Introduction In 2021, the Global Lung Initiative (GLI 2021) network recommended new static volume lung function reference equations, setting new normal ranges for lung hyperinflation indices and, as as result, for the classification of lung hyperinflation severity. This study examined how use of the GLI 2021 reference equations affected the detection of lung hyperinflation and the distribution of lung hyperinflation severity based on the lung hyperinflation severity grading scale, which relies on fixed % predicted cut-offs and z-scores. Methods An analysis was performed on data from 12 535 body plethysmography recordings performed from January 2013–June 2023. The GLI 2021 and the European Community for Steel and Coal working party (ECSC) reference equations were used to calculate the z-scores for residual volume (RV), total lung capacity (TLC), and RV/TLC. The % predicted RV/TLC ratios were calculated and the distribution of lung hyperinflation severity grading was assessed. Results Using % predicted cut-offs, severe lung hyperinflation was observed more frequently using GLI 2021 compared with the ECSC reference equation (27% versus 8.8%, p<0.001), while mild lung hyperinflation was identified in 7% of the recordings using GLI 2021 ( versus 21% using ECSC; p<0.001). Grading using the GLI 2021 reference equation and z-scores produced a similar distribution of lung hyperinflation severity to the use of % predicted cut-offs and ECSC reference equations. Discussion The study highlights a significant difference in lung hyperinflation grading using GLI 2021 reference equations, necessitating review of the severity scale when using %predicted cut-offs and z-scores with GLI 2021 reference equations.

Introduction In 2021, the Global Lung Initiative (GLI) network recommended new static volume lung function reference equations, setting new normal ranges for lung hyperinflation indices and, as a result, for the classification of lung hyperinflation severity. This study examined how use of the GLI 2021 reference equations affected the detection of lung hyperinflation and the distribution of lung hyperinflation severity based on the lung hyperinflation severity grading scale, which relies on fixed % predicted cut-offs and z-scores. Methods An analysis was performed on data from 12 535 body plethysmography recordings performed from January 2013 to June 2023. The GLI 2021 and the European Coal and Steel Community (ECSC) reference equations were used to calculate the z-scores for residual volume (RV), total lung capacity (TLC) and RV/TLC. The % predicted RV/TLC ratios were calculated and the distribution of lung hyperinflation severity grading was assessed. Results Using % predicted cut-offs, severe lung hyperinflation was observed more frequently using the GLI 2021 reference equation compared with the ECSC reference equation (27% versus 8.8%, p<0.001), while mild lung hyperinflation was identified in 7% of the recordings using the GLI 2021 references (versus 21% using ECSC; p<0.001). Grading using the GLI 2021 reference equations and z-scores produced a similar distribution of lung hyperinflation severity to the use of % predicted cut-offs and ECSC reference equations. Discussion The study highlights a significant difference in lung hyperinflation grading using GLI 2021 reference equations, necessitating review of the severity scale when using % predicted cut-offs and z-scores with GLI 2021 reference equations.

INTRODUCTION The treatment approach involving a combination of three cystic fibrosis (CF) transmembrane conductance regulatory (CFTR) protein modulators (elexacaftor, tezacaftor, ivacaftor) in the treatment of CF patients has provided beneficial results on FEV1. METHODS The aim of the retrospective single -center observational study was to show the impact of elexacaftor/tezacaftor/ivacaftor with special emphasis on full body plethysmography, exercise capacity and quality of life. Adult cystic fibrosis patients were evaluated after the initiation of triple CFTR therapy between July 2020 and March 2021. A two -tailed t -test for dependent samples with Bonferroni correction was used to compare outcomes between the two visits. RESULTS A total of 38 adult CF -patients (20 females), aged 37.2 +/- 11.6 years were included in the study. The analysis shows significant improvements in FEV1 and vital capacity (VC). The Tiffeneau-Index (FEV1/VC) only showed a minor increase from 59 +/- 14% to 62 +/- 13%. Hyperinflation (RV) and effective specific airway resistance (sRAWeff) significantly improved such as exercise capacity (6MWD) and CFQ-R. sRAWeff showed a strong significant association with an improvement in exercise capacity (Pearson's r=0.593; 95% CI: 0.296-0.786, p<0.001) and FEV1 (Pearson's r=0.560; 95% CI: 0.292-0.746, p<0.001) while all other parameters did not show significant correlations. CONCLUSIONS Triple CFTR modulator therapy improves not only FEV1 but also airway resistance and pulmonary hyperinflation. This is most reliably assessed by measuring sRAWeff, which is associated with exercise capacity, representing the work of breathing. Futures studies should incorporate body plethysmography assessments especially in patients with limited ability to perform spirometry or with non -reproducible spirometry results.

Background: Clinical trials have shown significant therapeutic benefits of extrafine formulation single-inhaler triple therapy (efSITT) consisting of beclometasone dipropionate/formoterol fumarate/glycopyrronium in the treatment of patients with asthma. The impact of efSITT on lung function in patients with asthma in a real-life setting is yet to be assessed. Aims and objectives: The TriMaximize study aims to provide the characteristics, therapy pathways and health-related outcomes of patients with moderate-to-severe asthma prescribed efSITT in real-world practice. We present an interim analysis of the changes in lung function in the first 284 patients from Germany, United Kingdom, Austria, and Denmark after three months of treatment with efSITT. Methods: This is a multicenter, multinational, prospective, observational study following patients with asthma for 1―3 years. Clinical data are collected from patients' medical records. Results: The majority (79.7%) of patients were on prior ICS/LABA treatment, and 20.3% on prior ICS/LABA/LAMA. Conclusions: Our data show a significant improvement in lung function and specific airway resistance in patients with moderate-to-severe asthma after three months of treatment with efSITT following a switch from ICS/LABA or ICS/LABA/LAMA.

ZusammenfassungDie aktualisierten Empfehlungen zur Lungenfunktion wurden zum Jahreskongress der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin (DGP) 2024 vorgestellt und sind in der Zeitschrift „Atemwegs- und Lungenkrankheiten, Jahrgang 50 (2024) März (111–184)“, publiziert, wo sie als PDF kostenlos abrufbar sind. Diese Empfehlungen integrieren auch neue Ansätze zur Interpretation von Funktionsuntersuchungen, wie sie von der ERS (European Respiratory Society) in Zusammenarbeit mit der ATS (American Thoracic Society) publiziert worden sind. Dies betrifft die Spirometrie, die Bodyplethysmografie, die Diffusionskapazitätsmessung, den Bronchodilatationstest, die unspezifische bronchiale Provokation sowie die Referenzwerte. Die Empfehlungen adressieren auch die Oszillometrie sowie die atemmuskuläre Funktionsdiagnostik. Die aktuell vorliegende Publikation versteht sich als Kurzversion der wesentlichen Inhalte dieser komplexen Empfehlungen zur Lungenfunktionsdiagnostik, weist aber auch darauf hin, dass dies nicht das Studium der Langversion der aktuellen Empfehlungen ersetzt, was es insbesondere vor dem Hintergrund der großen Bedeutsamkeit der Lungenfunktionsdiagnostik im klinisch-pneumologischen Alltag zu betonen gilt.

During the annual conference of the German Respiratory Society (DGP = Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin) in 2024, updated recommendations for lung function testing have been published. The original full-length version can be downloaded free of charge as pfd-paper from the journal entitled "Atemwegs- und Lungenkrankheiten, Jahrgang 50 (2024) März (111-184)". In the current recommendations new approaches have been embedded that focus on modern interpretations of lung function results, as has been proposed by the ERS (European Respiratory Society) in collaboration with the ATS (American Thoracic Society). This targets the spirometry, the whole bodyplethysmography, diffusion capacity testing, testing for bronchodilation, unspecific bronchoprovocation in addition to the reference values. Oscillometry and respiratory muscle function testing are also included in the recommendations. The current publication considers itself as a short version of the most important topics of the full-length lung function recommendations. However, reading also the full-length paper is strongly emphasised based on the understanding that lung function testing is highly important in daily clinical practice when dealing with patients suffering from respiratory diseases.

Rationale In patients with COPD, oxygen (O2)-supplementation via a constant flow oxygen system (CFOS) can result in insufficient oxygen saturation (SpO2 <90%) during exercise. An automatically titrating O2-system (ATOS) has been shown to be beneficial compared with an untitrated CFOS, however, it is unknown if ATOS is superior to CFOS, titrated during exercise as stipulated by guidelines. The aim was to investigate the effects of ATOS compared with titrated CFOS on walking capacity in people with hypoxaemic COPD. Methods Fifty participants completed this prospective randomised controlled, double-blind, crossover trial. Participants performed two endurance shuttle walk tests (ESWTs) with: (1) exercise titrated CFOS (ESWTCFOS) and (2) ATOS targeting an SpO2 of 92% (ESWTATOS). Primary outcome measure was walking time. Secondary measures were SpO2, transcutaneous-PCO2 (TcPCO2), respiratory rate (RR), heart rate (HR) at isotime (end of shortest ESWT) with blood gases and dyspnoea at rest and end exercise. Results Participants (median (IQR): age 66 (59, 70) years, FEV1 28.8 (24.8, 35.1) % predicted, PO2 54.7 (51.0, 57.7) mm Hg, PCO2 44.2 (38.2, 47.8) mm Hg) walked significantly longer with ESWTATOS in comparison to ESWTCFOS (median effect (95% CI) +144.5 (54 to 241.5) s, p<0.001). At isotime, SpO2 was significantly higher (+3 (95% CI 1 to 4) %, p<0.001) with ATOS while TcPCO2, RR and HR were comparable. End exercise, PO2 (+8.85 (95% CI 6.35 to 11.9) mm Hg) and dyspnoea (−0.5 (95% CI −1.0 to −0.5) points) differed significantly in favour of ATOS (each p<0.001) while PCO2 was comparable. Conclusion In patients with hypoxaemia with severe COPD the use of ATOS leads to significant, clinically relevant improvements in walking endurance time, SpO2, PO2 and dyspnoea with no impact on PCO2. Trial registration number NCT03803384.

ZusammenfassungDas Management von Asthma hat sich in den letzten Jahrzehnten fundamental gewandelt. Die vorliegende Leitlinie zur Diagnostik und Therapie von Asthma wurde für pneumologisch tätige Fachärztinnen und Fachärzte entwickelt, welche detaillierte und evidenzbasierte Informationen zu den neuen diagnostischen und therapeutischen Optionen von Asthma benötigen. Die Leitlinie zeigt die neue Bedeutung der Biomarker, insbesondere der Bluteosinophilen und des exhalierten NO (FeNO), in den diagnostischen Algorithmen von Asthma. Als erste Asthma-Leitlinie weltweit benennt die vorliegende Leitlinie die nachhaltige Symptomprävention und die Asthma-Remission als Asthma-Therapieziele, welche durch den Einsatz individuell angepasster, krankheitsmodifizierender Medikamente (wie inhalative Steroide, Allergenimmuntherapie oder Biologika) erreicht werden können. Die zentrale Bedeutung der Behandlung von typischen Asthma-Komorbiditäten wird zudem betont. Schließlich wird auch auf besondere Herausforderungen im Asthma-Management eingegangen, wie bspw. die Therapie von Asthma in der Schwangerschaft, die Behandlung von schwerem Asthma oder die Diagnostik und Therapie von arbeitsbedingten Asthma-Formen.

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Background People with very severe chronic obstructive pulmonary disease (COPD) using nocturnal non-invasive ventilation (NIV) for chronic hypercapnic respiratory failure (CHRF) experience reduced exercise capacity and severe dyspnoea during exercise training (ET). The use of NIV during ET can personalise training during pulmonary rehabilitation (PR) but whether high-intensity NIV (HI-NIV) during exercise is accepted and improves outcomes in these extremely physically limited patients is unknown. The aim of this trial was to determine if ET with HI-NIV during PR was more effective than without at improving exercise capacity and reducing dyspnoea during exercise.Methods Patients with COPD, CHRF and nocturnal-NIV were randomised to supervised cycle-ET as part of PR with HI-NIV or without (control). Primary outcome was change in cycle endurance time (ΔCETtime), while secondary outcomes were dyspnoea at isotime during the cycle endurance test and during ET-sessions and for the HI-NIV group, post-trial preferred exercising method.Results Twenty-six participants (forced expiratory volume in 1 s 22±7%pred, PaCO251±7 mm Hg) completed the trial (HI-NIV: n=13, ET: IPAP 26±3/EPAP 6±1 cm H2O; control n=13). At completion of a 3 week ET-programme, no significant between-group differences in ΔCETtime were seen (HI-NIV-control: Δ105 s 95% CI (−92 to 302), p=0.608). Within-group ΔCETtime was significant (HI-NIV: +246 s 95% CI (61 to 432); control: +141 s 95% CI (60 to 222); all p<0.05). The number of responders (Δ>minimal important difference (MID)101 s: n=53.8%) was the same in both groups for absolute ΔCETtime and 69.2% of control and 76.9% of the HI-NIV group had a %change>MID33%.Compared with control, the HI-NIV group reported less isotime dyspnoea (Δ−2.0 pts. 95% CI (−3.2 to −0.8), p=0.005) and during ET (Δ−3.2 pts. 95% CI (−4.6 to −1.9), p<0.001). Most of the HI-NIV group (n=12/13) preferred exercising with NIV.Conclusion In this small group of patients with very severe COPD requiring nocturnal NIV, participation in an ET-programme during PR significantly improved exercise capacity irrespective of HI-NIV use. Reported dyspnoea was in favour of HI-NIV.Trial registration number NCT03803358.

There is an interest in the role of blood eosinophils for predicting inhaled corticosteroid (ICS) response in chronic obstructive pulmonary disease (COPD). Most data are from interventional clinical studies; data from unselected real-world populations may help better inform treatment decisions. DACCORD is a non-interventional real-world study. Cohort 3 recruited patients with COPD who had received triple therapy for ≥ 6 months; prior to entry patients either continued triple therapy, or switched to a long-acting muscarinic antagonist/long-acting beta2-agonist (LABA/LAMA), and were followed for 12 months. For these post-hoc analyses, patients were divided into four groups based on exacerbation history and baseline blood eosinophil count (< 100 vs. > 300 cells/µL). Exacerbation rates were calculated overall and for the two treatments. Among the 430 patients in the current analyses, the largest groups had low exacerbation history with high (44.2%) or low eosinophils (36.7%). Most patients did not exacerbate during follow-up (68.8% overall; 83.2% and 63.7% with LABA/LAMA and triple therapy). The highest exacerbation rates were in groups with high exacerbation history, differing significantly in the overall analyses from those with low exacerbation history (matched by eosinophil count); rates did not differ when grouped by eosinophil count (matched by exacerbation history). Although most patients in these analyses did not exacerbate during follow-up, whereas exacerbation history is a predictor of future exacerbations, blood eosinophil count is not. This suggests that although eosinophil count may help to guide ICS initiation, this is less of a consideration when ‘stepping-down’ from triple therapy to a LABA/LAMA

FOR RELATED ARTICLE, SEE PAGE 828It is well-reflected that the respiratory system consists of two parts: the lungs that are responsible for the gas exchange and the pump that provides ventilation.1Roussos C. Macklem P.T. The respiratory muscles.N Engl J Med. 1982; 307: 786-797Crossref PubMed Scopus (452) Google Scholar The ventilatory pump includes the breathing center, the nerves connecting the breathing center to the respiratory muscles, and the chest wall that is displaced by the muscles. There are many disorders known to affect the ventilatory pump that lead to the inability of the respiratory muscles to generate adequate pressure to sufficiently guarantee ventilation.2McCool F.D. Tzelepis G.E. Dysfunction of the diaphragm.N Engl J Med. 2012; 366: 932-942Crossref PubMed Scopus (275) Google Scholar These disorders comprise disturbances of the respiratory drive, neuromuscular disorders, ineffective muscle configuration or coupling to the chest wall (such as hyperinflation or chest wall disorders), and conditions that lead to impaired pressure transmission (such as airway obstruction). For this reason, the assessment of respiratory muscle strength for both in- and expiration represents an essential part in the diagnosis of respiratory diseases.3Laveneziana P. Albuquerque A. Aliverti A. et al.ERS statement on respiratory muscle testing at rest and during exercise.Eur Respir J. 2019; 53: 1801214Crossref PubMed Scopus (293) Google Scholar,4American Thoracic Society/European Respiratory SocietyATS/ERS statement on respiratory muscle testing.Am J Respir Crit Care Med. 2002; 166: 518-624Crossref PubMed Scopus (1892) Google Scholar FOR RELATED ARTICLE, SEE PAGE 828 For the assessment of respiratory muscle strength, both volitional and nonvolitional tests are available.3Laveneziana P. Albuquerque A. Aliverti A. et al.ERS statement on respiratory muscle testing at rest and during exercise.Eur Respir J. 2019; 53: 1801214Crossref PubMed Scopus (293) Google Scholar,4American Thoracic Society/European Respiratory SocietyATS/ERS statement on respiratory muscle testing.Am J Respir Crit Care Med. 2002; 166: 518-624Crossref PubMed Scopus (1892) Google Scholar Nonvolitional tests, such as the assessment of transdiaphragmatic twitch pressures, are mostly invasive and technically complex and therefore are restricted to few highly experienced research centers. In contrast, volitional tests are by far less complex and have become widespread but are dependent on the patient making a truly maximal effort.3Laveneziana P. Albuquerque A. Aliverti A. et al.ERS statement on respiratory muscle testing at rest and during exercise.Eur Respir J. 2019; 53: 1801214Crossref PubMed Scopus (293) Google Scholar,4American Thoracic Society/European Respiratory SocietyATS/ERS statement on respiratory muscle testing.Am J Respir Crit Care Med. 2002; 166: 518-624Crossref PubMed Scopus (1892) Google Scholar Here, maximal static inspiratory and expiratory mouth pressures and maximal sniff nasal inspiratory pressures are the most frequently applied tests in a clinical setting. There are two important conditions that considerably impact the maximal pressure generation: first, a learning effect, and second, an adaption to an increase in neural drive after repetitive submaximal maneuvers (warm-up procedures), both of which lead to an increase in the pressure generation capacity.3Laveneziana P. Albuquerque A. Aliverti A. et al.ERS statement on respiratory muscle testing at rest and during exercise.Eur Respir J. 2019; 53: 1801214Crossref PubMed Scopus (293) Google Scholar, 4American Thoracic Society/European Respiratory SocietyATS/ERS statement on respiratory muscle testing.Am J Respir Crit Care Med. 2002; 166: 518-624Crossref PubMed Scopus (1892) Google Scholar, 5Gabriel D.A. Kamen G. Frost G. Neural adaptations to resistive exercise: mechanisms and recommendations for training practices.Sports Med. 2006; 36: 133-149Crossref PubMed Scopus (482) Google Scholar However, current guidelines clearly emphasize the impact of these two conditions, but clear recommendations on how to handle learning effects and warm-up procedures practically are missing, mainly because of failing evidence. In this issue of CHEST, Cruickshank et al6Cruickshank T. Flores-Opazo M. Tuesta M. Reyes Á. Reproducibility of maximum respiratory pressure assessment: a systematic review and meta-analysis.Chest. 2022; 162: 828-850Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar performed a systematic review and metanalysis on the reproducibility of maximum respiratory pressure assessment. Of nearly 2,000 articles retrieved, 32 were included in the metanalysis: 18 on healthy individuals and 14 on individuals with chronic medical conditions. Overall, both repeated testing sessions and warm-up protocols produced higher maximum respiratory pressures. Importantly, inspiratory muscle warm-up procedures were shown to induce higher increases in maximum inspiratory pressure in comparison with single and repeated testing sessions of maximum respiratory pressure in healthy individuals. From this data, it was concluded that inspiratory muscle warm-up protocols are more effective than single or repeated testing sessions of maximum respiratory pressure to obtain accurate and reliable values of respiratory muscle strength in healthy individuals. In addition, repeated testing sessions were shown to have similar effects in improving all respiratory outcomes when comparably addressing healthy individuals and clinical populations. The work of Cruickshank et al6Cruickshank T. Flores-Opazo M. Tuesta M. Reyes Á. Reproducibility of maximum respiratory pressure assessment: a systematic review and meta-analysis.Chest. 2022; 162: 828-850Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar is a valuable contribution in the field of respiratory muscle testing. It clearly shows that the practical application of volitional tests for the assessment of respiratory muscle strength needs standardization. According to the current results, warm-up protocols principally would best qualify for the standard procedure before maximal maneuvers. There are, however, some concerns. First, warm-up protocols as included in the current study were applied only in healthy individuals. The authors have speculated that it would be reasonable to expect similar results in clinical populations; however, this, in the end, still remains unclear. Warm-up protocols require individuals to perform repetitive submaximal breathing efforts, which, contrarily, could lead to a reduction in pressure generation during the actual maximal maneuver in more severely affected patients as a result of dyspnea (“mental fatigue”). In addition, repetitive submaximal breathing efforts could lead to hyperinflation in patients with airway obstruction, as in those with COPD, causing changes in respiratory mechanics that impact pressure generation. This has also been acknowledged by the authors.6Cruickshank T. Flores-Opazo M. Tuesta M. Reyes Á. Reproducibility of maximum respiratory pressure assessment: a systematic review and meta-analysis.Chest. 2022; 162: 828-850Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Second, warm-up protocols are not standardized. Here, both working volumes and working intensity are suggested to impact on the pressure increase during the subsequent maximal maneuver. The authors have indicated nicely that different settings have been chosen in the different studies.6Cruickshank T. Flores-Opazo M. Tuesta M. Reyes Á. Reproducibility of maximum respiratory pressure assessment: a systematic review and meta-analysis.Chest. 2022; 162: 828-850Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In addition, considering that the pathologic evidence of respiratory muscle weakness varies depending on the underlying condition (neural, muscular, muscle coupling, and others), it remains unclear if different diseases respond differently to warm-up protocols with different working volumes and working intensity. Finally, standardization of procedures that prepare a reliable and volitional assessment of respiratory muscle strength is not enough. There is increasing evidence that maximum respiratory pressure values are also highly dependent on the lung volumes (measurement level at residual volume vs functional residual capacity) and on how long maximal pressures are being sustained (peak pressures vs plateau pressures).3Laveneziana P. Albuquerque A. Aliverti A. et al.ERS statement on respiratory muscle testing at rest and during exercise.Eur Respir J. 2019; 53: 1801214Crossref PubMed Scopus (293) Google Scholar,4American Thoracic Society/European Respiratory SocietyATS/ERS statement on respiratory muscle testing.Am J Respir Crit Care Med. 2002; 166: 518-624Crossref PubMed Scopus (1892) Google Scholar,7Windisch W. Hennings E. Sorichter S. Hamm H. Criée C.P. Peak or plateau maximal inspiratory mouth pressure: which is best?.Eur Respir J. 2004; 23: 708-713Crossref PubMed Scopus (86) Google Scholar The studies included in the current analysis have also used different technical devices and different measurement protocols, which did also impact on the effect of procedures as assessed in the study. For example, repeated testing sessions produced similar improvements in all respiratory outcomes, except for maximal inspiratory pressure at functional residual capacity where studies showed the smallest improvement after two and three testing sessions; this was true for healthy individuals and individuals with respiratory diseases. In summary, the current study Cruickshank et al6Cruickshank T. Flores-Opazo M. Tuesta M. Reyes Á. Reproducibility of maximum respiratory pressure assessment: a systematic review and meta-analysis.Chest. 2022; 162: 828-850Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar is complex and comparably provides, for the first time, detailed evidence for both repeated testing sessions and warm-up protocols as used to achieve maximal pressure generation during subsequent maximum respiratory pressure assessment. Thereby, the most important studies over more than 3 decades have been included thoroughly in this metanalysis. It clearly shows that standardization of volitional maximum respiratory pressure assessment is mandatory. This is true not only for both the real measurements, but also for the steps required beforehand that are aimed at achieving maximal pressures generation (repeated testing sessions vs warm-up protocols). Here, more research clearly is required to standardize all steps of the maneuver more reliably. Financial/nonfinancial disclosures: None declared. Reproducibility of Maximum Respiratory Pressure Assessment: A Systematic Review and Meta-analysisCHESTVol. 162Issue 4PreviewInspiratory muscles warm-up procedures induce higher increases in maximum inspiratory pressure in comparison with single and repeated testing sessions of maximum respiratory pressure in healthy individuals. Warm-up protocols are more effective to obtain the maximum performance of inspiratory muscles in one testing session in comparison with other methods. Full-Text PDF

Purpose: Real-word evidence on the effectiveness of switching from dual therapies or triple therapies (multiple inhalers) to extrafine single-inhaler triple therapy (efSITT), which consists of the inhaled corticosteroid (ICS) beclomethasone, the long-acting β 2 -agonist (LABA) formoterol and the long-acting muscarinic antagonist (LAMA) glycopyrronium, in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) is limited. The impact of switching to efSITT on health-related quality of life (HRQoL), COPD specific symptoms, lung function and treatment adherence were assessed in routine clinical care. Patients and Methods: Patients were recruited at 148 sites in Germany between 2017 and 2020 in this multicenter, non-interventional observational study. Demographics, clinical data and treatment history were collected at baseline. HRQoL (measured by COPD Assessment Test [CAT]), lung function and adherence (measured by Test of Adherence to Inhalers [TAI]) were assessed at baseline and after six months. Descriptive analyses were conducted by prior treatment and GOLD groups as well as for the overall population. Results: 55.1% of the 2623 included patients were male. Mean age was 65.8 years. 57.5% of the patients were previously treated with ICS+LABA+LAMA (multiple inhalers), 23.9% with ICS/LABA (single or two inhalers) and 18.6% with LAMA/LABA (single or two inhalers). After six months, largest mean improvements in the total CAT score were observed in the ICS/LABA (−3.9) and LAMA/ LABA (−3.9) prior treatment groups as well as in patients in GOLD group B (−2.9). In the overall population, the CAT items for cough, phlegm, and dyspnea decreased on average by −0.4 points each. After six months, FEV 1 increased by 2.0 percentage points in relation to predicted values. The percentages of measured sRtot and RV of predicted values decreased by 24.5 and 4.4 percentage points, respectively. The percentage of patients with good adherence increased from 67.8% to 76.5%. Conclusion: Treatment switch to efSITT resulted in an improvement of HRQoL, COPD specific symptoms, lung function parameters and adherence under real-world conditions.

Switzerland is one of the few countries where high fertility rates have been reported in cattle hydatid cysts and where the cattle/dog cycle is the most important for the maintenance of Echinococcus granulosus. The developmental and morphological characteristics of E. granulosus of Swiss cattle origin were studied and compared with that of E. granulosus of domestic animal origin from Great Britain and Australia, countries where bovine hydatid cysts are usually sterile and cattle play little role in the life-cycle of the parasite. Adult E. granulosus of Swiss cattle origin differed markedly in its developmental characteristics compared to other isolates, particularly in its rate of maturation in dogs, producing eggs as early as 35 days post-infection. The morphology of E. granulosus of Swiss cattle origin was characteristic and it could be easily distinguished from other isolates of the parasite. Further, E. granulosus of Swiss cattle origin was found to closely resemble that occurring in cattle in South Africa where high fertility rates have also been reported in bovine hydatid cysts. It is concluded that a strain of E. granulosus exists which is adapted to cattle and that further studies are required to determine whether this strain warrants formal taxonomic status as the species E. ortleppi which was originally described for the parasite of South African cattle origin.

Several chronic underlying conditions (UCs) are known to be risk factors for developing herpes zoster (HZ) and to increase the severity of HZ and its risk of recurrence. The aim of this study was to investigate the incidence and recurrence of HZ in adult patients with one or multiple UCs. A retrospective cohort study based on claims data representing 13% of the statutory health insurance population from 2007 to 2018 in Germany was performed. Patients aged ≥ 18 years were included when at least one of the following UCs was diagnosed: asthma, chronic heart failure, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), depression, diabetes mellitus type 1 or 2, and rheumatoid arthritis (RA). Exact matching was used to account for differences in the distribution of age and sex between the case and matched control cohorts. Multi-morbidity was considered in sensitivity analyses by analyzing patients with only one UC. Patients with asthma, CHD, COPD, depression, and RA had, on average, a 30% increased risk of developing acute HZ compared to patients without any UC. RA was found to have the highest odds ratio among these conditions, varying from 1.37 to 1.57 for all age groups. Patients with depression also showed a high risk of developing HZ. Analysis of recurrence indicated that patients with at least one UC in the age groups 18–49 years and 50–59 years had the highest risk for a recurrent HZ. After experiencing a first recurrence, patients, regardless of age group, had a two- to threefold higher risk for a second recurrence. This study of representative claims data shows a higher HZ incidence and recurrence frequency in patients with UCs. These results provide relevant information for national health care guidelines and disease management programs. Shingles is caused by the reactivation of the chickenpox virus and is characterized by a painful skin rash with blisters, commonly occurring on the trunk. Underlying conditions (UCs) are conditions that persist for a long time, require ongoing medical attention, and are rarely completely cured (chronic conditions). UCs can increase the severity, the risk, and the frequency of shingles. Here, data from a large German health care insurance provider was used to investigate whether patients with one or more UCs have a higher risk for getting shingles compared to healthy people. In particular, patients with asthma, chronic heart failure, chronic obstructive pulmonary disease, coronary heart disease, depression, diabetes, and rheumatoid arthritis were investigated. The study shows that patients with asthma, coronary heart disease, chronic obstructive pulmonary disease, depression, and rheumatoid arthritis have, on average, a 30% higher risk of developing shingles, regardless of their age. The risk of developing shingles two or more times is also higher for patients with at least one UC, with those aged 18–59 experiencing an even greater risk. It was found that patients with an UC are more exposed to develop shingles and that younger patients have a higher risk of a recurrent episode. The findings provide important information for the development or adaption of national health care guidelines and shingles vaccination recommendations.