Pulmonary Flashcards
MANDALA
SABA + ICS for rescue inhalers in asthma reduced exacerbation rate in Mod-severe asthma. NEJM 2022.
Novel-START
LABA + ICS (Symbicort) used for rescue inhaler in mild asthma reduced exacerbations. NEJM 2019.
SMART
LABA (Salmeterol) alone increased mortality in asthma when not used with an ICS, especially in African Americans. CHEST 2006.
FLAME
LABA + LAMA (indacaterol+glycopyrronium) reduced AECOPD compared to LABA + ICS (salmeterol+fluticasone) in COPD with mMRC>=2. NEJM 2016.
NETT
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.
NOTT
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.
REDUCE
5 days of steroids for AECOPD was non-inferior to 14 day course. JAMA 2013.
TORCH
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.
UPLIFT
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.
WISDOM
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.
NLST
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.
MIST2
tPA/DNAse together, administered intrapleurally, reduces size of empyema. NEJM 2011.
MOPETT
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.
PEITHO
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.
PREPIC 2
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.
INPULSIS & INPULSIS-2
Nintedanib (OFEV) reduces decline of FEV1 in IPF. NEJM 2014.
INBUILD
Nintedanib (OFEV) reduces decline of FEV1 in progressive fibrosing ILD. No mortality or QoL improvement.
ASCEND
Pirfenidone (Esbriet) reduces decline of FEV1, 6MWT and progression-free survival in IPF. NEJM 2014.
CAPACITY
Pirfenidone (Esbriet) reduces FEV1 in a dose-dependent fashion in IPF. Lancet 2011.
SYGMA & SYGMA-2
PRN ICS-LABA was non-inferior to BID ICS in mild asthma for exacerbations, but was inferior in controlling symptoms. NEJM 2018.
AIR2
Bronchial thermoplasty improved symptoms & severe exacerbations in severe asthma. Sham-controlled. AJRCCM 2010.
AMAZES
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.
TORCH
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.
FLAME
In COPD, LABA/LAMA (indacaterol-glycopyrronium) reduced AECOPD. NEJM 2016.
IMPACT
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.
TRIBUTE
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.
ETHOS
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.
SUNSET
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.
REACT
In chronic bronchitis on ICS/LABA (usu w/ LAMA), roflumilast decreased exacerbations. Lancet 2015.
Azithromycin for Prevention of Exacerbations of COPD
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.
ADJUST-PE
Supports using age-adjusted d-dimer in low-probability patients to rule out PE. JAMA 2014.
PIOPED
VQ scans are useful if high probability or normal, but nothing in between. JAMA 1990.
