The first of four Clinical Year in Review sessions at the ATS 2023 International Conference detailed the latest developments in acute respiratory distress syndrome, pulmonary vascular disease, chronic obstructive pulmonary disease, and interstitial lung disease. New findings in each of these areas are likely to impact clinical practice and shift the course of future research. This session will be included in the On-Demand Highlights available through the ATS Store this summer.

ARDS

The familiar 2016 Berlin Criteria for ARDS, based on a combination of clinical, treatment, and radiologic findings, is changing. The proposed criteria would eliminate the current positive end-expiratory pressure assessment, add point-of-care ultrasound to the current bilateral chest opacities on chest radiography, and drop the need for respiratory support in resource-variable settings.

“This expanded definition proposed earlier this year is more practical and addresses some of the limitations of the Berlin Criteria,” said Derek W. Russell, MD, assistant professor of pulmonary, allergy, and critical care medicine, University of Alabama at Birmingham. “The goal of this is to treat patients who are similar biologically in similar ways.”

A pilot study of low, medium, and high oxygen saturation targets in critically ill adults on mechanical ventilation found no difference in survival or the proportion of those breathing without mechanical ventilation after 28 days.

“It can be quite safe to aim for a slightly higher saturation target in ARDS, which could be particularly important for patients with darker skin,” Dr. Russell said. “Stay tuned for Mega-ROX with 40,000 participants.”

Pulmonary Vascular Disease

In 2022, the European Society of Cardiology and European Respiratory Society updated guidelines for the diagnosis and treatment of pulmonary hypertension. Key changes include a new, broader hemodynamic definition of pulmonary hypertension, a new assessment of the clinical risk of mean pulmonary arterial pressure and pulmonary vascular resistance, and new treatment approaches.

“The goal is earlier detection,” said Gustavo A. Heresi, MD, MS, director of the Pulmonary Vascular and Chronic Thromboembolic Pulmonary Hypertension Program, Cleveland Clinic Respiratory Institute. “The guidelines emphasize early diagnosis and early referral to expert centers. There will be more patients diagnosed with pulmonary hypertension and pulmonary arterial hypertension.”

The STELLAR trial of sotatercept for pulmonary arterial hypertension identified a new mechanism and a novel treatment. The novel mechanism is an imbalance between activin and bone morphogenetic protein, which increases vascular proliferation. Sotatercept binds activins and growth differentiation factors to restore vascular homeostasis.

“This can be life-changing for a lot of patients,” Dr. Heresi said. “This medication should be approved by the Food and Drug Administration and be available sometime next year.”

COPD

The Lancet Commission recommended multiple new approaches to change the course of COPD toward disease elimination, reported Stephanie Christenson, MD, MS, associate professor of pulmonary, critical care, allergy, and sleep medicine at the University of California, San Francisco. The 2023 GOLD Report incorporated many of the commission’s recommendations.

“We need to consider multiple risk factors: the entire COPD exposome of early-life risk factors, noxious exposures, individual and social factors, and the general external environment,” Dr. Christenson said. “Tobacco smoke is not the only, or even the key, risk factor.”     

The GOLD Report proposed a new COPD taxonomy based on six etiotypes, echoing Lancet Commission recommendations to consider disease etiotypes in assessing and treating COPD. GOLD also refined its existing ABCD assessment tool to an ABE tool that considers exacerbation history.

There are also important changes in treatment recommendations. Dual long-acting muscarinic antagonist and long-acting beta agonist treatment is recommended over a single bronchodilator.

LABA and inhaled corticosteroids are not recommended in COPD, but triple therapy combining LAMA, LABA, and IC is preferred in the presence of eosinophilia, concomitant asthma, or other ICS indications.

ILD

Multiple recent trials have shown benefits in ILD, including a phase two study of pirfenidone in patients with rheumatoid arthritis-associated ILD. Pirfenidone showed a numerical, nonsignificant benefit in mortality or decline in forced vital capacity greater than or equal to 10 percent versus placebo.

“The pirfenidone group had a slower rate of decline in FEV than the placebo group,” reported Rachel Kate Putman, MD, MPH, Brigham and Women’s Hospital and instructor, Harvard Medical School. “It was safe and fairly well tolerated. Pirfenidone is not FDA-approved for this indication, but it is another tool we have available.”

RECITAL compared rituximab and intravenous cyclophosphamide in patients with connective tissue disease-associated ILD in the United Kingdom. Both approaches showed similar improvement in lung function and patient-reported quality of life, but rituximab had fewer reported adverse events. Dr. Putman said providers could be confident recommending either agent.

A phase two trial of a phosphodiesterase 4B inhibitor versus placebo showed significant benefit in FVC in a small, 12-week trial. Patients on the PDE4B inhibitor had stabilized lung function regardless of their background anti-fibrotic treatment.

“This is an exciting time to be in ILD,” Dr. Putman said. “We have more than 100 trials actively recruiting in ILD and IPF.”