Atrial Fibrillation Treatment & Management
Atlantic Health Hospitals Add Lung Cancer Detection Tool
Atlantic Health System's Overlook Medical Center and Morristown Medical Center are the latest New Jersey hospitals to offer a relatively new lung cancer screening tool.
The Ion endoluminal system is a robotic bronchoscopy platform that helps medical teams perform minimally invasive peripheral lung biopsies. The technology received clearance from the U.S. Food and Drug Administration in February 2019.
Announced during Lung Cancer Awareness Month, the system allows pulmonologists and thoracic surgeons to navigate inside the lungs with more precision and stability for early diagnosis of cancer, according to AHS.
Developed by Intuitive, the Ion system features an ultra-thin and -maneuverable catheter that allows physicians to navigate far into the peripheral lung with increased stability and precision.
The catheter can articulate 180 degrees in any direction to pass through small, difficult-to-navigate areas to reach all 18 segments of the lung, according to the announcement. Once the pulmonary nodule is reached, the catheter locks in place. Then, the Flexision biopsy needle passes through the catheter and deploys into the target location.
"The lungs are a complex system of small blood vessels and airways that continuously move, making the task of searching for problems such as early-stage lung cancer quite difficult," said Dr. Christopher DeCotiis.
DeCotiis is one of the pioneers of the use of Ion at the health network. He serves as co-director of interventional pulmonology for Atlantic Health System and section chief of pulmonary disease at Overlook Medical Center.
"The robotic platform's shape sensing ability, along with camera assistance, enhances our ability to maneuver within the patient's airways to reach the nodule that is being evaluated" said Dr. Bhavi Patel, co-director of interventional pulmonology at Atlantic Health System and section head of interventional pulmonology at Morristown Medical Center. 
Overlook Medical Center and Morristown Medical Center both recently introduced the Ion endoluminal system. The robotic bronchoscopy platform offers minimally invasive peripheral lung biopsy. – PROVIDED BY ATLANTIC HEALTH
"Being able to probe further into the lungs with greater precision will drastically improve our ability to locate and identify early-stage lung cancer which will give patients a better chance at early treatment and improved long-term survival," said Dr. Mark Widmann, a thoracic surgical oncologist, chief of thoracic surgery at Morristown Medical Center and director of the Lung Cancer Program at Atlantic Health System.
Overlook Medical recently ranked No. 1 among New Jersey hospitals for pulmonary care, according to Healthgrades' 2025 Specialty State Rankings.
Other hospitals around the state have also announced putting the system into practice, including:
GOLD COPD 2025 Report: Key Spirometry And Drug Updates, New Emphasis On CVD, PH
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) released its 2025 updated version of the GOLD Chronic Obstructive Pulmonary Disease (COPD) report earlier this month, just in time for World COPD Day on November 20. Updates to the report, which include new sections on pulmonary hypertension, cardiovascular disease (CVD), and climate change, were detailed at the 2024 GOLD COPD International Conference in Philadelphia, on November 12, by Claus Vogelmeier, MD, GOLD Science Committee chair, who also offered clues on what to expect in the 2026 report.
According to Dr Vogelmeier, key changes to the 2025 GOLD COPD report include:
The science committee sifted through about 3000 research articles, identified through a systematic literature search, to determine updates that were needed to the 2025 report, said Dr Vogelmeier. After performing a double-blind review of the literature, the Science Committee added 164 new references to the report.
No longer included in the GOLD COPD report is a chapter on COVID-19 and COPD that appeared in previous reports.
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If the pre-bronchodilator spirometry does not show obstruction…performing post-bronchodilator spirometry is not necessary unless there is a very high clinical suspicion of COPD.
The 2025 GOLD COPD report, titled "Global Strategy for Prevention, Diagnosis and Management of COPD: 2025 Report," can now be downloaded from the GOLD website, along with a pocket guide to the report and the "2025 GOLD Teaching Slide Set."
Spirometry UpdatesIn the 2025 report, the spirometric criterion for a COPD diagnosis continues to be postbronchodilator ratio of forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) less than 0.7. However, the report authors note that a fixed FEV1/FVC ratio less than 0.7 may lead to overdiagnosis of COPD in elderly patients and underdiagnosis in 1% of young adults, particularly for mild disease, compared with a cutoff based on the lower limit of normal values for FEV1/FVC. For adults aged younger than 50 years with suspected COPD and a repeated fixed ratio of at least 0.7, comparing the ratio with a predicted LLN or with z-scores may aid in managing this group of patients, the report authors stated.
"Importantly, the risk of misdiagnosis and overtreatment of individual patients using the fixed ratio as a diagnostic criterion is limited, as spirometry is only 1 biologic measurement to establish the clinical diagnosis of COPD in the appropriate clinical context (symptoms and risk factors)," the report authors stated. "Diagnostic simplicity and consistency are crucial for the busy clinician. Thus, GOLD favors using the fixed ratio over LLN."
Pre-/Post-Bronchodilator SpirometryIn a major shift, the GOLD science committee now puts greater emphasis on the value of pre-bronchodilator spirometry. "If the pre-bronchodilator spirometry does not show obstruction…performing post-bronchodilator spirometry is not necessary unless there is a very high clinical suspicion of COPD, in which case an FVC [forced vital capacity] volume response may reveal obstruction," the report authors noted. In the event pre-bronchodilator spirometry does show obstruction, a COPD diagnosis should be confirmed with post-bronchodilator spirometry.
Airflow obstruction based on 1 measurement of the post-bronchodilator FEV1/FVC ratio should be confirmed by repeat spirometry during a separate occasion if the measurement is 0.6 to 0.8, the committee advised. If the initial postbronchodilator FEV1/FVC ratio is less than 0.6, it is unlikely to increase spontaneously to greater than 0.7.
GLI Global Reference Equations RecommendedNotably, the 2025 report stresses that "LLN values and z-scores are highly dependent on the choice of valid reference equations." The GOLD Science Committee now recommends the use of Global Lung Function Initiative (GLI) Global reference values, which were developed to be race-neutral. At the same time, report authors acknowledge that these equations have limitations, in that they are based on "a weighted average of racial and ethnic categories, were derived from a population that did not include participants from many countries or global regions, and ignore the observed population differences in body proportions." The report authors noted that "lung function reference values change over time and require periodic revision."
GOLD also continues to advise use of FEV1 as a percentage of the predicted value for staging airflow obstruction severity. The percentage of the predicted GLI-Global equation value may be determined with use of the online GLI calculator.
CVD in Patients With COPDAfter an acute exacerbation of COPD, patients have a 20 times greater risk for a severe CV event or all-cause death within 7 days, said Dr Vogelmeier, in explaining the Science Committee's rationale for including a new section on cardiovascular risk in COPD in the 2025 report.
Cardiovascular disease (CVD) is also increased among patients with clinically stable COPD and is associated with mortality, especially in those with mild to moderate airflow obstruction. CVD, including arterial hypertension, coronary artery disease, heart failure, and arrythmia, should be assessed in patients with COPD and treated according to available guidelines, the committee noted. During exacerbations of COPD (ECOPD), the risk for an acute cardiovascular event increases, especially among patients with severe ECOPD requiring hospitalization.
"Importantly, this risk remains high during the first few weeks after hospital discharge, and it can still remain significantly increased even 1 year later," the committee stated. The GOLD recommendations advise an appropriate differential diagnosis of ECOPD from other conditions such as heart failure and that routine measurement of markers of CVD, including troponin and brain natriuretic peptide levels, may be performed during ECOPD.
Using CT in COPD AssessmentCT can be used to assess the structural and pathophysiologic abnormalities in patients with COPD, and quantitative analysis is increasingly used for emphysema extent and location and can assist with endobronchial valve treatment decision-making. CT also is being used in patients with COPD for assessment of pulmonary nodules identified on chest X-ray or evaluation for concurrent lung disease. "We've learned that imaging is becoming more and more relevant," Dr Vogelmeier noted. Other relevant uses of CT include airway abnormalities such as bronchiectasis, as well as comorbidities such as coronary artery calcium, pulmonary artery enlargement, bone density, muscle mass, interstitial lung abnormalities, hiatal hernias, and liver steatosis.
Pharmacologic COPD TreatmentsFor follow-up pharmacologic treatment in patients with dyspnea for whom the addition of a second long-acting bronchodilator does not improve symptoms, the committee suggests switching inhaler device or molecules, implementing or escalating nonpharmacologic treatment, or considering adding ensifentrine if available.
EnsifentrineEnsifentrine is a first-in-class inhaled dual inhibitor of phosphodiesterase 3 and 4 (PDE3, PDE4) that has anti-inflammatory activity and bronchodilator effects. Phase 3 studies reported that when delivered with a standard jet nebulizer, ensifentrine led to significant improvement in lung function and dyspnea, but its effects on quality of life were inconsistent.
Dupilumab and Other TherapiesAmong patients who continue to have exacerbations after treatment with long-acting beta-2 agonists (LABA) plus long-acting muscarinic antagonists (LAMA) plus ICS, GOLD recommends consideration of dupilumab in those with eosinophil levels 300 cells/µL or more and symptoms of chronic bronchitis. Azithromycin may be considered in patients who are not current smokers, and roflumilast may be administered to patients with FEV1 less than 50%, chronic bronchitis symptoms, and a history of previous severe exacerbations.
Dupilumab is a human monoclonal antibody that blocks the shared receptor component for interleukin-4 and interleukin-13. In a pair of phase 3 trials, patients with COPD, chronic bronchitis, a history of exacerbations despite treatment, and blood eosinophil count of at least 300 cells/µL who were treated with dupilumab had a reduction in exacerbations, improved lung function, and improved health at 1 year. Dupilumab was approved by the US Food and Drug Administration as an add-on maintenance therapy for certain adults with COPD in October.
ICS UseAmong patients who have COPD with no features of asthma treated with LABA/ICS and are well-controlled for symptoms and exacerbations, continuing LABA/ICS in an option, according to GOLD. For patients with further exacerbations, treatment is recommended to be escalated to LABA/LAMA/ICS if the blood eosinophil count is at least 100 cells/µL or switched to LABA/LAMA if less than 100 cells/µL. Patients with major symptoms are advised to change to LABA/LAMA or LABA LAMA/ICS depending on prior ICS response.
Pulmonary Hypertension in COPDThe importance of pulmonary hypertension in COPD "has been underestimated as of yet," said Dr Vogelmeier, in explaining the rationale for the new section on PH in the 2025 report.
Pulmonary hypertension is classified into 5 groups based on pathophysiologic mechanisms, clinical presentation, and management, and all 5 groups can be present in patients with COPD. Diagnosing pulmonary hypertension in patients with COPD requires assessment of the potential mechanisms leading to increased mean pulmonary arterial pressure, and echocardiography is the best noninvasive tool for estimating the probability and severity of pulmonary hypertension, the committee noted. "Patients with pulmonary hypertension–COPD should be referred to a pulmonary hypertension center with experience in respiratory diseases where they will undergo right heart catheterization and multidisciplinary assessment to guide treatment decision," the committee stated. "Long-term oxygen therapy is recommended in hypoxemic patients."
PAH in COPDAmong patients with COPD and pulmonary arterial hypertension (PAH), treatment should adhere to the 2022 European Society of Cardiology/European Respiratory Society guidelines, the committee advises. The preferred treatment in this group of patients is initial monotherapy followed by careful sequential combination therapy if the goals are not achieved. For patients with COPD who are diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH), a multidisciplinary CTEPH team evaluation will determine if pulmonary endarterectomy, angioplasty, and/or pulmonary hypertension medications are needed.
PAH medications are not advised in patients with nonsevere pulmonary hypertension–COPD. For patients with severe pulmonary hypertension–COPD, an individualized management approach is recommended, with off-label use of PDE5 inhibitors commonly suggested as treatment. Some research, however, reported that inhaled treprostinil had no clinical efficacy and was associated with potential adverse effects.
"Further well-designed randomized-controlled trials should be encouraged to firmly advise for or against the use of PAH medications in pulmonary hypertension–COPD," the committee stated.
Climate ChangeThe 2025 report addresses climate change in relation to COPD. Research has shown that patients with COPD have an increased mortality risk with exposure to heat and cold, with a higher risk for cold temperatures. Indoor temperatures and high indoor humidity also can affect COPD. Studies have found that higher outdoor temperature is associated with increased dyspnea, and higher indoor temperature is associated with increased symptoms and use of short-acting beta-2 agonists (SABA). Colder indoor and outdoor temperatures have been associated with an increase in cough, sputum, and SABA use and a decrease in FEV1.
"During heatwaves and periods of high temperature, patients should ensure they keep adequately hydrated, keep out of the heat, and try to keep living spaces less than 32°C and sleeping spaces less than 24°C as recommended by the World Health Organization," the committee advised.
Vaccinations and COPDGOLD recommends that patients with COPD receive all recommended vaccinations based on relevant guidelines. Influenza vaccination, for example, can reduce the risk of serious issues such as lower respiratory tract infections that require hospitalization, stroke, and mortality in patients with COPD. Pneumococcal vaccination may be co-administered with influenza vaccination in adults and has been shown to be immunogenic and safe. Researchers have found that respiratory syncytial virus (RSV) was associated with about 8% of outpatient-managed COPD exacerbations and may lead to as many as 10,000 deaths annually in older adults in the United States. Among adults with COPD, the CDC recommends Tdap vaccination in those who were not vaccinated in adolescence, as well as the shingles vaccine. GOLD also advises that patients with COPD receive the COVID-19 vaccine based on national recommendations.
Dysbiosis in COPD DevelopmentDysbiosis involves disruption of the microbiome and may occur in the airways of patients with COPD. The role of dysbiosis in the development and progression of COPD is addressed in a new section of the 2025 report. Dysbiosis has a cross-sectional association with COPD and multiple disease characteristics, including frequency of exacerbations, likely from mucosal defense alterations and stimulation of lung inflammation by immune responses. In addition, the microbiome profile is affected by viral infections and during exacerbations and by antibiotics and oral corticosteroids or ICS. Further research is needed on the effect of dysbiosis in COPD.
Pulmonary Rehab and TelerehabilitationThe COPD report chapter on "Non-pharmacological treatment of stable COPD" includes information about in-person and virtual delivery of pulmonary rehabilitation, education, and self-management. At the recent GOLD COPD conference, Vogelmeier told attendees that this section would undergo major revision in 2026.
The 2025 report states that an effective pulmonary rehabilitation program should include lower extremity endurance exercise training. Telerehabilitation requires appropriately trained staff and infrastructure and should not be misused, the authors noted. "Tele-education and self-management using information communication technology could have the potential to ease the working life of health practitioners and transform the way patients are monitored and health care is delivered," the group stated. "Despite the many advances in self-management, delivering self-management at distance using digital technology still raises many unanswered questions and important limitations." Presumably, these are the questions that may be addressed in next year's report.
Study Highlights Key RA-ILD Risk Factors, Urges Early Screening
This recent study highlights key risk factors for rheumatoid arthritis–associated interstitial lung disease (RA-ILD), emphasizing the importance of early screening to improve diagnosis and patient outcomes.
Patients with the following risk factors are likely to develop rheumatic arthritis–associated interstitial lung disease (RA-ILD): male gender, older age, ever-smoking status, pulmonary complications, the presence of rheumatoid nodules, older RA onset age, and leflunomide (LEF) usage.1
Authors of the BMJ Open Respiratory Research study explained that ILD is among the pulmonary complications of RA, with RA-ILD being the most common. Depending on the diagnostic criteria and investigation methods, the reported incidence of ILD in patients with RA ranges from 1.3 to 5.0 per 1000 person-years. Also, RA-ILD results in a 2- to 10-fold increase in mortality, with the median survival post diagnosis being less than 3 years.2
Most patients with RA-ILD are asymptomatic or present with nonspecific symptoms, like cough or dyspnea, in the early stages.1 Patients may remain undiagnosed if only those with pulmonary symptoms are screened using high-resolution CT. Therefore, the researchers emphasized the importance of identifying risk factors for incident RA-ILD and conducted a systematic literature review and meta-analysis to address this.
This recent study highlights key risk factors for rheumatoid arthritis–associated interstitial lung disease, emphasizing the importance of early screening to improve diagnosis and patient outcomes.Image Credit: PH alex aviles - stock.Adobe.Com
They conducted their literature review using various online databases, including PubMed, Web of Science, and Scopus. Eligible studies included cohort or nested case-control studies published by March 2021 that reported ORs or HRs of RA-ILD risk factors. They excluded studies with patients who had ILD before their RA diagnosis.
Two reviewers independently assessed the eligibility of the retrieved citations, with disagreements resolved by consensus. Potential eligible citations were further examined through a full-text review. Various data were extracted from eligible studies, including the sample size, ILD diagnosis criteria, and risk factors of incident RA-ILD. When the available information from the publications was incomplete, the reviewers attempted to retrieve it from other sources or by contacting the corresponding authors.
Initially, the researchers identified 3075 studies, 12 of which met the eligibility criteria and were included in the qualitative analysis. These consisted of 3 case-control and 9 cohort studies, with most published within the past 5 years and conducted in the US. The sample sizes ranged from 210 to 30,512, and the RA-ILD incidence rates ranged from 1.8 to 6.7 per 1000 person-years.
The researchers identified 17 RA-ILD risk factors, categorizing those reported in more than 2 studies. These were treatment regimens (glucocorticoids, methotrexate, LEF, biologics), demographics (gender, age, age at RA onset, smoking history), comorbidities (pulmonary, systemic), disease involvement (joint erosion, rheumatoid nodule), Disease Activity Score 28 (DAS28), and laboratory tests (rheumatoid factor, anticitrullinated peptide antibody, C reactive protein, erythrocyte sedimentation rate).
Among the identified risk factors, male gender (relative risk [RR], 1.94; 95% CI, 1.33-2.85; P < .001), age over 60 years (RR, 1.42; 95% CI, 1.05-1.94; P = .02), older age at RA onset (RR, 1.05; 95% CI, 1.01-1.10; P = .02), pulmonary comorbidities (RR, 2.72; 95% CI, 1.24-5.95; P = .01), ever-smoker status (RR, 1.37; 95% CI, 1.09-1.71; P = .006), the presence of rheumatoid nodules (RR, 1.85; 95% CI, 1.36-2.51; P < .001), and treatment with LEF (RR, 1.41; 95% CI, 1.02-1.96; P = .04) were associated with a significantly increased RA-ILD risk.
"Physicians should be aware that patients with RA with the above risk factors are likely to develop RA-ILD and perform close ILD screening during follow-ups so that the patients can be early diagnosed and treated and achieve improved prognosis," the authors wrote.
Lastly, the researchers acknowledged their limitations, one being that only cohort and nested case-control studies were included; therefore, a limited number of studies were analyzed. Despite their limitations, they expressed confidence in their findings, stressing the importance of early screening.
"Given that pulmonary fibrosis is usually irreversible, it is of significant importance to screen for ILD in high-risk patients to achieve early diagnosis and treatment, leading to a better long-term prognosis," the authors concluded.
References
1. Yu C, Zhang Y, Jin S, et al. Risk factors for incidence of interstitial lung disease in patients with rheumatoid arthritis: a systematic review and meta-analysis. BMJ Open Respir Res. 2024;11(1):e001817. Doi:10.1136/bmjresp-2023-001817
2. Dai Y, Wang W, Yu Y, Hu S. Rheumatoid arthritis-associated interstitial lung disease: an overview of epidemiology, pathogenesis and management. Clin Rheumatol. 2021;40(4):1211-1220. Doi:10.1007/s10067-020-05320-z
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