NPJ Primary Care Respiratory Medicine最新文献

The impact of climate change on chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease is becoming ever more apparent, with extremes of heat and cold, increased humidity, and severe weather events worsening the risk of negative outcomes in these patients, including mortality. In turn, climate change is altering the patterns and types of aeroallergens and viruses that also impact the day-to-day lives of patients with respiratory diseases. As a consequence, physicians caring for patients with chronic respiratory diseases may be especially interested in how climate change impacts these conditions and, conversely, how management of these diseases may affect the environment. In this setting, it is of note that poorly controlled respiratory diseases have a higher carbon footprint than well-controlled diseases, especially if an individual is hospitalised. Effective therapy that reduces the occurrence of symptoms and prevents exacerbations will therefore minimise the impact of a respiratory disease on the environment, regardless of the type of device used for delivery of maintenance therapy. In addition, any inhaler choice should be personalised, considering a patient's preference for, and ability to use the inhaler device correctly, but it is also important to consider the overall lifecycle carbon footprint of an inhaler, not only of the gases emitted. This narrative review summarises evidence on how climate change is impacting individuals with chronic respiratory diseases, and discusses how respiratory clinical practice can impact climate change. Importantly, we propose that the main contribution to minimising the impact of chronic respiratory diseases on the climate is to optimise disease control and self-management.

Asthma is the most common chronic childhood illness, however, many young children with asthma symptoms remain undiagnosed and/or misdiagnosed as pneumonia. We explored caregivers' and health care providers' understanding and practices around diagnosis and management of asthma in children less than 5 years. We conducted a cross-sectional study in primary care facilities in Uganda between June and August 2016. In-depth interviews with 25 participants, including caregivers (CGs) of young children with recurrent respiratory symptoms, healthcare workers (HCWs) and herbalists were triangulated. The findings indicated that all CGs described recurrent cough, wheeze and breathing difficulties in their children, which is suggestive of asthma, but were primarily diagnosed with pneumonia, bronchiolitis or bronchitis, and treated with antibiotics. This was in conformity with the HCWs' responses regarding their (HCWs) practices in management of children with respiratory illnesses. HCWs indicated that they did not diagnose asthma in young children but used terms like hyper-reactive airways disease or allergic cough. Caregivers were frustrated with the healthcare system due to lack of clear diagnoses and ineffective treatments. HCWs expressed frustration with unavailability of inhaled asthma medicines. The study highlighted major gaps in HCWs' practices in the management of asthma in young children leading to under-diagnosis of asthma and over-diagnosis of pneumonia., and overuse of antibiotics. Despite caregivers seeking care, their children did not get the right care, partly due to health system challenges including HCW competencies. Strategies for health system strengthening including improving HCWs' competences and availability of inhaled asthma medicines are urgently needed.

Pressurised metered dose inhalers (pMDIs) contain propellant gases with high global warming potential yet remain a cornerstone of management for asthma and chronic obstructive pulmonary disease (COPD). The aim of this study was to determine whether non-propellant alternatives of dry powder inhalers (DPIs) and soft mist inhalers (SMIs) had similar efficacy and safety. A systematic review was performed finding 44 randomised trials (24,710 participants) and moderate certainty evidence for most outcomes. No statistically significant or clinically important differences were found between inhaler types for any assessed measure. For asthma maintenance, the mean difference in peak expiratory flow rate between groups was 1.07 L/min (95% confidence interval [CI] -0.93 to 3.06). For COPD, the mean difference in FEV₁ between groups was 0.01 L (95% CI -0.01 to 0.02). While the choice of optimal inhaler for an individual patient is a multifaceted decision, this review provides reassurance that non-pMDI devices can perform equally well.

Asthma and chronic obstructive pulmonary disease (COPD) are the most prevalent chronic respiratory conditions globally, with management predominantly occurring in primary care settings. International guidelines from the Global Initiative for Asthma (GINA) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) have been instrumental in standardising care; however, these documents consistently use generic terminology such as "primary care physician" or "healthcare provider" without explicitly recognising the family physician as a distinct medical specialty. This omission creates a conceptual gap that may undermine guideline ownership, implementation fidelity, and coordinated care pathways-particularly in low- and middle-income countries where family physicians constitute the backbone of chronic respiratory disease management. This letter argues that explicit recognition of family physicians in future GINA and GOLD updates, alongside inclusion of family medicine representatives in guideline development committees and creation of implementation toolkits for primary care settings, would strengthen guideline relevance, enhance primary care engagement, and ultimately improve respiratory health outcomes worldwide.

In school-aged children, asthma exacerbation rates peak following the return to school after the summer break. A cluster randomised controlled trial (PLEASANT) found that sending a reminder letter from a family doctor to parents of children with asthma during summer holiday led to a 30% increase in prescription collection in August and a decrease in unscheduled care visits after school return in the period September to December. This intervention also resulted in an estimated cost saving of £36.07 per patient per year. We aimed to assess whether informing general practitioner (GP) practices about the PLEASANT trial and its results could lead to its adoptation in routine practice. A pragmatic open label cluster randomised trial was conducted in England, involving GP practices contributing to the Clinical Practice Research Datalink (CPRD). All GP practices in CPRD were stratified by practice size (decile) and randomly allocated (1:1) to either the intervention or control group. In June 2021, the intervention group received a letter from CPRD via mail and email, informing them about the PLEASANT study findings and offering recommendations. The primary outcome was the proportion of children with asthma (aged 4-15) who collected a preventer prescription in August and September 2021. The trial received both University of Sheffield and Independent Scientific Advisory Committee (ISAC) Ethics approval and was registered with ClinicalTrials.gov (NCT05226091). This study included 1389 GP practices and total of 105,746 children with asthma. The practices were randomly assigned to either the intervention group (n = 693 practices, 52,166 individuals) or the control group (n = 695 practices, 53,580 individuals). Analysis showed that 15,716 children (35.3%) in the intervention group and 16,001 children (35.1%) in the control group collected a preventer prescription. No statistically significant difference was found between the two groups (OR 1.01, 95% CI 0.97-1.04), suggesting the intervention had no effect on prescription collection. The study results indicate that a passive intervention, consisting of providing a letter to GPs, did not yield the desired results. To effectively bridge the gap between evidence and practice, it may be worthwhile to consider exploring more proactive strategies to address the identified issues. The trial was registered under ClinicalTrials.gov ID: NCT05226091.

Background: Tropospheric ozone (O₃) is a secondary air pollutant associated with respiratory morbidity. Lleida is an inland Mediterranean city with a continentalized climate, frequent winter thermal inversions and hot, dry summers, where ozone episodes and high humidity often co-occur under stagnant atmospheric conditions. This study explores the association between air pollutants, weather variables, and respiratory emergency admissions in Lleida, Spain.

Methods: We conducted a time-series analysis using distributed lag non-linear models (DLNM) on hospital emergency room admissions for acute respiratory conditions in Lleida (2010-2019). Data on weather (temperature, humidity, solar radiation) and air pollution (O₃, NO₂, PM10, SO₂) were obtained from local monitoring stations. The primary outcome was the daily number of admissions for respiratory conditions (ICD-10 codes J09-J18, J20-J22, J44.1, J45.9).

Results: A total of 19,428 respiratory admissions were recorded. High O₃ concentrations and elevated relative humidity were significantly associated with increased admissions, even after adjusting for temperature and solar radiation. The strongest effects were observed with delayed lags (up to 21 days). NO₂, PM10, CO and SO₂ levels did not show a significant association.

Conclusions: Our findings support a significant and independent association between elevated ozone concentrations, high humidity, and respiratory emergencies. These results highlight the need for public health strategies and policy interventions focused on environmental risk forecasting and air quality management, particularly in vulnerable inland Mediterranean regions.

Chronic obstructive pulmonary disease (COPD) imposes significant health and economic burdens globally. Screening and case-finding strategies are increasingly recognized as critical methods to enhance early diagnosis and management of COPD. It is important to understand the economic impact and cost-effectiveness of these strategies to inform the population health policies and real-world practice. In this study, we aim to summarize and compare the economic evaluations of COPD screening and case-finding strategies. We searched PubMed, EMBASE, Cochrane Library, and NHS economic databases for all published studies up to April 2025 that reported economic outcomes, including cost-effectiveness, budget impact, or cost analysis, related to screening and case-finding of COPD. Data extraction included study type, target population, methods, cost perspectives, and outcome measures. Findings were synthesized narratively. This systematic review was registered in PROSPERO (CRD42024516534). We identified 18 eligible studies that met the inclusion criteria, including 11 empirical and 7 modeling studies. A range of screening and case-finding approaches were evaluated, with most studies (n = 16) employing questionnaires either as standalone tools (n = 14) or for pre-screening purposes before the portable spirometer test (n = 8). Portable spirometers were also commonly used (n = 10). The economic outcome measures varied across studies, including cost per additional case detected, cost per quality-adjusted-life-year (QALY) gained, and program-level budget impact. Healthcare sector and payer's perspectives were the most commonly adopted. While studies consistently suggested that targeted screening strategies were likely to be cost-effective, considerable heterogeneity in study designs, target populations, and economic measures limited direct comparisons between the strategies. COPD screening and case-finding showed potential of being cost-effective preventive strategies, particularly for high-risk groups. However, the lack of standardized descriptions for the details of the implemented strategies and the diverse outcome measures reported across existing studies limits the comparability between these strategies. Future research is needed to assess the long-term economic impact on healthcare systems and to explore personalized compared with one-size-fits-all screening strategies for COPD.

Lung cancer is the leading cause of cancer-related mortality worldwide, with most patients diagnosed at advanced stages. Early detection through screening can significantly reduce mortality, making cost-effectiveness evidence crucial for guiding policy decisions. This systematic review aimed to evaluate the cost-effectiveness of lung cancer screening across various modalities, populations, and settings. A comprehensive search of PubMed, EMBASE, Web of Science, and Cochrane Library was conducted for studies up to March 18, 2025, adhering to PRISMA guidelines. A total of 79 studies from 21 countries were included, with model-based analyses prevalent and 89.9% rated as high quality. Low-dose computed tomography (LDCT) emerged as the primary screening modality, although evidence on artificial intelligence (AI) and biomarkers is limited. Fourteen studies comparing LDCT with no screening showed incremental cost-effectiveness ratios (ICERs) ranging from $8376 to $200,921 per quality-adjusted life-year (QALY) gained. Notably, 90.3% of LDCT strategies were cost-effective by national thresholds, particularly in older adults and high-risk groups. Biennial screening often proved more cost-effective than annual in many scenarios. Overall, LDCT screening demonstrated favorable cost-effectiveness, necessitating further evaluation for emerging technologies in underserved regions.

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.