Pulmonary Medicine

Vaping epidemic in US teens: problem and solutions Purpose of review Over the last decade, vaping has emerged into an epidemic of alarming proportions among US teens. This review evaluates the factors leading to the rise of vaping, reasons for its striking popularity among US teens, health consequences of vaping, and measures to mitigate the vaping epidemic. Recent findings Contemporary research highlights the continued rise of vaping amongst US teens and explains the reasons for its popularity, such as the variety of devices, a wide range of available flavors, youth-targeted advertisements, and lack of awareness of adverse consequences from vaping. This publication highlights current research findings of health consequences of vaping, including a discussion of EVALI (e-cigarette or vaping product use-associated lung injury) and provides an update on strategies to curtail the vaping epidemic. Summary Vaping has risen to epidemic proportions amongst US teens. This poses a clear and present danger to teens' health with adverse effects ranging from acute lung injury to long-term addiction. This article summarizes key research findings that explain the reasons for the epidemic, health consequences of vaping, and provides an overview of efforts to mitigate the vaping threat to US teens. Correspondence to Anand N. Venkata, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas, for Medical Sciences, 4301W. Markham St. #555, Little Rock, Arkansas 72205, USA. Tel: +1 501 686 5525; e-mail: Avenkata@uams.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Impact of obesity on pulmonary function: current understanding and knowledge gaps Purpose of review Obesity is an increasing world-wide public health concern. Obesity both causes respiratory symptoms and contributes to many cardiorespiratory diseases. The effects of obesity on commonly used lung function tests are reviewed. Recent findings The effects of obesity on lung function are attributed both to mechanical factors and to complex metabolic effects that contribute to a pro-inflammatory state. The effects of obesity on lung function correlate with BMI and correlate even better when the distribution of excess adipose tissue is taken into account, with central obesity associated with more prominent abnormalities. Obesity is associated with marked decreases in expiratory reserve volume and functional residual capacity. Total lung capacity, residual volume, and spirometry are less affected by obesity and are generally within the normal range except with severe obesity. Obesity decreases total respiratory system compliance primarily because of decreased lung compliance, with only mild effects on chest wall compliance. Obesity is associated with impaired gas transfer with decreases in oxygenation and varied but usually mild effects on diffusing capacity for carbon monoxide, while the carbon monoxide transfer coefficient is often increased. Summary Obesity has significant effects on lung function. The relative contribution of the mechanical effects of obesity and the production of inflammatory cytokines by adipose tissue on lung function needs further study. Correspondence to Matthew J. Hegewald, MD, Intermountain Medical Center, Division of Pulmonary & Critical Care Medicine, Sorensen Heart-Lung Center, 6th Floor, 5121 South Cottonwood Street, Murray, UT 84107, USA. Tel: +1 801 507 4870, fax: +1 801 507 4792; e-mail: matt.hegewald@imail.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

How might endotyping guide chronic obstructive pulmonary disease treatment? Current understanding, knowledge gaps and future research needs Purpose of review This review discusses emerging therapies directed at chronic obstructive pulmonary disease (COPD) endotypes and pathobiological processes that manifest as the disease. Recent findings Specific endotypes have been targeted in COPD. These include eosinophilic inflammation, overproduction of interleukin-17, chronic bronchitis and altered nature of mucous, and chronic infection. Therapies exactly directed at the cause of these endotypes or their resultant clinical findings have been assessed. Although some intermediate outcomes have seemed promising, there have been no findings that shift the paradigm of COPD therapy. Summary Basic and clinical scientists continue to define endotypes that may be directly addressed with therapeutics. As of the time of this up-to-date review, there is yet to be an endotype-directed therapy to demonstrate great clinical effect. Correspondence to Robert M. Burkes, MD, MSCR, University of Cincinnati Medical Center, 231 Albert Sabin Way, Cincinnati, OH 45229, USA. Tel: +1 513 558 4831; e-mail: burkesrt@ucmail.uc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Obstructive lung diseases and allergic bronchopulmonary aspergillosis Purpose of review Allergic bronchopulmonary aspergillosis (ABPA) is a disease frequently complicating asthma and cystic fibrosis. ABPA is increasingly recognized in other obstructive lung diseases (OLDs), including chronic obstructive pulmonary disease (COPD) and noncystic fibrosis bronchiectasis. Herein, we summarize the recent developments in ABPA complicating OLDs. Recent findings Recent research has described the clinical features and natural history of ABPA complicating asthma in children and the elderly. We have gained insights into the pathophysiology of ABPA, especially the role of eosinophil extracellular trap cell death and mucus plugs. The utility of recombinant fungal antigens in the diagnosis of ABPA has been established. Newer, more sensitive criteria for the diagnosis of ABPA have been proposed. Although ABPA is uncommon in COPD and noncystic fibrosis bronchiectasis, aspergillus sensitization is more common and is associated with a higher exacerbation rate. Summary Several advances have occurred in the diagnosis and treatment of ABPA in recent years. However, there is an unmet need for research into the genetic predisposition, pathophysiology, and treatment of ABPA. Apart from asthma and cystic fibrosis, patients with other OLDs also require evaluation for Aspergillus sensitization and ABPA. Correspondence to Dr Ritesh Agarwal, Professor, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh 160012, India. E-mail: agarwal.ritesh@outlook.in Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Unprecedented: the toxic synergism of Covid-19 and climate change Purpose of review To review and compare the constellations of causes and consequences of the two current pandemics, Covid-19 and climate change. Recent findings There has been a transient counterbalancing, in which the response to Covid-19 has briefly mitigated pollution and greenhouse gasses. This divergence belies multiple commonalities of cause and effect. Summary The convergence of these two pandemics is unprecedented. Although at first glance, they appear to be completely unrelated, they share striking commonalities. Both are caused by human behaviors, and some of those behaviors contribute to both pandemics at the same time. Both illustrate the fact that isolation is not an option; these are global issues that inescapably affect all persons and all nations. Both incur prodigious current and anticipated costs. Both have similar societal impacts, and disproportionately harm those with lesser resources, widening the gap between the 'haves and the have-nots.' One can only hope that the devastation caused by these unprecedented pandemics will lead to increased awareness of how human beings have helped to create them and how our responses can and will shape our future. Correspondence to Manish Joshi, MD, FCCP, Professor of Medicine, Pulmonary and Critical Care Division, University of Arkansas for Medical Sciences, 4301W. Markham, Mail Slot #555, Little Rock, AR 72205, USA. Tel: +1 501 686 5525; fax: +1 501 686 7893; e-mail: mjoshi@uams.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

A trio of articles on Covid-19, followed by articles on vaping, hypersensitivity pneumonitis, and several on obstructive airway and pulmonary diseases No abstract available

Beta-blockers in chronic obstructive pulmonary disease: the good, the bad and the ugly Purpose of review Several observational studies have suggested that β-blockers, especially cardioselective ones, are well tolerated and associated with a lower risk of acute exacerbations and death in patients with chronic obstructive pulmonary disease (COPD). However, there are dissenting studies. This review provides an update on the use of β-blockers in COPD, focusing on results of recent prospective studies and randomized controlled trials. Recent findings In totality, cohort studies indicate that β-blockers are generally well tolerated and effective in COPD patients who also have a clear cardiovascular indication for these groups. Although β-blockers on average reduce lung function acutely in COPD patients, the absolute decrease is relatively small, especially if cardioselective β-blockers are used. The results of two large randomized controlled trials suggest that concomitant β-blocker use does not reduce the therapeutic benefits of inhaled bronchodilators in COPD patients. The use of β-blockers in COPD patients, who do not have overt cardiovascular disease, does not prevent COPD exacerbations and may paradoxically increase the risk of COPD-related hospitalization and mortality. Summary The use of β-blockers is generally well tolerated and effective in COPD patients, who also have a clear cardiovascular indication for these drugs. However, they should not be used in patients who do not have overt cardiovascular disease as β-blockers can reduce lung function, worsen health status and increase the risk of COPD-related hospitalization. Correspondence to Don D. Sin, Tier 1 Canada Research Chair in COPD, de Lazzari Family Chair at the UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada V6Z 1Y6. Tel: +1 604 806 8346; fax: +1 604 806 9274; e-mail: don.sin@hli.ubc.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

ICU preparedness in pandemics: lessons learned from the coronavirus disease-2019 outbreak Purpose of review The worldwide SARS-CoV-2 pandemic has taken a heavy toll on ICUs worldwide. This review expounds on lessons learned for ICU preparedness during the pandemic and for future mass casualty events. Recent findings In the 21st century, there have already been several outbreaks of infectious diseases that have led to mass casualties creating ICU strain, providing multiple opportunities for hospitals and hospital systems to prepare their ICUs for future events. Unfortunately, the sheer scale and rapidity of the SARS-CoV-2 pandemic led to overwhelming strain on every aspect of ICU disaster preparedness. Yet, by analyzing experiences of hospitals throughout the first 7 months of the current pandemic in the areas of infection control, equipment preparedness, staffing strategies, ICU spatial logistics as well as acute and postacute treatment, various important lessons have already emerged that will prove critical for successful future ICU preparedness. Summary Preemptive planning, beginning with the early identification of staffing resources, supply chains and alternative equipment sources, coupled with strong infection control practices that also provide for the flexibility for evolving evidence is of utmost importance. However, there is no single approach that can be applied to every health system. Correspondence to Amesh Adalja, MD, Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD 21202, USA. Tel: +1 443 573 3304; e-mail: aadalja1@jhu.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Diagnostic and therapeutic challenges of chronic obstructive pulmonary disease in the elderly Purpose of review Chronic obstructive pulmonary disease (COPD) imposes a large burden on the global population and even more so for the elderly who face significant obstacles in the diagnosis, management, and psychosocial effects of the disease. This review describes the current challenges and key points in the management of COPD in the elderly. Recent findings Lower limit rather than fixed cut off of the FEV1/FVC ratio can improve the diagnosis and better predict COPD mortality. High relative to standard dose influenza vaccination reduces confirmed cases of influenza overall and reduces hospitalizations in older nursing home residents. Simple interventions that include electronic health record tracking can significantly improve vaccination rates. Although many inhaler and nebulized medications are available for the elderly, the final regimen is usually determined by a combination of expense, issues with proper device use (from difficulty with coordination, hand grip, inspiratory flows or cognitive function) and the side effect profile. Fortunately, the switch to cheaper or better covered alternatives can be well tolerated with improvement in adherence and exacerbations of COPD. Finally, caution should be made against ageism, which may be a factor in the recommendation of rehabilitation or palliative care in the elderly COPD patient, as both are underused despite evidence of benefit. Summary Although care for the elderly COPD patient can be difficult, we summarize key points that the physician should be cognizant of to provide comprehensive care. Correspondence to Loutfi S. Aboussouan, MD, Cleveland Clinic, Respiratory Institute, A90, 9500 Euclid Ave, Cleveland, OH 44195, USA. Tel: +1 216 444 0420; fax: +1 216 445 8160; e-mail: aboussl@ccf.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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