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We take our theme for this edition of Airwaves from the Thorax cover picture: ‘playing with fire’. The cover picture is from this month’s case based discussion, ‘Lung on fire: a very severe case of fire-eater’s lung.’ Don’t try this at home!
Come on baby light my fire
Non-adherence to treatment is a common cause of tension between patients and their clinical care teams and cystic fibrosis (with patients commonly spending around 2 hours per day on treatment) is a good example of this. However care teams often hesitate to intervene with adherence support because of a lack of evidence based interventions. In this month’s Thorax, Wildman and the CFHealthHub Study Team (see page 523) describe a trial where over 600 CF patients were randomised to an adherence intervention of data-logging nebulisers, a digital platform and behavioural change sessions vs data-logging nebulisers alone. The authors find no difference in the primary outcome outcome (pulmonary exacerbations). However, objectively measured adherence and body mass index (BMI) were better with the intervention. Treatment burden was also reduced for the intervention group. As Jim Morrison would have said: ‘The time to hesitate is through. No time to wallow in the mire… Come on, baby, light my fire’ (with an adherence intervention).
Burning down the house
Conventional research priorities are often driven by the commercial needs of pharma and the specific enthusiasms of academic investigators. Where is the patient community in all this? ‘Burning down the house,’ a song by Talking Heads from 1982, starts with the words: ‘Ah, watch out. You might get what you're after…’ In this issue of the journal, Goodridge and colleagues (see page 511) get exactly what they are after: the James Lind Alliance top 10 research questions for obstructive sleep apnoea. In a partnership between the patient community and clinicians, an important research theme identified is access to treatment. Access for those in rural areas; those receiving institutional care; access for indigenous people; and the influence of affordability and insurance. The authors conclude that these priorities should enthuse funders and researchers to fund patient-centred priorities. As Talking Heads would say: ‘Some things sure can sweep me off my feet. Burning down the house.’ Perhaps the funders can be swept off their feet, burning down the house of conventional funding priorities.
We didn’t start the fire
Billy Joel highlights in his 1989 song, detailing historic events in world history between 1948 and 1989, that the fire ‘was always burning”. Although the fire may not be always burning for our COPD patients, an exacerbations of COPD is often viewed as a flare up. Hurst et al (see page 505) investigated the acceptability of face covering and social distancing interventions to prevent exacerbations in people living with airways diseases as part of a survey of 4442 people with airways disease to gauge attitudes and intentions towards continuing such measures after the COVID-19 pandemic. 47% intended to continue wearing a face mask in indoor public spaces and 61% thought everyone should be required to do so during the influenza season. At least with these measures, we can keep the exacerbation fire from always burning.
No smoke without fire
‘It’s your life, you can do what you want, baby let me know.’Some people choose to smoke and, as will all choices there are consequences, and often with smoking this is a cellular fire within the lungs. The longer-term consequences are also known with well described associations with lung cancer, heart disease and COPD. There is also an association with Idiopathic Pulmonary Fibrosis (IPF) although the risk has not been well quantified. In this issue of Thorax (see page 470) Bae and colleagues use a population based cohort of over 23 million people of whom over 25 thousand had IPF. There was an increased risk of IPF in both current and former smokers and the risk was proportionate to the duration and extent of smoking. So if you keep Bad Company remember their lyrics ‘Yeah, just tell me what you wanna do now, tell me where you wanna go’ but our suggestion would be to cease smoking.
Set fire to the rain
Setting fire to rain is not necessarily an action that would be considered possible. However, considering actions that were previously considered not possible, nor helpful, is always important in research. Gravier et al (see page 486) investigate, in a systematic review and meta-analysis, the effects of exercise training in non-small cell lung cancer as part of ‘prehabilitation’ prior to lung resection. Fourteen studies, including 791 participants, demonstrated a reduction in post-operative complications by 42% and a 34% reduction in mortality. In addition, exercise training improved exercise capacity, pulmonary function and quality of life. As preoperative exercise reduces postoperative complications, perhaps setting fire to the rain is possible after all. Thanks, Adele.
We suspect only a subset of readers of Thorax will be familiar with the Pinkfong Rangers, and their childrens classic Fire Safety Song. To a catchy tune they sing lyrics such ‘In case of fire, 911’. Asbestos has long been used because fire retardant material because, despite what the Pinkfong Rangers may sing, we are unaware of firefighting elephants. Asbestos is particularly useful in area of high friction such as brake linings. However, asbestos has its own risks. In this issue of Thorax (see page 477) Thomsen and colleagues analysed data from a cohort of motor vehicle workers and found, not without controversy as described in the corresponding editorial (see page 426), that risk of mesothelioma was not increased in motor mechanics, in contrast with lung cancer and asbestosis both of which were increased in mechanics and lead to increased mortality. The answer is surely to try and find better ways of preventing fire than using asbestos. Perhaps the Pinkfong Rangers can provide some firefighting elephants?
A taster of fire eating
This taster image points you to the case based discussion by Nicolardi and colleagues in Rome, on the devastating effects of one episode of fire eating on the lung (see page 523).
We hope you have enjoyed airways and have been consumed, with what’s just transpired.