A significant proportion of infants ventilated for respiratory syncytial virus developed subclinical airway dysfunction; structured follow-up and early pulmonary rehabilitation may redefine recovery in paediatric bronchiolitis care https://bit.ly/41xOVM8.
The Global Initiative for Chronic Obstructive Lung Disease has greatly contributed to the management of COPD. However, several important issues persist. The initial conception of chronic bronchitis as a short-term illness caused by 1950s air pollution differs significantly from the current understanding of COPD. COPD and asthma are often diagnosed subjectively due to the lack of definitive diagnostic criteria. Asthma patients who lack classic features may be misclassified as having chronic bronchitis, contributing to diagnostic overlap and unnecessary heterogeneity. The inclusion of asthma patients in COPD studies may have introduced significant bias, leading to misguided management recommendations. Notably, studies that attempted to minimise asthma misclassification (such as by excluding patients with elevated blood eosinophil counts) demonstrated more favourable outcomes in the absence of inhaled corticosteroids compared to studies that applied no such exclusion criteria. COPD patients with blood eosinophilia respond to inhaled corticosteroids precisely because they probably have asthma. Bronchodilator reversibility and airway hyperresponsiveness tests have limited utility in ruling out asthma. Despite their limitations, lung function tests remain central to the assessment and management of COPD. Their clinical value is limited by measurement variability and controversies regarding their interpretation. The current "combined assessment" tool may have limited validity, particularly as treatment strategies have become increasingly standardised, emphasising early initiation of dual bronchodilators and avoidance of corticosteroids. Existing strategy documents remain subject to future revisions, as has occurred with previous versions. Realising their full potential requires critical engagement and thoughtful revision, particularly in addressing persistent areas of controversy.
AI and robotic bronchoscopy boost early lung cancer detection, dual-energy CT and cardiac MRI advance pulmonary vascular imaging, evidence-based standardised ultrasound training progresses. Innovation is reshaping respiratory medicine. https://bit.ly/454pPX3.
Background and objective: This study focused on the economic evaluation of the step-up diagnostic strategy (transbronchial cryobiopsy followed by surgical lung biopsy (SLB) when needed) compared with the immediate SLB strategy (immediate SLB) for diagnosing interstitial lung disease (ILD).
Methods: A cost-utility analysis was conducted from both a healthcare and a societal perspective. The societal perspective extended the healthcare perspective by including productivity losses and patient out-of-pocket expenses. This study was performed alongside a randomised controlled trial in which patients were randomised to the step-up strategy or the immediate SLB strategy, with a time horizon of 12 weeks. The primary outcome was the cost per quality-adjusted life-year (QALY). Costs were addressed irrespective of payer source and included healthcare costs by providers, costs of productivity loss by employers and disease-related out-of-pocket expenses by patients.
Results: 47 patients were included: 25 patients in the step-up diagnostic strategy group and 22 in the immediate SLB strategy group. A mean difference of 0.025 (96% confidence interval (CI) 0.004-0.047; p=0.04) QALYs was found in favour of the step-up strategy. The cost per patient from the healthcare perspective was €4644 (95% CI €3683-€5803) for the step-up strategy group and €8935 (95% CI €8019-€9979) for the immediate SLB group. From a societal perspective, the cost was €6873 (95% CI €5014-€9113) in the step-up strategy group versus €12 924 (95% CI €10 745-€15 325) in the immediate SLB group.
Conclusion: The step-up diagnostic strategy is a cost-effective strategy for patients undergoing lung tissue acquisition for diagnosing ILD; therefore, implementation of this strategy is recommended.
[This corrects the article DOI: 10.1183/23120541.00417-2024.].
Background: α-1 antitrypsin deficiency (AATD) is a rare genetic disorder caused by mutations in the SERPINA1 gene and associated with reduced levels of α-1 antitrypsin (AAT). It predisposes individuals to pulmonary diseases, including bronchiectasis, through protease-antiprotease imbalance and immune dysregulation. While the Pi*ZZ genotype has been extensively studied, the prevalence and characteristics of bronchiectasis in other genotypes remain unclear.
Methods: This cross-sectional study analysed data from the European α-1 Research Collaboration (EARCO) registry, focusing on individuals with bronchiectasis on computed tomography (CT). Participants were stratified by AATD genotypes (Pi*ZZ, Pi*SZ, Pi*SS and rare variants) and data were compared. Disease severity was evaluated using FACED (forced expiratory volume in 1 s (FEV1), age, chronic colonisation, extension and dyspnoea) score and bronchiectasis severity index (BSI) scores.
Results: 349 patients had bronchiectasis on a CT scan, of whom 70.5% had Pi*ZZ, 18.6% had Pi*SZ, 4.3% had Pi*SS and 6.6% had rare variants. Lower lobe involvement was predominant across genotypes, whereas Pi*SS exhibited distinct upper lobe patterns and Pi*SZ showed more frequent middle lobe involvement. People with rare genotypes and Pi*ZZ had worse lung function (FEV1 % of 65.3% and 71.4%, respectively) and higher disease severity scores. Emphysema co-occurrence was most frequent in Pi*ZZ (60.6%). No significant differences were observed in sputum microbiology or systemic inflammatory markers, except for lower platelet counts in Pi*ZZ subjects.
Conclusion: Bronchiectasis in AATD is not limited to the Pi*ZZ genotype, with significant phenotypic variability across genotypes. Lower lobe involvement and mild disease predominate; however, severe forms are more frequent in rare genotypes and Pi*ZZ. These findings underscore the importance of systematic screening and genotype-specific management to improve patient outcomes.
Background: Respiratory morbidity in infants with life-threatening respiratory syncytial virus (RSV) infection necessitating invasive mechanical ventilation (MV) is underexplored. We therefore sought to characterise infant respiratory morbidity and pulmonary function 6 to 12 months after paediatric intensive care unit (PICU) discharge.
Methods: We invited 463 infants with RSV bronchiolitis necessitating MV (December 2011 to January 2023) for clinical assessments (structured interview, physical examination) and pulmonary function testing using whole-body plethysmography and multiple breath washout (from 2016 onwards). Subjects were dichotomised by maximal expiratory flow at the functional residual capacity (V'maxFRC) z-score (normal versus abnormal).
Results: Data from 219 out of 463 subjects (47.3%) were available for analysis (mean±sd age at follow-up 50±16 weeks and 40.3±14.2 weeks since PICU discharge). 180 (82.2%) subjects had parent-reported respiratory symptoms and 68 (31.1%) used bronchodilator treatment as needed. For the whole cohort, mean±sd FRCp z-score was 1.0±1.5 and V'maxFRC z score was -1.42±1.1 compared to reference data. 72 (65%) subjects had lung clearance index values above the upper limit of normal. 24% of patients who underwent both tests had abnormal results in both tests. V'maxFRC < -2 sd was found in 27.9% of subjects. Patient and clinical characteristics were equally distributed between subjects with and without abnormal lung function values (V'maxFRC < -2 sd or lung clearance index above upper limit of normal). No risk factors for V'maxFRC < -2 sd were identified in logistic regression analysis.
Conclusions: Evidence of small airway dysfunction was found in almost one-third of subjects who have been ventilated for life-threatening RSV disease, although not always accompanied by respiratory symptoms.
Background: History of exacerbations is a predictor of future exacerbations in COPD but there are also predictors that are independent of exacerbation history. However, it is unclear whether their relative contribution is consistent across different degrees of airflow limitation.
Methods: This analysis used data from COMPASS, a prospective study in COPD. Baseline demographics, clinical history, spirometry and patient-reported outcomes were collected. Multivariable models were created to predict moderate or severe exacerbations in the 18 months after baseline. Covariates included forced expiratory volume in 1 s (FEV1) % predicted, Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade, modified Medical Research Council (mMRC) and COPD Assessment Test (CAT) scores, and exacerbation history. Goodness of fit was tested using C-statistics.
Results: At baseline there were 1696 patients; 89.6% males, 46.9% current smokers, mean±sd age of 65.4±7.5 years, post-bronchodilator FEV1 66.6±20.1% predicted and 0.5±1.0 moderate/severe exacerbations in the prior year. Over 18 months, 17.8% of patients had ≥1 moderate/severe exacerbation. The best fit model identified six independent variables, C-statistic 0.739. Subgroup analysis into GOLD grades I, II and III+IV combined showed different predictor patterns. In grade I, history of moderate exacerbations was the strongest predictor, together with chronic bronchitis and gastro-oesophageal reflux. In grades III+IV, only history of severe exacerbations and mMRC score were significant. Grade II showed an intermediate picture in which severe exacerbations, chronic bronchitis and gastro-oesophageal reflux were all significant.
Conclusions: There are multiple predictors of COPD exacerbations, which differ between GOLD grades. Future predictive models for exacerbation risk should take this into account.
There is heterogeneity of bronchiectasis within α1-AT deficiency; hence, there is a need for broader screening strategies to ensure timely access to emerging therapies and inclusion in ongoing research efforts https://bit.ly/4nCZsxM.
Background: Pulmonary rehabilitation has limited long-term effects on physical activity levels in patients with COPD. Dyspnoea-related anxiety, part of the affective dimension of dyspnoea, is a major barrier to physical activity. This study assessed whether hypnosis as an adjunct to standard pulmonary rehabilitation could improve the affective dimension of dyspnoea, as well as physical activity levels, 6 months after rehabilitation.
Methods: In a randomised, open-label trial (ClinicalTrials.gov: NCT04010825), 106 COPD patients were enrolled to receive either conventional 4-week inpatient pulmonary rehabilitation (CONT) or pulmonary rehabilitation plus five 1-h hypnosis sessions (HYPNO) primarily targeting emotional dyspnoea management. The primary outcome was the evolution of the affective dimension of dyspnoea at 6 months, assessed by the Multidimensional Dyspnoea Profile questionnaire. Secondary outcomes included changes in physical activity levels via the Simple Physical Activity Questionnaire.
Results: Affective dyspnoea scores decreased after pulmonary rehabilitation in both groups (p<0.01). At 6 months, improvement persisted only in the HYPNO group (p<0.001 versus baseline), whereas the CONT group returned to baseline (p=0.98). Physical activity levels increased only in the HYPNO group (p<0.05 versus baseline) and were higher than in the CONT group at follow-up (p<0.001). Changes in physical activity levels correlated with changes in affective dyspnoea (r= -0.26, p<0.05).
Conclusions: The results suggest that a brief intervention of five hypnosis sessions, as an adjunct to pulmonary rehabilitation, maintained the benefits of pulmonary rehabilitation on the affective dimension of dyspnoea 6 months after pulmonary rehabilitation. The improvement in the affective dimension of dyspnoea was associated with an increase in physical activity levels, a key goal of pulmonary rehabilitation that is poorly achieved in usual pulmonary rehabilitation programmes.
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