Citations

THE American Thoracic Society (ATS) International Conference took place in San Francisco, California, USA, from May 17th–21st, 2025, with over 14,000 attendees from more than 100 countries represented. The conference opened with an address from Kimberly Manning, Grady Hospital, Emory University, Atlanta, Georgia, USA, who is renowned for her contributions to the burgeoning field of narrative medicine. “I think the greatest teachers of all are the patients we have a privilege to care for.” She shared the story of a patient hospitalized for severe pneumonia, who gave a very busy Manning this advice: “One person doing one thing for a person other than themselves goes further than you think.” It was against this backdrop of the impact that pulmonologists and intensivists have on the lives of their patients that ATS commenced. During the conference, several thought-provoking and sometimes practice-changing trials were introduced or reviewed, spanning content ranging from septic shock to lung cancer. Herein, we explore some of the highlights of these discussions.

Abstract Introduction Tizanidine is an alpha-2 receptor adrenergic agonist employed for treatment of musculoskeletal pain and muscle spasticity. Drowsiness, xerostomia, and, less frequently, sleep disturbance are notable side effects. Central sleep apnea (CSA) occurs in patients taking other alpha-2 receptor agonists such as clonidine but the frequency of CSA among users of tizanidine is less well-known. Rarer still is the presence of central apneic episodes during wakefulness in patients without heart failure who have an intact brainstem and are not taking opioids or benzodiazepines. We report a case of a patient with central apneic episodes during wakefulness in the setting of tizanidine use. Report of case A 60-year-old white male was referred to our sleep center for sleep apnea. He was previously diagnosed with severe obstructive sleep apnea (apnea-hypopnea index of 104 events per hour) but was not adherent to continuous positive airway pressure (CPAP) due to a previous head injury which made use of CPAP straps intolerably painful. Thus, he had undergone a modified uvulopalatopharyngoplasty 3 months prior to evaluation. Despite UPPP he continued to have excessive daytime sleepiness. A repeat polysomnogram revealed frequent central apneic episodes during periods of wakefulness that did not persist after sleep onset. The patient had taken his nightly tizanidine 8 mg prior to testing. Echocardiogram prior to testing showed mild diastolic dysfunction and brain magnetic resonance imaging was unremarkable. A polysomnogram was repeated 1 month later, this time with tizanidine held for 1 week prior to testing. Wake-onset central apneic episodes had resolved without any other changes in medication or health status. Conclusion Certain medications such as opioids, benzodiazepines, and baclofen are known to induce CSA. However, to the best of our knowledge this is the first case of a commonly prescribed alpha-2 agonist implicated in the development of wake-onset central apneic episodes. More study is needed to elucidate the impact of tizanidine on ventilatory function in the wake and sleep states and whether similar effects may occur among other centrally acting medications. Support (if any)

Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized disease that often results in heart failure and death. Traditionally, biological staging systems are used to stratify disease severity. Reduced aerobic capacity has recently been described as useful in identifying higher risk of cardiovascular events and death. Assessment of lung volume via simple spirometry might also hold prognostic relevance. We aimed to assess the combined prognostic value of spirometry, cardiopulmonary exercise testing (CPET) and biomarker staging in ATTR-CA patients in a multi-parametric approach. We retrospectively reviewed patient records with pulmonary function and CPET testing. Patients were followed until study endpoint (MACE: composite of heart-failure-related hospitalization and all-cause death) or censure (1 April 2022). In total, 82 patients were enrolled. Median follow-up was 9 months with 31 (38%) MACE. Impaired peak VO2 and forced vital capacity (FVC) were independent predictors of MACE-free survival, with peak VO2 < 50% and FVC < 70% defining the highest risk group (HR 26, 95% CI: 5–142, mean survival: 15 months) compared to patients with the lowest risk (peak VO2 ≥ 50% and FVC ≥ 70%). Combined peak VO2, FVC and ATTR biomarker staging significantly improved MACE prediction by 35% compared to ATTR staging alone, with 67% patients reassigned a higher risk category (p < 0.01). In conclusion, combining functional and biological markers might synergistically improve risk stratification in ATTR-CA. Integrating simple, non-invasive and easily applicable CPET and spirometry in the routine management of ATTR-CA patients might prove useful for improved risk prediction, optimized monitoring and timely introduction of newer-generation therapies.

Abstract Background/Objective A subset of patients with idiopathic inflammatory myopathy (IIM) develops highly fatal, rapidly progressive interstitial lung disease (RP-ILD). Treatment strategies consist of glucocorticoid and adjunctive immunosuppressive therapies. Plasma exchange (PE) is an alternative therapy, but its benefit is unclear. In this study, we aimed to determine whether PE benefited outcomes for patients with RP-ILD. Methods In this medical records review study, we compared baseline characteristics and clinical outcomes for 2 groups of patients with IIM-related RP-ILD: those who received and did not receive PE. Results Our cohort consisted of 15 patients, 9 of whom received PE. Baseline demographic characteristics and severity of lung, skin, and musculoskeletal disease between the 2 groups of patients were not significantly different. Five patients required mechanical ventilation (2, PE; 3, no PE). Plasma exchange was generally a third-line adjunctive treatment option. The PE group had a longer median (interquartile range) hospitalization (27.0 [23.0–36.0] days) than the non-PE group (12.0 [8.0–14.0] days) (p = 0.02). There was a potential benefit in 30-day mortality improvement in those receiving PE (0% vs 33%, p = 0.14), with a statistically significant improvement in 2 important composite end points including 30-day mortality or need for lung transplant (0% vs 50%, p = 0.04) and 1-year mortality or need for lung transplant or hospital readmission for RP-ILD in those receiving PE (22% vs 83%, p = 0.04). Conclusions Plasma exchange may be an underutilized, safe salvage therapy for patients with IIM-related RP-ILD when other immunosuppressive therapies fail.