Nontuberculous Mycobacterial (NTM) Infections

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to The Respiratory Exchange Podcast. I'm Raed Dweik chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today as well as the patients of tomorrow. I hope you enjoy today's episode.

Hello everyone, and welcome to this episode of The Respiratory Exchange. I'm your host for today, Raed Dweik, chairmen of the Respiratory Institute at the Cleveland Clinic. And my guests today are Dr. Cyndee Miranda, who is an infectious disease specialist with a focus on nontuberculous mycobacteria. And she runs the granuloma delta group in the infectious disease department. And the other guest is Joseph Khabbaza, who is a pulmonary specialist with a focus and interest on nontuberculous mycobacteria as well. This is the topic for today, nontuberculous mycobacteria infections. And this is something that usually involves both infectious disease and pulmonary specialists. That's why we have them both for you today. Cyndee and Joe, welcome.

Cyndee Miranda, MD:

Thank you.

Joseph Khabbaza, MD:

Thanks for having us.

Raed Dweik, MD:

Yeah, I'm very excited about this. This is a very confusing topic to a lot of people, including even people like me who are specialists in pulmonary. They always like, look for more help from the experts because it's not something we see very often. So, it's good to have a couple of physicians who really are focused on this as part of their practice. So, to level set the field, can you just, Cyndee, tell us when we say nontuberculous mycobacteria infection, or NTM, what are we talking about here?

Cyndee Miranda, MD:

So NTM or as you said, nontuberculous mycobacteria, it's just a type of bacteria. It is related to, as the more popular mycobacteria, mycobacterium tuberculosis. But these groups of bacteria are not generally passed from person to person, it's not contagious. And it's usually more in the environment. So, in soil and water, that's where we find these bacteria.

Raed Dweik, MD:

So that's a good differentiator. TB is very infectious, of course, and very dangerous. You cannot be, you don't want to be around people with TB. But, you know, because that's something important actually for our physicians and patients to know, that it's not infectious. That's a good way to set the level. Anything to add to that, Joe?

Joseph Khabbaza, MD:

Yeah. So, it's really this family of mycobacteria. There's, you know, almost 200 species now and it's really anything mycobacteria except for tuberculosis and leprosy, I think, and I think they cover our whole globe, water and soil in this kind of 200 species. And that oftentimes, you know, can cause some confusion about cultures because then you might see some of the nontypical ones. And we'll get into some of that later because there are just a handful that predominantly cause pulmonary disease. And those are the ones we generally focus on in clinical practice.

Raed Dweik, MD:

So, what I have here, can you just tell us who should be tested for it? When do you suspect it and who should be testing for it?

Joseph Khabbaza, MD:

Yeah. So really anyone who has underlying pulmonary disease. Anything where the normal clearance of secretions, and mucus, and bacteria might be impaired, is going to be at risk of developing nontuberculous mycobacteria lung disease. So, I think about it most in people who have recurrent pneumonias. I mean that to me is, and I think in studies that's been one of the top comorbidities seen in people with NTM lung disease, a history of recurrent pneumonia that responds to regular antibiotics. So, these are not mycobacterial acute pneumonias but having that NTM in the background.

They form layers of slime inside of our windpipes, essentially. So those are what we call bio films. They also live intracellular inside the alveoli Macrophages. So, they kind of just hang out and kind of slowly kind of brew. Maybe because some low-grade inflammation and does not cause symptoms, but it makes people susceptible to regular pneumonias. So recurrent pneumonia is a big one for me. And anyone with a chronic cough or uncontrolled chronic lung disease. So, recurrence COPD exacerbation, recurrent asthma exacerbation.

These are people I'm always wondering, is there something brewing in their lower airways leading to this picture, but really anyone who has a pulmonary, any pulmonary, disease or is even on inhaled corticosteroids, is someone who is, it should be in your differential if they run into symptoms or uncontrolled disease down the road.

Raed Dweik, MD:

That's a lot of people. You know, I really, I'm thinking here now everybody in my clinic looks like that and sounds like that. Is there a, like, some higher-level criteria? You are actually proposing that we test or at least have a high suspicion for everybody in our clinics basically?

Joseph Khabbaza, MD:

I think we have to think about it earlier. I'll tell you, when I came out of training, and I knew very little about NTM and bronchiectasis. And when I first kind of took that career path where it really became a big passion of mine, it started by me starting to think about it more. So very early on most of my NTM patients were people I was already caring for who had COPD or asthma that I never thought about it in their differential. And I just started sending cultures. And then I'd be capturing it. So, these were people under my nose for years. These were not new bronchiectasis referrals; they were not new NTM patients. These were people I was taking care of. And by developing that index of suspicion, I was able to catch many.

You know, many of these patients act, because many of us don't think about NTM, oftentimes there's a big delay from their first symptom until they actually get a diagnosis of NTM. And that delay can lead to progressive changes in the airways and worsening bronchiectasis. And of course, it could make it harder to be sure once antibiotics are started.

Raed Dweik, MD:

Oh. So Cyndee, any thoughts on that? That seems like a lot of people. But in ID you probably have a different view when you see them, yeah.

Cyndee Miranda, MD:

Yeah. So, I agree with, actually, with what Joe has said. Especially those that have, let's say, bronchiectasis patients, COPD, frequent exacerbations that really don't get better on antibiotics and it's one exacerbation after another. That's when you think about sending mycobacterial cultures specifically. We also think about NTM diagnosis in those, of course, with compatible symptoms like respiratory symptoms or systemic symptoms in patients who are also immunosuppressed. And patients who are on, like, TNF Alpha inhibitors, might increase their risk for developing NTM disease.

There is also a group of patients with no obvious risk factors. And this is the Lady Windermere syndrome, which you probably heard about. And these are typically post-menopausal women, tall, slender, with certain body habits. Like pectus excavatum and scoliosis. So, we have seen NTM lung disease in these patients as well.

Raed Dweik, MD:

Yeah. That's a good, that's the classic example we learned in medical school and in training. But now obviously it's going beyond that. So, the one thing I remember from a while back is, like, when you get the TB results, you know, the acid-fast bacilli test, everybody kind of freaks out. And then it's not TB, they say, "Oh, don't worry about it." But the reality is we know now that you need to worry about it also. It's not just TB you need to worry about. So, you know, do you have to treat these, you know, patients and how do you treat them? We can start with you.

Cyndee Miranda, MD:

So, again, as Joe pointed out, there are a lot of NTM species. Like over 200. And just to point out, not all of them are significant. Or not all of them cause disease. And certainly not all of them cause specifically pulmonary infections. So, for example, you know, because there could be environmental contamination that can be attributed to NTMs, especially if you just find it in one sputum.

For example, like mycobacterium gordonae, when we see that in cultures, it's usually not significant. However, the ones that we see in sputum cultures that we will think about treatment are mycobacterium avium complex. So, it's actually a, it's complex because there's many different species in that group. But typically, mycobacterium avian complex if we isolate that. Mycobacterium kansasii is another important nontuberculous mycobacterial infection in the lung. And mycobacterium abscesses. And then there's others like mycobacterium xenopi.

So, when you see NTM in your cultures, you have to, one, really know is the species important? Is this, should this species be treated? And then after that, you know, ATS, IDSA, they've come up with guidelines on how to treat NTM infections, particularly the ones that I mentioned. And so, they, there is a diagnostic criterion for this. First of all, you've got to have compatible clinical symptoms, systemic symptoms which as Joe had said, you know, persistent cough, sputum production, shortness of breath, fatigue. You know, for some. Not as common as TB, you may have fever and weight loss in some patients.

And then of course radiologic findings, which maybe Joe can expound on in a little bit. Such of one, of course, there's the cavitary lesions, which tend to progress more quickly. And then those with what we call the nodular bronchiectatic type of disease.

And then the other criteria are meeting micro biologic criteria. Meaning patients should not have just one, as you had said. Having just one sputum culture positive for a significant mycobacterium is not diagnostic. You must have two sputum cultures that are positive for the organism. Or you could have one, a bronchial culture from a bronchial wash or lavage or a biopsy which shows granulomatis inflammation AFB and positive culture with it. So, these guidelines are there to help us decide, you know, who meets criteria for diagnosis of these nontuberculous mycobacterial infections.

Raed Dweik, MD:

Yeah. And as pulmonologists, we always think bronchoscopy, Joe. So, do we need a bronchoscopy to make a diagnosis? Or how do you approach these patients?

Joseph Khabbaza, MD:

So hopefully patients are producing sputum and I think a lot of our patients do have a productive cough. I think probably more than half of patients with NTM lung disease do have a productive cough. But there's a big chunk that doesn't. A lot of people have dry cough, a lot of people just present with non-specific symptoms, like fatigue, weight loss, you know, low energy without a single cough even. And that's why I think some of these non-specific symptoms are part of why index of suspicion is low because sometimes they don't always point to the thought that there could be a lung infection because there are no respiratory symptoms. So that index of suspicion is very important. But once you go down that path of trying to see if they meet the diagnostic criteria, you know, the CAT scan becomes very helpful.

And another thing that kind of leads to delay in diagnosis, which is something I wanted to do an easy, kind of quick study on is a lot of these people with mild kind of, you know, nodular bronchiectatic changes, even just kind of small, scattered tree and bud areas. Maybe not significant bronchiectasis. Oftentimes, these are changes that aren't caught on an X-ray. So many of these patients do get an X-ray even with chronic dry cough and they have a clear X-ray. So, when there is a clear X-ray, a lot of primary care doctors and pulmonologists think a chronic infection is less likely. But with persistent symptoms, I really recommend getting a CAT scan because you'll be surprised how much of these changes you might uncover.

And I'm someone who thinks about NTM all the time, almost too much probably. And even just, you know, a year ago I had a patient with mild asthma. And she kind of had weird symptoms, largely controlled. But I would have some vague chest pains and just seemed a little bit off. Clear X-ray, normal spirometry. But so, I just wanted just to get a CAT scan because we had kind of exhausted everything. I just wanted to, you know, see if it suggested any possible ideology to these vague symptoms. This is a lady I've been caring for years, never thought about NTM. And we got a scan and she's got findings suggestive of NTM.

So, she does not produce sputum. But so, if we wanted a diagnosis for those people our two options are to get an induced sputum. And that's not available at as many as I initially thought. And especially now post COVID there's less you need specific negative pressure rooms to get that. But induced sputum is an option to get. But if people cannot get induced sputum, then a bronchoscopy would be needed to make that diagnosis to try to reach that diagnostic criterion.

And Cyndee had mentioned the four more common types of NTM pulmonary disease. But in, and it's kind of can vary from regions and continents. But in North America about 80 percent of them are MAC, so MAC is oftentimes our big focus.

Raed Dweik, MD:

Mycobacterium avian complex.

Joseph Khabbaza, MD:

Yes.

Raed Dweik, MD:

Yeah, yeah.

Joseph Khabbaza, MD:

Yeah. So, a lot of the treatment guidelines and most of the studies are kind of centered around MAC just because that's what we most commonly see. But we, the guidelines, do still use some of the, you know, the data for the other common species we see. But the diagnostic criteria do hold the same regardless of species. You want to keep seeing it pop up to be confident that that's what's driving the picture.

Raed Dweik, MD:

Yeah, great. And back to you, Cyndee, and how do you decide, we talked about diagnostic criteria presenting symptoms. How do you decide who to treat? When do you make that decision? Does everybody need treatment, or can we be selective in that?

Cyndee Miranda, MD:

Again, they've also mentioned in the guidelines that if you meet the diagnostic criteria for NTM pulmonary infection, it doesn't always mean starting treatment. So however, there are patients where we don't delay treatment. And those are patients that have risk factors for progression. For example, patients with cavitary disease tend to progress more. So, we don't delay treating these patients. There's also for those patients who are smear positive on the AFB culture, they also tend to progress more. So, we might consider treating those patients earlier. Other risk factors for progression are in patients with low BMI that's found to be a risk factor as well.

Of course, you have to take into consideration the severity of symptoms, you know, affecting the patient's quality of life and of course, radiographic progression. But there are patients with, let's say, the nodular bronchiectatic type of disease. If they have minimal symptoms, minimal radiographic changes, there might be room to monitor them closely. Again, if we don't choose to treat, we have to monitor. Or if the patient doesn't choose to treat because, you know, sometimes there are multiple things to consider like comorbidities, drug side effects. We have to follow these patients closely.

Raed Dweik, MD:

Yeah. So, can you comment more on this watchful waiting approach, Joe? Like when do you watch your judgment and when do you decide to kind of pull the trigger on treatment?

Joseph Khabbaza, MD:

Yeah. So, I think kind of the default in a lot of our training, I think certainly on the pulmonary side was that we're almost kind of taught to scare patients out of treatment. We're almost taught the line treatment's worse than the disease, you know, it's not that big a deal. And we can watch. But with time and as you get immersed in NTM, you realize the disease itself can be pretty bad.

But I think what's important, watchful waiting is appropriate for a lot of patients. But I think what's important, people who are put in that watchful waiting category, is that the watching actually occurs. Too many people are just labeled watchful waiting but then it's just waiting. They're told to call me if you have symptoms down the road. And they may not show up for five, 10 plus years. And then they'll kind of resurface. And at that point they can have quite extensive disease because things can progress before symptoms change tremendously.

And I think what I see often as I've met many pulmonary and ID physicians, really around the country while talking about NTM is that oftentimes, you know, pulmonary will diagnose NTM with bronchoscopy, what have you. They'll get a diagnosis, then they'll refer to ID and run away. You know? And kind of, you know, where ID is kind of now left on an island in a way. And I hear that from many of my ID colleagues where, you know, there's not much pulmonary support. So, because ID is not really built to watch minimally symptomatic chronic infections. I think it is because the pulmonary predisposing factors are generally why most people have NTM. I think as a pulmonologist, you know, we should have, you know, really taken the responsibility of the watching part.

So, people with minimal symptoms who are not low BMI, who don't have those risk factors of progression with smear positive or cavitary disease, think watchful waiting is an option for them. But having that discussion with them up front, here's what watchful waiting could entail, here's the pros and cons there. Here are the pros and cons of treating now. And I try to have them make that decision. Because watchful waiting may be appropriate. It depends on their preference, you know? I think as long as they are being monitored, the risks of watching are probably on the lower end, as long as they're not in those high-risk factors. And we let the patients decide.

You know, I've had a couple patients who've had really minimal disease kind of incidentally found who I don't think any of us have felt would warrant treatment. But the patients were so anxious about having this kind of even minimal chronic infection. They want it to be treated upfront. So, then I would treat a patient like that because that is their preference. So, I think you know, I think things are shifting to at least giving patients the option and having them understand what each route meant. And to not get too off topic, but an important part, you know, and because I think the initial treatment starts with airway clearance. So especially, whether it's mild disease or severe, trying to clear those airways of the secretions and mucous and bacteria that builds up in these stretched out airways is crucial. Because even if you're on the right guideline-based regimen for NTM, if you're not doing anything to try to mobilize those secretions, the antibiotics will be less effective.

So, my first start with all these patients is having them understand and get on a very good airway clearance regimen because airway clearance, I think when it comes to bronchiectasis and these indolent infections, there's a form of source control. That is a way to eliminate bacteria before touching a single antibiotic.

Raed Dweik, MD:

Yeah. That makes a lot of sense. But I want to come back to this watchful approach as to what do you watch for? What are we actually watching for when you are not treating? Just a watchful, and I'll ask Cyndee what she watches for when she treats, but I like to hear from you when you are not treating, what do you watch for?

Joseph Khabbaza, MD:

Yeah. So, we're looking to see what happens with their cough, their sputum production, any respiratory symptoms they may have. And also, what happens with their spirometry. So, we do track their FEV1 usually every six months or so. So, if that's starting to decline slowly, I would use that as something to discuss with.

Raed Dweik, MD:

You do CT or X-rays or?

Joseph Khabbaza, MD:

So, radiographs I don't, we, I don't follow too closely in close intervals because secretions can shift a lot. So, it's very common to have fleeting nodular changes on CT scan which can kind of muddy the picture. And does not always correlate also with treatment failure or with disease progression always. At least in close intervals. So, I'm more concerned about their symptoms, how's their weight, appetite, fatigue and spirometry. So CTs we sometimes check, you know, every couple of years especially if someone’s pretty stable. And we might extend their follow up period. But CTs are not super reliable in following completely just because things can just shift based on how the secretions moved that morning.

Raed Dweik, MD:

That's great. Cyndee, I don't know if you want to comment on that? But I really want you also to focus on what do you watch for with people on treatment now? Yeah.

Cyndee Miranda, MD:

So actually, just what Joe had said, you know, I have, to tell the story of a patient of mine, that she met the diagnosis, you know, for NTM pulmonary disease. She had MAC. And actually, it's what Joe was saying, we had the conversation, you know, regarding treatment. What the side effects were. And at that time, she didn't have a lot of symptoms. She worked in the medical field, so she weighed the risks and benefits and she said, "I'd rather not go into treatment."

And so, however with the watchful waiting, I do make it a point that they have to do airway clearance. Because actually that's the treatment, that's a form of treatment for me and my pulmonary colleagues have taught me the importance of that. So, I do partner typically, I like to partner with one of our pulmonary colleagues and to monitor the patient. And I make, I really, really tell them how important it is that if they're not on treatment with drugs, that they are on airway clearance.

And my patient actually later on had frequent exacerbations one after another. And I told her, you know, "I think, you know, at this time we should consider that this is MAC causing it and that we should start you on treatment." Which we did. She actually felt much better after that. So, and this didn't happen over a period of a month or two months. I watched her for a year which can, because sometimes these NTM lung disease can, they don't progress. Like especially with MAC, some can progress slowly over time. But I think most of them will progress. And at some point, need treatment. And so that's what I watch for. As Joe said, we don't do CAT scans, like, every three months. But we do do them periodically just in case some with nodular lesions have now cavitary disease.

But we monitor, of course, their sputum. There's a few that might actually convert to negative spontaneously on their own, which doesn't happen often. But we do monitor their sputum and then symptoms are important. I think treatment of NTM is really an individualized approach, you know, depends on, really a discussion with the patient because comorbidities and sometimes we diagnose this disease in patients who are older. So that's something to consider.

Raed Dweik, MD:

And how long do you treat?

Cyndee Miranda, MD:

So typically, so for example for MAC, typically the treatment one just it's multiple drugs, right. And it's given usually for a year, 12 months after you've converted your sputum. So usually that may take a few months. So typically, patients might be on treatment for around 18 months, because it's 12 months from when they clear the MAC from their sputum cultures. For, like, kansasii the same thing. For abscesses it's a little more complicated I would say.

Raed Dweik, MD:

Yeah. So, back to you, Joe, here. So, when do you know that you're successful when, maybe frame it the other way. Treatment failure. How do you define treatment failure in these patients?

Joseph Khabbaza, MD:

Yeah. Well in 2020, the first NTM treatment guideline update came out since 2007. And it did emphasize kind of one kind of new point, focusing on that six-month mark. So, people who are on guideline-based therapy should be getting monthly sputum cultures because that's how we see if we're successful. And that's when the clock starts ticking of duration of treatment. You know, 12 months from the initial negative sputum culture.

But people, if they're still culture positive at six months, that's been found to be a very critical point in the journey in suggesting treatment failure on that initial guideline-based regimen. And that's what we'd call refractory MAC pulmonary disease. Or NTM, whichever one. We often use MAC and NTM interchangeably because MAC is so common. So, people who are refractory at six months means it's been associated with worse progression of lung disease. So, because they still have a lot more mycobacterial burden in their airways. And less likely to really culture convert throughout the rest of that treatment plan.

And so, if people are still culture positive at six months, that is a pivotal point for me that says they would need a step up in therapy. And the guidelines now strongly recommend inhaled liposomal in that case and to be added at that point to try to increase the odds of culture conversion.

Raed Dweik, MD:

So, the other thing that comes up with treatment is surgery. Cyndee, you know, any thoughts on do you ever refer them surgery? When do you decide to refer them to surgery? Any thoughts on that?

Cyndee Miranda, MD:

Yes. So, we have actually had few patients who have undergone surgery for I would say most of them have been for MAC. But so, when we refer to them it's usually, you know, when medical therapy has failed. That usually happens in the setting where they have a resistant mycobacterium or a resistant MAC, particularly those that are azithromycin resistant. Refer patients typically with cavitary disease. Particularly localized disease. So those are the patients we refer to. Patients who are not tolerating medical treatment is one indication to refer them to surgery. And of course, those who have more serious symptoms like hemophthisis, so for more for symptom control.

So those are the patients that we've referred. I would say that it's mainly for cavitary disease and for those who have localized disease that are not clearing may be good candidates for surgery.

Raed Dweik, MD:

Any other thoughts on that?

Joseph Khabbaza, MD:

Yeah, that's spot on. A real localized disease and sometimes some people if they have extensive disease but have a localized, like, big cavity that seems to be driving the picture and with adequate lung function, that's somebody who might be able to potentially be evaluated to tolerate. And she brought up a good point of macrolide resistance. Because that is a very big deal that I don't think is taught or spoken about enough, especially in the pulmonary circles. And macrolide is your most important antibiotic at successfully treating these family of bacteria and especially MAC. When MAC is macrolide resistant, azithromycin is the most common one we use, it becomes I think harder to cure than, like, multi drug resistant TB, I think.

And so, and this might be a little off topic on the question. But I think a big take away point, I would add to really avoid macrolide monotherapy in the treatment of MAC. Because then you're more likely to develop resistance, but also in our pulmonary patients who are on macrolide monotherapy whether it be for COPD or bronchiectasis, to always screen AFB cultures to really minimize the odds of developing macrolide resistance. Because that is a huge correlation with treatment failure and really increasing the odds of needing a potential resection if you have macrolide resistant disease.

Raed Dweik, MD:

That's wonderful. That's amazing, I really learned a lot today. I know this is an area that many pulmonologists and even ID specialists are not very comfortable with unless they see more and more of it. So, I thank you both for sharing your insights. I'm gonna just maybe share with the audience a couple of takeaways that I heard from you today.

One, we should have a high index of suspicion for nontuberculous mycobacteria or mycobacterium avian complex, MAC, in patient with lung disease, underlying lung disease who have persistent symptoms or have frequent exacerbations and do not respond to therapy as you would expect to. Second point is sputum is the main way to make the diagnosis and you have to do repeated sputum cultures, X-rays may not be really helpful. I you really want imaging, maybe a CT scan is the way to go. And bronchoscopy is usually reserved for those who do not make sputum. Because if you make sputum that's an easy way to make the diagnosis.

And about treatment, really, it looks like it's a shared decision making with the physician and the patient. There's plenty of side effects for these drugs, but also, they work. So, you know, I know there's a lot of maybe misconception out there that the treatment is worse than the disease. But really, it's all about weighing risks and benefits. And some patients definitely watchful waiting is the right approach and others really aggressive treatment is the right approach. And that decision has to be made jointly with the patient. Any other thoughts you have before we close this out?

Joseph Khabbaza, MD:

Yeah. I'd say from a treatment standpoint I think what I try to remind patients, most patients don't have the side effects. And I think it kind of gets sold to them that they're very likely to have the most side effects we look for. But I've found in my experience that most patients do tolerate them and the ones who do tolerate them, you know, that journey's a lot easier. Because if they're not having daily side effects of symptoms, the duration is less stressful to them.

And so that's also what I remind a lot of my colleagues that, you know, I think every patient, if they want deserves a trial of treatment, you know, if they want to try. I've had patients and I mean there's, 91 was the oldest I tried treatment on because that's what he wanted. You know, we went through everything. And, you know, most people do not develop the side effects. But we talk to them about the higher risk ones to be aware of when they're on it. But they only know by trying, and many patients, especially ones who are referred to us who have had, talked to other doctors about NTM are really surprised at how well they tolerated the treatment because they'd been told for so long that they're likely to feel terrible on them. So, it can be very rewarding to help patients go through that journey and kind of inform them and kind of be by their side. Because it's very intimidating and scary.

Raed Dweik, MD:

Cyndee, we'll give you the last word.

Cyndee Miranda, MD:

We’ve certainly had many patients that have successfully completed treatment for NTM lung disease as Joe has said. Again, it's an individualized approach. But many patients tolerate it, you know, if they keep close communication with their physicians. We do help them through these side effects, there are certain maneuvers we can do that, to help them tolerate the drugs better. And I do think that treatment is really a partnership with the patient, the physician and of course, like, for me with my pulmonary colleagues.

Raed Dweik, MD:

Wonderful. Thank you both again for joining me today. And thank you to our audience. Again, this is your host Raed Dweik, chairman of the Respiratory Institute. And my guests today were Dr. Joe Khabbaza, who's a pulmonologist with a special interest in nontuberculous mycobacteria and bronchiectasis. And Dr. Cyndee Miranda, who’s an infectious disease specialist and leads the delta group for granuloma on our team, with also special interest in nontuberculous mycobacteria. So, thank you and have a great day.

Thank you for listening to this episode of Respiratory Exchange podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @raeddweikmd.

Dr. Cyndee Miranda and Dr. Joseph Khabbaza ,experts from the Infectious Disease and Pulmonary Medicine departments at Cleveland Clinic respectively, delve into NTM: how developing an index of suspicion can help identify patients early, what diagnostic criteria work well, when watchful waiting is called for, and the benefits of following a guideline-based regimen to determine success.