The Clinical Statement Group (CSG) was chaired by Dr Caroline Baxter and Professor Jeremy Brown. Membership was drawn from respiratory medicine physicians, nurse specialists, pharmacists, infectious disease physicians and medical mycologists, and included input from all nations of the United Kingdom. The overall content was developed to reflect the scope approved by the BTS Standards of Care Committee (SOCC) and is summarised through clinical practice points (presented in box 1). A final edited draft was reviewed by the BTS SOCC before posting for public consultation and peer review on the BTS website in July 2024. The revised document was re-approved by the BTS SOCC in October 2024 before final publication.

Exophiala dermatitidis is increasingly isolated from cystic fibrosis (CF) respiratory samples. The decision to treat is hampered by limited evidence demonstrating the clinical significance of isolating E. dermatitidis. The objective was to assess the impact of E. dermatitidis isolation on the lung function of CF patients. The rate of lung function decline in the local CF population was calculated using historic lung function data. A control population who had never had E. dermatitidis cultured from the respiratory tract was compared with the E. dermatitidis group, calculating their rate of lung function decline before and after the first isolation of the organism. A total of 1840 lung function measurements were reviewed between the 31 E. dermatitidis group patients and 62 control patients. Their demographics were similar. The control group declined at a rate of −0.824 FEV1%/year. The rate of decline in the E. dermatitidis group prior to infection was −0.337 FEV1%/year (p = 0.2). However, post infection with E. dermatitidis, there was a significant increase in the rate of decline in lung function (−1.824 FEV1%/year, p < 0.01). The results suggest E. dermatitidis has a temporal relationship with accelerated rate of lung function decline. It is not clear if this is a cause or effect, but this accelerated rate of decline indicates a need for further investigation.

Pneumocystis pneumonia (PcP) is a serious complication of many significant immunocompromising conditions. Prior incidence estimates in Wales are based on PcP’s presentation in the HIV and transplant populations. The objectives were to describe the incidence of PcP in Wales using laboratory reporting measures and assess the impact of underlying immunosuppression cause on mortality. All positive PCR results for PcP between 2015 and 2018 were identified. The total number of unique positives with clinical and radiological correlation was 159 patients, a mean of 39.75 annually. The healthcare records of these patients were reviewed. The mortality at one month was 35.2% and 49.1% at one year. HIV remains the commonest cause of immunosuppression but has lower mortality than non-HIV conditions (12% vs. 59% at one year, p < 0.00001). Non-HIV conditions were categorised as life-threatening and non-life threatening but had a non-significant mortality (66% vs. 54%; p = 0.149), highlighting the negative impact of PcP. An incidence of PcP in Wales of 1.23–1.26 cases per 100,000 has been identified, 32–35% greater than the upper limit previously estimated. There is high mortality in non-HIV patients regardless of immunosuppression cause. A heightened awareness of PcP in these groups will hasten diagnosis and potentially improve mortality.

Cigarette smoking remains the commonest cause of chronic obstructive pulmonary disease (COPD) and respiratory bronchiolitis-associated interstitial lung disease (RB-ILD). Biomass combustion remains a high risk for causing respiratory disease. We present a case of a 41-year-old woman and never-smoker with worsening breathlessness. It was identified that she made fire pits burning sage and oils for spiritual work but beyond this had no respiratory risk factors. Radiological evidence of RB-ILD was identified and a bronchoscopic lavage demonstrated the presence of striking green pigmented macrophages, presumed to be chlorophyll uptake. Cessation of burning sage exposure has resulted in a positive outcome. This case highlights the need for an extensive occupational or exposure history in respiratory medicine and describes histological features of interstitial lung disease not previously identified.