NPJ Primary Care Respiratory Medicine最新文献

Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory condition and a major cause of morbidity and mortality. Atrial fibrillation (AF) is the most common chronic arrhythmia in patients with and without COPD, with numerous factors contributing to its development. These include hypoxemia, hypercapnia, hyperinflammation and changes in cardiac geometry and autonomic function. The presence of COPD is associated with an elevated risk of thromboembolic events, recurrence of atrial fibrillation after cardioversion, and increased all-cause mortality. Conversely, AF itself further increases the risk of mortality in patients with COPD. Medications employed in the COPD treatment may have deleterious effects on AF, while medications used to treat AF have the potential to exacerbate COPD. The majority of bronchodilator agents have been observed to increase heart rate and induce AF episodes. However, antimuscarinic agents appear to be better tolerated than β-receptor agonists in COPD. It is imperative that the AF treatment be tailored to the individual needs of patients with COPD. The efficacy and safety of AF catheter ablation in cases with COPD appears to be well-established. Further research is warranted to develop appropriate AF screening protocols in COPD patients, incorporating artificial intelligence and telemonitoring, as well as to establish COPD-specific tools for estimating thromboembolic risk. This narrative review comprehensively explores the complex relationship between COPD and AF, incorporating the latest evidence and offering novel insights and updated perspectives.

Whether COPD should be diagnosed using the lower limit of normal (LLN) or a fixed FEV₁/FVC ratio <0.70 (FR) is debated. We compared symptom and disease burden in COPD patients with FEV₁/FVC below both thresholds (FR + /LLN + ) versus those between them (FR + /LLN-). This cohort study included 572 COPD patients from primary and secondary care in the central Swedish regions of Dalarna, Gävleborg, and Uppsala. FR + /LLN + COPD patients with FEV₁ ≥ 60% predicted (n = 194) was compared to FR + /LLN- COPD patients (n = 85) in order to have similar FEV₁ levels in both groups. The symptom burden was assessed using the modified British Medical Research Council scale of dyspnoea (mMRC), the COPD Assessment Test (CAT), and the Clinical COPD Questionnaire (CCQ). The disease burden was assessed by exacerbations and hospital admissions over the subsequent three years. The 279 studied patients (57% females) had a mean age of 68.2 years and a mean FEV₁% predicted of 73.0%. The FR + /LLN+ group had comparable clinical characteristics to the FR + /LLN- group regarding FEV₁% predicted (72.5 vs 74.2%), use of inhaled medicines (76.3 vs 76.5%), and previous exacerbations (23.2 vs 18.8%), all p-values > 0.05. Moreover, comparable prevalence of exacerbations and hospital admissions were found during the subsequent three years (31.7 vs 37.7%, and 4.8 vs 2.6%, respectively, all p-values > 0.05). Symptom burden was comparable for mMRC and CCQ, but the FR + /LLN- group had a higher CAT score than the FR + /LLN+ group (10.6 vs 12.6, p = 0.038), a finding also confirmed in adjusted analyses. FR + /LLN+ and FR + /LLN- COPD patients had relatively comparable symptom and disease burden, suggesting that not meeting the LLN criteria does not indicate a milder disease in clinically diagnosed COPD with comparable FEV₁.

Patients with Chronic Obstructive Pulmonary Disease (COPD) often experience limited health literacy, hampering health status assessment via standard questionnaires like the Clinical COPD Questionnaire (CCQ). We aimed to develop and validate a modified, literacy-sensitive version, the CCQgraphic (CCQg), for all patients with COPD co-designed with a large stakeholder group. CCQ items were rephrased and complemented with graphics, followed by optimization through semi-structured interviews with patients with limited health literacy. In adequate health literacy (n = 64) concordance of CCQg and CCQ was 0.88 (95% CI: 0.82-0.92). Correlation with the COPD Assessment Test (CAT) was 0.81 (95% CI: 0.70-0.88). Agreement showed a mean bias of 0.22 (95% CI: 0.10-0.34, P < 0.001) with higher scores on mental and functional domains compared to the original CCQ. Test-retest reliability in limited health literacy (n = 25) was high, CCC = 0.93 (95% CI: 0.86-0.97). The majority (88%) rated the CCQg as equal or better to the original. The CCQg offers a validated, literacy-sensitive tool, narrowing the gap in health status assessment for patients with COPD with varying literacy skills.

This systematic review aimed to systematise the different models used to deliver pulmonary rehabilitation (PR) during chronic respiratory diseases (CRDs) and explore which ones are the most effective in terms of dyspnea, exercise capacity, and health-related quality of life (HRQoL). The literature search strategy involved structured searches of PubMed, Web of Science, and Cochrane Library for relevant articles published from January 2013 to March 2025. The risk of bias was assessed using ROB 2.0. Descriptive analysis and meta-analysis were performed. Forest plots and the node-splitting model presented results. Network meta-analysis was conducted in R 4.3.2. 33 studies(n = 2538) were included in this review and of those, 27 studies(n = 2106) were used for meta-analysis. 22 (66.7%) studies were at high risk of bias and the certainty of evidence for all outcomes (6MWT, dyspnea, HRQoL) was rated as low due to study limitations and imprecision. Compared with usual care, PR patients have significant improvement on 6MWT as well as mMRC (both P < 0.01). The cumulative ranking probability curves and forest plot analyses revealed a hierarchical efficacy profile among rehabilitation modalities for CRDs, with outpatient presented the larger effects on mMRC (mean difference (MD)= -0.82, 95%Cl [-1.45, -0.19]), 6MWT(MD = 65.45, 95%Cl [45.06, 85.84]). Our findings suggest that PR probably improves exercise capacity and reduces dyspnea in patients with CRDs, with outpatient-based programmes generally showing the largest effects, while the high risk of bias limits interpretation of this finding.PROSPERO ID: CRD420251013615.

Asthma is associated with adverse cardiovascular outcomes, but little is known about its role in the development of cardiometabolic multimorbidity (CMM). We aimed to examine the associations of asthma with both incident and coexisting cardiometabolic diseases (CMDs), characterizing their patterns and transitions to CMM in men and women. This prospective cohort study, based on the UK Biobank, included 51,335 participants with asthma and 395,890 without asthma at baseline in 2006-2010. Participants were followed for the development of CMDs, including type 2 diabetes, coronary heart disease, and stroke, using primary care records, hospital admission and death register data, and self-reported medical information up to December 31, 2022. CMM was defined as the coexistence of two or more CMDs. We used Cox proportional hazards models and multi-state models to assess the associations of asthma with the incidence and transitions to CMDs and CMM among participants free of CMDs. During a median follow-up of 13.8 years, 60,033 participants (13.4%) developed CMD, of whom 7,048 (1.6%) progressed to CMM. Asthma was associated with increased risks of all incident CMDs and CMM (hazard ratio [HR] = 1.54, 95% confidence interval = 1.44-1.64), as well as CMD counts and CMM patterns (e.g., HR = 1.60 [1.50-1.71] for 2 CMDs, and HR = 1.70 [1.56-1.84] for comorbid type 2 diabetes and coronary heart disease). For the transitions from no CMD to first CMD, from first CMD to CMM, and from no CMDs to death, the hazard ratios were 1.29 (1.26-1.33), 1.20 (1.12-1.28), and 1.14 (1.09-1.18), respectively. All these associations were more pronounced in women. In summary, individuals with asthma were at increased risk of developing cardiometabolic diseases and progressing to cardiometabolic multimorbidity. Early prevention and management of asthma, with integration into cardiometabolic risk assessment, may be crucial for mitigating future cardiometabolic multimorbidity.

The aim was to evaluate the diagnostic accuracy of lung function measurements for asthma in primary care, including trial treatment. Undiagnosed patients seeking care for asthma-like symptoms were assessed at primary healthcare centers in Sweden. Participants underwent remote or in-clinic spirometry with bronchodilator responsiveness testing (BDR), remote diurnal variability testing of forced expiratory volume in 1 s (FEV₁) and peak expiratory flow (PEF) over 2-4 weeks using a home spirometry system; and if necessary, three-months trial treatment with inhaled corticosteroids. Overall, 71/123 (58%) were diagnosed with asthma. When comparing patients by asthma diagnosis, sensitivity and specificity for documented diagnosis were 9% (95% CI 3-17) and 100% (93-100) for BDR; 61% (48-72) and 58% (43-71) for FEV₁; and 76% (64-85) and 69% (55-81) for PEF. Diurnal variability testing via home spirometry showed the strongest balance among sensitivity and specificity for asthma.

The association between depressive symptoms and respiratory health remains inconclusive, with limited research exploring dynamic changes in overall and symptom-specific depression. This study aimed to investigate the relationship between depressive symptom trajectories and the risk of chronic lung diseases (CLDs) as well as pulmonary function. We used data from two prospective cohorts: the China Health and Retirement Longitudinal Study (CHARLS) and the Health and Retirement Study (HRS). Depressive symptoms were assessed using the 10-item and 8-item CES-D scales, respectively, at three time points (CHARLS: wave1-3; HRS: wave 5-7), and classified into five trajectories: consistently low, decreasing, fluctuating, increasing, and consistently high. Incident CLDs were identified by self-reported physician diagnoses (CHARLS: wave 4-5; HRS: wave 8-12), and pulmonary function was evaluated by peak expiratory flow (PEF, CHARLS: wave 3; HRS: wave 8). Cox proportional hazards and linear regression models were used to estimate hazard ratios (HRs), beta coefficients (β), and 95% confidence intervals (CIs), adjusting for potential confounders. At baseline, individuals with depressive symptoms had a higher risk of Incident CLDs and lower PEF values. Compared to the consistently low group, the fluctuating (CHARLS: HR = 1.56, 95% CI: 1.33, 1.84; HRS: HR = 1.52, 95% CI: 1.30, 1.77), increasing (CHARLS: HR = 2.39, 95% CI: 1.86, 3.07; HRS: HR = 1.62, 95% CI: 1.13, 2.31), and consistently high (CHARLS: HR = 2.59, 95% CI: 2.16, 3.11; HRS: HR = 1.66, 95% CI: 1.30, 2.13) trajectories were associated with significantly increased CLDs risk. These trajectories were also significantly associated with lower PEF. The decreasing trajectory showed no significant association with CLDs risk or PEF. Total and somatic depressive symptoms demonstrated stronger associations with adverse respiratory outcomes. Depressive symptom trajectories characterized by fluctuation, increase, or persistent elevation are associated with higher CLDs risk and poorer pulmonary function. In contrast, symptom remission appears unrelated to respiratory outcomes. Total and somatic symptoms may serve as more sensitive indicators for predicting respiratory health.

Background: The Global Initiative for Asthma 2024 report recommends a shared decision-making approach to guide treatment choice, encompassing patients' goals, beliefs and concerns about asthma and medications (GINA. Global Strategy for Asthma Management and Prevention, 2024). There is limited guidance on ways to achieve this goal. This consensus programme aimed to create recommendations on optimal selection of inhaler treatment while considering patient perspectives and needs.

Methods: A literature review was conducted on literature published between 01/01/2014 and 23/04/2024 using agreed keywords and search parameters in PubMed and Cochrane databases. Evidence on impact of patient factors on adherence and asthma control, plus inhaler preference data, was analysed. A consensus voting panel was selected via screening questionnaire, with 50 patients with asthma duration ≥5 years and 39 healthcare professionals with expertise in asthma from five European countries (Germany, France, Czechia, Italy, Greece). A two-round Delphi method was used.

Results: 40/135 papers were considered relevant. From these, 20 consensus statements were developed in four areas: patient-centred treatment selection, medication/asthma beliefs, patient preference + shared decision-making, and tools for patient-centred care. 18/20 consensus statements were accepted with an agreement threshold >85% on the first round of voting. Two revised statements underwent a second Delphi round, again failing to reach consensus.

Conclusions: This important initiative generated much-needed guidance on integrating patient views and needs into treatment decision-making following a well-established methodology through 18 consensus statements, with nearly equal input from patients and healthcare professionals.

Asthma is a common respiratory disease that leads to significant morbidity and mortality. Family physicians play a fundamental role alongside pulmonologists in the diagnosis, treatment, and follow-up of asthma. Our study aimed to evaluate the knowledge and attitudes of family physicians in Turkey regarding asthma management in light of the GINA Strategy Report. A total of 596 family physicians from all 12 NUTS regions in the country participated in our cross-sectional analytical study. Data were collected through an online survey prepared by the researchers, referencing the GINA Strategy Report. Descriptive data are presented as numbers and percentages, and differences between independent groups were analyzed using the chi-square test. The majority of participants (96.8%) knew that spirometry is used in the diagnosis of asthma. Regarding asthma control, 11.9% of physicians used the Asthma Control Test, and more than half (61.2%) checked the number of attacks. While only 37.4% correctly understood that the regular use of SABA alone is not part of stepwise treatment, 77.2% correctly indicated that the combination of ICS and formoterol can be used as a reliever and for maintenance in stepwise treatment. About half of the participants believed that high-dose SABA use does not increase the risk of exacerbations (49.7%). A total of 96.9% of physicians reported that they request training in asthma management. Our findings indicate that there are gaps in the implementation of asthma management in primary care and that adherence to the Strategy Report is insufficient.

Previous studies often focused on single pollutant source, failing to replicate real-world exposure scenarios for chronic respiratory disease (CRD) risk. We aimed to explore the mixed exposure patterns of CRD risk factors and investigate interactions with smoking and genetic risk. We identified air pollution exposure modes using latent class analysis (LCA) in the UK Biobank. Cox model assessed associations between exposure modes and lung cancer (LC), idiopathic pulmonary fibrosis (IPF), chronic obstructive pulmonary disease (COPD) and asthma. Interactions among exposure modes, smoking and genetic risk were analyzed. LCA divided participants into five groups, and hazard ratios (HRs) for "High air pollution" group were 1.28 for LC (95% CI: 1.08-1.52), 1.23 for IPF (95% CI: 1.03-1.48), 1.28 for COPD (95% CI: 1.17-1.39) and 1.09 for asthma (95% CI: 1.01-1.18). Significant additive interactions between high air pollution and smoking were observed for LC and COPD. Individuals with high genetic risk exposed to both smoking and high air pollution showed the relative excess risk due to interaction (RERI) of 2.74 for LC, 3.93 for IPF, and 1.68 for COPD. Smoking and air pollution together accounted for over 40% of LC, IPF and COPD cases. Our findings highlight the complex interplay between environmental air pollution, smoking, and genetic risk in CRD development in real-world exposure scenarios.