Pulmonary Therapy最新文献

Introduction: Respiratory syncytial virus (RSV) is a leading cause of medically attended lower respiratory tract disease (MA-LRTD) and hospitalization among infants in the USA. With the introduction in 2023 of nirsevimab, a long-acting monoclonal antibody for infant RSV prevention, early data on observed uptake provides an opportunity to quantify its public health impact. We hypothesized that the observed nirsevimab immunization coverage rate during the 2024-2025 RSV season substantially reduced the clinical burden of RSV relative to the pre-2023 standard of practice (SoP) and that increasing coverage levels comparable with other routine pediatric immunizations would yield substantial reductions in RSV-associated outcomes.

Methods: We employed a previously published and validated static decision model to estimate RSV MA-LRTDs under multiple nirsevimab coverage scenarios. The analysis compared projected RSV burden under the pre-2023 SoP where only high-risk infants receive palivizumab with scenarios reflecting the observed national nirsevimab coverage during the 2024-2025 RSV season (44.7%) and higher hypothetical coverage levels up to universal, 100% coverage among infants not eligible for palivizumab. Outcomes included RSV-related hospitalizations, emergency room (ER) visits, primary care (PC) visits, and RSV-associated deaths. Number needed to immunize (NNI) values were also calculated relative to the pre-2023 SoP.

Results: Under the pre-2023 SoP, the model estimated 523,594 RSV MA-LRTDs among infants during the 2024-2025 RSV season. At the observed nirsevimab coverage of 44.7%, 204,306 RSV MA-LRTDs were averted, including 18,765 hospitalizations (42% reduction), 49,570 ER visits (39%), and 135,942 PC visits (39%). Increasing coverage to 80.4%-aligned with uptake for other routine infant vaccines-was projected to avert 364,204 RSV MA-LRTDs (159,898 additional cases prevented beyond the 44.7% scenario), including 32,404 hospitalizations (73% reduction). Universal coverage (100%) yielded the greatest benefit, averting 451,991 cases (86% reduction) and 39,891 hospitalizations. The number needed to immunize (NNI) was 9 for one MA-LRTD averted, 91 for one hospitalization, and 34 for one ER visit.

Conclusions: Nirsevimab has already achieved substantial reductions in RSV-associated clinical burden at current national coverage levels. Modeled increases in coverage demonstrate large, incremental public health gains with complete universal immunization yielding up to an 86% reduction in RSV MA-LRTDs. These findings highlight the importance of implementing strategies that enhance access, reduce inequities, and support higher, sustained coverage to maximize population-level benefits of RSV prophylaxis.

Introduction: Dry powder inhalers (DPIs) have a 20-40-fold lower carbon footprint compared to pressurized metered-dose inhalers (pMDIs). Switching from pMDI to DPI is therefore beneficial from an environmental perspective, but many health care professionals are concerned that this may worsen treatment outcomes in asthma and chronic obstructive pulmonary disease (COPD).

Methods: We analyzed patient outcomes and carbon footprints of switching inhaler treatment from pMDI to DPI. We performed a post hoc analysis on clinical outcomes data from a 12-week real-world, non-interventional study of adult patients with asthma or COPD who switched treatment from pMDI to the budesonide-formoterol Easyhaler DPI. Clinical end points included asthma control test (ACT), Mini-Asthma Quality of Life Questionnaire (Mini-AQLQ), lung function tests, and reliever use (asthma), and COPD assessment test (CAT), and modified Medical Research Council dyspnea scale (mMRC) (COPD). In the carbon footprint calculation, we used estimates from the Montreal Protocol for pMDI and for DPI the estimate as reported.

Results: Among all 237 patients (142 asthma, 95 COPD) by switching their treatment clinical improvements were observed in all the outcome measures (p < 0.001). Furthermore, the need for reliever medication decreased among patients with asthma (p < 0.001). The amount of estimated kg CO₂e emissions per year for maintenance treatment was 97.0% lower for the DPI than for pMDI. For reliever medication among patients with asthma, it was 99.6% lower. Among them, the emission savings could amount to approximately 131 kg CO₂e annually. This is of similar magnitude, as individual high-impact environmental actions such as eating a plant-based diet or purchasing green energy.

Conclusions: Our results show that disease control was maintained among patients with asthma or COPD when they switched from pMDI to DPI, while the carbon footprint of inhaler treatment was reduced.

Introduction: Pulmonary arterial hypertension (PAH) is a rare, progressive disease resulting from elevated pulmonary arterial pressure leading to right ventricular failure and death. Optimal adherence and persistence to medical therapy are necessary to improve outcomes. The objective of this study was to characterize adherence and persistence to first-line PAH therapies in patients newly initiating treatment.

Methods: This retrospective cohort study utilized Komodo Research Database claims data. Adults initiating therapy were identified based on ≥ 1 claim for a phosphodiesterase 5 inhibitor (PDE5i) and/or an endothelin receptor antagonist (ERA) from January 1, 2017, to June 30, 2022 (index date), continuous medical and pharmacy health plan enrollment for ≥ 12 months before and including index, ≥ 1 inpatient or ≥ 2 outpatient claims for pulmonary hypertension/PAH, and ≥ 1 claim for right heart catheterization. Adherence was measured by proportion of days covered (PDC); nonadherence was defined as PDC < 80%. Persistence was defined as time from index to treatment discontinuation (gap in therapy > 60 days). Propensity score matching was utilized 1:1:1 across groups.

Results: A total of 9176 patients met the study criteria (6989 PDE5i, 1006 ERA, 1181 dual combination). After matching, each cohort included 714 patients. Median (95% confidence interval) persistence was highest for ERA monotherapy (26.5 [19.0-33.0] months), followed by dual combination therapy (19.8 [16.6-23.4] months) and PDE5i monotherapy (12.9 [10.8-17.4] months)-P = 0.019, dual combination versus ERA; P = 0.026, dual combination versus PDE5i. Nonadherence was highest with dual combination therapy (35.4%), followed by PDE5i monotherapy (17.1%) and ERA monotherapy (11.9%)-P < 0.001, dual combination versus each monotherapy.

Conclusions: Adherence to initial PAH therapy is suboptimal, especially with upfront dual combination therapy. Persistence was highest for ERA monotherapy, followed by dual combination therapy and PDE5i monotherapy. Strategies to improve adherence and persistence are crucial to optimizing outcomes.

Introduction: The modification of an inhaler's air flow resistance influences a patient's inhalation flow profile, thereby affecting the exit velocity of an aerosol leaving the Respimat® mouthpiece. A slower inhalation maneuver results in reduced plume velocity and thus a decreased oropharyngeal deposition due to reduced impaction. This could not only lead to fewer unwanted side effects associated with inhaled therapies, but also enhance lung deposition.

Methods: Device prototypes with different air flow resistances were designed using custom-made inserts that can be clipped into the Respimat mouthpiece. The consequences on aerosol characteristics, as well as on in vitro deposition, were analyzed. Computational fluid dynamics simulations contributed to a better understanding of the modified aerodynamic conditions.

Results: Different insert geometries resulted in modified device resistances. However, an increased flow resistance does not necessarily result in an improved in vitro performance. The flow restrictors critically determine aerosol characteristics such as plume velocity and spray pattern, thereby altering in vitro deposition patterns. Quantitative data on mouth-throat deposition and aerosol characteristics are reported.

Conclusions: Integrating flow restrictors into the Respimat mouthpiece offers a promising approach to enhance patient centricity by promoting slower inhalation, thereby reducing the likelihood of suboptimal use. The use of a porous insert acting as a diffuser demonstrated minimal impact on internal airflow dynamics and in vitro deposition, suggesting that such designs can support correct inhalation technique without compromising aerosol performance. By minimizing the influence of patient-dependent factors, this strategy may help standardize the inhalation process and improve therapeutic outcomes. Video Abstract available for this article. Video Abstract (MP4 85313 KB).

Introduction: Despite fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) being available for asthma treatment in the US (United states) since 2020, real-world evidence on its clinical and economic benefits in patients with asthma is lacking. This study aimed to assess the effectiveness of FF/UMEC/VI (100/62.5/25 µg and 200/62.5/25 µg) in US patients with asthma previously on inhaled corticosteroid/long-acting β₂-agonists (ICS/LABA) using administrative claims data.

Methods: Retrospective, longitudinal, pre-post study utilizing data from the Komodo Health database between 09/09/2019 and 12/31/2023. Eligible adults with asthma had been treated with ICS/LABA prior to FF/UMEC/VI initiation (index date: first FF/UMEC/VI prescription). Rates of moderate-severe exacerbations, asthma-related healthcare resource utilization, oral corticosteroid (OCS) and short-acting β₂-agonist (SABA) use, and asthma-related medical costs were evaluated pre- (12 months pre-index) and post-FF/UMEC/VI initiation (12 months post-index). Statistical analyses involved rate ratios (RRs) from a Poisson regression model, odds ratios (ORs) from logistic regression models, and mean differences from linear regression models. Exploratory analyses stratified these results by pre-index ICS/LABA combination and FF/UMEC/VI index dose.

Results: In total, 17,959 patients were included. Following FF/UMEC/VI initiation, odds of having ≥ 1 exacerbation were reduced by 52% (OR [95% confidence interval (CI)] 0.48 [0.46, 0.50]; P < 0.001), rate of moderate-severe exacerbations reduced by 38% (RR [95% CI] 0.62 [0.61, 0.64]; P < 0.001) and asthma-related hospitalizations by 25% (RR [95% CI] 0.75 [0.68, 0.83]; P < 0.001). Odds of ≥ 1 OCS dispensing were reduced by 36% (OR [95% CI] 0.64 [0.62, 0.67]; P < 0.001) and ≥ 1 SABA canister use by 54% (OR [95% CI]: 0.46 [0.44, 0.48]; P < 0.001) post initiation; mean annualized asthma-related medical costs were reduced by $1115 ([95% CI] [$ -1771, $ -459]; P < 0.001). Both FF/UMEC/VI dosage groups had similar results.

Conclusions: In patients who remain uncontrolled despite ICS/LABA treatment, escalating to FF/UMEC/VI is associated with reductions in asthma exacerbations, asthma-related hospitalizations, OCS use, SABA use, and asthma-related medical costs.

Introduction: Neutropenia is a common clinical condition in critically ill patients and may be associated with poor outcomes, particularly in the context of acute respiratory failure (ARF). However, evidence on its prognostic impact remains inconsistent, and there are a lack of data, particularly in noncancer and immunocompetent populations. This study evaluates the association between neutropenia and mortality in critically ill patients with ARF and identifies risk factors for mortality among patients with neutropenia.

Methods: In this retrospective cohort study, 2412 adult patients with ARF admitted to the intensive care unit (ICU) of a tertiary center between January 2019 and December 2023 were analyzed. Neutropenia was defined as an absolute neutrophil count < 1.5 × 10⁹/L at ICU admission. The primary outcome was hospital mortality; secondary outcomes included ICU mortality. Multivariable Cox proportional hazards models were used to assess the association between neutropenia and outcomes. Subgroup analyses and risk factor assessments were conducted among patients with neutropenia.

Results: Among the 2412 patients, 411 (17.0%) had neutropenia at ICU admission. Compared with their counterparts without neutropenia, patients with neutropenia had higher ICU mortality (48.0% versus 18.9%, P < 0.001) and hospital mortality (60.1% versus 28.3%, P = 0.007). Neutropenia remained independently associated with increased ICU (adjusted hazard ratio [HR] 1.48; 95% confidence interval [CI], 1.20-1.83) and hospital mortality (adjusted HR 1.27; 95% CI 1.07-1.52). The association was more pronounced in patients without cancer (adjusted HR 3.08) than in patients with cancer (adjusted HR 1.48; P for interaction < 0.001). Among patients with neutropenia, sequential organ failure assessment (SOFA) score was an independent predictor of hospital mortality (adjusted HR 1.15; 95% CI 1.11-1.20; P < 0.001).

Conclusions: Neutropenia at ICU admission is independently associated with increased mortality in patients with ARF, particularly among those without cancer. SOFA score is a strong prognostic indicator among patients with neutropenia. These findings highlight the need for improved risk stratification, and suggest that patients with neutropenia may benefit from specific management strategies, which should be investigated in future studies.

Introduction: It is important that treatment recommendations reflect real-world data when available, as randomised controlled trials have stringent eligibility criteria and do not represent the entire asthma population or their usual ecosystem of care. Limited real-world evidence has compared the effectiveness of fluticasone furoate/vilanterol (FF/VI) and budesonide/formoterol (BUD/FOR) to date in asthma; we explored this in England using patients from general practice.

Methodology: We retrospectively compared new FF/VI users and new BUD/FOR users from 1 December 2015 to 28 February 2019, based on de-identified data from the Clinical Practice Research Datalink. The baseline period pre-index was ≥ 1 year; the follow-up period was 1 year. At index, eligible adults (≥ 18 years) with diagnosed asthma had ≥ 1 prescription for FF/VI or BUD/FOR, ≥ 1 years' general practitioner registration and records eligible for linkage to Hospital Episode Statistics. Chronic obstructive pulmonary disease was an exclusion criterion. The primary study outcome assessed the overall asthma exacerbation rate in new FF/VI or BUD/FOR users. Secondary outcomes included oral corticosteroid (OCS) use and medication persistence (analysed using Kaplan-Meier curves). For each treatment comparison, propensity scores were generated and confounding between baseline group characteristics was adjusted via inverse probability of treatment weighting, separately carried out for each study outcome. Intercurrent events (ICEs) were considered for analyses, such as death, loss to follow-up, rescue-medication use, treatment discontinuation or switching.

Results: Between groups, baseline attributes were well balanced. Annual per-person rates of exacerbation were numerically similar in the while on-treatment population (measuring outcome until ICE; FF/VI, 0.1356; BUD/FOR, 0.1583 [P = 0.3023]). Patients who continued initiation treatment for 1 year without interruption had significantly lower annual per-person exacerbation rates with FF/VI (0.0722 [n = 425]) versus BUD/FOR (0.2258 [n = 546]) (rate ratio 0.3197 [P = 0.0003]). Patients indexed on FF/VI had significantly fewer OCS prescriptions and lower OCS dosage versus BUD/FOR (respective coefficients: - 0.29 [P = 0.0352]; 0.41 [P = 0.0004]) and improved treatment persistence (hazard ratio: 0.62 [P < 0.0001]).

Conclusions: Patients who continued initiation treatment for a year without interruption had reduced exacerbation rates with FF/VI versus BUD/FOR. The FF/VI group also had reduced treatment discontinuation and OCS use.

Introduction: This study was undertaken in COVID-19 patients treated with and without Paxlovid™ (Paxlovid) in an outpatient setting to determine hospitalization from the community.

Methods: This retrospective secondary data observational cohort study was conducted between February and November 2022. All patients diagnosed by polymerase chain reaction for COVID-19 and at risk of COVID-19 disease progression were offered Paxlovid in the outpatient setting. Potential associations between Paxlovid use and likelihood of hospitalization, antibiotic use, and other clinical outcomes were explored using regression models as appropriate (i.e., logistic, multinomial, ordinal), adjusted for World Health Organization risk classification.

Results: Of 3011 COVID-19 patients offered Paxlovid, 2005 (67%) were treated with Paxlovid and 1006 (33%) chose not to take treatment. There was no evidence of a difference between groups in terms of vaccination status, viral load, age, or gender, although more patients of Arab ethnicity chose not to take treatment (p < 0.001). There were fewer hospital admissions in the group that took Paxlovid (p < 0.001). Some evidence of a reduction in the number of hospitalizations was found when adjusted for World Health Organization risk category (adjusted odds ratio [aOR] 0.60, 95% confidence interval [CI] 0.45-0.77), and a reduction was similarly found for the number of hospitalizations among patients with readmission (aOR 0.47, 95% CI 0.26-0.84). A reduction in the odds of antibiotic use was observed in the treated group for any cause (aOR 0.80, 95% CI 0.67-0.94) and specifically for COVID-19 (aOR 0.58, 95% CI 0.44-0.77).

Conclusions: Paxlovid treatment reduced hospitalization and antibiotic use, indicating its benefit in reducing severe outcomes and healthcare burden and supporting its use for reducing severe outcomes in COVID-19 patients.

Trial registration: ClinicalTrials.gov identifier, NCT06291831.

Introduction: Respiratory syncytial virus (RSV) is a public health concern, particularly among neonates/young infants, in individuals with chronic medical conditions, and for older adults. In contrast to children, limits in surveillance and substantial underreporting obscure the full impact of RSV infections on adults. A structured process for adult RSV disease decision-making can guide public health epidemiology and planning.

Methods: Twelve experts from six Asian countries (Indonesia, Malaysia, Philippines, Singapore, Taiwan, and Thailand) participated in a modified Delphi consensus study to guide surveillance, diagnosis, and impact of RSV in adults in Asia. The expert recommendations could be organized into four themes: epidemiology and surveillance, diagnosis, high-risk groups, and healthcare utilization.

Results: The expert panel recommended strengthening RSV disease monitoring through integration within current influenza and COVID-19 surveillance systems. Furthermore, to standardize RSV case definitions, it was recommended that the RSV respiratory infection clinical criteria exclude fever. Although rapid antigen tests are employed as standard of care, polymerase chain reaction (PCR) testing should be utilized whenever feasible. Along with year-round testing in Asia to establish incidence, an adjustment factor of at least 2.2-fold was recommended to address the underestimation of RSV-related hospitalization rates based on single-specimen PCR testing. For all adults aged ≥ 75 as well as for those adults aged ≥ 60 with comorbid or immunocompromising conditions, or those residing in long-term care facilities, the experts recommended universal RSV vaccination (contingent upon vaccine licensure), and cost-effectiveness analyses should be used to inform region-specific policy decisions.

Conclusions: Priority actions proposed for adult RSV infection and disease include streamlining diagnostic testing processes, launching disease awareness campaigns, and engaging public health authorities to advance prevention programs in coordinated efforts with policymakers and payers.

Chronic obstructive pulmonary disease (COPD) is a multifaceted lung condition characterized by persistent airflow limitation that leads to chronic symptoms, including dyspnea, cough, and exacerbations. To date, a major focus for the assessment and management of COPD has been on mitigating exacerbations. However, dyspnea is the most common symptom of COPD and is responsible for substantial negative effects on patients' quality of life. Dyspnea is also a substantial contributor to the symptoms associated with acute exacerbations in COPD. Though a portion of the current recommendations for the assessment and management of COPD are dedicated to dyspnea treatment intervention strategies, there remains a need for improvement in communication between healthcare practitioners and their patients regarding the understanding of dyspnea and the implementation of key nonpharmacologic and pharmacologic treatment options. This clinical commentary outlines practical considerations and recommendations for the real-world assessment and management of dyspnea in COPD, including underlying causes, patient and healthcare provider dialogue, measurement of severity, and management strategies.