Nasal high-flow therapy with oxygen entrained (HFNO) and non-invasive ventilation (NIV) are important therapies for managing acute respiratory failure (ARF) in the ward-based setting. The European Respiratory Society released guidelines in 2022 recommending the use of HFNO over conventional oxygen therapy and NIV in patients with hypoxic ARF. We conducted a 12-month retrospective audit of ward-based HFNO and NIV use at our hospital to determine prescribing practices for these therapies and to assist with the safe implementation of the recent European Respiratory Society guidelines. We found significant variation in prescribing practices for both HFNO and NIV.

Obstructive sleep apnoea (OSA) is highly prevalent and exacerbated by alcohol consumption. With an increasing uptake of unsupervised home-based sleep studies for diagnosis, alcohol use can significantly confound results and impact clinical management. We present the case of a 65 year-old male referred for OSA evaluation. An initial home sleep study, performed in the setting of significant alcohol intake, demonstrated moderate OSA (AHI 22.1) with predominantly supine sleep (99% of total sleep time). A subsequent alcohol-free in-lab study revealed only mild OSA (7.5) with predominantly non-supine sleep (41.9% of total sleep time supine). This marked change reflects the effect of alcohol on OSA severity and sleep architecture. Our case emphasises the importance of documenting alcohol use prior to and during sleep studies and the incorporation of alcohol reduction in OSA management for selected patients.

Background/Objectives: Non-invasive ventilation (NIV) is a highly effective and safe treatment for hypercapnic acute respiratory failure (ARF). This study aimed to identify and examine the content and recommendations within local health guidance documents (LHGDs) that facilitate ward-based implementation of NIV for the treatment of ARF in adults in Australian health services. Methods: A scoping review was conducted on 26 May 2023, updated on 11 January 2024 and 16 September 2025 to identify public health services NIV LHGDs. Data were extracted and analysed regarding NIV initiation, monitoring, maintenance and weaning, and management of clinical deterioration. Results: Twenty-two LHGDs were included, of which only six (27.3%) referenced international NIV guidelines. Most LHGDs (n = 17, 77.3%) required an arterial blood gas (ABG) measurement before NIV initiation, with eight (36.4%) specifying PaCO2 > 45 mmHg and pH < 7.35 as a basis to consider NIV initiation. Most (n = 13, 59.1%) specified a target SpO2 range to monitor NIV, but recommendations varied. NIV implementation recommendations general wards (n = 12, 54.5%) were most common, followed by respiratory wards (n = 5, 22.7%) and respiratory care units (n = 4, 18.2%). Most LHGDs did not specify criteria for medical review (n = 13, 59.1%), clinical escalation (n = 13, 59.1%) or palliation care (n = 13, 59.1%), and weaning guidance was rarely specified (n = 7, 31.8%). Conclusions: There was substantial variation in the structure and content of LHGDs for ward-based NIV across Australian hospitals, including inconsistencies in initiation, monitoring, weaning, and detection of patient deterioration. Variation and limited alignment with major clinical guidelines may impact care quality and safety.

Dupilumab has been associated with adverse reactions including symptomatic hypereosinophilia. This study reports the incidence of dupilumab-related eosinophilia and adverse reactions in severe asthma patients at an Australian tertiary centre. https://bit.ly/3JgZ5Ya.

Abstract Introduction Untreated obstructive sleep apnoea (OSA) is often unrecognised pre-operatively and is associated with increased post-operative complications and morbidity. Anaesthetist screening of OSA risk in pre-admission clinic (PAC) prompts referral to a sleep physician to investigate. Aim To explore the novel concept of integrating a sleep physician into PAC. Methods An audit sampling a PAC service was conducted at a tertiary hospital, pre and post integration of a sleep physician into PAC. Pre-integration, anaesthetists who identified patients at risk of OSA based on STOPBANG questionnaire were referred to the sleep clinic on a future date. Post integration, such patients were referred to the sleep physician in PAC on the same day. Demographic variables, times to assessments and hospital outcomes were reviewed. Results 382 patients were reviewed in PAC pre-integration (26% bariatric, 31% orthopaedic, 43% other) and 355 post-integration (16% bariatric, 39% orthopaedic, 45% other). Comparing pre-integration with post-integration: 8 (2%) vs 71 (20%) patients were referred for sleep physician assessment. Mean days to: sleep physician assessment (120 vs 0), sleep study (91 vs 25), OSA management (138 vs 13) and surgery (261 vs 38). The 30-day mortality and unplanned non-invasive ventilation (NIV) post-operatively did not occur in either group referred for sleep assessment. Discussion Integration of a sleep physician into PAC resulted in 10 times more referrals for assessment of OSA. Time to: see a sleep physician, sleep study, management and surgery was reduced. Limitations of this study include a small sample size and confounders affecting clinical wait times.

Abstract Study Objectives Multiple sleep latency testing (MSLT) and maintenance of wakefulness testing (MWT) are validated objective assessments of excessive daytime sleepiness. However, both are open to the confounding effects of drugs. This study aims to determine the rates of detection of drugs with known effects of sleep architecture using both immunoassay (IA) and mass spectrometry (MS) urinary drug screens (UDS) during MSLT/MWT testing. Methods A retrospective audit was performed on all patients who underwent an MSLT/MWT test at a tertiary hospital sleep laboratory between 2013-2023. Data was collected on the rates of positive IA and MS UDS, disclosure of the drug to their treating physician, demographics, comorbidities, and polysomnographic variables. Results 162 patients were included in the analysis, 137 MSLT patients and 25 MWT patients. 29/162 (17.9%) and 67/162 (51.3%) of patients had a positive IA-UDS and MS-UDS respectively. These drugs were disclosed in 44% of positive IA-UDS and 68% of MS-UDS positive patients. Patients with a positive IA and MS UDS during MSLT were more likely to have an elevated HADS-A questionnaire result and clinically diagnosed anxiety and depression, history of malignancy (IA-UDS) and chronic pain (MS-UDS). There was no correlation between positive UDS results and any variables in patients undergoing MWT. Conclusions There is limited data on the rates of positive UDS routinely performed as part of MSLT/MWT. This has made it difficult to determine the optimal screening method. This study demonstrates that in patients undergoing MSTL/MWT testing, positive IA and MS-UDS are common and frequently not disclosed.

Swyer-James-MacLeod Syndrome is a rare obliterative lung disease typically caused by childhood infection resulting in arrested pulmonary development. Imaging findings include unilateral hyperlucency on chest x-ray, and hyperlucency, hypovascularity and expiratory gas trapping on computed tomography. Recognition of abnormal imaging can lead to earlier diagnosis and institution of appropriate management.

Background: The incidence of silicosis has increased due to occupational silica exposure from artificial stone, with no treatments proven to halt or reverse the disease. Whole lung lavage (WLL) involves the instillation of fluid into the lungs to wash out silica particles and disease-causing inflammatory cells. This study aimed to determine the feasibility, safety, and possible benefit of WILL in patients with artificial stone silicosis. Methods: In this prospective observational study, people with progressive silicosis with ground glass predominant radiological changes underwent WLL. High resolution computed tomography (HRCT) chest, X-ray velocimetry (XV), lung function tests, forced oscillation technique (FOT), and cardiopulmonary exercise tests (CPET) were performed before and six months after the procedure. Results: Eight patients underwent WLL between June 2021 and November 2022. Five participants had an improvement in the International Classification of High Resolution Computed Tomography for Occupational and Environmental Respiratory Diseases (ICOERD) CT scores and reduction in XV regional ventilation distribution pre- and six months post-WLL. There was no difference in lung function [annualized rate of change in forced vital capacity (FVC) % predicted mean difference (MD) 1.81; 95% CI: -1.53 to 5.15, P=0.27; forced expiratory volume in 1 second (FEV1) % predicted MD -1.13, 95% CI: -5.08 to 2.83, P=0.55; diffusing capacity for carbon monoxide (DLCO) % predicted MD -2.62, 95% CI: -10.04 to 4.80, P=0.46]. There was no significant difference in CPET or FOT measurements. Following WILL, all patients experienced transient throat discomfort, one had fever and two required oral antibiotics. There were no serious adverse events. Conclusions: WILL for artificial stone silicosis is safe in an expert centre who has experience in performing WILL in this population, and there may be limited benefit in selected patients. Further research is required to select those who will derive the most benefit.

The seven-item Hospital Anxiety and Depression Scale Depression subscale (HADS-D) and the total score of the 14-item HADS (HADS-T) are both used for major depression screening. Compared to the HADS-D, the HADS-T includes anxiety items and requires more time to complete. We compared the screening accuracy of the HADS-D and HADS-T for major depression detection. We conducted an individual participant data meta-analysis and fit bivariate random effects models to assess diagnostic accuracy among participants with both HADS-D and HADS-T scores. We identified optimal cutoffs, estimated sensitivity and specificity with 95% confidence intervals, and compared screening accuracy across paired cutoffs via two-stage and individual-level models. We used a 0.05 equivalence margin to assess equivalency in sensitivity and specificity. 20,700 participants (2,285 major depression cases) from 98 studies were included. Cutoffs of ≥7 for the HADS-D (sensitivity 0.79 [0.75, 0.83], specificity 0.78 [0.75, 0.80]) and ≥15 for the HADS-T (sensitivity 0.79 [0.76, 0.82], specificity 0.81 [0.78, 0.83]) minimized the distance to the top-left corner of the receiver operating characteristic curve. Across all sets of paired cutoffs evaluated, differences of sensitivity between HADS-T and HADS-D ranged from -0.05 to 0.01 (0.00 at paired optimal cutoffs), and differences of specificity were within 0.03 for all cutoffs (0.02-0.03). The pattern was similar among outpatients, although the HADS-T was slightly (not nonequivalently) more specific among inpatients. The accuracy of HADS-T was equivalent to the HADS-D for detecting major depression. In most settings, the shorter HADS-D would be preferred. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Rationale Frailty is an increasingly recognized aspect of chronic obstructive pulmonary disease (COPD). The impact of frailty on long-term survival after admission to an Intensive Care Unit (ICU) due to an exacerbation of COPD has not been described. Objective To quantify the impact of frailty on time to death up to four years after admission to ICU in Australia and New Zealand with an exacerbation of COPD. Methods We performed a multicenter retrospective cohort study of adult patients admitted to 179 ICUs with a primary diagnosis of an exacerbation of COPD using the Australian and New Zealand Intensive Care Society Adult Patient Database from 1st January 2018 through 31st December 2020 in New Zealand, and 31st March 2022 in Australia. Frailty was measured using the Clinical Frailty Scale (CFS). The primary outcome was survival up to four years after ICU admission. The secondary outcome was readmission to the ICU due to an exacerbation of COPD. Measurements and Main Results We examined 7,126 patients, of which 3,859 (54.1%) were frail (CFS 5-8). Mortality in the not-frail vs. frail at one and four years was 19.8% vs. 40.4%, and 56.8% vs. 77.3% respectively (both p<0.001). Frailty was independently associated with a shorter time to death (adjusted HR 1.66; 95% CI 1.54-1.80).There was no difference in the proportion of survivors with or without frailty who were readmitted to ICU during a subsequent hospitalization. Conclusions Frailty was independently associated with poorer long-term survival in patients admitted to ICU with an exacerbation of COPD.

BACKGROUND:Multidisciplinary systematic assessment improves outcomes in difficult-to-treat asthma, but without clear response predictors. Using a treatable-traits framework, we stratified patients by trait profile, examining clinical impact and treatment responsiveness to systematic assessment.METHODS:We performed latent class analysis using 12 traits on difficult-to-treat asthma patients undergoing systematic assessment at our institution. We examined Asthma Control Questionnaire (ACQ-6) and Asthma Quality of Life Questionnaire (AQLQ) scores, FEV1 , exacerbation frequency, and maintenance oral corticosteroid (mOCS) dose, at baseline and following systematic assessment.RESULTS:Among 241 patients, two airway-centric profiles were characterized by early-onset with allergic rhinitis (n = 46) and adult onset with eosinophilia/chronic rhinosinusitis (n = 60), respectively, with minimal comorbid or psychosocial traits; three non-airway-centric profiles exhibited either comorbid (obesity, vocal cord dysfunction, dysfunctional breathing) dominance (n = 51), psychosocial (anxiety, depression, smoking, unemployment) dominance (n = 72), or multi-domain impairment (n = 12). Compared to airway-centric profiles, non-airway-centric profiles had worse baseline ACQ-6 (2.7 vs. 2.2, p < .001) and AQLQ (3.8 vs. 4.5, p < .001) scores. Following systematic assessment, the cohort showed overall improvements across all outcomes. However, airway-centric profiles had more FEV1 improvement (5.6% vs. 2.2% predicted, p < .05) while non-airway-centric profiles trended to greater exacerbation reduction (1.7 vs. 1.0, p = .07); mOCS dose reduction was similar (3.1 mg vs. 3.5 mg, p = .782).CONCLUSION:Distinct trait profiles in difficult-to-treat asthma are associated with different clinical outcomes and treatment responsiveness to systematic assessment. These findings yield clinical and mechanistic insights into difficult-to-treat asthma, offer a conceptual framework to address disease heterogeneity, and highlight areas responsive to targeted intervention.

Background: There has been a rapid growth in wearables marketed to measure sleep. Fitbit trackers collect data through an internal accelerometer and use heart rate variability to estimate the sleep-wake state. There is a paucity of “real-world” data in patients who are being evaluated for sleep disorders. Aim: To evaluate the agreement between Fitbit Charge3TM & in-lab polysomnography (PSG) in patients who require a PSG for assessment. Methods: A prospective study of patients attending a PSG through Epworth Camberwell Sleep Lab between 2020-2021 was conducted. Fitbit Charge3TM was worn on the dominant wrist with concurrent PSG monitoring. Parameters measured included total sleep time; TST (min), Sleep onset latency; SOL (min), sleep efficiency; SE (%), wake after sleep onset; WASO (min) and time spent in N1, N2, N3 and REM sleep (min). 30 second epoch-by-epoch analyses were conducted. Results: Seventy patients (male=52), median age of 55 years; IQR(45,67) completed the study. On average, the Fitbit significantly overestimated light sleep by 62.99 min, TST by 29.50 min, and SE by 3.33% and underestimated deep sleep by 40.55 min WASO by 28 min. Fitbit and PSG did not significantly differ on REM or SOL measurements. Conclusion: Our findings may support the use of Fitbit Charge3TM as an initial screening device to assess sleep duration and architecture in select patients attending sleep clinics Table 1: Comparison of sleep variables between PSG and Fitbit Charge 3TM

Introduction: Chronic obstructive pulmonary disease (COPD) is a treatable and preventable disease characterised by persistent respiratory symptoms and chronic airflow limitation on spirometry. COPD is highly prevalent and is associated with exacerbations and comorbid conditions. "COPD-X" provides quarterly updates in COPD care and is published by the Lung Foundation Australia and the Thoracic Society of Australia and New Zealand. Main recommendations: The COPD-X guidelines (version 2.65) encompass 26 recommendations addressing: case finding and confirming diagnosis; optimising function; preventing deterioration; developing a plan of care; and managing an exacerbation. Changes in management as a result of these guidelines: Both non-pharmacological and pharmacological strategies are included within these recommendations, reflecting the importance of a holistic approach to clinical care for people living with COPD to delay disease progression, optimise quality of life and ensure best practice care in the community and hospital settings when managing exacerbations. Several of the new recommendations, if put into practice in the appropriate circumstances, and notwithstanding known variations in the social determinants of health, could improve quality of life and reduce exacerbations, hospitalisations and mortality for people living with COPD.