Pulmonary Health Hub

SAN FRANCISCO – Coughing, shortness of breath, and other exercise-related respiratory symptoms substantially limit the ability of children with asthma to participate in normal physical activities.

In addition, many asthmatic children who experience such symptoms are not using short-acting bronchodilators as recommended in national guidelines.

Those are key findings from a national survey of parents that set out to evaluate the impact of exercise-related respiratory symptoms on physical activities of children with asthma.

"Kids with asthma need to be active to be healthy," Dr. Nancy K. Ostrom said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "A lot of them have exercise-induced bronchospasm that needs to be recognized and treated. This is a critical issue for health in the United States right now. If you can’t be physically active, you are not going to be able to be fit."

The telephone survey included 516 parents of children or adolescents with current asthma contacted between Dec. 8, 2009, and Jan. 3, 2010, said Dr. Ostrom, codirector of the San Diego–based Allergy and Asthma Medical Group and Research Center. The study by Dr. Ostrom and her colleagues, known as the EIB Landmark Survey, consisted of 84 questions structured to provide data on demographics, symptoms experienced, and impact of exercise-induced bronchospasm (EIB) on daily function.

More than three-quarters of parents of children with asthma (79%) reported that their child experienced at least one exercise-related respiratory symptom, and nearly half (46%) reported that their child experienced four or more such symptoms. The three most common symptoms were coughing (62%), shortness of breath (61%), and wheezing (53%).

Adolescents were more likely than younger children to avoid activities because of exercise-related respiratory symptoms (32% vs. 22%, respectively). At the same time, parents of children aged 4-12 years reported that asthma limited their child’s ability to participate either "a lot" or "some" in sports/recreation (30%), normal physical exertion (21%), and other outdoor activities (26%). The corresponding figures for adolescents were 21%, 24%, and 54%, respectively.

"That’s a huge number of kids with potential impact," Dr. Ostrom commented. "You tend to learn exercise habits when you’re a child, not when you’re an adult."

Adolescents were also more likely to be limited "a lot" in sports competition, compared with younger children (13% vs. 7%, respectively).

Use of bronchodilators such as albuterol before exercise was infrequent. Only 23% of children and adolescents with asthma took bronchodilators "always" or "most of the time," 19% took them "sometimes," 15% took them rarely, and 42% never took them (1% was unknown).

In their poster, the researchers stated that adherence to controller therapy and prevention of exercise-related symptoms with short-acting bronchodilators "should be optimized per current treatment guidelines." One way to achieve that goal, Dr. Ostrom said, is to ask parents and asthmatic children during office visits if they ever experience shortness of breath, coughing, or other respiratory symptoms during or shortly after physical activity. "The important question is, ‘Does that keep you from what you want to do or what you should be doing from a health standpoint?’ " she said. "Exercise is critical. These health habits need to begin in childhood."

Dr. Ostrom acknowledged certain limitations of the study, including the fact that it surveyed parents, not the children directly.

The study was sponsored by Teva Respiratory. Dr. Ostrom disclosed that she has served in one or more capacities as a consultant, clinical investigator, or speaker for multiple companies, including Teva, GlaxoSmithKline, and Merck.

SAN FRANCISCO – Coughing, shortness of breath, and other exercise-related respiratory symptoms substantially limit the ability of children with asthma to participate in normal physical activities.

In addition, many asthmatic children who experience such symptoms are not using short-acting bronchodilators as recommended in national guidelines.

Those are key findings from a national survey of parents that set out to evaluate the impact of exercise-related respiratory symptoms on physical activities of children with asthma.

"Kids with asthma need to be active to be healthy," Dr. Nancy K. Ostrom said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "A lot of them have exercise-induced bronchospasm that needs to be recognized and treated. This is a critical issue for health in the United States right now. If you can’t be physically active, you are not going to be able to be fit."

The telephone survey included 516 parents of children or adolescents with current asthma contacted between Dec. 8, 2009, and Jan. 3, 2010, said Dr. Ostrom, codirector of the San Diego–based Allergy and Asthma Medical Group and Research Center. The study by Dr. Ostrom and her colleagues, known as the EIB Landmark Survey, consisted of 84 questions structured to provide data on demographics, symptoms experienced, and impact of exercise-induced bronchospasm (EIB) on daily function.

More than three-quarters of parents of children with asthma (79%) reported that their child experienced at least one exercise-related respiratory symptom, and nearly half (46%) reported that their child experienced four or more such symptoms. The three most common symptoms were coughing (62%), shortness of breath (61%), and wheezing (53%).

Adolescents were more likely than younger children to avoid activities because of exercise-related respiratory symptoms (32% vs. 22%, respectively). At the same time, parents of children aged 4-12 years reported that asthma limited their child’s ability to participate either "a lot" or "some" in sports/recreation (30%), normal physical exertion (21%), and other outdoor activities (26%). The corresponding figures for adolescents were 21%, 24%, and 54%, respectively.

"That’s a huge number of kids with potential impact," Dr. Ostrom commented. "You tend to learn exercise habits when you’re a child, not when you’re an adult."

Adolescents were also more likely to be limited "a lot" in sports competition, compared with younger children (13% vs. 7%, respectively).

Use of bronchodilators such as albuterol before exercise was infrequent. Only 23% of children and adolescents with asthma took bronchodilators "always" or "most of the time," 19% took them "sometimes," 15% took them rarely, and 42% never took them (1% was unknown).

In their poster, the researchers stated that adherence to controller therapy and prevention of exercise-related symptoms with short-acting bronchodilators "should be optimized per current treatment guidelines." One way to achieve that goal, Dr. Ostrom said, is to ask parents and asthmatic children during office visits if they ever experience shortness of breath, coughing, or other respiratory symptoms during or shortly after physical activity. "The important question is, ‘Does that keep you from what you want to do or what you should be doing from a health standpoint?’ " she said. "Exercise is critical. These health habits need to begin in childhood."

Dr. Ostrom acknowledged certain limitations of the study, including the fact that it surveyed parents, not the children directly.

The study was sponsored by Teva Respiratory. Dr. Ostrom disclosed that she has served in one or more capacities as a consultant, clinical investigator, or speaker for multiple companies, including Teva, GlaxoSmithKline, and Merck.

SAN FRANCISCO – Coughing, shortness of breath, and other exercise-related respiratory symptoms substantially limit the ability of children with asthma to participate in normal physical activities.

In addition, many asthmatic children who experience such symptoms are not using short-acting bronchodilators as recommended in national guidelines.

Those are key findings from a national survey of parents that set out to evaluate the impact of exercise-related respiratory symptoms on physical activities of children with asthma.

"Kids with asthma need to be active to be healthy," Dr. Nancy K. Ostrom said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "A lot of them have exercise-induced bronchospasm that needs to be recognized and treated. This is a critical issue for health in the United States right now. If you can’t be physically active, you are not going to be able to be fit."

The telephone survey included 516 parents of children or adolescents with current asthma contacted between Dec. 8, 2009, and Jan. 3, 2010, said Dr. Ostrom, codirector of the San Diego–based Allergy and Asthma Medical Group and Research Center. The study by Dr. Ostrom and her colleagues, known as the EIB Landmark Survey, consisted of 84 questions structured to provide data on demographics, symptoms experienced, and impact of exercise-induced bronchospasm (EIB) on daily function.

More than three-quarters of parents of children with asthma (79%) reported that their child experienced at least one exercise-related respiratory symptom, and nearly half (46%) reported that their child experienced four or more such symptoms. The three most common symptoms were coughing (62%), shortness of breath (61%), and wheezing (53%).

Adolescents were more likely than younger children to avoid activities because of exercise-related respiratory symptoms (32% vs. 22%, respectively). At the same time, parents of children aged 4-12 years reported that asthma limited their child’s ability to participate either "a lot" or "some" in sports/recreation (30%), normal physical exertion (21%), and other outdoor activities (26%). The corresponding figures for adolescents were 21%, 24%, and 54%, respectively.

"That’s a huge number of kids with potential impact," Dr. Ostrom commented. "You tend to learn exercise habits when you’re a child, not when you’re an adult."

Adolescents were also more likely to be limited "a lot" in sports competition, compared with younger children (13% vs. 7%, respectively).

Use of bronchodilators such as albuterol before exercise was infrequent. Only 23% of children and adolescents with asthma took bronchodilators "always" or "most of the time," 19% took them "sometimes," 15% took them rarely, and 42% never took them (1% was unknown).

In their poster, the researchers stated that adherence to controller therapy and prevention of exercise-related symptoms with short-acting bronchodilators "should be optimized per current treatment guidelines." One way to achieve that goal, Dr. Ostrom said, is to ask parents and asthmatic children during office visits if they ever experience shortness of breath, coughing, or other respiratory symptoms during or shortly after physical activity. "The important question is, ‘Does that keep you from what you want to do or what you should be doing from a health standpoint?’ " she said. "Exercise is critical. These health habits need to begin in childhood."

Dr. Ostrom acknowledged certain limitations of the study, including the fact that it surveyed parents, not the children directly.

The study was sponsored by Teva Respiratory. Dr. Ostrom disclosed that she has served in one or more capacities as a consultant, clinical investigator, or speaker for multiple companies, including Teva, GlaxoSmithKline, and Merck.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – The 2005 revision of the lung allocation system for U.S. lung transplants succeeded, resulting in fewer patients dying while on the lung waiting list, Dr. Robert M. Kotloff said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Reduced deaths in wait-listed patients "was the major goal" of the revision, "so the LAS [lung allocation system] worked," said Dr. Kotloff, professor of medicine and chief of the section of advanced lung disease and lung transplantation at the University of Pennsylvania in Philadelphia.

The new LAS also triggered other changes in the pattern of U.S. lung transplantations during the subsequent 5 years, some of which took several years to become apparent.

The revised system for allocation of donor lungs shifted the weight of the different pulmonary diseases that lead to lung transplantation, reducing the priority of chronic obstructive pulmonary disease (COPD) and boosting the importance of idiopathic pulmonary fibrosis (IPF). As recently as a decade ago, 45% of U.S. lung transplantations were done in patients with COPD and 20% in those with IPF. Although the gap between the two had narrowed considerably by 2005, that year COPD still remained the leading indication. But by 2007, IPF inched ahead of COPD, and today IPF is the leading reason why U.S. patients receive a lung transplant, Dr. Kotloff said.

"IPF is a no-brainer for listing," with a median survival of 3-4 years, and with half of IPF deaths occurring after a sudden patient decline, he said. Although some patients have an indolent form of IPF, "what’s unsettling is that half of IPF deaths are sudden and unpredictable, occurring in patients who recently had stable or mild disease. We have all had IPF patients who were told they weren’t sick enough to list and to return in 6 months – who then show up in the ICU on a ventilator, a missed opportunity" for transplantation. Because of experiences like these, IPF patients now undergo a thorough evaluation for transplantation so that if they suddenly wind up in the ICU, it’s easier to get them a transplant quickly.

Patients who receive a lung transplant have a median 5-year survival rate of 50%, which means that patients with a disease that has a similar or better prognosis are not good candidates. The poorer average survival rate of IPF patients helps explain why they are good transplant candidates.

The U.S. Department of Health and Human Services mandated a 2005 revision of the allocation systems for all organs based on medical urgency rather than time on the waiting list, a system biased against patients with more aggressive disease such as IPF. The LAS scoring formula put in place by the Organ Procurement and Transplantation Network took into account both the urgency of a patient’s need for a lung transplant and the patient’s likelihood of survival following transplantation (Chest 2007;132:1954-61). Two patient features carry the most weight in the formula: the patient’s underlying disease, and whether the patient requires mechanical ventilation and how much oxygen he or she needs. Today, about the only way for a patient to have a really high LAS score of 80 or greater is to be on a ventilator with high-flow oxygen.

The 2005 LAS revision led to a dramatic shortening of the U.S. waiting list for lungs – from more than 2,000 patients before 2005 to roughly 1,000 patients today – largely because it deemphasized time on the list and made "time banking" unnecessary. Time banking had been a practice by which potential lung transplant candidates without an immediate need got listed in case they needed a transplant in the future. If they did eventually need a transplant, they had accumulated time on the list, which boosted their chances of getting the transplant more quickly. If they eventually got a call for a transplant but still did not immediately need it, they could withdraw from accepting that organ but still retain their relatively high priority on the list, Dr. Kotloff explained.

With the new allocation formula, patients with no immediate need and an uncertain future need for a transplant, such as many COPD patients, are simply kept off the list until their transplant need becomes clear. The downside to the current system is that many patients with potentially severe and unstable lung disease, such as many IPF patients, move from referral to listing to transplantation in just a few weeks – so rapidly that they do not have time to receive adequate counseling about the consequences and possible drawbacks of lung transplantation, Dr. Kotloff said.

Dr. Kotloff said that he had no disclosures.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

LAS VEGAS – Early mobility aids faster and better recovery of patients in the intensive care unit, Dr. Russell R. Miller III said at the annual meeting of the National Association for Medical Direction of Respiratory Care.

Fostering early mobility requires a "culture of mobility" in the respiratory intensive care unit, he said. "You need a strategy, a process of care and collaboration between all members" of the ICU team. "You need a distinct [ICU] culture to pull this off." Creating an ICU culture of mobility and reconditioning means improving teamwork among the ICU disciplines, linking effective teamwork with patient-focused outcomes, recognizing current practice patterns that interfere with achieving mobility, and ensuring that the process is reliable, said Dr. Miller, medical director of the respiratory ICU at Intermountain Healthcare in Salt Lake City.

Traditionally, ICU physicians paid little attention to patient mobility or to the role of neuromuscular function in patients with critical illness. But evidence reported over the past 10 years suggested that weakness and immobility in the ICU may diminish health-related quality of life over the long term. The mortality rate of patients during their first year following ICU discharge is likely twice their rate while in the ICU, and part of that is because of ICU inactivity, he said. Other causes of post-ICU mortality might include inflammatory muscle injury, sepsis, deconditioning, hyperglycemia, steroid treatment, and catabolism.

The first strong suggestion that muscle wasting and weakness in ICU patients could have long-term effects during the year following discharge came in a 1-year follow-up study of 198 medical and surgical ICU patients treated in Toronto (N. Engl. J. Med. 2003;348:683-93). Subsequent reports began presenting evidence that early activity in ICU patients could be undertaken safely and could significantly reduce the duration of hospitalization (Crit. Care Med. 2006;34:A20).

Researchers reported results in 2009 from a prospective, randomized, multicenter U.S. study with 104 ICU patients showing that an early start to physical and occupational therapy led to a significant 50% decrease in the average number of days with delirium (Lancet 2009;373:1874-82). The 2009 report constituted the first evidence that early ICU mobility could have a meaningful impact on a clinical outcome, Dr. Miller said. Controlling delirium is crucial because each additional day a patient is delirious is linked with a 10% increased mortality risk, and length of stay for delirious patients averages 10 days longer. At least half of the patients who are delirious for more than 3 days develop long-term cognitive impairment, Dr. Miller said.

In his opinion, evidence now backs ICU mobilization for patients who are medically directed to bed rest (such as those with an unstable spine), coma patients, and patients with modest or severe hemodynamic instability. "All of these patients would have been considered excluded from mobilization in the ICU just 10 years ago," he said.

Other patients for whom mobilization should be considered, but in whom it is more challenging, include those with delirium, a history of stroke, a critical illness myoneuropathy, or a high fraction of inspired oxygen divided by positive end-expiratory pressure, as well as those on continuous dialysis, he said. But even among these patients, ICU staff should be "aggressive" in their approach to rehabilitation management, Dr. Miller said.

Staff also can help patients achieve early mobilization by avoiding overuse of sedation, minimizing narcotic use, and supporting breathing to prevent desaturation during activity. Staff members should not passively accept a patient’s refusal of activity, just as they would not automatically accept a patient’s refusal of an antibiotic or other any important intervention.

The intensity of activity should progress rapidly, although activity could be suspended for a day if a patient has an acute, unstable event. In patients who do not appear to have the strength for both reconditioning and weaning, reconditioning should take priority because it will make weaning easier.

Dr. Miller said that he had no disclosures relevant to this topic.

SAN FRANCISCO – Physicians don’t always follow federal asthma guidelines, and quality of life has improved only slightly for asthma patients since 1998, according to two studies.

"We have not moved the pendulum very far despite of all the information and studies that have occurred over the last 12 to 13 years. [Doctors] know about the guidelines, but they don’t incorporate them into practice. Three and half years of writing guidelines didn’t change a thing," said asthma specialist Dr. Stuart Stoloff, a clinical professor at the University of Nevada, Reno, and one of the experts who worked on the National Heart, Lung, and Blood Institute guidelines.

The problem is "patients have not received information about how good they should be able to feel. The other part of it is that clinicians who provide care for those patients are not aware of how well someone should feel with the disease," said Dr. Stoloff, an author on both studies, which were presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The first study compared 1998 Asthma in America survey results from 2,509 pediatric and adult asthma patients with 2009 Asthma Insight and Management survey results from 2,500 pediatric and adult asthma patients, assessing disease burden and other issues.

The findings: Asthma exacerbations sent about the same percentage of patients to the emergency department or hospital in 2009 as in 1998, while the 2009 patients missed only slightly less work or school due to asthma.

In 1998, 64% of adults said asthma limited their daily activities. In 2009, it was 55%.

About 28% of patients owned peak-flow meters in 1998 and 35% had lung function testing in the previous year. In 2008, 35% owned a meter and 33% had their lungs tested within a year.

In the second study, 309 asthma specialists and general practitioners were surveyed. The findings reveal that what many consider to be adequate asthma control falls short of treatment goals in the NHLBI 2007 Guidelines for the Diagnosis and Management of Asthma.

About 96% of physicians surveyed knew about the NHLBI guidelines, but only 28% said that they "always" complied with them. The numbers were slightly higher for allergists and pulmonologists.

Half of physicians considered asthma well managed if patients had two urgent doctor visits per year. About a third considered both one ED visit and three to four exacerbations per year compatible with good management. One in five physicians thought patients who needed quick relief medication three times per week were well managed.

For adults with mild persistent asthma, only 67% of physicians overall preferred inhaled corticosteroid monotherapy as the first-line treatment, though the number was a bit higher for specialists. Only about half reported drawing up asthma action plans as recommended by the guidelines for most or all of their patients.

Dr. Stoloff said pay-for-performance is solution. Physicians should be rewarded for good outcomes and compensated for patient education and other efforts to achieve good outcomes.

Accountable care organizations and patient-centered medical homes are moving in that direction, but "we need to accelerate the process," he said.

Asthma mortality has decreased in recent years because of better diagnosis and treatment, but Dr. Stoloff said the findings indicate that change is "not occurring fast enough."

Outcome benchmarks in pay-for-performance models should include "patients going to school, going to work, going to play" and "normal or near-normal lung function; not ending up in an emergency room or hospital; [and] not taking oral steroids," he said.

Dr. Stoloff is a consultant for AstraZeneca, Alcon, Merck & Co., Novartis, Dey Pharma, GlaxoSmithKline, Boehringer-Ingelheim, Sepracor, and Teva Pharmaceuticals. The studies were funded by Merck.

SAN FRANCISCO – Physicians don’t always follow federal asthma guidelines, and quality of life has improved only slightly for asthma patients since 1998, according to two studies.

"We have not moved the pendulum very far despite of all the information and studies that have occurred over the last 12 to 13 years. [Doctors] know about the guidelines, but they don’t incorporate them into practice. Three and half years of writing guidelines didn’t change a thing," said asthma specialist Dr. Stuart Stoloff, a clinical professor at the University of Nevada, Reno, and one of the experts who worked on the National Heart, Lung, and Blood Institute guidelines.

The problem is "patients have not received information about how good they should be able to feel. The other part of it is that clinicians who provide care for those patients are not aware of how well someone should feel with the disease," said Dr. Stoloff, an author on both studies, which were presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The first study compared 1998 Asthma in America survey results from 2,509 pediatric and adult asthma patients with 2009 Asthma Insight and Management survey results from 2,500 pediatric and adult asthma patients, assessing disease burden and other issues.

The findings: Asthma exacerbations sent about the same percentage of patients to the emergency department or hospital in 2009 as in 1998, while the 2009 patients missed only slightly less work or school due to asthma.

In 1998, 64% of adults said asthma limited their daily activities. In 2009, it was 55%.

About 28% of patients owned peak-flow meters in 1998 and 35% had lung function testing in the previous year. In 2008, 35% owned a meter and 33% had their lungs tested within a year.

In the second study, 309 asthma specialists and general practitioners were surveyed. The findings reveal that what many consider to be adequate asthma control falls short of treatment goals in the NHLBI 2007 Guidelines for the Diagnosis and Management of Asthma.

About 96% of physicians surveyed knew about the NHLBI guidelines, but only 28% said that they "always" complied with them. The numbers were slightly higher for allergists and pulmonologists.

Half of physicians considered asthma well managed if patients had two urgent doctor visits per year. About a third considered both one ED visit and three to four exacerbations per year compatible with good management. One in five physicians thought patients who needed quick relief medication three times per week were well managed.

For adults with mild persistent asthma, only 67% of physicians overall preferred inhaled corticosteroid monotherapy as the first-line treatment, though the number was a bit higher for specialists. Only about half reported drawing up asthma action plans as recommended by the guidelines for most or all of their patients.

Dr. Stoloff said pay-for-performance is solution. Physicians should be rewarded for good outcomes and compensated for patient education and other efforts to achieve good outcomes.

Accountable care organizations and patient-centered medical homes are moving in that direction, but "we need to accelerate the process," he said.

Asthma mortality has decreased in recent years because of better diagnosis and treatment, but Dr. Stoloff said the findings indicate that change is "not occurring fast enough."

Outcome benchmarks in pay-for-performance models should include "patients going to school, going to work, going to play" and "normal or near-normal lung function; not ending up in an emergency room or hospital; [and] not taking oral steroids," he said.

Dr. Stoloff is a consultant for AstraZeneca, Alcon, Merck & Co., Novartis, Dey Pharma, GlaxoSmithKline, Boehringer-Ingelheim, Sepracor, and Teva Pharmaceuticals. The studies were funded by Merck.

SAN FRANCISCO – Physicians don’t always follow federal asthma guidelines, and quality of life has improved only slightly for asthma patients since 1998, according to two studies.

"We have not moved the pendulum very far despite of all the information and studies that have occurred over the last 12 to 13 years. [Doctors] know about the guidelines, but they don’t incorporate them into practice. Three and half years of writing guidelines didn’t change a thing," said asthma specialist Dr. Stuart Stoloff, a clinical professor at the University of Nevada, Reno, and one of the experts who worked on the National Heart, Lung, and Blood Institute guidelines.

The problem is "patients have not received information about how good they should be able to feel. The other part of it is that clinicians who provide care for those patients are not aware of how well someone should feel with the disease," said Dr. Stoloff, an author on both studies, which were presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The first study compared 1998 Asthma in America survey results from 2,509 pediatric and adult asthma patients with 2009 Asthma Insight and Management survey results from 2,500 pediatric and adult asthma patients, assessing disease burden and other issues.

The findings: Asthma exacerbations sent about the same percentage of patients to the emergency department or hospital in 2009 as in 1998, while the 2009 patients missed only slightly less work or school due to asthma.

In 1998, 64% of adults said asthma limited their daily activities. In 2009, it was 55%.

About 28% of patients owned peak-flow meters in 1998 and 35% had lung function testing in the previous year. In 2008, 35% owned a meter and 33% had their lungs tested within a year.

In the second study, 309 asthma specialists and general practitioners were surveyed. The findings reveal that what many consider to be adequate asthma control falls short of treatment goals in the NHLBI 2007 Guidelines for the Diagnosis and Management of Asthma.

About 96% of physicians surveyed knew about the NHLBI guidelines, but only 28% said that they "always" complied with them. The numbers were slightly higher for allergists and pulmonologists.

Half of physicians considered asthma well managed if patients had two urgent doctor visits per year. About a third considered both one ED visit and three to four exacerbations per year compatible with good management. One in five physicians thought patients who needed quick relief medication three times per week were well managed.

For adults with mild persistent asthma, only 67% of physicians overall preferred inhaled corticosteroid monotherapy as the first-line treatment, though the number was a bit higher for specialists. Only about half reported drawing up asthma action plans as recommended by the guidelines for most or all of their patients.

Dr. Stoloff said pay-for-performance is solution. Physicians should be rewarded for good outcomes and compensated for patient education and other efforts to achieve good outcomes.

Accountable care organizations and patient-centered medical homes are moving in that direction, but "we need to accelerate the process," he said.

Asthma mortality has decreased in recent years because of better diagnosis and treatment, but Dr. Stoloff said the findings indicate that change is "not occurring fast enough."

Outcome benchmarks in pay-for-performance models should include "patients going to school, going to work, going to play" and "normal or near-normal lung function; not ending up in an emergency room or hospital; [and] not taking oral steroids," he said.

Dr. Stoloff is a consultant for AstraZeneca, Alcon, Merck & Co., Novartis, Dey Pharma, GlaxoSmithKline, Boehringer-Ingelheim, Sepracor, and Teva Pharmaceuticals. The studies were funded by Merck.

SAN FRANCISCO – Physicians don’t always follow federal asthma guidelines, and quality of life has improved only slightly for asthma patients since 1998, according to two studies.

"We have not moved the pendulum very far despite of all the information and studies that have occurred over the last 12 to 13 years. [Doctors] know about the guidelines, but they don’t incorporate them into practice. Three and half years of writing guidelines didn’t change a thing," said asthma specialist Dr. Stuart Stoloff, a clinical professor at the University of Nevada, Reno, and one of the experts who worked on the National Heart, Lung, and Blood Institute guidelines.

The problem is "patients have not received information about how good they should be able to feel. The other part of it is that clinicians who provide care for those patients are not aware of how well someone should feel with the disease," said Dr. Stoloff, an author on both studies, which were presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The first study compared 1998 Asthma in America survey results from 2,509 pediatric and adult asthma patients with 2009 Asthma Insight and Management survey results from 2,500 pediatric and adult asthma patients, assessing disease burden and other issues.

The findings: Asthma exacerbations sent about the same percentage of patients to the emergency department or hospital in 2009 as in 1998, while the 2009 patients missed only slightly less work or school due to asthma.

In 1998, 64% of adults said asthma limited their daily activities. In 2009, it was 55%.

About 28% of patients owned peak-flow meters in 1998 and 35% had lung function testing in the previous year. In 2008, 35% owned a meter and 33% had their lungs tested within a year.

In the second study, 309 asthma specialists and general practitioners were surveyed. The findings reveal that what many consider to be adequate asthma control falls short of treatment goals in the NHLBI 2007 Guidelines for the Diagnosis and Management of Asthma.

About 96% of physicians surveyed knew about the NHLBI guidelines, but only 28% said that they "always" complied with them. The numbers were slightly higher for allergists and pulmonologists.

Half of physicians considered asthma well managed if patients had two urgent doctor visits per year. About a third considered both one ED visit and three to four exacerbations per year compatible with good management. One in five physicians thought patients who needed quick relief medication three times per week were well managed.

For adults with mild persistent asthma, only 67% of physicians overall preferred inhaled corticosteroid monotherapy as the first-line treatment, though the number was a bit higher for specialists. Only about half reported drawing up asthma action plans as recommended by the guidelines for most or all of their patients.

Dr. Stoloff said pay-for-performance is solution. Physicians should be rewarded for good outcomes and compensated for patient education and other efforts to achieve good outcomes.

Accountable care organizations and patient-centered medical homes are moving in that direction, but "we need to accelerate the process," he said.

Asthma mortality has decreased in recent years because of better diagnosis and treatment, but Dr. Stoloff said the findings indicate that change is "not occurring fast enough."

Outcome benchmarks in pay-for-performance models should include "patients going to school, going to work, going to play" and "normal or near-normal lung function; not ending up in an emergency room or hospital; [and] not taking oral steroids," he said.

Dr. Stoloff is a consultant for AstraZeneca, Alcon, Merck & Co., Novartis, Dey Pharma, GlaxoSmithKline, Boehringer-Ingelheim, Sepracor, and Teva Pharmaceuticals. The studies were funded by Merck.

SAN FRANCISCO – Physicians don’t always follow federal asthma guidelines, and quality of life has improved only slightly for asthma patients since 1998, according to two studies.

"We have not moved the pendulum very far despite of all the information and studies that have occurred over the last 12 to 13 years. [Doctors] know about the guidelines, but they don’t incorporate them into practice. Three and half years of writing guidelines didn’t change a thing," said asthma specialist Dr. Stuart Stoloff, a clinical professor at the University of Nevada, Reno, and one of the experts who worked on the National Heart, Lung, and Blood Institute guidelines.

The problem is "patients have not received information about how good they should be able to feel. The other part of it is that clinicians who provide care for those patients are not aware of how well someone should feel with the disease," said Dr. Stoloff, an author on both studies, which were presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The first study compared 1998 Asthma in America survey results from 2,509 pediatric and adult asthma patients with 2009 Asthma Insight and Management survey results from 2,500 pediatric and adult asthma patients, assessing disease burden and other issues.

The findings: Asthma exacerbations sent about the same percentage of patients to the emergency department or hospital in 2009 as in 1998, while the 2009 patients missed only slightly less work or school due to asthma.

In 1998, 64% of adults said asthma limited their daily activities. In 2009, it was 55%.

About 28% of patients owned peak-flow meters in 1998 and 35% had lung function testing in the previous year. In 2008, 35% owned a meter and 33% had their lungs tested within a year.

In the second study, 309 asthma specialists and general practitioners were surveyed. The findings reveal that what many consider to be adequate asthma control falls short of treatment goals in the NHLBI 2007 Guidelines for the Diagnosis and Management of Asthma.

About 96% of physicians surveyed knew about the NHLBI guidelines, but only 28% said that they "always" complied with them. The numbers were slightly higher for allergists and pulmonologists.

Half of physicians considered asthma well managed if patients had two urgent doctor visits per year. About a third considered both one ED visit and three to four exacerbations per year compatible with good management. One in five physicians thought patients who needed quick relief medication three times per week were well managed.

For adults with mild persistent asthma, only 67% of physicians overall preferred inhaled corticosteroid monotherapy as the first-line treatment, though the number was a bit higher for specialists. Only about half reported drawing up asthma action plans as recommended by the guidelines for most or all of their patients.

Dr. Stoloff said pay-for-performance is solution. Physicians should be rewarded for good outcomes and compensated for patient education and other efforts to achieve good outcomes.

Accountable care organizations and patient-centered medical homes are moving in that direction, but "we need to accelerate the process," he said.

Asthma mortality has decreased in recent years because of better diagnosis and treatment, but Dr. Stoloff said the findings indicate that change is "not occurring fast enough."

Outcome benchmarks in pay-for-performance models should include "patients going to school, going to work, going to play" and "normal or near-normal lung function; not ending up in an emergency room or hospital; [and] not taking oral steroids," he said.

Dr. Stoloff is a consultant for AstraZeneca, Alcon, Merck & Co., Novartis, Dey Pharma, GlaxoSmithKline, Boehringer-Ingelheim, Sepracor, and Teva Pharmaceuticals. The studies were funded by Merck.

SAN FRANCISCO – Physicians don’t always follow federal asthma guidelines, and quality of life has improved only slightly for asthma patients since 1998, according to two studies.

"We have not moved the pendulum very far despite of all the information and studies that have occurred over the last 12 to 13 years. [Doctors] know about the guidelines, but they don’t incorporate them into practice. Three and half years of writing guidelines didn’t change a thing," said asthma specialist Dr. Stuart Stoloff, a clinical professor at the University of Nevada, Reno, and one of the experts who worked on the National Heart, Lung, and Blood Institute guidelines.

The problem is "patients have not received information about how good they should be able to feel. The other part of it is that clinicians who provide care for those patients are not aware of how well someone should feel with the disease," said Dr. Stoloff, an author on both studies, which were presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The first study compared 1998 Asthma in America survey results from 2,509 pediatric and adult asthma patients with 2009 Asthma Insight and Management survey results from 2,500 pediatric and adult asthma patients, assessing disease burden and other issues.

The findings: Asthma exacerbations sent about the same percentage of patients to the emergency department or hospital in 2009 as in 1998, while the 2009 patients missed only slightly less work or school due to asthma.

In 1998, 64% of adults said asthma limited their daily activities. In 2009, it was 55%.

About 28% of patients owned peak-flow meters in 1998 and 35% had lung function testing in the previous year. In 2008, 35% owned a meter and 33% had their lungs tested within a year.

In the second study, 309 asthma specialists and general practitioners were surveyed. The findings reveal that what many consider to be adequate asthma control falls short of treatment goals in the NHLBI 2007 Guidelines for the Diagnosis and Management of Asthma.

About 96% of physicians surveyed knew about the NHLBI guidelines, but only 28% said that they "always" complied with them. The numbers were slightly higher for allergists and pulmonologists.

Half of physicians considered asthma well managed if patients had two urgent doctor visits per year. About a third considered both one ED visit and three to four exacerbations per year compatible with good management. One in five physicians thought patients who needed quick relief medication three times per week were well managed.

For adults with mild persistent asthma, only 67% of physicians overall preferred inhaled corticosteroid monotherapy as the first-line treatment, though the number was a bit higher for specialists. Only about half reported drawing up asthma action plans as recommended by the guidelines for most or all of their patients.

Dr. Stoloff said pay-for-performance is solution. Physicians should be rewarded for good outcomes and compensated for patient education and other efforts to achieve good outcomes.

Accountable care organizations and patient-centered medical homes are moving in that direction, but "we need to accelerate the process," he said.

Asthma mortality has decreased in recent years because of better diagnosis and treatment, but Dr. Stoloff said the findings indicate that change is "not occurring fast enough."

Outcome benchmarks in pay-for-performance models should include "patients going to school, going to work, going to play" and "normal or near-normal lung function; not ending up in an emergency room or hospital; [and] not taking oral steroids," he said.

Dr. Stoloff is a consultant for AstraZeneca, Alcon, Merck & Co., Novartis, Dey Pharma, GlaxoSmithKline, Boehringer-Ingelheim, Sepracor, and Teva Pharmaceuticals. The studies were funded by Merck.

Biologics appear to be associated with a significantly greater rate of total adverse events, withdrawals due to adverse events, and an increased risk of tuberculosis reactivation compared with control agents, based on a meta-analysis involving more than 60,000 patients.

However, there were no significant differences in the rates of serious adverse events, serious infections, lymphoma, and congestive heart failure between biologics and control agents.

"Our review included indirect comparisons of the safety of biologics and should provide some guidance to clinicians and patients until head-to-head comparisons become available," wrote Dr. Jasvinder A. Singh and his coauthors (Cochrane Database Syst. Rev. 2011 [doi: 10.1002/14651858.CD008794.pub2]).

The results come from a network meta-analysis and Cochrane overview of the adverse effects of biologic drugs that are approved for the treatment of rheumatoid arthritis and other conditions in Europe, the United Kingdom, the United States, Canada, and Australia.

The investigators included randomized controlled trials (RCTs), controlled clinical trials, and open-label extension studies that involved one of the nine biologics for use in any indication and that reported this study’s prespecified adverse outcomes. The researchers did not include studies on biologics for the treatment of HIV/AIDS. The nine biologics investigated were abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan/MabThera), and tocilizumab (Actemra).

They searched the Cochrane Library, Medline, and Embase (through January 2010). The investigators performed mixed-effects logistic regression using an arm-based, random-effects model within an empirical Bayes framework for the network meta-analysis.

In all, included in the analysis were 163 RCTs with 50,010 adult participants and 46 extension studies with 11,954 adult participants. The median duration was 6 months for the RCTs and 13 months for the extension studies. Given the short duration of the RCTs, all the results should be interpreted as applying to a fairly short time frame.

After the analysis was adjusted for dose, biologics as a group were associated with a significantly greater rate of total adverse events (odds ratio 1.19) and withdrawals due to adverse events (OR 1.32), as well as an increased risk of TB reactivation (OR 4.68), compared with control agents.

Notably, certolizumab pegol was associated with a significantly greater risk of serious infections than was control treatment (OR 3.51). Infliximab was associated with a significantly greater risk of withdrawals due to adverse events compared with the control (OR 2.04).

Heart failure and cancer have been of particular concern with the use of biologic drugs. There appears to be little or no difference in the number of people who experienced heart failure or cancer taking any biologic compared with people who took placebo. However, there were not many cases of congestive heart failure or cancer, so confidence in these results is low.

The researchers also were able to indirectly compare individual biologic drugs. These analyses revealed that abatacept and anakinra were associated with a significantly lower risk of serious adverse events than were most other biologics. In addition, certolizumab pegol was associated with significantly greater odds of serious infections than were etanercept, adalimumab, abatacept, anakinra, golimumab, infliximab, and rituximab. Abatacept was significantly less likely than infliximab and tocilizumab to be associated with serious infections; abatacept, adalimumab, etanercept, and golimumab were significantly less likely than infliximab to result in withdrawals due to adverse events. However, the authors noted that the overall numbers were relatively small and that these comparisons should be interpreted with caution.

The lack of long-term studies of biologics is still a concern, they added. "There is an urgent need for more research regarding the long-term safety of biologics and the comparative safety of different biologics," they concluded.

Dr. Singh and several of his coauthors reported that they have significant financial relationships with several pharmaceutical companies.

Biologics appear to be associated with a significantly greater rate of total adverse events, withdrawals due to adverse events, and an increased risk of tuberculosis reactivation compared with control agents, based on a meta-analysis involving more than 60,000 patients.

However, there were no significant differences in the rates of serious adverse events, serious infections, lymphoma, and congestive heart failure between biologics and control agents.

"Our review included indirect comparisons of the safety of biologics and should provide some guidance to clinicians and patients until head-to-head comparisons become available," wrote Dr. Jasvinder A. Singh and his coauthors (Cochrane Database Syst. Rev. 2011 [doi: 10.1002/14651858.CD008794.pub2]).

The results come from a network meta-analysis and Cochrane overview of the adverse effects of biologic drugs that are approved for the treatment of rheumatoid arthritis and other conditions in Europe, the United Kingdom, the United States, Canada, and Australia.

The investigators included randomized controlled trials (RCTs), controlled clinical trials, and open-label extension studies that involved one of the nine biologics for use in any indication and that reported this study’s prespecified adverse outcomes. The researchers did not include studies on biologics for the treatment of HIV/AIDS. The nine biologics investigated were abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan/MabThera), and tocilizumab (Actemra).

They searched the Cochrane Library, Medline, and Embase (through January 2010). The investigators performed mixed-effects logistic regression using an arm-based, random-effects model within an empirical Bayes framework for the network meta-analysis.

In all, included in the analysis were 163 RCTs with 50,010 adult participants and 46 extension studies with 11,954 adult participants. The median duration was 6 months for the RCTs and 13 months for the extension studies. Given the short duration of the RCTs, all the results should be interpreted as applying to a fairly short time frame.

After the analysis was adjusted for dose, biologics as a group were associated with a significantly greater rate of total adverse events (odds ratio 1.19) and withdrawals due to adverse events (OR 1.32), as well as an increased risk of TB reactivation (OR 4.68), compared with control agents.

Notably, certolizumab pegol was associated with a significantly greater risk of serious infections than was control treatment (OR 3.51). Infliximab was associated with a significantly greater risk of withdrawals due to adverse events compared with the control (OR 2.04).

Heart failure and cancer have been of particular concern with the use of biologic drugs. There appears to be little or no difference in the number of people who experienced heart failure or cancer taking any biologic compared with people who took placebo. However, there were not many cases of congestive heart failure or cancer, so confidence in these results is low.

The researchers also were able to indirectly compare individual biologic drugs. These analyses revealed that abatacept and anakinra were associated with a significantly lower risk of serious adverse events than were most other biologics. In addition, certolizumab pegol was associated with significantly greater odds of serious infections than were etanercept, adalimumab, abatacept, anakinra, golimumab, infliximab, and rituximab. Abatacept was significantly less likely than infliximab and tocilizumab to be associated with serious infections; abatacept, adalimumab, etanercept, and golimumab were significantly less likely than infliximab to result in withdrawals due to adverse events. However, the authors noted that the overall numbers were relatively small and that these comparisons should be interpreted with caution.

The lack of long-term studies of biologics is still a concern, they added. "There is an urgent need for more research regarding the long-term safety of biologics and the comparative safety of different biologics," they concluded.

Dr. Singh and several of his coauthors reported that they have significant financial relationships with several pharmaceutical companies.

Biologics appear to be associated with a significantly greater rate of total adverse events, withdrawals due to adverse events, and an increased risk of tuberculosis reactivation compared with control agents, based on a meta-analysis involving more than 60,000 patients.

However, there were no significant differences in the rates of serious adverse events, serious infections, lymphoma, and congestive heart failure between biologics and control agents.

"Our review included indirect comparisons of the safety of biologics and should provide some guidance to clinicians and patients until head-to-head comparisons become available," wrote Dr. Jasvinder A. Singh and his coauthors (Cochrane Database Syst. Rev. 2011 [doi: 10.1002/14651858.CD008794.pub2]).

The results come from a network meta-analysis and Cochrane overview of the adverse effects of biologic drugs that are approved for the treatment of rheumatoid arthritis and other conditions in Europe, the United Kingdom, the United States, Canada, and Australia.

The investigators included randomized controlled trials (RCTs), controlled clinical trials, and open-label extension studies that involved one of the nine biologics for use in any indication and that reported this study’s prespecified adverse outcomes. The researchers did not include studies on biologics for the treatment of HIV/AIDS. The nine biologics investigated were abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab pegol (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan/MabThera), and tocilizumab (Actemra).

They searched the Cochrane Library, Medline, and Embase (through January 2010). The investigators performed mixed-effects logistic regression using an arm-based, random-effects model within an empirical Bayes framework for the network meta-analysis.

In all, included in the analysis were 163 RCTs with 50,010 adult participants and 46 extension studies with 11,954 adult participants. The median duration was 6 months for the RCTs and 13 months for the extension studies. Given the short duration of the RCTs, all the results should be interpreted as applying to a fairly short time frame.

After the analysis was adjusted for dose, biologics as a group were associated with a significantly greater rate of total adverse events (odds ratio 1.19) and withdrawals due to adverse events (OR 1.32), as well as an increased risk of TB reactivation (OR 4.68), compared with control agents.

Notably, certolizumab pegol was associated with a significantly greater risk of serious infections than was control treatment (OR 3.51). Infliximab was associated with a significantly greater risk of withdrawals due to adverse events compared with the control (OR 2.04).

Heart failure and cancer have been of particular concern with the use of biologic drugs. There appears to be little or no difference in the number of people who experienced heart failure or cancer taking any biologic compared with people who took placebo. However, there were not many cases of congestive heart failure or cancer, so confidence in these results is low.

The researchers also were able to indirectly compare individual biologic drugs. These analyses revealed that abatacept and anakinra were associated with a significantly lower risk of serious adverse events than were most other biologics. In addition, certolizumab pegol was associated with significantly greater odds of serious infections than were etanercept, adalimumab, abatacept, anakinra, golimumab, infliximab, and rituximab. Abatacept was significantly less likely than infliximab and tocilizumab to be associated with serious infections; abatacept, adalimumab, etanercept, and golimumab were significantly less likely than infliximab to result in withdrawals due to adverse events. However, the authors noted that the overall numbers were relatively small and that these comparisons should be interpreted with caution.

The lack of long-term studies of biologics is still a concern, they added. "There is an urgent need for more research regarding the long-term safety of biologics and the comparative safety of different biologics," they concluded.

Dr. Singh and several of his coauthors reported that they have significant financial relationships with several pharmaceutical companies.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.

SAN FRANCISCO – Beware of vocal cord dysfunction mimicking asthma and other respiratory problems, especially in women, the overweight, and in patients with psychiatric diagnoses, according to a retrospective chart review of patients with the condition.

Of 100 patients diagnosed with vocal cord dysfunction at the University of Pittsburgh Medical Center’s outpatient adult allergy and immunology clinic, 86 were female, 68 were overweight, and 50 had psychiatric conditions.

For those patients especially, the possibility of vocal cord dysfunction (VCD) must be kept in mind when working up airway problems, said lead investigator Dr. Chitra Rao, an internal medicine resident at the medical center.

The reason is that VCD – in which the vocal cords spasm or even, to some extent, close on inspiration – is a notorious mimic of asthma, anaphylaxis, and other respiratory problems. Identifying it quickly not only speeds treatment but also prevents mistreatment for conditions patients do not have.

"I think it should definitely be on the differential, especially of severe or poorly controlled asthma. It can very much act like asthma," Dr. Rao said.

Dr. Rao and her colleagues reviewed the charts of 100 VCD patients and found that 26 had been misdiagnosed with asthma before presenting or being referred to the clinic; 9 were misdiagnosed with angioedema, 7 with anaphylaxis, and 3 with drug allergies.

In one, VCD had been mistaken for a reaction to omalizumab (Xolair). "While we were doing a desensitization challenge, [the patient] complained of the symptoms. We had a scope there and looked, and her vocal chords were spasming," Dr. Rao said.

The remaining 55 patients came to the clinic with undiagnosed respiratory complaints, including shortness of breath, wheezing, chest tightness, and throat tightness.

History and laryngoscopy ruled out asthma in half (13) of the patients mistakenly diagnosed with it; methacholine challenge testing excluded the other half.

Most patients were diagnosed with VCD by laryngoscopy, the remainder by history. Paradoxical vocal cord motion or other abnormalities were found by laryngoscope in 61 asymptomatic patients, without trigger maneuvers. A strong scent – Christian Dior’s "Poison" – was used to trigger an attack in some other patients to help seal the diagnosis.

"If you can actually illicit their attacks, it’s much easier for [patients] to buy into treatment," which includes breathing exercises, Dr. Rao said.

Vocal cord inflammation is the underlying problem in VCD, and the conditions that cause it, including gastroesophageal reflux (GERD), allergic rhinitis, and asthma – properly diagnosed – were common among patients. Treatment of those conditions can also help VCD.

GERD likely explains at least part of the link with obesity, but it remains unclear why women and people with anxiety and other psychiatric problems seem predisposed, Dr. Rao said.

Proper diagnosis is important. "If [attacks are] severe enough that [patients] go to the ER, they are going to get frequent steroids, which are not going to help them," Dr. Rao said.

"In severe cases, people who are not familiar with this disease may actually intubate [patients], and that’s actually counterproductive. It’s very difficult to extubate them because the whole underlying process is inflammation of the vocal chords. When you put in a breathing tube, it actually makes the symptoms worse," she said.

Dr. Rao said she has nothing to disclose.