Respiration最新文献

Background: Incidental pulmonary nodules (IPNs) detected during routine thoracic CT scans offer a promising opportunity to shift lung cancer (LC) diagnoses toward earlier, more curable stages across a broad patient population. Despite their high potential to reduce LC-related mortality, the complexity and heterogeneity of existing guidelines, combined with inefficient follow-up processes, continue to limit the diagnostic and therapeutic benefits of IPN detection.

Summary: This article examines the systemic barriers to effective IPN management and outlines strategic solutions, including automation and structured workflows as well as standardized patient communication. With the recent implementation of national lung cancer screening (LCS) programs, new opportunities arise to synergize infrastructures and optimize pulmonary nodule management within a unified framework.

Key message: Therefore, a clearer understanding of how IPNs should be managed - and how they can be integrated into broader early detection strategies - is essential for a truly holistic approach to early LC detection.

Introduction: Optimal initiation and management of long-term home non-invasive ventilation (LTH-NIV) therapy requires a personalised approach that may not be possible within some healthcare systems. This survey of Italian physicians determined current practices regarding LTH-NIV initiation and follow-up in patients with chronic hypercapnic chronic obstructive pulmonary disease (COPD), areas for process improvements, and use of telemonitoring.

Methods: A 35-question survey was developed then sent via email for completion using computer-assisted web interviewing methodology. Respondents were Italian hospital-based physicians identified using a healthcare professional database who had 3 years' experience in pulmonology, treated/followed up at least 50 patients on NIV, and consented to participate.

Results: Sixty of 71 physicians approached completed the online survey. Of these, 41/60 (68%) said that LTH-NIV prescription followed hospitalisation for acute COPD exacerbation. The most important clinical aspects to monitor early after discharge and during long-term follow-up were reported as mask fit and patient quality of life. Physicians reported a high workload for management of patients on LTH-NIV but felt that many therapy management tasks could be performed by other providers, especially outpatient pulmonologists and homecare providers. Only 32% of respondents were currently using telemonitoring; reasons for non-use were lack of human resources (63%) or regulatory framework (37%), and cost/reimbursement issues (22%).

Conclusion: These data highlight substantial differences between LTH-NIV clinical practice for chronic hypercapnic COPD in Italy and current guidelines, suggesting that guideline-mandated processes may not be achievable or sustainable in real-world settings. Involvement of homecare providers and use of telemonitoring could help improve the management of LTH-NIV therapy.

Introduction: Loss of muscle mass and sarcopenia are associated with poor prognosis in chronic respiratory illnesses and are currently emerging as coexisting conditions that deserve attention in patients with idiopathic pulmonary fibrosis (IPF). However, the exact impact of muscle changes in this deadly disease is not entirely understood. Our study aimed to investigate the role of muscle loss/myosteatosis assessed by computed tomography in the short- and long-term survival of patients with IPF treated with antifibrotics.

Methods: Ninety-six patients with IPF (16 females, 80 males) were retrospectively enrolled between March 2014 and December 2022. Demographic, functional, and radiological data were collected at diagnosis. Area and density of the paravertebral muscle at the level of the 12th thoracic vertebra were collected, and myosteatosis was defined as Hounsfield Unit (Hu) value <30; moreover, using the same segmentation, 54 radiomic variables were extracted.

Results: Forty-four out of 96 patients (46%) had myosteatosis. Patients with myosteatosis were older (74.6 vs. 67.4 years; p < 0.001) with lower GERD comorbidities (25% vs. 54%; p = 0.006) compared with patients with preserved muscle density. Patients with myosteatosis had lower 2-year survival (p = 0.03), but no significant differences occurred for the overall survival. In the multivariable Cox regression analysis, myosteatosis was an independent predictor of 2-year mortality [HR 6.13, 95% CI (1.62-23.12); p = 0.007].

Conclusion: Myosteatosis is already present in half of the IPF population at diagnosis and impacts short-term survival after 2 years. Our findings highlight the importance of a fully comprehensive assessment of IPF patients to address early nutritional intervention and/or rehabilitation programs.

Introduction: Available endobronchial valves (EBVs) for lung volume reduction in severe emphysema are limited in variety and predominantly feature complex metal-silicone designs (e.g., Zephyr®). This study aimed to introduce a novel, all-silicone endobronchial valve (ESV) designed to simplify manufacturing and potentially improve biocompatibility.

Methods: A preclinical study implanted ESVs or Zephyr® EBVs (1:1) into unilateral caudal lobes of 8 pigs, assessed using computed tomography, bronchoscopy, and necropsy over 6 weeks. A first-in-human (FIH) trial enrolled 3 severe emphysema patients (male, aged 48-72 years, collateral ventilation-negative). ESVs were placed using a bronchoscope under general anaesthesia. Outcomes included procedural success, safety, target lobar volume reduction, lung function, quality of life, and exercise capacity at baseline and 3 and 6 months.

Results: Preclinically, all valves (12 ESV, 12 Zephyr®) were successfully implanted and removed. Complete target lobe atelectasis occurred by 6 weeks in all animals, without major adverse events; localised granulation was observed. In the FIH trial, all ESVs were successfully deployed (procedure time: 5-20 min). Target lobar volume reductions occurred at 6 months in 2 of 3 cases (Case 1: 1.5 L, Case 2: 0.4 L). Emphysema volume decreased at 3 and 6 months. Lung function, quality of life, and exercise capacity showed trends toward improvement. One patient experienced an acute exacerbation of chronic obstructive pulmonary disease; no pneumothorax, pneumonia, or haemoptysis occurred.

Conclusion: Overall, ESV was shown to have an initial feasibility for endobronchial lung volume reduction in humans. Further studies are needed to evaluate the sustained effects.

Introduction: The sedation required for rigid medical thoracoscopy may be associated with hypoventilation and intermittent hypoxaemia. High-flow oxygen administration has been shown to decrease hypoxaemia during sedation for flexible bronchoscopy, a procedure using similar sedation protocols to medical thoracoscopy.

Methods: An investigator-initiated randomised controlled trial to compare conventional oxygen (starting at 4 L/min) to high-flow nasal oxygen (starting rate 60 L/min and fraction of oxygen 0.6) during sedation for medical thoracoscopy. The mean nadir oxygen saturation (SpO₂) during the procedure was the primary endpoint.

Results: Between February 2022 and June 2023, 36 patients were randomised to either conventional oxygen (n = 20) or high-flow oxygen (n = 16). The majority of participants (20/36, 55.6%) were male, and the mean age was 75.4 ± 10.4 years. The nadir SpO₂ was 88.3% using high flow as compared to 85.0% for conventional oxygen (p = 0.20). The average SpO₂ (96.3% vs. 96.2%, p = 0.81) was similar between groups. There was a tendency towards a higher peak P_tcCO2 in the conventional oxygen group (49.6 mm Hg vs. 55.5 mm Hg, p = 0.13).

Conclusion: Oxygen supplementation using nasal high flow provides similar SpO₂ to conventional nasal oxygen during sedation for rigid medical thoracoscopy.

Introduction: Well-selected patients with advanced emphysema and hyperinflation benefit from lung volume reduction (LVR), including bronchoscopic LVR with endobronchial valves (EBVs) and LVR surgery (LVRS). As bilateral EBV placement may not be advisable, an alternative approach is required. This prospective case series evaluates hybrid LVR, where contralateral LVRS is performed for patients with functional decline despite persistent atelectasis post-EBV.

Case presentation: Six patients underwent hybrid LVR with a median baseline pre-EBV FEV₁ of 750 mL (range, 430-880), residual volume (RV) of 226% (187-293), and 6-min walking distance (6MWD) of 342 m (245-378). Baseline SGRQ was 70 points (47-86). Time between EBV and LVRS was 698.5 days (403-1,027), and all had persistent atelectasis at the time of contralateral LVRS. Post-LVRS hospital stay was 5.5 days (2-44), with complications in 2 patients (chest tube replacement, arrhythmia requiring upgrade to intensive care unit). There was no 90-day mortality. Compared to pre-EBV, 6 months post-LVRS, FEV₁ improved by 80 mL (-20 to 410), RV decreased by 1,000 mL (740-1,870), 6MWD increased by 59.5 m (-65 to 123), and SGRQ dropped by 11.5 points (-33 to 19).

Conclusion: This case series on hybrid LVR demonstrates its potential to improve lung function and quality of life in selected patients who experience a deterioration in lung function following successful EBV placement.

Background: Bronchoscopy is essential for diagnosing and treating lung diseases, yet conventional techniques are limited by incomplete anatomical coverage, unstable image quality, high rates of missed lesions, and significant operator dependency. These challenges exacerbate disparities in healthcare quality, especially in regions with unevenly distributed medical resources.

Summary: This study conducts a systematic analysis of the potential for adapting deep learning technologies to the field of medical endoscopy. It specifically explores the application prospects of artificial intelligence (AI) for enhancing the quality control and diagnostic analysis of bronchoscopic images.

Key messages: The findings highlight AI's significant potential to innovate bronchoscopic image analysis. However, current research has limitations, particularly in the generalizability of models. Future work must focus on multicenter clinical validation to optimize model robustness and on developing real-time decision support systems to ultimately standardize bronchoscopic procedures and improve diagnostic efficiency.

Introduction: It is not known if pulse oximetry oxygen saturation measurements (SpO₂) are subject to even-number bias and boundary effects which have been reported for other physiological measurements.

Methods: We reviewed three large SpO₂ datasets from two countries for even-number bias: 3,351,981 continuous automated SpO₂ entries in Denmark (DK-continuous), 7,602,352 manual SpO₂ entries in Denmark (DK-manual), and 949,718 manual SpO₂ entries in the UK (UK-manual).

Results: Even-numbered SpO₂ entries were commoner than odd numbers in all three datasets. Even numbers accounted for 50.6% of DK-continuous entries (95% CI: 50.6-50.7), 57.5% of DK-manual entries (95% CI: 57.4-57.6), and 59.7% of UK-manual entries (95% CI: 59.6-59.8): DK-manual vs. DK-continuous, relative risk [RR]: 1.14, 95% CI: 1.13-1.14, p < 0.0001; UK-manual vs. DK-continuous RR 1.18, 95% CI: 1.18-1.18, p < 0.0001. The even-number bias was more pronounced in UK medical patients for whom 64.9% of SpO₂ entries had even numbers (UK-manual medical entries vs. DK-continuous medical entries RR 1.29, 95% CI: 1.29-1.30, p < 0.0001). The proportion of even SpO₂ numbers was particularly high (67.0%; 95% CI: 66.5-67.5%) for UK medical patients who were using supplemental oxygen.

Conclusions: We identified even-number bias in routine pulse oximetry entries in the UK and Denmark. The bias was substantially greater for manually collected data than for automated continuous data. The high degree of even-number bias in patients who were receiving supplemental oxygen suggests that the SpO₂ might be rounded to meet target saturation range or Early Warning Score boundaries. This bias could influence patient management and clinical outcomes.

Introduction: Prolonged weaning from invasive mechanical ventilation remains a major clinical challenge. While outcomes from certified weaning centers are increasingly documented, data on long-term survival and post-discharge trajectories are limited. This study evaluated both in-hospital weaning outcomes and long-term survival in patients treated at two specialized weaning centers in Germany.

Methods: We conducted a retrospective cohort study using the WeanNet registry, focusing on patients admitted for prolonged weaning between 2016 and 2020 at two centers (Greifswald and Hemer). After data cleaning, 718 patients (Greifswald: 337; Hemer: 381) were included. The 3-year follow-up was performed using structured outpatient assessments, clinical records, and telephone interviews.

Results: In-hospital mortality was markedly lower in both centers (Greifswald: 6.2%; Hemer: 3.4%) compared to national WeanNet data (13.4%). Among discharged patients, increased age, discharge with invasive ventilation (hazard ratio [HR] 2.60; 95% confidence interval [CI]: 1.99-3.39), and tracheostomy without ventilation (HR 1.90; 95% CI: 1.40-2.60) were significantly associated with higher 36-month mortality. Comorbidities such as left heart failure, thoracorestrictive disease, chronic kidney disease, oncologic disease, and diabetes were also linked to poorer outcomes.

Conclusion: Patients discharged with invasive ventilation or tracheostomy exhibit significantly reduced long-term survival, highlighting the urgent need for structured post-discharge care pathways. Regular re-evaluation of weaning potential and tracheostomy decannulation should be integrated into follow-up programs to improve outcomes in this vulnerable population.

Introduction: Intrapleural fibrinolytic therapy, involving the sequential administration of DNase and tissue plasminogen activator (tPA), is a key component in the management of pleural infections. This approach has been shown to reduce hospital length of stay and the need for surgical intervention. However, it remains unclear whether these agents are pharmaceutically compatible for concurrent administration. This study investigated the compatibility of DNase and tPA when mixed together.

Methods: We prepared the following combinations of tPA (Actilyse, Boehringer Ingelheim B.V.) and DNase (Pulmozyme, Roche Nederland B.V.): undiluted (10 mg tPA + 5 mg DNase), diluted in 50 mL saline, and diluted in 500 mL saline. Control solutions containing only tPA, only DNase, or only saline were also prepared. Physical stability was assessed by visual inspection for particulate formation, haze, precipitation, color change, or gas evolution. Physical compatibility was evaluated by measuring pH at baseline, 2 h, and 4 h post-preparation, at both room temperature and 40°C. Incompatibility was defined as a mean absolute pH change greater than 1 unit over time.

Results: All tested solutions remained physically compatible across all time points, dilutions, and temperatures.

Conclusion: Our findings demonstrate that tPA and DNase are pharmaceutically compatible when mixed and diluted in normal saline. This supports the feasibility of concurrent intrapleural administration, which may reduce labor intensity, improve protocol adherence, and lower the risk of iatrogenic infections in patients with pleural infections.