection of HP among patients with newly detected ILD. METHODS: This systematic review was undertaken in the context of development of an American Thoracic Society (ATS), Japanese Respiratory Society (JRS), and Asociación Latinoamericana del Tórax (ALAT) clinical practice guideline. The clinical question was, should patients with newly detected ILD undergo BAL fluid lymphocyte analysis to diagnose HP? Medline, Embase, and grey literature were searched through October 2019. Studies that reported the percentage of BAL fluid lymphocytes for various ILDs were selected for inclusion. Meta-analyses compared the mean percentage of BAL fluid lymphocytes among patients with HP to that among patients with Idiopathic Pulmonary Fibrosis (IPF) or sarcoidosis. The sensitivity and specificity by which various percentages of BAL fluid lymphocytes distinguish HP from IPF and sarcoidosis were also evaluated. RESULTS: Eighty-four articles were selected. No randomized trials or observational studies were identified that compared BAL fluid lymphocyte analysis to no BAL fluid lymphocyte analysis in patients with ILD. Included studies were case series describing BAL fluid cell differentials in patients with various ILDs. The percentage of BAL fluid lymphocytes was significantly higher in both fibrotic and nonfibrotic HP compared to IPF. Similarly, the percentage of BAL fluid lymphocytes was significantly higher in both fibrotic and nonfibrotic HP compared to sarcoidosis. A threshold of 20% BAL fluid lymphocytes distinguished fibrotic HP from IPF with a sensitivity and specificity of 69% and 61% respectively, and nonfibrotic HP from IPF with a sensitivity and specificity of 95% and 61% respectively. It distinguished fibrotic HP from sarcoidosis with a sensitivity and specificity of 69% and 26% respectively, and nonfibrotic HP from sarcoidosis with a sensitivity and specificity of 95% and 26% respectively. CONCLUSION: The percentage of BAL fluid lymphocytes is higher in HP than IPF or sarcoidosis. However, a threshold that distinguishes HP from IPF or sarcoidosis with both high sensitivity and high specificity was not identified

Updated guidance on the management of COVID-19:from an American Thoracic Society/European Respiratory Society coordinated International Task Force (29 July 2020)

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-coronavirus-2. Consensus suggestions can standardise care, thereby improving outcomes and facilitating future research. METHODS: An International Task Force was composed and agreement regarding courses of action was measured using the Convergence of Opinion on Recommendations and Evidence (CORE) process. 70% agreement was necessary to make a consensus suggestion. RESULTS: The Task Force made consensus suggestions to treat patients with acute COVID-19 pneumonia with remdesivir and dexamethasone but suggested against hydroxychloroquine except in the context of a clinical trial; these are revisions of prior suggestions resulting from the interim publication of several randomised trials. It also suggested that COVID-19 patients with a venous thromboembolic event be treated with therapeutic anticoagulant therapy for 3 months. The Task Force was unable to reach sufficient agreement to yield consensus suggestions for the post-hospital care of COVID-19 survivors. The Task Force fell one vote shy of suggesting routine screening for depression, anxiety and post-traumatic stress disorder. CONCLUSIONS: The Task Force addressed questions related to pharmacotherapy in patients with COVID-19 and the post-hospital care of survivors, yielding several consensus suggestions. Management options for which there is insufficient agreement to formulate a suggestion represent research priorities.status: Published onlin

Questionnaires or Serum IgG Testing in the Diagnosis of Hypersensitivity Pneumonitis among Patients with Interstitial Lung Disease

RATIONALE: Hypersensitivity Pneumonitis (HP) results from exposure to a variety of stimuli, which are challenging to identify. Questionnaires and serum IgG testing are methods to identify potentially causative exposures. OBJECTIVE: To perform a systematic review to determine the usefulness of questionnaires and serum IgG testing in identifying exposures that may have caused HP. METHODS: This systematic review informed an international, multi-disciplinary panel that developed a clinical practice guideline on the diagnosis of HP for the American Thoracic Society (ATS), Japanese Respiratory Society (JRS), and Asociación Latinoamericana del Tórax (ALAT). MEDLINE, the Cochrane Library, and EMBASE were searched from January 1946 through October 2019 for studies that utilized a questionnaire or serum IgG testing to identify exposures that may have caused HP. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to appraise the quality of the evidence. RESULTS: Searches identified 1,141 and 926 potentially relevant articles for questionnaires and serum IgG testing, respectively. The full texts of 32 and 49 articles, respectively, were reviewed. Two observational studies for questionnaires and 17 observational studies for serum IgG testing were selected. Questionnaires were better at detecting potentially relevant exposures compared to clinical history (100% vs. 26%, RR 3.80, 95% CI 1.79-8.06) and serum IgG testing (100% vs. 63%, RR 1.58, 95% CI 1.12-2.23), but were not different compared to serum IgG plus bronchial challenge testing (59% vs. 65%, RR 0.90, 95% CI 0.65-1.24). Longer, detailed questionnaires were more likely to identify potential exposures. Only 70% of potential exposures identified by questionnaires were subsequently confirmed by environmental testing. Serum IgG testing distinguished HP from healthy exposed and unexposed controls with high sensitivity (90% and 92% respectively) and high specificity (91% and 100% respectively) but did not distinguish HP as effectively from interstitial lung diseases (sensitivity 83% and specificity 68%). CONCLUSION: Using a questionnaire may help clinicians identify potentially relevant exposures when evaluating a patient with newly identified ILD for HP. Serum IgG testing may also identify potentially relevant exposures, but it is poor at distinguishing HP from other types of ILD

Transbronchial Biopsy and Cryobiopsy in the Diagnosis of Hypersensitivity Pneumonitis among Patients with Interstitial Lung Disease

RATIONALE: Hypersensitivity Pneumonitis (HP) is an interstitial lung disease (ILD) whose diagnosis is based on clinical, radiological, and pathological findings. The evidence supporting transbronchial forceps lung biopsy (TBBx) and transbronchial lung cryobiopsy (TBLC) as sampling techniques to diagnose HP in patients with newly detected ILD has not been reviewed systematically. OBJECTIVE: A systematic review was performed to assess the diagnostic yield and complication rates of TBBx or TBLC in patients with newly detected ILD whose differential diagnosis includes HP and to inform the development of the American Thoracic Society (ATS), Japanese Respiratory Society (JRS), and Asociación Latinoamericana del Tórax (ALAT) clinical practice guideline on the diagnosis of HP. METHODS: Medline, EMBASE and the Cochrane Library were searched through October 2019. Studies that enrolled patients with ILD and reported the diagnostic yield of TBBx or TBLC were selected for inclusion. Data related to diagnostic yield and safety outcomes were extracted and then pooled across studies via meta-analysis. The quality of the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS: Histopathologic diagnostic yield (number of procedures that yielded a histopathologic diagnosis divided by the total number of procedures performed) of TBBx and TBLC were 37% (95% CI 32-42%) and 82% (95% CI 78-86%) respectively among patients with ILD. Among those diagnosed by TBBx, the proportion with HP could not be determined. However, among those diagnosed by TBLC, 13.4% had HP. TBBx was complicated by moderate to severe bleeding, severe bleeding, and pneumothorax in 4% (95% CI 0-8%), 0% (95% CI 0-1%), and 7% (95% 2-13%) of patients, respectively. TBLC was complicated by any bleeding, severe bleeding, and pneumothorax in 11% (95% CI 7-15%), 0% (95% CI 0-1%), and 11% (95% 9-14%) of patients, respectively. The quality of the evidence was very low due to the uncontrolled study designs, lack of consecutive enrollment, and inconsistent results. CONCLUSION: Very low quality evidence indicated that TBLC had a higher diagnostic yield than TBBx among patients with ILD, although complications were more common with TBLC

Use and outcomes of peripheral vasopressors in early sepsis-induced hypotension across Michigan hospitals: a retrospective cohort study

Vasopressors are traditionally administered via central access, but newer data suggest peripheral administration may be safe and avoid delays and complications associated with central line placement. How commonly are vasopressors initiated through peripheral IVs in routine practice? Is vasopressor initiation route associated with in-hospital mortality? This retrospective cohort study included adults hospitalized with sepsis (11/2020-9/2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. 594 patients received vasopressors within 6 hours of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594, 67.3%). Patients with peripheral vs central initiation were similar; body mass index was the only patient factor independently associated with initiation route (aOR of peripheral initiation [per 1 kg/m2 increase]: 0.98, 95%CI: 0.97-1.00, p=0.015). Hospital had a large impact on initiation route (median OR: 2.19, 95%CI: 1.31-3.07). Compared to central, peripheral initiation was faster (median 2.5 vs 2.7 hours from hospital arrival, p=0.002) but associated with less initial norepinephrine use (84.3% vs 96.8%, p=0.001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%, aOR 0.66, 95%CI: 0.39-1.12). There was no documented tissue injury from peripheral vasopressors. Of patients with peripheral initiation, 135/400 (33.8%) never had a central line placed. Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, there was wide practice variation not explained by patient case-mix and lower use of first-line norepinephrine with peripheral administration, suggesting additional standardization may be needed

The Effect of Hospital Discharge with Empiric Noninvasive Ventilation on Mortality in Hospitalized Patients with Obesity Hypoventilation Syndrome: An Individual Patient Data Meta-Analysis

International audienc

Diagnosis of Hypersensitivity Pneumonitis in Adults An Official ATS/JRS/ALAT Clinical Practice Guideline

BACKGROUND: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort between the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana de Tórax. METHODS: Systematic reviews were performed for six questions. The evidence was discussed and then recommendations formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and hypersensitivity pneumonitis (HP) using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS: The guideline committee defined HP and clinical, radiographic, and pathologic features were described. HP was classified into non-fibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed upon. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with non-fibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage fluid for lymphocyte cellular analysis, as well as suggestions for transbronchial lung biopsy and surgical lung biopsy. For patients with fibrotic HP, suggestions were made in favor of obtaining bronchoalveolar lavage fluid for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions. CONCLUSIONS: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates

Diagnosis of Hypersensitivity Pneumonitis in Adults An Official ATS/JRS/ALAT Clinical Practice Guideline

Background: This guideline addresses the diagnosis of hypersensitivity pneumonitis (HP). It represents a collaborative effort among the American Thoracic Society, Japanese Respiratory Society, and Asociación Latinoamericana del Tórax.Methods: Systematic reviews were performed for six questions. The evidence was discussed, and then recommendations were formulated by a multidisciplinary committee of experts in the field of interstitial lung disease and HP using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach.Results: The guideline committee defined HP, and clinical, radiographic, and pathological features were described. HP was classified into nonfibrotic and fibrotic phenotypes. There was limited evidence that was directly applicable to all questions. The need for a thorough history and a validated questionnaire to identify potential exposures was agreed on. Serum IgG testing against potential antigens associated with HP was suggested to identify potential exposures. For patients with nonfibrotic HP, a recommendation was made in favor of obtaining bronchoalveolar lavage (BAL) fluid for lymphocyte cellular analysis, and suggestions for transbronchial lung biopsy and surgical lung biopsy were also made. For patients with fibrotic HP, suggestions were made in favor of obtaining BAL for lymphocyte cellular analysis, transbronchial lung cryobiopsy, and surgical lung biopsy. Diagnostic criteria were established, and a diagnostic algorithm was created by expert consensus. Knowledge gaps were identified as future research directions.Conclusions: The guideline committee developed a systematic approach to the diagnosis of HP. The approach should be reevaluated as new evidence accumulates.status: publishe