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  1. The Triumvirate

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Good luck everyone

As we write this edition of Airwaves we are bracing for the Global COVID-19 Pandemic. Normally we choose a theme with humorous undertones to highlight some of the excellent content that we publish in each monthly edition of the Journal. We are aware, however, that as you read this you will have experience the global COVID-19 pandemic whereas, at the time of writing, we have no real idea how our health systems across the world will cope. Currently, there have been over 2 million cases throughout the world and nearly 150,000 deaths. We stand with colleagues in the respiratory and critical care community in every affected country who have worked tirelessly to defeat the pandemic. Many colleagues will have acquired COVID-19 and some will have succumbed. Forgive us then if our Airwaves section focuses on the science rather than the theme for which we chose the meme from Blackadder Goes Forth, unfortunately apt at this time. Indeed under ‘Controversies and challenges in respiratory medicine,’ we present a pro from Joseph Barker and colleagues (see page 367) and a con from Jillian Baker and Milind Sovani (see page 368) discussing the cross infection risks posed by non-invasive ventilation and CPAP in the community during the COVID-19 pandemic.

A cunning and subtle plan…

To our knowledge, Baldrick has never been asked to sit on a guidelines committee, despite his aptitude for devising “a cunning and subtle plan”. In this month’s journal we bring you the British Thoracic Society guideline for the use of long term macrolides in adults with respiratory disease (see page 370). Long term oral macrolides are recommended for adults with bronchiectasis and COPD where there have been more than three exacerbations per year. For asthma, recommendations are more restrictive (50–70 years only and where there is >80% adherence to high dose inhaled steroids). In an accompanying article (see page 405) David Smith reminds us of the known adverse effects of macrolides (hearing loss, QT prolongation and antimicrobial resistance). Blackadder once remarked scathingly: “Am I jumping the gun, Baldrick, or are the words 'I have a cunning plan' marching with ill-deserved confidence in the direction of this conversation?” No ill-deserved confidence in the BTS macrolide guidelines – but rather conscientious use of the GRADE approach (BMJ 2008;336:924–926) and careful evaluation of the evidence.

Pitt the younger

When Pitt the Younger threatened to propose his brother as a candidate to run against Blackadder in a rigged election, Blackadder retorted as follows: “And which Pitt would this be? Pitt the Toddler? Pitt the Embryo? Pitt the Glint in the Milkman's Eye?” Blackadder was clearly talking about the childhood origins of adult disease here – an issue addressed by Chan and colleagues in this month’s Thorax (see page 422). In a prospective study, 243 of a cohort of 619 children, who had baseline polysomnography, attended a 10 year follow-up visit. Moderate-to-severe obstructive sleep apnoea (OSA) at baseline was associated with a higher risk of hypertension (RR 2.5; 95% CI 1.2, 5.3). The “cunning plan” proposed by the authors is that OSA may be a modifiable childhood risk factor and targeting this might reduce the adult cardiovascular disease burden.

Non-inferiority for Baldrick?

In “Blackadder Goes Forth,” Captain Blackadder responds rather pessimistically to a new military strategy. “Would this brilliant plan involve us climbing out of our trenches and walking very slowly towards the enemy?” Walking slowly for 6 min was the primary outcome is a trial of pulmonary tele-rehabilitation by Hansen and colleagues in this month’s issue (see page 413). Pulmonary rehabilitation is an effective treatment for many people with COPD but its impact is limited by low rates of uptake and a high drop out. Pulmonary tele-rehabilitation may overcome some of the practical difficulties which prevent participation. In this randomised controlled trial of tele-rehabilitation vs. conventional pulmonary rehabilitation in COPD there was no significant in the primary outcome of difference between groups in the 6 min walk test (from baseline to 10 weeks). The authors suggest a future trial of this intervention should have a non-inferiority design. No chance of non-inferiority for Baldrick under the constant onslaught of Blackadder’s insults: “Baldrick, your head is as empty as a eunuch’s underpants.”

Don’t call me auntie

In series 2 Lady Whiteadder admonishes her nephew for referring to her as Auntie as ‘a relative is evidence of sex’. Sex, and gender related differences are important in many diseases. However, to what extent they are real or due to bias is not fully understood. In this issue of Thorax (see page 407), Assayag and colleagues investigate the importance of gender bias in Idiopathic Pulmonary Fibrosis (IPF). The find that although men were more likely to be diagnosed with IPF, especially if the CT scan was not classical, women had a high mortality suggesting men were more often misclassified as having IPF. As Queen Elizabeth, who spectacularly overcame gender bias, once said, ‘The past cannot be cured.’, the future is very much in our hands especially when it comes to diagnosing IPF.

A remarkable artery…

Our teaser image links to the article by Li et al (see page 435). Take care if you find a cauliflower-like lesion in the trachea on bronchoscopy. Consider imaging before resection!

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