Pulmonary

Question 1

MANDALA

Answer 1

SABA + ICS for rescue inhalers in asthma reduced exacerbation rate in Mod-severe asthma. NEJM 2022.

Question 2

Novel-START

Answer 2

LABA + ICS (Symbicort) used for rescue inhaler in mild asthma reduced exacerbations. NEJM 2019.

Question 3

SMART

Answer 3

LABA (Salmeterol) alone increased mortality in asthma when not used with an ICS, especially in African Americans. CHEST 2006.

Question 4

FLAME

Answer 4

LABA + LAMA (indacaterol+glycopyrronium) reduced AECOPD compared to LABA + ICS (salmeterol+fluticasone) in COPD with mMRC>=2. NEJM 2016.

Question 5

NETT

Answer 5

Lung volume reduction surgery in patients with severe bilateral emphysema does not improve survival but is associated with improved exercise tolerance when compared to medical therapy alone. A survival benefit may be present for low- and moderate-risk patients with upper lobe emphysema and low exercise capacity (25W for women, 40W for men). NEJM 2003.

Question 6

NOTT

Answer 6

In patients with COPD and hypoxemia at rest, continuous oxygen therapy significantly reduces mortality when compared to nocturnal oxygen therapy. Annals of Internal Medicine 1980.

Question 7

REDUCE

Answer 7

5 days of steroids for AECOPD was non-inferior to 14 day course. JAMA 2013.

Question 8

TORCH

Answer 8

In COPD, combo LABA/ICS reduced AECOPD compared to placebo or either component, but there was only a trend towards improved survival at 3 years. NEJM 2007.

Question 9

UPLIFT

Answer 9

Tiotropium did not significantly slow the decline of FEV1, but did reduce the incidence of COPD exacerbations among individuals with moderate to severe COPD, and showed a trend towards improved survival. NEJM 2008.

Question 10

WISDOM

Answer 10

In stable COPD patients on triple therapy, withdraw of ICS was not associated with increase in AECOPD. Minimal worsening of FEV1, uncertain significance. NEJM 2014.

Question 11

NLST

Answer 11

National Lung Cancer Screening Trial - low-dose CT in 30 pack-year smokers, currently smoking or quit within 15 years, aged 55-74. NEJM 2011.

Question 12

MIST2

Answer 12

tPA/DNAse together, administered intrapleurally, reduces size of empyema. NEJM 2011.

Question 13

MOPETT

Answer 13

In patients with submassive PE, low-dose tPA (50mg) reduced pulmonary hypertension. Everyone got heparin. No mortality benefit. Limitations: single center, un-blinded, no bleeding in either group reported. Am J Cardiology 2013.

Question 14

PEITHO

Answer 14

Among patients with submassive PE being treated with unfractionated heparin, administration of tenecteplase reduces a composite endpoint of all-cause mortality or hemodynamic decompensation at 7 days when compared to placebo, though this was driven by reduced hemodynamic decompensation. NEJM 2014.

Question 15

PREPIC 2

Answer 15

In patients with pulmonary embolism at high risk of recurrence, the routine placement of a retrievable IVC filter does not reduce the risk of recurrent pulmonary embolism when compared to anticoagulation alone. JAMA 2015.

Question 16

INPULSIS & INPULSIS-2

Answer 16

Nintedanib (OFEV) reduces decline of FEV1 in IPF. NEJM 2014.

Question 17

INBUILD

Answer 17

Nintedanib (OFEV) reduces decline of FEV1 in progressive fibrosing ILD. No mortality or QoL improvement.

Question 18

ASCEND

Answer 18

Pirfenidone (Esbriet) reduces decline of FEV1, 6MWT and progression-free survival in IPF. NEJM 2014.

Question 19

CAPACITY

Answer 19

Pirfenidone (Esbriet) reduces FEV1 in a dose-dependent fashion in IPF. Lancet 2011.

Question 20

SYGMA & SYGMA-2

Answer 20

PRN ICS-LABA was non-inferior to BID ICS in mild asthma for exacerbations, but was inferior in controlling symptoms. NEJM 2018.

Question 21

AIR2

Answer 21

Bronchial thermoplasty improved symptoms & severe exacerbations in severe asthma. Sham-controlled. AJRCCM 2010.

Question 22

AMAZES

Answer 22

3/wk Azithro in symptomatic severe asthma despite maximum medical therapy did decrease exacerbations. Small, under-powered. Excluded smokers, QTc prolongation and arrhythmias. 20% non-adherence. Lancet 2017.

Question 23

TORCH

Answer 23

In COPD, combo ICS/LABA (salmeterol-fluticasone) (vs placebo) reduced exacerbations (NNT=4) and trended toward improved all-cause-mortality (p=0.52). COPD-mortality improved (p=0.011). More PNA (NNH=17). NEJM 2007.

Question 24

FLAME

Answer 24

In COPD, LABA/LAMA (indacaterol-glycopyrronium) reduced AECOPD. NEJM 2016.

Question 25

IMPACT

Answer 25

For COPD, triple therapy > ICS/LABA > LABA/LAMA for AECOPD. Didn’t look at mortality. Mortality improved with ICS-containing regimens. Criticism is that asthma not excluded and 40% of patients on ICS on enrollment; therefore the LABA/LAMA group had lots of early exacerbations due to ICS withdraw from asthmatics. NEJM 2018.

Question 26

TRIBUTE

Answer 26

For COPD, triple therapy reduced exacerbations (vs LABA/LAMA) by 0.5 AECOPD/yr. More benefit with high sputum eosinophils or chronic bronchitis. Lancet 2018.

Question 27

ETHOS

Answer 27

In COPD, triple therapy lowered each of AECOPD and mortality. Unlike IMPACT, asthma was excluded and results were independent of baseline ICS use. Breztri. NEJM 2020.

Question 28

SUNSET

Answer 28

In stable COPD on triple therapy, de-escalation to LABA/LAMA is safe. 30cc decrease FEV1 and no drop in exacerbations. Subgroup with blood eosinophils >300 had worse FEV1 decline. AJRCCM 2018.

Question 29

REACT

Answer 29

In chronic bronchitis on ICS/LABA (usu w/ LAMA), roflumilast decreased exacerbations. Lancet 2015.

Question 30

Azithromycin for Prevention of Exacerbations of COPD

Answer 30

In severe COPD, adding azithromycin to therapy prolonged time to next exacerbation from 6 to 9 months and improved SGRQ. Tox includes macrolide-resistant nasopharyngeal colonization and hearing loss. Excluded QTc prolongation, but didn’t check it. NEJM 2011.

Question 31

ADJUST-PE

Answer 31

Supports using age-adjusted d-dimer in low-probability patients to rule out PE. JAMA 2014.

Question 32

PIOPED

Answer 32

VQ scans are useful if high probability or normal, but nothing in between. JAMA 1990.