pulmonary review - chest world congress madrid 2014

LITERATURE REVIEW

• Advisor to Esteve Teijin in the area of

home respiratory therapy

• I have no other relevant financial

relationships to disclose

Conflict of interest

• I will not be discussing off-label uses.

INDEX

• Pneumonia

• Lung Cancer

• Pulmonary Fibrosis

• Pneumonia

• Lower respiratory tract infection the third most common cause of death in the world (3.5 million deaths/year)

• Streptococcus pneumoniae major cause of morbidity and mortality

worldwide (bacteremia, meningitis, pneumonia and acute otitis media)

• Serious disease mainly in children under two years of age and in elderly

• 1.6 million deaths / year estimated in 2005 (0.7–1 million children)

• PPSV23 less effective than expected

• Pneumococcal strains nonsusceptible to penicillin and erythromycin could have reached 41% by 2004 in the absence of a PCV

PNEUMONIA: INTRODUCTION

WHO, 2013 (http://www.who.int/mediacentre/factsheets/fs310/en/index.html).

Jackson LA. An OficialPublication of the Infectious Diseases Society of America

2008;47:1328–38.

Richard G. et al. N Engl J Med 2014;370:543-51.

McCormick et al. AW Nat Med 2003;9:424-30.

PNEUMONIA

http://www.who.int/mediacentre/factsheets/fs310/en/index.html

Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013

PNEUMONIA

PNEUMONIA

PUBMED search March 2014. Number of publications related to the topic.

• PCV7 introduced in USA in 2000

• Major reduction in the incidence of invasive disease in all age groups

• Aim: the early observed reductions in hospitalizations for pneumonia

were sustained throughout the first decade of PCV7 use?

PNEUMONIA

PNEUMONIA: BACKGROUND


• National Inpatient Sample (NIS)

• 1050 hospitals in 44 States

• ICD-9-CM/ pneumonia as 1st diagnosis or meningitis, septicemia or

empyema + pneumonia as 2nd

PNEUMONIA

PNEUMONIA: METHODS/DATA SOURCES


PNEUMONIA

Average Annual Rates of U.S. Hospitalizations for Pneumonia before and after the Introduction of PCV7, According to Age Group.


Hospitalizations for Pneumonia among U.S. Children.

PNEUMONIA


PNEUMONIA

The annual rates of hospitalization for pneumonia from 1997 through 2009.


PNEUMONIA

Hospitalizations for Pneumonia among U.S. Adults.


PNEUMONIA

Differences in Rates of Hospitalization for Pneumonia from Any Cause 3 Years before and 7 to 9 Years after the Introduction of PCV7.


Rates of In-Hospital Death Related to Pneumonia from Any Cause 3 Years before and 7 to 9 Years after the Introduction of PCV7.

PNEUMONIA


PNEUMONIA: CONCLUSIONS

PNEUMONIA

• Declines in hospitalizations for childhood pneumonia were

sustained during the decade after the introduction of PCV7.

• Substantial reductions in hospitalizations for pneumonia among

adults were also observed.


PNEUMONIA: MESSAGES

PNEUMONIA

Hammit et al. J Infect Dis. Volume 193(11):1487-94 Apr 27, 2006Weinberger, Lancet 2011; 378: 1962–73Letters to the editor. NEJM 369;17 nejm.org october, 2013Singleton, JAMA. 2007;297:1784-1792

• Probably the “herd” effect protects elderly people– Hammit et al. J Infect Dis. Volume 193(11):1487-94 Apr 27, 2006

• Consequences of Serotype replacement There is not enough datato evaluate the impact

– Weinberger, Lancet 2011; 378: 1962–73

• Species replacement Other pathogens like Staphylococcus aureusis a concern

– Reed A. Siemieniuk M.D. Letters to the editor. NEJM 369;17 nejm.org october, 2013

• Pneumonia complications (Empyema) seems to arise– Alessando Amaddeo. Letters to the editor. NEJM 369;17 nejm.org october, 2013

• We will have to wait to see the effects on mortality

• A decade of PVC13 is open

INDEX

• Pneumonia

• Lung Cancer

• Pulmonary Fibrosis

• Lung Cancer

• Lung cancer 1.59 million deaths in 2012

• More individuals die from lung cancer than from colon, breast

and prostate cancer combined

• Rx radiographs and sputum screenings didn’t meet the

expectations, mortality?

• IELCAP results opened the door to RCTs

WHO Fact sheet N°297. Feb 2014. http://www.who.int/mediacentre/factsheets/fs297/en/

Detterbeck, CHEST 2013; 143(5)(Suppl):e78S–e92S

Shlomi, Eur Respir J 2014; in press

LUNG CANCER: INTRODUCTION

LUNG CANCER

http://www.who.int/mediacentre/factsheets/fs297/en/

LUNG CANCER

RCT’S:

• DANTE A randomized study of lung cancer screening with spiral

computed tomography: three-year results from the DANTE trial.

• DLCST CT screening for lung cancer brings forward early disease. The

randomised Danish Lung Cancer Screening Trial: status after five

annual screening rounds with low-dose CT.

• NELSON Volumetric computed tomography screening for lung cancer:

three rounds of the NELSON trial.

• ITALUNG Four-year results of low-dose CT screening and nodule

management in the ITALUNG trial.

• NLST NLST Research Team

• >86.000 patients included in total

Am J Respir Crit Care Med. 2009 Sep 1;180(5):445-53.

Thorax. 2012 Apr;67(4):296-301.Singleton, JAMA. 2007;297:1784-1792

Eur Respir J. 2013 Dec;42(6):1659-67.

J Thorac Oncol. 2013 Jul;8(7):866-75.

N Engl J Med. 2011 Aug 4;365(5):395-409.

Inclusion criteria:

• 55–74 years

• ≥30 pack-years

• Former smokers (within the previous 15 years)

• LDCT vs. chest radiography – 3 annual rounds: T0, T1, T2

• For LDCT, noncalcified nodules of ≥4 mm (maximum diam.) -

positive

NLST Research Team, N Engl J Med 2011;365:395-409.

LUNG CANCER


LUNG CANCER

Aberle, N Engl J Med 2013;369:920-31.

LUNG CANCER


LUNG CANCER

• LDCT diagnosed more cancer (1,1% vs 0,7%)

• More stage I Ca in LDCT group

• Tendency of stage-shift

• Sensibility of LDCT 93,8% and Specificity 73,4%

• In LDCT group more positive screenings and more Dg procedures


LUNG CANCER

LUNG CANCER


Data extracted from original

LUNG CANCER


Sensitivity, specificity and positive predictive value for LDCT in T1 and T2.Data extracted from original

LUNG CANCER


T0; Number of patients diagnosed of lung cancer according to Stage.Data extracted from original

LUNG CANCER


T1; Number of patients diagnosed of lung cancer acording to Stage.Data extracted from original

LUNG CANCER


T2; Number of patients diagnosed of lung cancer acording to Stage.Data extracted from original

LUNG CANCER


T1; PPV according to lung nodule size.Data extracted from original

LUNG CANCER



• Low-dose CT detects more lung cancers than radiography

• Stage shift toward early-stage in non–small-cell lung cancers

• Performance characteristics of low-dose CT may be

enhanced

LUNG CANCER

LUNG CANCER: CONCLUSIONS


• Selection criteria–Detterbeck, CHEST 2013; 143(5)(Suppl):e78S–e92S

–Kovalchik, N Engl J Med 2013;369:245-54

• Results may improve with the volumetric study –Horeweg, Eur Respir J 2013; 42: 1659–1667

• Results may also improve with pet-ct (>8mm) –Shlomi, Eur Respir J. 2014 Feb 13.

• Awareness of concept of slow-growing lung cancer!–Infante, Eur Respir J 2013; 42: 1706–1722

• Biomarkers as additional screening tool–Sozzi, J Clin Oncol 2014 32:768-773.

LUNG CANCER: MESSAGES 1

LUNG CANCER

Detterbeck, CHEST 2013; 143(5)(Suppl):e78S–e92SHoreweg, Eur Respir J 2013; 42: 1659–1667Shlomi, Eur Respir J. 2014 Feb 13.Infante, Eur Respir J 2013; 42: 1706–1722Kovalchik, N Engl J Med 2013;369:245-54

Benefits

• Effect on mortality

• Effect on smoking

behavior

Harms

• False positives

• Diagnostic procedure

complications

• Overdiagnosis

• Radiation exposure

• Quality of life

Screening could be performed such

that benefits outweigh the harms.

LUNG CANCER

Bach, JAMA. 2012;307(22):2418-2429

LUNG CANCER: MESSAGES 2

INDEX

• Pneumonia

• Lung Cancer

• Pulmonary Fibrosis• Pulmonary Fibrosis

PULMONARY FIBROSIS: INTRODUCTION

PULMONARY FIBROSIS

Navaratnam et al., Thorax 2011;66(6):462-7

PULMONARY FIBROSIS

Kern et al., Ann Intern Med 1998;129(4):261-72

PULMONARY FIBROSIS

Taken from: http://cxjinxing.en.alibaba.com/product/514495564-213102141/Nylon_flock_powder.html

PULMONARY FIBROSIS

Turcotte, CHEST 2013; 143(6):1642–1648

PULMONARY FIBROSIS

Navaratnam et al., Thorax 2011;66(6):462-7


PULMONARY FIBROSIS

Turcotte, CHEST 2013; 143(6):1642–1648

Natural history of FWL disease. Adapted from original

PULMONARY FIBROSIS

Turcotte, CHEST 2013; 143(6):1642–1648

• In summary, the natural history of FWL includes complete resolution;

persistent, but stable ILD with a restrictive pulmonary function deficit;

mixed obstructive/restrictive pulmonary function deficits; and

progressive fibrosis leading to respiratory failure, pulmonary

hypertension, and death.

PULMONARY FIBROSIS

PULMONARY FIBROSIS: CONCLUSIONS

Turcotte, CHEST 2013; 143(6):1642–1648

PULMONARY FIBROSIS

• Natural history of the interstitial lung diseases is not uniform and even

can be reversed

• It is important, when possible, to determine the cause of the disease–Am J Respir Crit Care Med. 2014 Jan 1;189(1):48-56.

PULMONARY FIBROSIS: MESSAGES

PULMONARY FIBROSIS

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pulmonary review - chest world congress madrid 2014

Health & Medicine

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