ERJ Open Research最新文献

Introduction: Exacerbation of COPD complicated by respiratory acidaemia is the commonest indication for noninvasive ventilation (NIV). The NIV outcomes (NIVO) score offers the best estimate of survival for those ventilated. Unfortunately, two-thirds of cases of COPD are unrecognised, and patients may present without COPD having been confirmed by spirometry.

Methods: In the 10-centre NIVO validation study there was no pre-admission spirometry in 111 of 844 consecutive patients (termed "clinical diagnosis" patients). We compared the performance of the NIVO, DECAF and CURB-65 scores for in-hospital mortality in the clinical diagnosis cohort. Usual clinical practice was not influenced, but confirmation of COPD in the year following discharge was captured.

Results: In the clinical diagnosis cohort, in-hospital mortality was 19.8% and rose incrementally across the NIVO risk categories, consistent with the NIVO validation cohort. NIVO showed good discrimination in the clinical diagnosis cohort: area under the receiver operating curve 0.724, versus 0.79 in the NIVO validation cohort. At 1 year after discharge, 41 of 89 clinical diagnosis patients had undertaken diagnostic spirometry; 33 of 41 had confirmation of airflow obstruction (forced expiratory volume in 1 s/(forced) vital capacity <0.7), meaning the diagnosis of COPD was incorrect in 19.5% of cases.

Discussion: These data support the use of the NIVO score in patients with a "clinical diagnosis" of COPD. NIVO can help guide shared decision-making, assess risk-adjusted outcomes by centre and challenge prognostic pessimism. Accurate diagnosis is critical to ensure that acute and long-term treatment is optimised; this study highlights failings in the follow-up of such patients.

A global survey revealed marked heterogeneity in long COVID management worldwide https://bit.ly/4dVTJ2t.

Background: COPD, a preventable and treatable disease, is characterised by persistent respiratory symptoms and airflow limitations, with high incidence, disability, mortality and disease burden. Currently, drug treatments mainly include bronchodilators and glucocorticoids, which are used to alleviate symptoms and improve lung function. Traditional medical care models and patients' lack of understanding of the disease result in regular and long-term hospitalisations, affect patients' quality of life and cause a need to explore more effective comprehensive intervention plans.

Methods: This study is designed as a multicentre, randomised controlled trial consisting of three parallel groups. Group A will receive early pulmonary rehabilitation in the hospital and remote internet pulmonary rehabilitation after discharge. Group B will receive the same early pulmonary rehabilitation in the hospital but outpatient pulmonary rehabilitation after discharge for 8 weeks and routine follow-up management. Group C will receive outpatient pulmonary rehabilitation during a stable period of 3-4 weeks after discharge and routine follow-up management. 1482 patients will be enrolled from 10 centres in China. The primary outcome measures will be the readmission rate due to acute exacerbation at 90 days and the 12-month readmission rate due to acute exacerbation. The secondary outcomes will mainly include differences in all-cause mortality; the number of acute exacerbations; COPD Assessment Test, modified Medical Research Council scale and St George's Respiratory Questionnaire scores; the pulmonary rehabilitation treatment completion rate; patient compliance; and patient and physician satisfaction scores among the three groups at 3, 6 and 12 months after the different interventions. In addition, the proportion of people with ≥2 acute exacerbations within 12 months and the time of the first acute exacerbation will also be included.

Conclusions: This study aims to further verify the substitutability of remote internet pulmonary rehabilitation for outpatient rehabilitation and its short-term and long-term effects in patients, providing comprehensive interventional evidence for the treatment of COPD.

Williams-Campbell syndrome (WCS) presents diagnostic challenges. This case series highlights clinical complexities and genetic/environmental interplay, and underscores the need for personalised treatment approaches. #WCS #RareDisease https://bit.ly/3Xqze8x.

Chronic cough is a prevalent and challenging condition, with limited treatment options available. The interpretation of clinical trial results for antitussive drugs is complicated by the presence of the placebo response, which can confound outcomes and impede regulatory approval. This review aims to explore the impact of the placebo response on clinical trials for cough medications and elucidate the underlying mechanisms involved. The multifaceted nature of antitussive effects, including pharmacological, psychological/neurobiological and nonspecific effects, is discussed. Additionally, potential solutions to address the placebo response in future cough medication development, such as strategic study design, appropriate choice of end-points and meticulous patient selection, are proposed. More progress to harness this issue is urgently needed.

Background: Patients with pulmonary vascular disease (PVD) often suffer from nocturnal hypoxaemia, but also from sleep apnoea. Short-term use of acetazolamide increases ventilation due to metabolic acidosis and also reduces loop gain. We investigated whether prolonged use of acetazolamide improves sleep disordered breathing in PVD.

Methods: In a randomised controlled crossover trial, patients with PVD were randomly assigned to acetazolamide 250 mg and placebo twice daily for 5 weeks. Patients underwent respiratory polygraphy at baseline and at the end of each intervention phase. Outcomes of interest were the effect of acetazolamide on mean nocturnal oxygen saturation (S _pO2 ), time with oxygen saturation <90% (t _<90), apnoea-hypopnoea index (AHI) and sleep apnoea severity.

Results: In 20 patients with PVD (55% women, nine with pulmonary arterial hypertension, 11 with distal chronic thromboembolic pulmonary hypertension; mean±sd nocturnal S _pO2 88.8±3.5%, obstructive AHI 12.6±12.3 events·h^-1), 5 weeks of acetazolamide resulted in a significant improvement in nocturnal oxygenation compared to placebo (mean nocturnal S _pO2 +2.3% (95% CI 1.3-3.3%); p<0.001 and t _<90 -18.8% (95% CI -29.6- -8.0%); p=0.001). Acetazolamide increased the proportion of patients with mean nocturnal S _pO2 ≥90% from 45% to 85%. The percentage of patients with AHI >5 events·h^-1 was reduced from 75% to 60% and with AHI >15 events·h^-1 from 30% to 15%. Two patients discontinued the study because of mild side-effects.

Conclusions: Acetazolamide given for 5 weeks reduces nocturnal hypoxaemia in PVD to a clinically relevant level and reduces the proportion of patients with obstructive sleep apnoea.

Background: Interstitial lung disease (ILD) is common in primary Sjögren's disease (pSD); its functional course is poorly known. Our aim was to characterise the long-term functional course and prognosis in patients with pSD-ILD. We determined the role of baseline demographic and clinical variables in the evolution of lung function and identified risk factors for death or transplantation.

Methods: In a retrospective observational cohort study, patients with pSD and ILD were retrospectively identified from two French ILD centres. Forced vital capacity (FVC) and diffusing capacity of the lungs for carbon monoxide (D _LCO) slopes were obtained from joint models. Latent class mixed models identified clusters of FVC and D _LCO trajectories.

Results: We included 73 patients (63% women, mean age 63 years), with a median follow-up of 9.3 years. At baseline, mean FVC was 73±21% and D _LCO 51±16%. On average, FVC was stable, while there was an annual decline in D _LCO of 1% of the predicted value. Male sex, a pattern of usual interstitial pneumonia (UIP) or indeterminate for UIP on high-resolution computed tomography (HRCT), and features of fibrosis on HRCT, were associated with an accelerated decline in FVC and D _LCO.

Conclusion: We identified clusters of lung function evolution. 1) Two FVC trajectories: patients with stable FVC (n=56, 78%); patients with FVC decline (n=16, 22%) of 2.4% per year, characterised by a low baseline D _LCO (39%) and a higher risk of death or transplantation (HR 52, 95% CI 10-273). 2) Three D _LCO trajectories: patients with stable D _LCO (n=44, 66%); patients with a slow decline in D _LCO (n=12, 18%) of 2.8% per year; patients with a rapid decline in D _LCO (n=11, 16%) of 4.8% per year, characterised by a low baseline D _LCO (41%) and a higher risk of death or transplantation (HR 156, 95% CI 18-1352).

Research is needed to explore the broader links between oxygen desaturation episodes, ventricular repolarisation instability and genesis of malignant arrhythmic events https://bit.ly/3WeQNHy.

Background: Inspiratory threshold loading (ITL) and associated dyspnoea have been shown to interfere with cognition during cognitive-motor dual tasking. However, ITL has not been compared with another rhythmic muscle activity, such as lower limb pedalling. While ITL has been shown to interfere with cognition, the mechanism of the prefrontal cortex (PFC) during ITL or other rhythmical muscle dual tasking, has not been elucidated. Given the cognitive interference that arises during ITL, we hypothesise that ITL cognitive-motor dual tasking will result in greater cognitive decrements and increased PFC activity compared with the pedalling cognitive-motor dual task.

Methods: 30 healthy participants (16 females; median age 23 (interquartile range 23-24) years) were recruited. They performed five 3-min tasks in a single visit in a random order: single tasks were ITL, pedalling and Stroop task and dual tasks were ITL-Stroop and pedalling-Stroop. Participant's PFC activity was assessed bilaterally using functional near-infrared spectroscopy throughout each task. Single- and dual-task cognitive performance was evaluated by measuring Stroop task reaction time and accuracy. Dyspnoea and rating of perceived exertion were evaluated at the end of each task.

Results: ITL-Stroop resulted in greater impairments in reaction time (p<0.001), accuracy (p<0.01) and increased medial/dorsolateral PFC activity (p≤0.006) than pedalling-Stroop. ITL-Stroop elicited greater Borg dyspnoea and rating of perceived exertion than pedalling-Stroop (p<0.001), despite pedalling-Stroop having a greater heart rate response (p<0.001).

Conclusion: The heightened cognitive decrements, perceptual response and PFC activity suggest that inspiratory muscle loading and its accompanied dyspnoea results in greater cognitive interference than rhythmic pedalling.

Background: Treating children with acute severe asthma (ASA) who fail to respond to first-line inhaled bronchodilators is problematic: use of intravenous agents is inconsistent and side-effects are common. High-flow humidified oxygen (HiFlo) has shown promise in other respiratory conditions and is increasingly used in ASA, but with little evidence.

Methods: We conducted a feasibility randomised controlled trial with deferred consent to assess early HiFlo in children aged 2-11 years with ASA not responding to "burst" therapy (high-dose inhaled salbutamol ± ipratropium). Children with Paediatric Respiratory Assessment Measure (PRAM) score 5+ after "burst" were randomised to commence HiFlo or follow standard care. Candidate primary outcomes assessed were treatment failure requiring escalation, and time to meeting hospital discharge criteria.

Results: The target was met despite coronavirus disease 2019 pandemic disruption: 56 children were randomised across four sites, with deferred consent received in 50 out of 56 (89%), and mean recruitment rate 1.1 per site per month. 28 were allocated early HiFlo and 22 standard care. Data collection was complete for both candidate primary outcomes. Treatment failure requiring escalation occurred in 18 of 28 children (64%) in the HiFlo arm and in 19 of 22 (86%) in the standard care arm. Median (interquartile range) time from randomisation to meeting discharge criteria was 29.3 h (21.8-43.7 h) in the HiFlo arm and 36.8 h (24.1-46.3 h) in the standard care arm.

Conclusions: HiFlo in childhood ASA is a potentially promising intervention whose use is increasing despite lack of evidence. A definitive randomised controlled trial to assess its effectiveness is required and appears to be feasible.