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In an era in which medical practice is increasingly determined by evidence-based guidelines, it must be acknowledged from the outset that current evidence in sarcoidosis, especially with regard to treatment, is weak. [...]a number of the conclusions in this Statement are based on expert opinion and accumulated clinical experience. [...]a great many patients do not need to be treated: the broad indications for initiating therapy are (1) a high risk of mortality or disability due to major organ involvement; and (2) unacceptable loss of quality of life. While higher dose treatment regimens may be required in high-risk disease, a highly flexible patient-centred approach is essential when treatment is introduced solely for quality of life reasons. [...]it is important to note that in a few areas of diagnosis and management where there was a non-unanimous consensus among the statement authors, this is clearly indicated. All patients should be encouraged to complete an inventory of quality of life measures and, as part of this, clinicians should emphasise the concept of ‘self-care’, that is, a deliberate activity that sarcoidosis patients undertake to look after their physical, mental or emotional well-being.

Sufferers experience significantly impaired quality of life (QoL). CC in a patient with a normal CXR and no response to treatment of known or suspected triggers should be referred on to secondary care. Upper airway symptoms Symptoms of chronic rhinosinusitis (CRS) should prompt an empirical trial of a nasal steroid. British Thoracic Society clinical statement on CC in adults Introduction CC represents a significant part of everyday practice for practitioners in primary and secondary care. Since the last British Thoracic Society (BTS) guideline on CC in Adults in 2006,4 there has been major progress in the diagnosis, and therapy of this condition but it remains a challenging area with a limited evidence base.5 6 Clinical advances, particularly the recognition of cough hypersensitivity syndrome and the use of appropriate drug and non-pharmacological cough treatment, has not yet embedded in most routine clinical practice in the UK.

Learning disability is the preferred term used in the UK to refer to individuals who have ‘significantly reduced ability to understand new or complex information, to learn new skills’ and a ‘reduced ability to cope independently which starts before adulthood with lasting effects on development’.1 Individuals with learning disability represent a widely heterogeneous group of people and can be associated with a broad range of primary diagnoses and comorbidities.2 There is no definitive record of the number of people with learning disability in England. A series of measures have been introduced by the National Health Service (NHS) to help improve the identification of people with learning disability.4 The life expectancy of people with learning disability is reduced compared with the general population; only 37% of adults with learning disability live beyond 65 years of age compared with 85% of the general population.2 Pneumonia is the most common cause of death among adults with learning disability and is also a common cause of death in CYP with learning disability, with bacterial pneumonia accounting for a significant proportion of these (adults 24%, children 21%).5 A further 16% of adult and 3% of paediatric deaths in the learning disability population are caused by aspiration pneumonia (AP).5 CAP is a major contributor to the increased hospitalisation risk that has been described for people with learning disability and results in longer hospital stays than the general population.6 People with learning disability also experience increased rates of repeated admission secondary to CAP.7 As CAP is a major cause of death in people with learning disability, prevention, early detection and proactive management are key to reducing mortality from avoidable causes.8 It is important that public sector organisations make reasonable adjustments in their approach or provision to ensure that people with learning disability have equitable access to good quality healthcare.9 10 Scope Learning disability is variously defined. [...]the statement is structured with an emphasis on risk factor identification and instigation of preventive measures. Engagement and assessment Engaging effectively with the person with learning disability and their parents/carers is fundamental to the early identification of CAP risk factors and the judicious implementation of preventive care and treatment.

Correspondence to Dr William Man; W.Man@rbht.nhs.uk Introduction The evidence-based British Thoracic Society (BTS) Guideline for pulmonary rehabilitation (PR) in adults was published in 2013.1 There is a strong evidence base for the benefits of PR,2 and it is one of the most cost-effective interventions for adults with chronic obstructive pulmonary disease (COPD).3 Furthermore, PR improves exercise capacity and health-related quality of life (HRQOL) in COPD to a much greater magnitude than observed with bronchodilator therapy.4 Since the Guideline, there is deeper understanding of referral characteristics, outcome measures, patient selection, programme delivery, potential adjuncts and the role of maintenance following PR. The BTS Clinical Statement on PR is a narrative review which provides a snapshot of current knowledge and best practice in topical areas by providing a series of clinical practice points that are informed by evidence where this exists, or based on expert opinion and collective clinical experience where evidence is limited. Measurement of core outcomes before and after PR. These should include a validated exercise test, measures of breathlessness and health-related quality of life, and other outcomes that evaluate core components of the intervention, such as lower limb muscle strength and disease knowledge. PR providers should work closely with relevant national professional societies and other stakeholders to develop competency documents and training programmes to maintain, upskill and expand the skilled workforce needed to deliver increased PR. Assessment and outcomes A high-quality PR assessment should include a multisystem approach that helps identify individuals who might benefit from other cost-effective interventions (such as vaccination and smoking cessation) or onward referral to multidisciplinary specialists. Assessment of patient safety for exercise training and exercise capacity to facilitate exercise prescription should be conducted in-person using a validated field walking test (incremental shuttle walk (ISWT), 6 min walk tests (6MWT)) or laboratory cardiopulmonary exercise test.

Impaired swallowing can lead to malnutrition, dehydration, choking, reduced quality of life and death.5–7 Because so many people are at risk of developing AP, a significant emphasis of this Statement is on prevention. [...]microaspiration due to abnormal swallowing results from a wide range of pathologies, and so heterogeneous patient groups are included in published studies on AP. Every hospital and care home should have at least one oral health ‘champion’ promoting good oral healthcare. Oral examination should be performed in all hospitalised patients at risk of AP or with suspected AP, and at least weekly in care home residents, checking for infection (eg, candidiasis), quality of dentition, food residue and cleanliness of mucosal surfaces.

[...]passengers booking such flights should note that airlines may, for operational reasons, switch at short notice to an aircraft with a higher normal cabin altitude. Besides the passenger’s respiratory condition and significant comorbidities, a decision regarding suitability for air travel should consider flight duration and timings, destination (especially if at altitude or subject to extreme weather conditions), equipment and medications, and whether equipment will operate effectively and safely at altitude. [...]the equipment used to deliver oxygen has changed significantly over the last decade, with much greater availability of portable oxygen concentrators (POCs). Attention has, therefore, been drawn in this Statement to newer data, especially those published since the 2011 BTS recommendations.1 Readers wanting more detailed background information on physiology and the flight environment should consult the 2002 and 2011 BTS documents.1 2 Scope The clinical statement provides practical advice for healthcare professionals in primary and secondary care managing passengers with pre-existing respiratory conditions planning commercial air travel, including those recovering from an acute event/exacerbation. The document does not cover emergency aero-medical evacuation, or travel on non-commercial flights.

Summary of clinical practice points Section 1—introduction Healthcare professionals should be aware that occupational exposures account for around one in six cases of asthma in adults of working age. Patients with OA should be provided with written information confirming their diagnosis, the implications this has on their current and future jobs as well as Industrial Injuries Disablement Benefit (IIDB) and civil compensation advice. For those in employment, asthma control may be adversely affected by factors in the workplace, and the term ‘work-related asthma’ (WRA) is used.1 3 Although the true frequency of this condition is unknown, it is relatively common, affecting around 20%–25% of working individuals with asthma.4–6 WRA is subdivided into three main phenotypes—work-aggravated asthma (WAA), allergic occupational asthma due to sensitisation and irritant-induced asthma (IIA)3 (figure 1). Causation Although there are over 400 known causes of OA (known as asthmagens),2 most cases in the UK are related to exposure to a small number of workplace allergens, most commonly flour dust or isocyanates.8 Asthmagens are usually divided into HMW or LMW sensitisers1 9; commonly reported causes are shown in table 1.

Correspondence to Dr James H Hull, Respiratory Medicine, Royal Brompton Hospital, London, UK; j.hull@rbht.nhs.uk Introduction This British Thoracic Society (BTS) Clinical Statement addresses the diagnosis, evaluation and management of respiratory problems in athletic individuals. [...]it is estimated that at least one in four individuals report troublesome exercise-related respiratory issues, such as breathlessness, cough and/or wheeze.1 Moreover, in competitive athletes, asthma is the most prevalent medical condition and encountered in approximately a quarter of those partaking in endurance sport.2 3 Although athletic individuals can develop any cardiorespiratory illness and thus general clinical guideline documents are broadly applicable, studies over the past three decades have highlighted issues that are particularly relevant when assessing respiratory problems in athletic individuals or in certain sporting scenarios. Scope The purpose of this document was to provide concise and pragmatic guidance to help clinicians from all aspects of the multidisciplinary team (ie, including doctors, physiotherapists, speech and language therapists, pharmacists, physiologists, psychologists and specialist nurses), in both primary and secondary care settings, in assessing and managing respiratory problems in athletic individuals. A thorough history should characterise the precise nature of exercise-related clinical features (eg, breathlessness and wheeze) and their relationship with exercise intensity and recovery.

Correspondence to Prof Sanjay Agrawal, Department of Respiratory Medicine, Glenfield Hospital, Institute for Lung Health, Leicester, UK; sanjay.agrawal@uhl-tr.nhs.uk Summary of key clinical practice points Building block 1: screen for tobacco dependence Ask every patient if they smoke Record ‘tobacco dependency’ as an active disease in the medical history Ensure any electronic systems for recording smoking status and supporting referral to the specialist tobacco dependency team are completed Building block 2: advise on the role of nicotine Nicotine drives the dependency to tobacco but is NOT the cause of the harms of smoking The harms of smoking come from thousands of toxic chemicals produced when tobacco is burnt to create smoke Keeping these toxic chemicals out of the body during the hospital admission will help acutely unwell patients recover more quickly Nicotine withdrawal can be very unpleasant, and it is important to provide nicotine in safe, alternative ways to help alleviate this Being smoke-free does not have to mean being nicotine-free during a hospital admission or after discharge from hospital Building block 3: initiate combination nicotine replacement therapy (NRT) as soon as possible Use a Rapid Inpatient NRT Prescribing Protocol and prescribe a 25 mg/16hour nicotine patch plus a fast-acting nicotine product (inhalator, lozenge, mouth spray) The most serious risk of relapsing back to smoking is prescribing an insufficient dose of NRT and not adequately addressing the patient’s withdrawal symptoms and urges to smoke Building block 4: complete a referral to an on-site tobacco dependency advisor (TDA) Refer all patients with tobacco dependence to the TDA team unless they opt-out or ensure automated referral processes to the TDA team when the patient is recorded as tobacco dependent, allowing them to opt-out at first approach by the TDA Advise on the benefits of working with specialist tobacco dependency advisors If no on-site team is available, complete an automated onward referral to local community services to provide ongoing treatment & support after discharge Building block 5: provide accurate and consistent information on Vaping Nicotine vapes deliver high dose fast-acting nicotine which can help to alleviate withdrawal and urges to smoke Vaping is an effective tool in the treatment for tobacco dependency and can be used to support patients during a hospital admission and to help achieve long term abstinence When using nicotine vapes as part of their tobacco dependency treatment plan, inpatients should be advised to switch entirely from smoking to vaping (and NRT) to maximise the harm reduction, both during the admission and after discharge If provided in the inpatient setting, nicotine vapes should be used alongside combination NRT as patients may not be able to use the vape at certain times or in certain environments (eg, the internal hospital building) Vaping is more likely to be effective when provided alongside behaviour change support from a TDA during the hospital admission and after discharge Vaping is not risk free. Additional information on reputable sources can be sought from local government stop smoking services From an environmental perspective, avoid single-use products Vapes should not be used when using home oxygen therapy Building block 6: discuss, offer and prescribe nicotine analogue medications Nicotine analogue medications (varenicline, cytisine) are effective treatments for tobacco dependency and can be discussed and commenced at the point of admission or during the admission Combination therapies (eg, NRT and nicotine analogues) are as effective if not more effective than single therapies and support abstinence in the unique environment of the inpatient setting (NRT provides additional nicotine needed during the escalation phase of varenicline during a smoke-free admission) Scope This Clinical Statement provides evidenced-based, practical advice for hospital clinicians to identify, initiate treatment and ensure specialist care for adult inpatients with a dependency to tobacco. By following the framework set out below, hospital clinicians can ensure optimal patient outcomes by: helping to alleviate withdrawal and urges to smoke for inpatients facilitating smoke-free hospital admissions referring for specialist support to help change deeply engrained smoking behaviours and start many patients on the journey to achieving long term abstinence from tobacco While the interventions and pharmacotherapy used in hospital are similar to those in community settings or other outpatient settings, the focus of this clinical statement is inpatients in the hospital setting. Building Blocks Framework – quick reference version Specialist behaviour change training and motivational interviewing for tobacco dependency advisors was considered outside the scope of this document and outside that of most hospital clinicians’ day to day work.