Respiratory disease

A national registry of SCLC-specific management and outcomes data could improve the quality and safety of care

Joanna Huang · Wasek Faisal · Margaret Brand · Shantelle Smith · Marliese Alexander · Lisa Briggs · Matthew Conron · Mary Duffy · Thomas John · David Langton · Jacqueline Lesage · Michael MacManus · Paul Mitchell · Inger Olesen · Phillip Parente · Jennifer Philip · Evangeline Samuel · Javier Torres · Craig R Underhill · John R Zalcberg · Susan Harden · Rob Stirling

The burden of asthma for patients and doctors can be reduced through simple evidence-based approaches to care and self-management

Christine R Jenkins · Philip G Bardin · John Blakey · Kerry L Hancock · Peter Gibson · Vanessa M McDonald

Insomnia is a risk factor for workplace productivity loss in young workers

Amy C Reynolds · Pieter Coenen · Bastien Lechat · Leon Straker · Juliana Zabatiero · Kath J Maddison · Robert J Adams · Peter Eastwood

A 32-year-old woman from a remote Indigenous community in Far North Queensland presented to her local health clinic with a one-day history of odynophagia

Simon Smith · James Stewart · Joshua Hanson · Julian Harris · Fred JJ Chuang · Gavin Quail · Bryan Hawarden · Roshni Lad · Shannon McNee · Benjamin McCartney · Tonia Marquardt · Ian Wilson · Catherine Tacon · Bernard CS Whitfield

Increased in-hospital mortality may reflect changes in care across the Australian health system that need to be rectified

Sing Chee Tan · Tess Evans · Matthew L Durie · Paul J Secombe · David Pilcher

In-hospital mortality was not higher for transferred patients, confirming careful case selection and sustained commitment to care by hospitals

the SPRINT‐SARI Australia investigators

Off-label use in young children suggests that health care professionals and the public underappreciate their risks

Abrar Arbaeen · Nial J Wheate · Jared A Brown · Rose Cairns

Recent advances in critical care relevant to a broad range of clinicians

Yasmine Ali Abdelhamid · Adam Deane · Rinaldo Bellomo

Encouraging public compliance with measures that limit community transmission would benefit everyone, with only minor inconvenience

Gwendolyn L Gilbert

Effective modulator treatments now available for most people will probably add years to their lives

John Massie

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

A 38-year-old woman presented to the emergency department with a 2-week history of fever, headache and mild dry cough

Arvind Yerramilli · Michelle Sam · Aadith Ashok · Eugene Athan

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

The COPD-X guidelines aspire to standardise COPD care, optimise health outcomes, and enhance the quality of life of people with COPD

Eli Dabscheck · Johnson George · Kelcie Hermann · Christine F McDonald · Vanessa M McDonald · Renae McNamara · Mearon O’Brien · Brian Smith · Nicholas A Zwar · Ian A Yang

A 76-year-old woman with no significant medical history presented to hospital after 3 days of vomiting

Nicholas M Stacey · Martin Feddersen

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

The NORDR is designed to protect workers and prevent occupational respiratory disease but will require widespread stakeholder engagement and interaction to succeed

Ryan F Hoy · Fraser J Brims

A precision medicine approach to asthma places the patient at the centre of their care

Vanessa M McDonald · Peter G Gibson

Asthma is one of the most common chronic diseases in Australia, affecting 11% of the population

Helen K Reddel

A previously well 32-year-old Caucasian man with no history of smoking presented with a 6-week history of progressive exertional dyspnoea, a productive cough, and night sweats

Samantha Dean · Rachel Lennox · Clare Senko · Sagun Parakh

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

An 85-year-old man with a history of type 2 diabetes, vascular disease and chronic kidney disease awoke with central sharp pleuritic pain radiating through to his back

Elliot T Bowden · Paul Smith · Karen M Dwyer