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Respiratory disease

Infectious diseases Research 23 January 2023 Open Access

Emergency department presentations during the COVID‐19 pandemic in Queensland (to June 2021): interrupted time series analysis

Restrictions should be accompanied by advice about appropriate locations for seeking medical care, by condition severity and type

Amy L Sweeny · Gerben Keijzers · Andrea Marshall · Emma J Hall · Jamie Ranse · Ping Zhang · Gary Grant · Ya‐Ling Huang · Dinesh Palipana · Yang D Teng · Benjamin Gerhardy · Jaimi H Greenslade · Philip Jones · Julia L Crilly

Mja2 51819
Respiratory disease Research letter 16 January 2023 Free

Diagnosis of cystic fibrosis in adults: Australian Cystic Fibrosis Data Registry data, 2000–2019

CF diagnosed in adults can manifest with milder symptoms across a range of organ systems than classical CF

Amelia Lin · Keith Wong · Simone K Visser · Helen Jo · Yasmeen Al‐Hindawi · Katrin Kosbab‐Jackson · Molly Cocks · Anastasia Volovets · Paul Haber · Kirsten Hammond · Nicole Taylor · Veronica Yozghatlian · Edmund MT Lau · Nathaniel S Marshall · Tara Aquino‐Salomon · Sheila Sivam

Mja2 51797
Respiratory disease Letters 6 June 2022 Free

COVID‐19 highlights the need for action on pulse oximeter accuracy in people with dark skin

To the Editor: Recently published studies have highlighted concerns that pulse oximeter devices may underestimate hypoxia (overestimate oxygen saturation) in patients with dark skin. This occurs at levels where key decisions are made around supplemental oxygen and hospital admission (arterial oxygen saturation [SaO2] 88–94%). Amid the coronavirus disease 2019 (COVID‐19) pandemic, this important public health issue prompted the Therapeutic Goods Administration (TGA) to publish a medical device safety update.1 Long‐standing concerns about reduced pulse oximeter accuracy in people with dark skin2,3 have evolved into characterisation of significant racial discrepancies. A recent article compared 48097 pairs of measurements by pulse oximetry and arterial blood gas (ABG) in adults receiving oxygen across 179 hospitals in the United States. Among patients saturating >92% on pulse oximetry, hypoxaemia (ABG saturation<88%) was nearly three times more common in black patients than in white patients. Graphs illustrate the median oxygen saturation bias for black patients was 3% in the 89–96% range.4 A recent retrospective cohort study analysed registry SaO2 data in 372 individuals (73.1% with COVID‐19) about to undergo extracorporeal membrane oxygenation for respiratory failure. In patients with pulse oximeter readings of 92–96%, ABG oxygen saturation was <88% in 21.5% of black patients and in 10.2% of white patients.5 In these retrospective audits, patient ethnicity was based on hospital record identification, not skin colour. The oximetry devices used were not specified. COVID‐19 guidelines may incorporate pulse oximeter readings into decisions regarding hospital transfer of home‐care patients. Clinicians and services should arguably have lower thresholds for hospital review and admission of patients with dark skin (including Indigenous Australians and those of African and South Asian descent) with borderline oxygen saturations, while balancing risks of increased ABG and invasive treatment rates. Device manufacturers should develop pulse oximeters that perform accurately across more diverse populations. Further research must identify mechanisms of racial discrepancies in oxygen saturation and address them through device design. Calibration and testing processes for existing devices should be strengthened. The pre‐market approval processes of the US Food and Drug Administration currently require that only 15% of a study population have darker skin, while Australia has no specified requirement. The TGA does not regulate pulse oximeters sold directly to consumers (in stores or online) for general wellness or sporting purposes only. There are significant constraints on the scope for regulatory interventions for medical device pulse oximeters: this essential equipment cannot be excluded from the market or its supply compromised; mandating changes to instructions for use may have limited impact; differentiating between devices is hampered by evidence limitations and any consequent actions would be legally fraught; and mandating accuracy studies would be difficult to enforce. Contemporary evidence demonstrates that dark skin is a risk factor for hypoxia being undetected by pulse oximetry. Clinicians should adjust treatments and guidelines accordingly and consider audits of devices used in their institutions. Failure to address this problem at a design and testing level compromises racial equity in health care outcomes.

Jeffrey J Brownscombe · Heather Loane · Bridget Honan

Mja2 51522
Respiratory disease Letters 18 April 2022 Free

E‐cigarette or vaping product use‐associated lung injury in an adolescent

To the Editor: Chan and colleagues1 recently reported a case of putative e‐cigarette or vaping product use‐associated lung injury (EVALI) in a 15 year‐old girl who was a low level user of vaporised nicotine (without adulterants). We believe that, rather than EVALI, her presentation is better explained by urosepsis‐related acute lung injury. Current guidance from the United States Centers for Disease Control and Prevention (CDC)2 emphasises the role of adulterants, especially vitamin E acetate, in EVALI. In a US study completed before the widespread adoption of e‐cigarettes, the incidence of acute lung injury in 15–19‐year‐olds was 16 per 100 000 patient‐years, with many cases stemming from non‐pulmonary sepsis.3 In February 2020, only 2807 cases of vaping lung injury had been reported in the US, representing an incidence of well under one case per 100 000 patient‐years.1 Given these rates, as well as the patient’s prominent dysuria, polyuria, back pain and worsening pyrexia, we think urosepsis triggered the acute lung injury in this case. The authors say that sepsis was ruled out due to negative blood and urine cultures. However, if samples were collected after the initiation of antibiotics, false negative cultures are common in sepsis. The patient met the accepted criteria for sepsis, with suspected infection, a systemic inflammatory response syndrome and acute end‐organ failure,4 and was treated for this condition with antibiotics and corticosteroids for the acute lung injury. The CDC criteria for EVALI emphasise that the diagnosis should only be made where there is “no evidence in [the] medical record of alternative plausible diagnoses”.5 Dysuria, polyuria and back pain are not known symptoms of EVALI, and the authors have not explained how EVALI could account for this aspect of her presentation nor why these symptoms preceded the respiratory symptoms. In conclusion, the evidence to support a diagnosis of EVALI is insufficient in this case, and an alternative explanation is far more likely. Therefore, this case report should not be regarded as evidence for a case of EVALI occurring in Australia.

Cameron RL McKenzie · Joshua Davis · Adrian J Dunlop

Mja2 51462
Respiratory disease Perspectives 31 May 2021 Free

Dust diseases in modern Australia: a discussion of the new TSANZ position statement on respiratory surveillance

New measures are designed to improve health outcomes for workers in the coal mining, artificial stone and other dust‐generating industries In Australia, there has recently been a worrying resurgence of dust‐related lung diseases (pneumoconioses) previously assumed to be obsolete. Pneumoconioses are chronic fibrotic lung diseases produced by inhaling mineral dust or dusts (pneumon = lung; konis = dust [Greek]). Conditions include coal workers’ pneumoconiosis (black lung disease) and silicosis.1,2,3,4 Many cases of these diseases have been described in Australia for the first time in over 40 years, including a new type of accelerated silicosis caused by cutting and polishing engineered (artificial) stone seen in kitchen and bathroom benchtop workers.5,6 The latter has occurred in men, often at the height of their working lives, producing much disability and distress and resulting in completely preventable deaths. Artificial stone silicosis differs from other types of silicosis in that it progresses more rapidly and is also associated with a higher rate of development of autoimmunity than classical silicosis. Pneumoconiosis has recurred primarily due to a widespread failure of regulatory controls in a situation where the medical evidence for efficacy of surveillance and prevention is very well established.7,8,9 This has included deficiencies in dust monitoring and control, even in industries where lung health is notoriously at risk (eg, mining), as well as potential changes in dust exposure due to increases in length of shifts and changes in mining technologies.9,10,11 New technologies may have altered the types and characteristics of respirable dust particles as well as the total dust levels.4,12 In some industries, new products like artificial stone have been introduced without adequate awareness of likely hazards, alongside lack of labelling, inadequate respiratory protection, and widespread complacency about dust control measures.13 Dry cutting of stone is notoriously dangerous,7,8 yet was occurring frequently and is still not banned throughout Australia. Many employers (often in small businesses without access to any occupational medical advice) did not appreciate the potential hazards of products they were using, and were not warned by the regulators. Thus, they failed to assess the type or levels of respirable dusts, implement any health surveillance, or use even basic dust control measures.7,8 Because symptoms occur only very late in these diseases, workers were often unaware of any adverse effects. Many workplaces were non‐unionised and workers came from non‐English speaking backgrounds, and did not have access to information about dust hazards and ways to find help. Workers were reluctant to be identified because of job insecurity and financial concerns. Even after a respiratory abnormality had been identified, there was sometimes a failure to identify the disease as occupational in origin.10,11 It was only after cases of severe disease were described by the medical profession, and after several cases had been referred for lung transplantation, that the resurgence of pneumoconiosis was identified.3,4,5 These events are a stark reminder that occupational lung diseases are still a real issue in Australia and that we as health professionals need to maintain vigilance to prevent them in the future. As health professionals, we also need to be aware of the full range of health effects resulting from dust exposures. Inhaled dusts have been shown to cause a broader range of disorders than was originally understood.7,8,14 Pneumoconiosis is only one of several lung disorders which can arise from dust inhalation. In general, high dust levels are needed to produce lung fibrosis; however, other diseases have different, often lower, dose–response profiles. There is now convincing evidence that coal and silica/silicate dust inhalation also produces chronic bronchitis, emphysema and diffuse dust‐related pulmonary fibrosis,7,8,14 and that these effects are additive and not only attributable to tobacco smoking. It is also underappreciated that lung cancer and tuberculosis risk rises in a dose‐related manner after silica exposure, and particularly with silicosis itself.7,14,15 Dust exposure is a factor related to several systemic connective tissue diseases,16,17 including Sjögren’s syndrome, rheumatoid arthritis and mixed connective tissue disorder,18 and renal dysfunction has also been described.7,8 Positive auto‐antibodies are particularly common after artificial stone exposure.16 Clinicians must therefore be aware that inhaled dust produces a broader spectrum of disease than just pneumoconiosis. The primary management of pneumoconiosis has always been to reduce or stop dust exposure. This slows the rate of progression of disease and increases time from exposure to development of symptoms (or disease latency).7,8,19 This has been the rationale for respiratory surveillance programs, which involve regular assessment of a worker’s respiratory health in the workplace every few years, and usually include a questionnaire, spirometry and chest x‐ray, with reduction or removal from exposure once a threshold for early disease diagnosis has been reached. These programs have been the cornerstone of the reductions in incidence of pneumoconiosis worldwide19,20 and are compulsory for workers exposed to several dusts in most Australian states and territories. General practitioners often become involved in these programs either as examining doctors or after an abnormal result has been detected, and are key players in ensuring disease recognition, implementing appropriate work plans, and referring for support. It was because of serious concerns about disease resurgence that members of the Thoracic Society of Australia and New Zealand (TSANZ), Australia’s primary organisation representing respiratory health, developed recommendations in June 2016 aimed at controlling coal mine lung dust diseases.3 The TSANZ suggested standardisation of coal mine dust exposure limits throughout Australia, and alignment to international standards (which were generally lower levels than those in Australia). It also suggested a standardised national surveillance program for at‐risk workers and highlighted the need for better education regarding occupational hazards.3 Following media interest and political support, the federal government established a National Dust Disease Taskforce21 to establish a national approach to the prevention, early identification, control and management of occupational dust diseases. It supported establishing a National Dust Disease Register and provided some funds for new research.21 To assist with the forthcoming recommendations of this Taskforce, the TSANZ has reviewed the evidence and developed a position statement22 in light of advances in knowledge and new techniques available for diagnosing respiratory disease. Respiratory surveillance programs for pneumoconioses22 have been mainly based on the World Health Organization recommendations from the late 1970s,19 but respiratory medicine has advanced since those times, enabling detection of much earlier disease. Modern computed tomography scans provide excellent visualisation of lung anatomy at much lower radiation doses than before, and global initiatives have standardised lung function measurement and reporting.23 The gathering, storage and analysis of data have been revolutionised. In its position statement, the TSANZ recommends enhanced methods for respiratory surveillance of dust‐exposed workers using contemporary methods22 (Box 1). Despite legislated reductions in exposure limits,24,25,26,27 dust levels may not always achieve these limits, and workplace exposure data need to be collected and made available in a central repository to enable improved assessment of a worker’s likelihood of developing disease. This would also significantly improve existing understanding of dose–response relationships, especially with artificial stone. Periodic assessments of respiratory health need to involve a standardised format and high quality, standardised imaging and full lung function assessments. Workers with early abnormalities need to be optimally clinically assessed, treated where possible, and protected by suitable legislation from loss or downgrading of employment.22 Implementing such recommendations will inevitably involve detection of other lung disorders, including those which are non‐occupational in origin, and workers will be referred back to their GP for advice. It is therefore important that GPs understand the possible spectrum of diseases induced by dusts and other toxins, and obtain adequate and ongoing training in occupational lung disorders, including local support systems and when to refer for specialist advice (Box 2). The Royal Australian College of General Practitioners has a training resource for GPs which is a useful tool.28 Ultimately, such a system should prove beneficial to the health of both the individual and the community. However, it will require support and careful implementation in its initial stages. Early disease is difficult to distinguish in clinical practice from other lung pathologies, but difficulties in diagnosis can be overcome using modern techniques. International standards for diagnosis are available and new treatments are under evaluation. Multidisciplinary team meetings in hospitals have been established for respiratory disease diagnosis for many years and are now embedded nationally, and a similar system for occupational lung diseases would be a valuable addition to improving the diagnostic process. An occupational multidisciplinary team in each jurisdiction would bring together a wide range of specialties (primary care, occupational and respiratory medicine, occupational hygiene, radiology, pathology and allied health) and could assist hugely in improving diagnostic standards, improving expertise and disseminating information. This would be best advanced using new virtual technologies, which would also enhance involvement by community and rural physicians. The TSANZ recommendations represent best practice on the basis of existing information and need to evolve with new evidence. The TSANZ has also recommended careful evaluation of the efficacy of new measures using prospective studies, and updating in the light of new research. Changing the system would inevitably require increased resources. However, long term costs are likely to eventually decrease for health services and the economy, given the chronic debilitating nature of these preventable diseases. The TSANZ recommendations are a start in the process of re‐engaging industry and regulator, workers, doctors and politicians; hopefully, they will lead Australia towards a future where preventable death and disablement from occupational lung diseases does not occur. [Corrections added on 22 June 2021 after first online publication: the article title was amended and a footnote was added to Box 1.] Box 1 – Thoracic Society of Australia and New Zealand (TSANZ) proposed improvements to periodic health surveillance in the coal mining and artificial stone industries22 Regular training of staff in accordance with international standards of respiratory surveillance (including quality control and assurance). Plain chest radiographs to be performed using International Labour Organization recommended techniques, technically acceptable, with classification only by qualified thoracic radiologists, and compared with previous images. Individual spirometry to be performed according to American Thoracic Society/European Respiratory Society standards; results to be interpreted using reference values of the Global Lung Initiative. Serial data to be compared with longitudinal predicted values using the lower limit of normal to define lung function abnormality, and spirometry longitudinal data analysis software (SPIROLA). Dust monitoring to be performed under typical working conditions (≥ 75% capacity) and recorded using an accredited facility, with individualised data available for periodic surveillance. Extending surveillance methods for artificial stone exposure to potentially include low dose CT. Careful evaluation of the role of ultra low dose CT for coal miners and artificial stone workers in longitudinal prospective studies. Extending surveillance methods for all workers to include lung diffusing capacity (DLCO) at intervals of 3years or less; careful evaluation of such surveillance within longitudinal prospective studies. A flexible, individualised approach to the timing of surveillance of coal mine dust workers, including annual spirometry and DLCO if results are abnormal but do not yet fulfil diagnostic criteria for disease. Active case finding for artificial stone workers previously exposed to high respirable crystalline silica levels using conventional high resolution CT/spirometry/DLCO performed at accredited respiratory laboratories and radiological facilities using recommended protocols; follow‐up by expert treating specialists/teams, preferably at occupational respiratory disorder multidisciplinary team meetings. For artificial stone workers, pre‐employment plain chest radiographs to exclude major abnormalities. For artificial stone workers undergoing active case finding without abnormal chest x‐ray or high resolution CT, annual spirometry/DLCO and imaging 3‐yearly or more often depending on individual factors and test results. Chest x‐ray imaging to be complemented with high resolution CT scans in high risk groups (eg, borderline fibrosis found on plain chest radiographs and/or discrepancy with lung function findings). Improving existing medical databases to allow capacity to compare serial lung function data, occupational exposure history, imaging findings and dust measurements over time. Early evaluation of the diagnostic utility of best available tests (low dose CT, ultra low dose CT and DLCO) using data collected prospectively with consent from workers, ideally in a research setting. CT = computed tomography; DLCO = diffusing capacity of the lung for carbon monoxide. Adapted from: Perret et al. Respiratory surveillance for coal mine dust and artificial stone exposed workers in Australia and New Zealand: a position statement from the Thoracic Society of Australia and New Zealand. https://doi.org/10.1111/resp.13952. Licence at http://creativecommons.org/licenses/by/4.0. Box 2 – How to manage a case of possible pneumoconiosis in primary care: first steps Be aware that many dusts, fumes and vapours can cause lung diseases. The time between exposure and disease occurrence (latency period) can be very long, usually years. Take time to go through a patient’s full occupational history in detail, from leaving school to retirement. A chronological table of jobs may help (www.atsdr.cdc.gov/csem/exphistory/docs/CSEMExposHist-26-29.pdf). If the patient uses technical descriptions of a particular job, make sure you know exactly what they mean. Ask them to describe exactly what was done. Ask about conditions in the job, including dust controls like ventilation, use of personal protective equipment, dust measurements and any workplace respiratory health surveillance. Ask about shifts, including length of time worked and any improvements in symptoms when away from work (especially on holidays). Ask whether any other workers were affected. Ask if the patient has access to any safety data sheets. These are information sheets which are meant to be made available from the employer if a worker is exposed to a potentially hazardous exposure (www.safeworkaustralia.gov.au/sds). If unavailable, search the internet for the suspected agent of concern, or contact the Australasian Faculty of Occupational and Environmental Medicine to find a suitable occupational physician and obtain advice (www.racp.edu.au/about/college-structure/australasian-faculty-of-occupational-and-environmental-medicine). Make contact with an occupational health practitioner if possible (an occupational physician and/or occupational health nurse and/or occupational hygienist). Small employers may not employ such specialists, but a local occupational health practitioner may be a local GP. Be careful not to contact a patient’s employer without obtaining permission first! Your local WorkSafe or similar government agency may be helpful in identifying a potential hazard and can often provide anonymous advice (ACT: www.worksafe.act.gov.au; New South Wales: www.icare.nsw.gov.au; Northern Territory: worksafe.nt.gov.au; Queensland: www.business.qld.gov.au/industries/mining-energy-water/resources/safety-health/mining; South Australia: www.safework.sa.gov.au; Tasmania: worksafe.tas.gov.au; Victoria: www.worksafe.vic.gov.au; Western Australia: www.workcover.wa.gov.au). Keep careful records of all the above. Negative information is also useful. Ensure that a complete history of the patient’s other risk factors (eg, tobacco use, other inhaled substance usage) is recorded. Obtain relevant investigations performed to recommended standards (spirometry, chest x‐ray, computed tomography scan if indicated). If there is reasonable suspicion of an occupational disease, refer to an occupational physician and/or a respiratory physician with occupational lung expertise (www.racp.edu.au/about/college-structure/australasian-faculty-of-occupational-and-environmental-medicine; www.thoracic.org.au). Costs of care may be covered by WorkCover if a link with employment is established, but this may take time to confirm. Standards for accepting an occupational disease vary in different jurisdictions and do not always accord with medical diagnoses. Other support is available to workers via their local SafeWork or similar government agency.

Deborah H Yates · Jennifer L Perret · Margaret Davidson · Susan E Miles · AW Musk

Mja2 51097

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