NPJ Primary Care Respiratory Medicine最新文献

Acute exacerbations of COPD (ECOPD) are an important event in the life of a COPD patient as it causes significant deterioration of physical, mental, and social health, hastens disease progression, increases the risk of dying and causes a huge economic loss. Preventing ECOPD is therefore one of the most important goals in the management of COPD. Before the patient is discharged after hospitalization for ECOPD, it is crucial to offer an evidence-based care bundle protocol that will help minimize the future risk of readmissions and death. To develop the content of this quality care bundle, an Expert Working Group was formed, which performed a systematic review of literature, brainstormed, and debated on key clinical issues before arriving at a consensus strategy that could help physicians achieve this goal. A 7-point consensus strategy was prepared, which included: (1) enhancing awareness and seriousness of ECOPD, (2) identifying patients at risk for future exacerbations, (3) optimizing pharmacologic treatment of COPD, (4) identifying and treating comorbidities, (5) preventing bacterial and viral infections, (6) pulmonary rehabilitation, and (7) palliative care. Physicians may find this 7-point care bundle useful to minimize the risk of future exacerbations and reduce morbidity and mortality.

Baduanjin has been shown to be an effective method of exercise for promoting body function in patients with chronic obstructive pulmonary disease (COPD). However, this method is rarely used by rural doctors in rural communities. The aim of this study was to compare the therapeutic effects of Baduanjin exercise with those of conventional pulmonary rehabilitation (CPR) implemented by rural doctors in patients with COPD. A total of 472 COPD patients from 18 village clinics were randomly allocated to the Baduanjin group (n = 158), CPR group (n = 154), or control group (n = 160). The Baduanjin group received six months of Baduanjin training, the CPR group received six months of rehabilitation training, and the control group received usual care. The primary outcomes were changes in health status, as measured by the COPD Assessment Test (CAT), and dyspnoea, as assessed via the modified Medical Research Council (mMRC) dyspnoea scale. The secondary outcomes included six-minute walking distance (6MWD) performance and anxiety and depression scores on the Hospital Anxiety and Depression Scale (HADS-A and HADS-D, respectively). Baseline data were collected before randomization, and outcomes were ascertained at the six-month follow-up by blinded assessors. After six months of training, compared with the control group, the Baduanjin group presented significant improvements in CAT scores (t = 5.121, P < 0.001), mMRC scale scores (t = 5.719, P < 0.001), 6MWD performance (t = 12.608, P < 0.001), HADS-A scores (t = 6.210, P < 0.001), and HADS-D scores (t = 2.945, P = 0.010). The CPR group also presented significant improvements in CAT scores (t = 4.725, P < 0.001), mMRC scale scores (t = 5.499, P < 0.001), 6MWD performance (t = 11.662, P < 0.001), HADS-A scores (t = 5.697, P < 0.001), and HADS-D scores (t = 2.671, P = 0.023). In contrast, the control group participants showed no significant changes in CAT scores (t = -0.252, P = 0.801), mMRC scale scores (t = -0.085, P = 0.932), 6MWD performance (t = -0.463, P = 0.644), HADS-A scores (t = -2.75, P = 0.783), or HADS-D scores (t = -0.281, P = 0.779). No adverse events were reported during the study. The positive effects of Baduanjin exercise on the subjective symptoms of COPD patients are similar to those of CPR. The trial was registered with the Chinese Clinical Trials Registry (reference: ChiCTR-TRC-12001958) (22/02/2012).

Asthma affects 7% of Dutch children and poses an increasing challenge, highlighting the need for effective paediatric asthma care. Achieving optimal asthma control is crucial given the potentially negative long-term effects of bad asthma control on lung development and quality of life in young children. The aim was to understand the challenges and requirements of existing asthma management practices in children. In a qualitative explorative study design, semi-structured, in-depth interviews were held among 37 Dutch stakeholders. A total of 15 patients/parents, 10 general practitioners (GPs), 5 paediatricians/paediatric pulmonologists and 7 nursing specialist/pulmonary nurses participated. Analysis was based on a thematic inductive analysis, using open and axial coding. GPs tended to emphasise the treatment of patients/parents with acute symptoms and underestimate the diagnosis and management of chronic symptoms, leading to possible over- and undertreatment. Asthma care between primary and secondary healthcare is fragmented and worsens these challenges. Moreover, the absence of well-established follow-up structures in primary care contributes to insufficient self-management skills among patients. Shared Decision-Making in children lacks a tailored approach, with variable engagement levels among healthcare providers. Limited focus on preventive strategies leads to little attention to, for example, promoting healthy lifestyles. Moreover, children are often not actively involved in decision-making. The study provides valuable insights to improve the quality and continuity of care for children with asthma and their parents. It underlines the need for a comprehensive and integrated care pathway to minimise the long-term negative effects of uncontrolled asthma.

Half of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are caused by bacterial infection, but self-management plans (SMPs) generally advocate use of antibiotics and steroids for all events. We report findings from a qualitative study exploring the acceptability of a sputum colour chart and SMP to guide patient use of antibiotics and steroids (commonly termed a 'rescue pack'). Qualitative interviews were conducted with healthcare professionals (HCPs) and patients from the Colour COPD trial - a randomised controlled trial of usual care (SMP alone) versus usual care plus sputum colour chart to manage AECOPD across England and sampled to promote maximum variation. Interviews were audio-recorded, transcribed clean verbatim, then analysed thematically, using an adapted Framework approach. Expert patients contributed to the patient data analysis. Fourteen HCPs and 39 patients were interviewed from primary and secondary care. Three overarching themes were identified. (1) Handling tensions: the tension between stewardship of antimicrobials and need to reduce risk of serious illness. (2) Clinical and embodied legacies: established clinical practices of infection control and patient's own experiences of managing their condition over time have focused on early intervention for AECOPD. (3) Changing self-management practices: opportunities for changing practices through negotiating change between HCP and patient. In conclusion, while, in principle, the assessment of sputum colour using a chart to manage AECOPD was acceptable to both patients and HCPs, in practice, it is unlikely to have significant impact on well-established clinical practices for infection control and patient habits of self-management.

There is uncertainty about how best to diagnose asthma, especially in primary care where mis-diagnosis is common. To address this, we developed a clinical decision support system (CDSS) for asthma diagnosis in children and young people (aged 5-25 years). This study explored the feasibility and acceptability of the CDSS in UK primary care. We recruited general practices from England and Scotland. The CDSS was available for use during routine consultations for six months. We analysed CDSS usage and, toward the end of the study, undertook qualitative interviews with clinicians who had used the CDSS. Within the 10 practices who completed the study, the CDSS was used by 75 out of 94 clinicians. 11 clinicians from 8 practices were interviewed. The CDSS was acceptable to participants who particularly commented on the ease of use and auto-population of information from the patient record. Barriers to use included the inability to record findings directly into the patient notes and a sense that, whilst possibly useful for trainees and junior colleagues, the CDSS would not necessarily lead to a change in their own practice. The CDSS was generally well received by primary care clinicians, though participants felt it would be most useful for trainees and less experienced colleagues.

Primary care clinicians play a key role in asthma and asthma exacerbation management worldwide because most patients with asthma are treated in primary care settings. The high burden of asthma exacerbations persists and important practice gaps remain, despite continual advances in asthma care. Lack of primary care-specific guidance, uncontrolled asthma, incomplete assessment of exacerbation and asthma control history, and reliance on systemic corticosteroids or short-acting beta₂-agonist-only therapy are challenges clinicians face today with asthma care. Evidence supports the use of inhaled corticosteroids (ICS) + fast-acting bronchodilator treatments when used as needed in response to symptoms to improve asthma control and reduce rates of exacerbations, and the symptoms that occur leading up to an asthma exacerbation provide a window of opportunity to intervene with ICS. Incorporating patient perspectives and preferences when designing asthma regimens will help patients be more engaged in their therapy and may contribute to improved adherence and outcomes. This expert consensus contains 10 Best Practice Advice Points from a panel of primary care clinicians and a patient representative, formed in collaboration with the International Primary Care Respiratory Group (IPCRG), a clinically led charitable organization that works locally and globally in primary care to improve respiratory health. The panel met virtually and developed a series of best practice statements, which were drafted and subsequently voted on to obtain consensus. Primary care clinicians globally are encouraged to review and adapt these best practice advice points on preventing and managing asthma exacerbations to their local practice patterns to enhance asthma care within their practice.

Web-based pulmonary telerehabilitation (WBPTR) can serve as a valuable tool when access to conventional care is limited. This review assesses a series of studies that explore pulmonary telerehabilitation programmes delivered via web-based platforms. The studies involved participants with moderate to severe chronic obstructive pulmonary disease (COPD). Of the 3190 participants, 1697 engaged in WBPTR platforms, while the remaining 1493 comprised the control groups. Sixteen studies were included in the meta-analysis. Web-based pulmonary telerehabilitation led to an increase in daily step count (MD 446.66, 95% CI 96.47 to 796.86), though this did not meet the minimum clinically important difference. Additionally, WBPTR did not yield significant improvements in the six-minute walking test (MD 5.01, 95% CI - 5.19 to 15.21), health-related quality of life as measured by the St. George's Respiratory Questionnaire (MD - 0.15, 95% CI - 2.24 to 1.95), or the Chronic Respiratory Disease Questionnaire (MD 0.17, 95% CI - 0.13 to 0.46). Moreover, there was no significant improvement in dyspnoea-related health status, as assessed by the Chronic Respiratory Disease Questionnaire (MD - 0.01, 95% CI - 0.29 to 0.27) or the modified Medical Research Council Dyspnoea Scale (MD - 0.14, 95% CI - 0.43 to 0.14). Based on these findings, this review concludes that WBPTR does not offer substantial advantages over traditional care. While slight improvements in exercise performance were observed, no meaningful enhancements were noted in dyspnoea or quality of life metrics. Overall, WBPTR remains a complementary and accessible option for managing and monitoring COPD patients. However, further research and innovation are required to improve its efficacy and adapt it to various clinical environments.

Antibiotic resistance (AR) poses a significant challenging issue in public health worldwide. This phenomenon led to the emergence of antibiotic-resistant bacterial strains, making the treatment of respiratory infections increasingly difficult. Educational interventions targeting healthcare professionals are important to improve prescription practices and promote responsible antibiotic use. Digital tools, including clinical decision support systems and mobile applications, have proven to effectively enhance educational interventions and clinical decision-making. The eHealthResp project is one such initiative that includes an online course and a mobile app designed to improve antibiotic use for upper respiratory tract infections (URTIs). The online course provides clinical information and case studies, whereas the mobile app acts as a clinical decision support system for URTIs diagnosis. The purpose of this study is to analyse the utilization patterns of eHealthResp digital tools among primary care physicians and community pharmacists. Results showed that both physicians and pharmacists (n = 35) had favorable progress and high grades when completing the online course assessment. The mobile app data indicated a diverse range of searched cases with different respiratory symptoms, with the most common being acute nasal discharge and pain when swallowing. Most observations presented mild symptoms for less than seven days, suggesting the occurrence of acute self-limited infections. Despite limitations, digital tools show promise in enhancing patient care outcomes for managing URTIs. Future efforts should focus on expanding participation among health professionals and enhancing educational interventions to promote responsible antibiotic use.

Over-use of SABA is associated with poor asthma control and greater risk of exacerbations and death. Identifying and addressing the beliefs driving SABA over-reliance is key to reducing over-use. This study aimed to assess the utility, impact and acceptability of the Reliever Reliance Test (RRT), a brief patient self-test behaviour-change tool to identify and address SABA over-reliance. Patients with asthma who completed the RRT in Argentina were invited to an online survey exploring the acceptability of the RRT, and its impact on patients' perceptions of SABA and intention to discuss asthma treatment with a doctor. 93 patients completed the questionnaire. The RRT classified 76/93 (82%) as medium-to-high risk of SABA over-reliance (a mindset where SABA is perceived as the most important aspect of asthma treatment), with 73% of these reporting SABA overuse (3 or more times a week). 75% intended to follow the RRT recommendations to review their asthma treatment with their doctor. The RRT is acceptable to patients and was effective at raising awareness of, identifying and addressing SABA over-reliance and encouraging patients to review their treatment with their doctor.

Inhaled corticosteroid (ICS) is the mainstay therapy for asthma, but general adherence is low. There is a paucity of real-world inhaler prescribing and adherence data from Asia and at the population level. To address these gaps, we performed a real-world data analysis of inhaler prescribing pattern and adherence in a multi-ethnic Asian asthma cohort and evaluated the association with asthma outcomes. We performed a retrospective analysis of adult asthma patients (aged ≥18 years) treated in the primary and specialist care settings in Singapore between 2015 to 2019. Medication adherence was measured using the medication possession ratio (MPR), and categorised into good adherence (MPR 0.75-1.2), poor adherence (MPR 0.75) or medication oversupply (MPR > 1.2). All statistical analyses were performed using R Studio. 8023 patients, mean age 57 years, were evaluated between 2015 and 2019. Most patients were receiving primary care (70.4%) and on GINA step 1-3 therapies (78.2%). ICS-long-acting beta-2 agonist (ICS-LABA) users increased over the years especially in the primary care, from 33% to 52%. Correspondingly, inpatient admission and ED visit rates decreased over the years. Between 2015 and 2019, the proportion of patients with poor adherence decreased from 12.8% to 10.5% (for ICS) and from 30.0% to 26.8% (for ICS-LABA) respectively. Factors associated with poor adherence included minority ethnic groups (Odds ratio of MPR 0.75-1.2: 0.73-0.93; compared to Chinese), presence of COPD (OR 0.75, 95% CI 0.59-0.96) and GINA step 4 treatment ladder (OR 0.71, 95% CI 0.61-0.85). Factors associated with good adherence were male gender (OR 1.14, 95% CI 1.01-1.28), single site of care (OR 1.22 for primary care and OR 1.76 for specialist care), GINA step 2 treatment ladder (OR 1.28, 95% CI 1.08-1.50). Good adherence was also associated with less frequent inpatient admission (OR 0.91, 95% CI 0.84-0.98), greater SABA overdispensing (OR 1.66, 95% CI 1.47-1.87) and oral corticosteroids use (OR 1.10, 95% CI 1.05-1.14). Inhaled corticosteroid (ICS) adherence has improved generally, however, poor adherence was observed for patients receiving asthma care in both primary and specialist care, and those from the minority ethnicities.