Pulmonary Medicine

Beta-blockers in chronic obstructive pulmonary disease: the good, the bad and the ugly Purpose of review Several observational studies have suggested that β-blockers, especially cardioselective ones, are well tolerated and associated with a lower risk of acute exacerbations and death in patients with chronic obstructive pulmonary disease (COPD). However, there are dissenting studies. This review provides an update on the use of β-blockers in COPD, focusing on results of recent prospective studies and randomized controlled trials. Recent findings In totality, cohort studies indicate that β-blockers are generally well tolerated and effective in COPD patients who also have a clear cardiovascular indication for these groups. Although β-blockers on average reduce lung function acutely in COPD patients, the absolute decrease is relatively small, especially if cardioselective β-blockers are used. The results of two large randomized controlled trials suggest that concomitant β-blocker use does not reduce the therapeutic benefits of inhaled bronchodilators in COPD patients. The use of β-blockers in COPD patients, who do not have overt cardiovascular disease, does not prevent COPD exacerbations and may paradoxically increase the risk of COPD-related hospitalization and mortality. Summary The use of β-blockers is generally well tolerated and effective in COPD patients, who also have a clear cardiovascular indication for these drugs. However, they should not be used in patients who do not have overt cardiovascular disease as β-blockers can reduce lung function, worsen health status and increase the risk of COPD-related hospitalization. Correspondence to Don D. Sin, Tier 1 Canada Research Chair in COPD, de Lazzari Family Chair at the UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada V6Z 1Y6. Tel: +1 604 806 8346; fax: +1 604 806 9274; e-mail: don.sin@hli.ubc.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

ICU preparedness in pandemics: lessons learned from the coronavirus disease-2019 outbreak Purpose of review The worldwide SARS-CoV-2 pandemic has taken a heavy toll on ICUs worldwide. This review expounds on lessons learned for ICU preparedness during the pandemic and for future mass casualty events. Recent findings In the 21st century, there have already been several outbreaks of infectious diseases that have led to mass casualties creating ICU strain, providing multiple opportunities for hospitals and hospital systems to prepare their ICUs for future events. Unfortunately, the sheer scale and rapidity of the SARS-CoV-2 pandemic led to overwhelming strain on every aspect of ICU disaster preparedness. Yet, by analyzing experiences of hospitals throughout the first 7 months of the current pandemic in the areas of infection control, equipment preparedness, staffing strategies, ICU spatial logistics as well as acute and postacute treatment, various important lessons have already emerged that will prove critical for successful future ICU preparedness. Summary Preemptive planning, beginning with the early identification of staffing resources, supply chains and alternative equipment sources, coupled with strong infection control practices that also provide for the flexibility for evolving evidence is of utmost importance. However, there is no single approach that can be applied to every health system. Correspondence to Amesh Adalja, MD, Johns Hopkins Center for Health Security, 621 East Pratt Street, Suite 210, Baltimore, MD 21202, USA. Tel: +1 443 573 3304; e-mail: aadalja1@jhu.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Diagnostic and therapeutic challenges of chronic obstructive pulmonary disease in the elderly Purpose of review Chronic obstructive pulmonary disease (COPD) imposes a large burden on the global population and even more so for the elderly who face significant obstacles in the diagnosis, management, and psychosocial effects of the disease. This review describes the current challenges and key points in the management of COPD in the elderly. Recent findings Lower limit rather than fixed cut off of the FEV1/FVC ratio can improve the diagnosis and better predict COPD mortality. High relative to standard dose influenza vaccination reduces confirmed cases of influenza overall and reduces hospitalizations in older nursing home residents. Simple interventions that include electronic health record tracking can significantly improve vaccination rates. Although many inhaler and nebulized medications are available for the elderly, the final regimen is usually determined by a combination of expense, issues with proper device use (from difficulty with coordination, hand grip, inspiratory flows or cognitive function) and the side effect profile. Fortunately, the switch to cheaper or better covered alternatives can be well tolerated with improvement in adherence and exacerbations of COPD. Finally, caution should be made against ageism, which may be a factor in the recommendation of rehabilitation or palliative care in the elderly COPD patient, as both are underused despite evidence of benefit. Summary Although care for the elderly COPD patient can be difficult, we summarize key points that the physician should be cognizant of to provide comprehensive care. Correspondence to Loutfi S. Aboussouan, MD, Cleveland Clinic, Respiratory Institute, A90, 9500 Euclid Ave, Cleveland, OH 44195, USA. Tel: +1 216 444 0420; fax: +1 216 445 8160; e-mail: aboussl@ccf.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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