Expert Review of Respiratory Medicine最新文献

Objective: To determine the predictive factors of nebulized morphine (nMOR) failure in patients with chest trauma.

Research design and methods: This was an interventional clinical study. Patients admitted with isolated chest trauma with a pain visual analog score > 4 were included. Each patient received 10 mg nMOR. If pain was still > 4 after 10 minutes of nebulization, the latter was repeated every 10 minutes until pain was relieved (i.e. ≤ 4). If pain was > 4 at 30 minutes, nMOR was considered a failure. Patients were divided into two groups: MOR (+) and MOR (-) (good response to and nMOR failure, respectively).

Results: Seventy-five patients were included. Analysis of the risk factors revealed that road traffic accidents (relative risk (RR): 0.117 [0.031-0.443]; p = 0.002), number of fractured ribs > 4 (RR: 0.317 [0.092-0.543]; p = 0.006), bilateral injury (RR: 0.114 [0.037-0.349]; p < 0.001), flail chest (RR: 0.120 [0.037-0.386]; p < 0.001), hemothorax (RR: 0.203 [0.062-0.660]; p = 0.008), pulmonary contusion (RR: 0.202 [0.069-0.589]; p = 0.003), and pain at admission > 7 (RR: 0.363 [0.147-0.579]; p = 0.004) were predictors of nMOR failure.

Conclusion: Our results can help optimize the analgesic management of chest trauma patients by identifying the most eligible patients to benefit from nMOR.

Clinical trial registration: www.clinicaltrials.gov identifier is NCT03580187.

Background: The results of associations between single nucleotide polymorphisms (SNPs) of genes in DNA repairing pathway and lung cancer (LC) risk are inconsistent.

Methods: We applied allele, dominant and recessive models to explore the risk of researched variants to LC in total LC and subgroups by ethnicity or LC subtypes with a cutoff point of p < 0.05.

Results: A total of 76,935 cases and 88,649 controls from 192 articles were included. Among the analyzed 40 variants from 20 genes, we found 9 statistically significant variants in overall populations by allele model, including five SNPs (rs1760944, rs9344, rs13181, rs1001581, and rs915927) increasing LC risk (odd ratios [ORs] = 1.10-1.71) and four SNPs (rs1042522, rs3213245, rs11615, and rs238406) decreasing the risk (ORs = 0.75-0.94). We identified rs1042522 and rs13181 as significant variants for LC in three models. Additionally, we identified differential significant SNPs in ethnic and subtype's analysis with comparison to total population.

Conclusions: There are five SNPs in DNA repairing pathway associated with increased LC risk and four others decreased LC risk. Besides, the risky SNPs in different ethnicities and various LC subtypes were partly different, and the contribution of different genotypes to risk alleles were various as well.

Introduction: Asthma is a chronic airways disease characterized by episodes of wheeze, chest tightness, and evidence of reversible airflow obstruction. Symptoms are frequently triggered by exercise, exposure to aeroallergens, and respiratory viruses. It is the commonest non-communicable respiratory condition in children, affecting over 5.5 million children in the European Union alone. Both over- and under- diagnosis of asthma are common for several reasons.

Areas covered: The diagnosis is frequently based on parental or patient reported non-specific symptoms alone. All major asthma guidelines now recommend the use of objective tests, including spirometry, bronchodilator reversibility testing, fraction of exhaled nitric oxide measurements and challenge testing to confirm the diagnosis. Recently, the European Respiratory Society published the first evidence-based international guidelines for diagnosing asthma in school-age children using objective measures. Major barriers to implementation in primary care and less well-resourced healthcare settings are access to relevant objective tests for children and quality assurance to obtain reliable results.

Expert opinion: We highlight the importance of diagnosing asthma in school-age children using objective tests and outline a practical approach for the use of widely available tests. We also review challenges and barriers to implementation of objective testing in children managed outside specialist settings.

Introduction: Patient self-inflicted lung injury (P-SILI) has been proposed as a form of lung injury caused by strong inspiratory efforts consequent to a high respiratory drive in patients with hypoxemic acute respiratory failure (hARF). Increased respiratory drive and effort may lead to variable combinations of deleterious phenomena, such as excessive transpulmonary pressure, pendelluft, intra-tidal recruitment, local lung volutrauma, and pulmonary edema. Gas exchange and respiratory mechanics derangements further increase respiratory drive and effort, thus inducing a vicious circle. Forms of partial ventilatory support may further add to the detrimental effects of P-SILI. Since P-SILI may worsen patient outcome, strategies aimed at identifying and preventing P-SILI would be of great importance.

Areas covered: We systematically searched Pubmed since inception until 15 April 2022 to review the patho-physiological mechanisms of P-SILI and the strategies to identify those patients at risk of P-SILI.

Expert opinion: Although the concept of P-SILI has been increasingly supported by experimental and clinical data, no study has insofar demonstrated the efficacy of any strategy to identify it in the clinical setting. Further research is thus needed to ascertain the detrimental effects of spontaneous breathing and identify patients with hARF at high risk of developing P-SILI.

Background: Coronavirus disease 2019 (COVID-19) may result in rapid onset of hypoxemic respiratory failure. This study aimed to characterize the factors and outcomes associated with prolonged hypoxia in patients with COVID-19. Prolonged severe hypoxia (PSH) was defined as hypoxia requiring ≥6 L/min of oxygen by nasal cannula or equivalent for more than 10 days.

Research design and methods: This study was designed as a single-center retrospective analysis. Multivariable logistic regression was utilized to assess factors associated with PSH.

Results: The sample included 554 patients with 117 (21%) having PSH. Median length of stay of patients with PSH was significantly longer (median IQR: 18 days vs 6 days, p < 0.0001). Patients with PSH had significantly higher rates of venous thromboembolism (p < 0.0001) and major bleeding (p < 0.004). The presence of cirrhosis (OR 3.32, 95% CI [1.02 to 10.83]) and hypertension (OR 1.99, 95% CI [1.12 to 3.53]) were independently associated with PSH, while outpatient use of anti-platelet agents had an inverse association (OR 0.57, 95% CI [0.36 to 0.91]).

Conclusion: PSH is associated with increased length of stay, morbidity, and mortality. Hypertension and liver cirrhosis were significantly associated with higher odds of PSH, while use of anti-platelet therapy had a protective effect.

Background: Whether sonographic features of mediastinal lymph nodes can differentiate malignancy from tuberculosis remains unclear.

Research design and methods: We retrospectively identified subjects with a confirmed diagnosis of tuberculosis or malignancy on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Our primary objective was to compare the endosonographic characteristics of lymph nodes on EBUS between tuberculosis and malignancy. Our secondary objective was to assess the diagnostic performance of endosonographic characteristics in predicting malignancy.

Results: We included 774 subjects (1,498 lymph nodes) with a confirmed diagnosis of tuberculosis (n = 497) or malignancy (n = 277). Distinct lymph node margins (84.1% vs. 93.8%, P < 0.001) and coagulation necrosis sign (11.2% vs. 29.8%, P < 0.001) were less common in malignancy than tuberculosis. The absence of central hilar structure had the highest sensitivity (92.1%) for malignancy. Endosonographic characteristics had poor specificity for malignancy(round shape and coagulation necrosis sign, 77.3% and 70.2%. In multivariate analysis, coagulation necrosis sign was associated with a lower odds of malignancy (odds ratio 0.45 [95% confidence intervals, 0.21-0.95]).

Conclusions: Endosonographic characteristics, such as round shape and the coagulation necrosis sign, are not specific for malignancy in high tuberculosis prevalence areas.

Introduction: As millions of people worldwide recover from COVID-19, a substantial proportion continue to have persistent symptoms, pulmonary function abnormalities, and radiological findings suggestive of post-COVID interstitial lung disease (ILD). To date, there is limited scientific evidence on the management of post-COVID ILD, necessitating a consensus-based approach.

Areas covered: A panel of experts in pulmonology and thoracic radiology was constituted. Key questions regarding the management of post-COVID ILD were identified. A search was performed on PubMed and EMBASE and updated till 1 March 2022. The relevant literature regarding the epidemiology, pathophysiology, diagnosis and treatment of post-COVID ILD was summarized. Subsequently, suggestions regarding the management of these patients were framed, and a consensus was obtained using the Delphi approach. Those suggestions which were approved by over 80% of the panelists were accepted. The final document was approved by all panel members.

Expert opinion: Dedicated facilities should be established for the care of patients with post-COVID ILD. Symptom screening, pulmonary function testing, and thoracic imaging have a role in the diagnosis. The pharmacologic and non-pharmacologic options for the management of post-COVID ILD are discussed. Further research into the pathophysiology and management of post-COVID ILD will improve our understanding of this condition.

Background: Predicting omalizumab treatment response has been a challenge and significant aspect for selecting suitable severe allergic asthma patients for omalizumab use.

Objective: To determine which domains of pretreatment baseline characteristics predict omalizumab treatment response among asthmatic patients.

Methods: Electronic bases were searched for eligible studies that reported potential biomarkers that could predict omalizumab responsiveness and efficacy. Patients who accepted omalizumab treatment were stratified into responders and non-responders. WMD, OR, and their 95%CI were used to access the differences between those omalizumab receivers. Sensitivity analysis and subgroup analysis were conducted for potential heterogeneity.

Results: A total of 41 studies evaluating efficacy predictors of omalizumab were included in this meta-analysis. The pooled results showed that omalizumab responders had significantly younger age in the adult subgroup, higher pretreatment total serum IgE level, percent predicted FEV₁ and FeNO than that non-responder. We further confirmed that higher blood eosinophil counts and total serum IgE levels are useful markers for selecting asthma patients who may benefit more from omalizumab.

Conclusions: Pre-treatment blood eosinophil counts and total serum IgE level can be a useful efficacy predictor in selecting allergic asthma patients for omalizumab treatment.

Introduction: The recent continuous positive airway pressure (CPAP) crisis has highlighted the need for alternative obstructive sleep apnea (OSA) therapies. This article serves to review OSA pathophysiology and how sleep apnea mechanisms may be utilized to individualize alternative treatment options.

Areas covered: The research highlighted below focuses on 1) mechanisms of OSA pathogenesis and 2) CPAP alternative therapies based on mechanism of disease. We reviewed PubMed from inception to July 2022 for relevant articles pertaining to OSA pathogenesis, sleep apnea surgery, as well as sleep apnea alternative therapies.

Expert opinion: Although the field of individualized OSA treatment is still in its infancy, much has been learned about OSA traits and how they may be targeted based on a patient's physiology and preferences. While CPAP remains the gold-standard for OSA management, several novel alternatives are emerging. CPAP is a universal treatment approach for all severities of OSA. We believe that a personalized approach to OSA treatment beyond CPAP lies ahead. Additional research is needed with respect to implementation and combination of therapies longitudinally, but we are enthusiastic about the future of OSA treatment based on the data presented here.