Respiration最新文献

Introduction: Individuals who survive acute coronavirus disease 2019 (COVID-19) might experience diaphragm muscle weakness. Diaphragm ultrasound may be an easy-to-obtain bedside tool for determining diaphragm function. However, twitch transdiaphragmatic pressure (twPdi) following magnetic stimulation (MS) of the phrenic nerves is the gold standard for non-volitional assessment of diaphragm strength. This study investigated whether diaphragm thickening ratio (DTR) measured on diaphragm ultrasound reflects diaphragm strength as measured by twPdi following MS of the phrenic nerves or other (volitional) invasively obtained pressure values and could therefore be used to accurately diagnose diaphragm weakness.

Methods: One year after discharge, 50 individuals (14 female, age 58±12 years) who had been hospitalised and treated for moderate-severe COVID-19 underwent standard spirometry and diaphragm ultrasound. TwPdi following cervical MS of the phrenic nerve and volitional inspiratory manoeuvres (Sniff and Mueller manoeuvre) were measured using oesophageal and gastric balloon catheters after transnasal placement.

Results: At follow-up, no clinically meaningful restrictive lung function impairment was evident on spirometry. On diaphragm ultrasound, diaphragm dysfunction, i. e. an impaired diaphragm thickening ratio was detected in 24% (12/50) of participants. An objective diagnosis of diaphragm dysfunction, defined as twPdi <16 cmH2O, was made in 60% (30/50) of participants. The measurement results of the two methods did not agree, given that there were many false negative, but also false positive results, so diaphragm ultrasound diagnosed in parts other patients with diaphragm dysfunction than TwPdi. Diaphragm ultrasound had a sensitivity of 26.67% and a specificity of 80.0% in the detection of diaphragm dysfunction (Positive predictive value 66.67%, negative predictive value 42.10%).

Conclusion: Diagnosis of diaphragm weakness in individuals who have recovered from COVID-19 cannot be made accurately on diaphragm ultrasound (via DTR), but requires twPdi as the gold standard for assessment of diaphragm strength.

Background Established structured weaning approaches, which are effective for patients in simple and difficult weaning, are often not appropriate for patients undergoing prolonged weaning. Addressing the complexity of weaning failure requires personalized precision medicine. The therapeutic concept of Treatable Traits (TTs) has been proposed as a new paradigm for the management of chronic respiratory diseases. It is based on a multidimensional assessment of specific characteristics, which can be addressed by specific interventions that go beyond traditional diagnostic criteria. The concept is increasingly adopted for other complex diseases. Summary This is a narrative review and an expert opinion on the development of a concept of TTs for patients undergoing prolonged weaning. The proposed TTs are based on a systematic review of risk factors for prolonged weaning, an analysis of claims data to assess risk factors within 96 hours of IMV onset and data from the WEAN-SAFE study. A multidisciplinary team identified clinically important TTs and determined appropriate interventions. The following TTs have been identified: Airway disorders and complications associated with tracheostomy or intubation, such as airway obstruction, strictures or tracheomalacia, infectious aspects, anxiety, depression, delirium, post-traumatic stress disorder, anemia, pulmonary and cardio-renal disease. The multidimensional holistic approach also includes tailored sedation and pain management, nutritional therapy, early mobilization and physiotherapy. Key message We propose a framework of relevant considerations for a multidimensional approach to the management of patients undergoing prolonged weaning that supports the regain of respiratory capacity, reduces the respiratory load and thus could resolve the respiratory workload imbalance.

Introduction: This case report addresses the complexity of management of air leak and persisting infection in polymorbid patients.

Case presentation: A 56-year-old former marble mason presented with major hemoptysis. Chest CT revealed severe silicosis and pneumonia with an abscess in the right lower lobe and a pulmonary artery pseudoaneurysm. An open lower bilobectomy with empyema debridement was performed, and the posterior upper lobe segment was covered with a serratus anterior muscle flap. The second examination revealed persistent air leakage from the infected posterior upper lobe segment and necrosis of the muscle flap. Atypical resection of this segment was performed, and the surface of the lower part of the remnant lung was covered with a fat flap and then the omentum. The patient was discharged but was readmitted 2 weeks later due to empyema. During reoperation, a persistent infection in the remnant posterior upper lobe segment was observed in addition to a bronchopleural fistula. The only possible surgery that would cure the patient was right completion pneumonectomy. To avoid this high-risk operation, an endobronchial valve was placed intraoperatively in the posterior segment bronchus, leading to closure of the fistula and resolution of the infection. The patient recovered well and was discharged 10 days later. At the 1-year follow-up, the patient was free of symptoms and reported a good quality of life.

Conclusion: This case is an excellent example of successful cooperation between an interventional pulmonologist and a thoracic surgeon to avoid right pneumonectomy in a polymorbid patient.

Introduction: Training-induced adaptations of the oxidative capacity have been shown to be blunted in alpha-1 antitrypsin deficiency (AATD)-related chronic obstructive pulmonary disease (COPD). To improve training outcomes in AATD, this study was aimed to compare the effects of two exercise training programs with different training intensities.

Methods: 30 patients with AATD (genotype PiZZ) and COPD III-IV were randomly assigned either to high-intensity (HIT) or moderate-intensity training (MIT), each consisting of endurance, strength and a squat training for a duration of 3 weeks. 6-minute walk distance (6MWD) was used as the primary outcome.

Results: 25 subjects augmented with alpha-1 antitrypsin (HIT: n=12, FEV1 41.3±17.4%pred., MIT: n=13, FEV1 45.9±15.5%pred.) completed the study. In HIT and MIT, 6MWD (+37±43m vs. +32±28m, p=0.741), 1-minute sit-to-stand test (5.6±4.9 repetitions vs. 5.6±4.5 repetitions, p=0.766), exercise-induced BORG dyspnoea (-1.4±1.7pts vs. -1.5±2.4pts, p=0.952) and all CRQ domains have improved after training without between-group differences. When considering only subgroups of (probably) anxious or depressive patients (Hospital Anxiety and Depression Scale [HADS] ≥ 8 pts), only HIT induced a significant reduction of anxiety (-4.8 pts, 95% CI [2.1 to 7.5]) or depression symptoms (-5.0 pts, 95% CI [2.8 to 7.3]).

Conclusion: Although HIT and MIT were equally effective by improving exercise capacity, quality of life and dyspnoea in homozygous AATD, HIT may show advantages over MIT, if anxiety or depression symptoms were present. The goal should be personalized training based on the patient's personal preference in order to achieve long-term adherence.

Introduction: Simulation-based training has proven effective for learning flexible bronchoscopy. However, no studies have tested the efficacy of training towards established proficiency criteria i.e., mastery learning (ML). We wish to test the effectiveness of ML compared to Directed Self-Regulated Learning (DSRL) on novice bronchoscopists' end-of-training performance.

Methods: In a standardized simulated setting, novices without prior bronchoscopy experience trained using an artificial intelligence (AI) guidance system that automatically recognizes the bronchial segments. They were randomized into two groups: the ML group and the DSRL group. The ML group trained until they completed two procedures meeting the proficiency targets: 18 inspected segments, 18 structured progressions, <120 seconds procedure time. The DSRL group trained until they no longer perceived any additional benefits from training. Both groups then did a finalizing test, without the AI-guidance enabled.

Results: 24 participants completed the study, with 12 in each group. Both groups had a high mean number of inspected segments (ML=17.2 segments, DSRL=17.3 segments, P=.85) and structured progressions (ML=15.5 progressions, DSRL=14.8 progressions, P=.58), but the ML group performed the test procedure significantly faster (ML=107 seconds, DSRL=180 seconds, P<.001). The ML did not spend significantly longer time training (ML=114 minutes, DSRL=109 minutes, P=.84).

Conclusions: ML is a very efficient training form allowing novice trainees to learn how to perform a thorough, systematic, and quick flexible bronchoscopy. ML does not require longer time spent training compared to DSRL, and we therefore recommend training of future bronchoscopists by this method.

Introduction: The change in prevalence and management of chronic obstructive pulmonary disease (COPD) led to changes in outcomes and costs. We aimed to assess current clinical outcomes, resource utilisation, and costs in COPD.

Methods: Retrospective, observational study of a cohort of consecutive COPD patients who visited the emergency department (ED) of a large tertiary hospital in 2018. The study measured baseline characteristics, 30-day and 1-year mortality, readmission, re-ED visit rates, and costs using the Clinical Outcomes, HEalthcare REsource utilisatioN, and relaTed costs (COHERENT) model, validated for heart failure. This model, featuring a colour graphic system, tracks time spent in different clinical situations (home, ED, hospital), considering vital status, healthcare resource use, and related costs.

Results: In 2018, 2,384 patients with a primary COPD diagnosis visited the ED. The average age was 76 years, with 40% women. Observed mortality rates were 7.6% in-hospital, 8.5% at 30 days, and 23.4% at 1 year. The readmission rates were 9.9% and 36.1%, respectively. The cohort's 1-year cost was approximately EUR 14.6 million (USD 15.95 million), with a median cost per patient of EUR 3,298 (USD 3,603.96). Hospitalisation incurred the highest costs, with initial hospitalisation and readmissions accounting for 44.7% and 42.6% of expenditures, respectively.

Conclusion: One-year mortality and readmission rates for patients with COPD visiting the ED remain high with a significant economic impact on the health system. This burden justifies special programs to improve their care.

Introduction: Patent foramen ovale (PFO) affects about 25% of the population. We studied outcomes in cystic fibrosis (CF).

Methods: We conducted a case-control study of patients with CF (PwCF) and age and sex-matched controls who underwent agitated saline contrast (bubble) echocardiography, 1998-2020. We assessed PFO impacts using linear, logistic, quasipoisson and proportional hazards models.

Result: 59 of 64 PwCF and 88 of 93 controls underwent bubble studies to investigate unexplained hypoxemia or dyspnea. PwCF had higher mean pulmonary artery pressure (PAP, 6.9 mm Hg, 95% Confidence Interval [CI] = 2.35-11.4), reduced tricuspid annular plane systolic excursion (TAPSE, -3.78 mm, CI = -5.64 to -1.93) and similar right ventricular diastolic sizes. Absent hypoxemia, PFO incidence was similar between PwCF and controls; with hypoxemia, PFO was more common in CF (Odds Ratio [OR] = 5.00, CI = 1.32-19.0). In CF, oxygen supplementation occurred at a percent predicted forced expiratory volume in 1 s (FEV1%) 22.5 points higher with PFO. Adjusted for FEV1%, PFO was associated with 0.59 more prior year pulmonary exacerbations (CI = 0.20-0.98) and shorter time to next exacerbation (Hazard Ratio = 1.86, CI = 1.06-3.26). Associations between PFO and hypoxemia or exacerbations were insensitive to PAP, TAPSE and CF transmembrane regulator protein modulator treatments. PFO was not associated with CF time to death or lung transplantation (median 1.87 years) adjusted for age, sex, FEV1% and prior year exacerbation counts.

Conclusion: PFO in CF is associated with hypoxemia at higher FEV1% and more pulmonary exacerbations but not survival.

Introduction: Interventional pneumology plays a crucial role in the diagnosis of peripheral pulmonary lesions (PPLs), offering a minimally invasive approach with a low risk of complications. Iriscope® is a novel device that provides a direct and real-time image of PPLs. The objective of this study was to demonstrate the feasibility and impact of Iriscope® in diagnosing PPLs by analyzing its ability to directly visualize lesions and support accurate sampling during radial probe endobronchial ultrasound (rEBUS) and electromagnetic navigation bronchoscopy (ENB) combined with rEBUS.

Methods: A single-center prospective study was conducted from December 2022 to October 2023 on patients with suspicious PPLs. The diagnostic approach involved either rEBUS alone or in combination with ENB. In all cases, an additional novel technique called Iriscope® (Lys Medical, Charleroi, Belgium) was also applied. Iriscope® findings of each lesion were evaluated individually by three expert interventional pulmonologists.

Results: Seventy PPLs suspected of malignancy were included in the study. The PPLs underwent examination by ENB combined with rEBUS (55) or by rEBUS alone (15). Diagnosis was obtained in 68.6% (48/70) of cases. Iriscope® provided a direct, real-time view of 57.1% (40/70) of PPLs with a positive predictive value of 92.5% (37/40). This technique was able to visualize 72% (39/54) of malignant lesions, while only 6.1% (1/16) of benign lesions showed pathologic changes. The most common findings observed with Iriscope® were mucosal thickening and infiltration (92.5%), increased capillary vascularization (82%), pale or grayish mucosa (72.5%), obstruction with accumulation of secretions (50%), and cobblestone mucosa (15%).

Conclusion: Iriscope® is a promising technique in the diagnostic process of PPLs, providing real-time pathologic imaging that facilitates accurate sampling. Further studies are needed to evaluate success rate of Iriscope-mediated repositioning and to establish predictive patterns for malignant or even benign diseases.

Introduction: Impulse oscillometry (IOS) is an effortless test compared to spirometry. Numerous studies explored the role of IOS in spirometry-based chronic obstructive pulmonary disease (COPD), but most of them had limited sample sizes with poor statistical power. This systematic review and meta-analysis aimed to pool the individual data and quantitatively analyze the clinical value of IOS in COPD.

Methods: PubMed, Web of Science, Ovid, Cochrane Library, China National Knowledge Internet, and Wanfang were searched for studies with comparisons of IOS indicators between COPD patients and healthy controls, including respiratory resistance at 5 Hz (R5) and 20 Hz (R20), difference between R5 and R20 (R5-R20), respiratory reactance at 5 Hz (X5), resonant frequency (Fres), and area of reactance (Ax). Meta-analyses were conducted to calculate the weighted mean differences (WMDs) and 95% confidence intervals (CIs).

Results: 39 eligible studies were enrolled, involving 6,144 COPD patients and 4,611 healthy controls. Relative to healthy controls, COPD patients had significantly higher R5 (WMD: 0.17, 95% CI: 0.14, 0.20), R5-R20 (WMD: 0.13, 95% CI: 0.11, 0.15), Fres (WMD: 9.04, 95% CI: 7.66, 10.42), Ax (WMD: 1.24, 95% CI: 0.86, 1.61), and lower X5 (WMD: -0.15, 95% CI: -0.18, -0.11), and such differences became even greater as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage escalated. Pooled correlation coefficients presented that R5, R5-R20, Fres, and X5 were significantly related to post-bronchodilator forced expiratory volume in the first second (FEV1)/forced vital capacity ratio (meta r = -0.37, -0.45, -0.53, and 0.42, respectively) and FEV1 as a percentage of predicted value (meta r = -0.43, -0.54, -0.59, and 0.56, respectively).

Conclusion: IOS may be a supplement to spirometry in diagnosing and assessing COPD, especially when spirometry is inappropriate. More well-designed, large sample-sized, prospective studies are warranted to establish an IOS-based criterion for COPD management.