Respiratory Medicine: X最新文献

Background

Nonadherence to treatment recommendation, common in patients with COPD and Asthma, leads to poor disease control, frequent exacerbations and emergency room visits. We studied the effect of a single home visit (HV) on adherence and health care utilization in a cohort of non-compliant Asthma and COPD patients.

Methods

Patients with severe Asthma and COPD with frequent exacerbations deemed non-compliant were subjected to a single home visit by a multidisciplinary team. Adherence to inhalers and office visits, and healthcare utilization were assessed a year prior to and after the home visit.

Results

A total of 60 patients had an attempted home visit. Contact was made with 36 patients during the home visits and these were subject to analyses. Mean age was 60, and 61% were women. Average FEV1 was 1.56 L (55% predicted). There was a significant increase in compliance with office visits in the year following the HV as compared to the year before HV (87 vs 145 visits post-HV). Similarly, there was a significant reduction in the ER visits (76 visits vs 34 visits post-HV), and hospital admission (39 visits vs 24 post HV) and this was associated with a significant improvement in patient adherence to maintenance inhaler use - 17% (6 of 36) vs 53% (19 of 36).

Conclusion

In patients with frequent exacerbations of Asthma and COPD with confirmed non-compliance, a single home visit by a multidisciplinary team improved patient adherence to inhalers and office visits and reduced healthcare utilization.

Background

Diagnosing and monitoring of children with respiratory disorders is often challenging. Respiratory sounds (RS) are simple, non-invasive and universally available measures that are directly related to movement of air, within the tracheobronchial tree. Thus, RS may be valuable indicators of respiratory health, their characteristics in the paediatric population are scattered in the literature and not systematized.

Aim

Systematically review the different acoustic RS properties in healthy children and in children with different respiratory disorders. Methods: MEDLINE, EMBASE, AMED and CINHAL databases were searched on Sept 2020. One author extracted data and two independently assessed the quality of the articles using the National Heart Lung and Blood Institute quality assessment tool.

Results

Twenty-eight studies were included with a total 2032 participants (44% with a respiratory condition, such as asthma, bronchiolitis, cystic fibrosis, presence of wheezing and non-specified low respiratory tract infections). A high heterogeneity in the procedures, outcomes and outcome measures used was found. Healthy participants showed lower values of F50 (from 194 ± 26 to 521 ± 18Hz) than those with asthma (from 140 ± 8 to 769 ± 85Hz) or bronchiolitis (from 100 to 80Hz). F50 tend to increase with provocation tests (136 ± 9 to 909 ± 81Hz) and decrease with treatments (128 ± 6 to 781 ± 57Hz). Wheeze rates ranged from 0 to 24.7 ± 25% on asthmatic participants. Crackles findings ranged from 6% on people with recurrent wheezing to 30.8% in middle lobe atelectasis.

Conclusion

RS show different acoustic properties in healthy children vs with different respiratory disorders and thus may be useful in the diagnostic and monitoring on paediatrics.

Background

The burden of frequent respiratory exacerbations in COPD patients with mild-to-moderate spirometric impairment and smokers with preserved lung function is unknown.

Methods

We categorized COPD participants in COPDGene with post-bronchodilator FEV1%predicted≥50% by the annual exacerbation frequency into three groups: i)frequent exacerbators (top 5%; n = 109), ii)exacerbators (>0 but less than frequent exacerbators; n = 1,009), and iii)No exacerbation (n = 981). Exacerbations were defined as respiratory episodes requiring antibiotics and/or systemic steroids. We performed a Cox proportional hazards regression analysis to examine the association with mortality. We repeated the same process in current/former smokers with preserved spirometry (FEV1≥80%predicted and FEV1/FVC≥0.7).

Results

Among 2,099 COPD participants, frequent exacerbators had ≥1.8 exacerbations/year and were responsible for 34.3% of the total exacerbations. There were 102 (10.4%) deaths in the group with no exacerbations, 119 (11.8%) in the exacerbator group, and 24 (22%) in the frequent exacerbators. Adjusted mortality in frequent exacerbators was higher relative to individuals with no exacerbations (hazard ratio (HR) = 1.98; 95%CI = 1.25–3.13). An increase in frequency of exacerbations by one exacerbation/year was associated with increased mortality (HR = 1.40,95%CI = 1.21–1.62). Among 3,143 participants with preserved spirometry, frequent exacerbators had ≥0.8 exacerbations/year and were responsible for more than half of the exacerbations. There were 93 (4.2%) deaths in the group with no exacerbations, 28 (3.8%) in the exacerbator group, and 14 (7.6%) in the frequent exacerbators. The adjusted mortality was increased in frequent exacerbators with preserved spirometry relative to those with no exacerbations (HR = 2.25; 95%CI = 1.26–4.01).

Conclusions

In COPD participants with mild-to-moderate spirometric impairment and smokers with preserved spirometry, the frequent exacerbator phenotype is responsible for a large proportion of total exacerbations and associated with high mortality.

Background

In Phase 3 LIBERTY ASTHMA VENTURE (NCT02528214), add-on dupilumab reduced oral corticosteroid (OCS) use while reducing severe exacerbations and improving pre-bronchodilator (BD) forced expiratory volume in 1 s (FEV₁) in OCS-dependent severe asthma patients.

Objective

This post hoc study evaluated dupilumab's efficacy based on several lung function parameters for the overall population and subgroups defined by baseline biomarkers.

Methods

Lung function parameters were pre- and post-BD FEV₁, pre-BD forced vital capacity (FVC), FEV₁/FVC, and forced expiratory flow 25–75% (FEF_25–75%). Dupilumab's steroid-sparing efficacy according to FEV₁ improvement (≥ 200 mL vs < 200 mL) or in patients with 0 exacerbations was also assessed.

Results

At Week 24 in the overall population, pre- and post-BD FEV₁ had improved by 0.22 L (95% CI 0.09–0.34; p = 0.0007) and 0.19 L (95% CI 0.08–0.30; p = 0.0009) vs placebo, respectively; FVC by 0.27 L (95% CI 0.13–0.41; p = 0.0003); FEV₁/FVC by 1.90% (95% CI -0.26–4.07; p = 0.08); and FEF_25–75% by 0.15 L/s (95% CI 0.02–0.28; p = 0.02). Improvements were early and generally sustained over 24-weeks’ treatment. Improvements were observed regardless of baseline eosinophils or FeNO and were generally greatest in patients with eosinophils ≥ 300 cells/μL. Significant steroid-sparing effects were observed with dupilumab irrespective of FEV₁ improvement, and in exacerbation-free patients.

Conclusions

Dupilumab rapidly improved various lung function measures regardless of baseline biomarkers in OCS-dependent severe asthma patients. It showed steroid-sparing effects regardless of FEV₁ improvement, and in exacerbation-free patients. This population appears to be highly skewed toward type 2 inflammation.

Purpose

Dual bronchodilator therapy with a long-acting muscarinic antagonist (LAMA) and a long-acting β₂-agonist (LABA) is recommended in the pharmacological management of chronic obstructive pulmonary disease (COPD) according to the Global Initiative for Chronic Obstructive Lung Disease. To better understand the evidence supporting use of LAMA+LABA therapy in COPD and evaluate consistency within and across clinical research study types, we systematically reviewed and analyzed data from both randomized controlled trials (RCTs) and real-world studies.

Methods

We searched PubMed from inception until April 4, 2019, for phase 2/3/4 RCTs of ≥24 weeks’ duration and real-world studies in which the efficacy and/or safety of LAMA+LABAs were compared with monotherapies, other LAMA+LABAs, LABA+inhaled corticosteroid (ICS), or triple therapy (LAMA+LABA+ICS). We extracted primary and key secondary outcomes data from relevant articles for descriptive purposes.

Results

Overall, 24 RCTs and 8 real-world studies were included in the analysis based on predefined inclusion criteria. LAMA+LABAs improved lung function and health-related quality of life, and reduced exacerbation rates and dyspnea when compared with monotherapies, LABA+ICS, or triple therapy in both RCTs and real-world studies. Importantly, all LAMA+LABAs were well tolerated, with their safety profiles comparable to those of respective monotherapies, and had lower incidences of pneumonia than ICS-containing regimens.

Conclusion

Results of RCTs and real-world studies are largely consistent; demonstrate that LAMA+LABAs improve lung function and health-related quality of life and reduce exacerbation rates and dyspnea relative to other available pharmacotherapies; and reinforce the position of LAMA+LABAs in the pharmacological management of COPD.

Background

Asthma, a chronic inflammatory airway disease, shares common pathophysiological mechanisms with ischemic stroke. The aim of the study is to assess the association between asthma, levels of asthma control and ischemic stroke risk in men and women and by smoking habits.

Methods

This prospective population-based cohort study utilized data on 58 712 adults from HUNT Study in Norway free from stroke. Self-reported asthma was categorized as ever asthma, non-active asthma and active asthma (i.e., being on asthma medication within 12 months of the baseline). Asthma control was defined according to the Global Initiative for Asthma questionnaire and was categorized into controlled and not controlled asthma. Stroke was ascertained by linking HUNT data with Nord-Trøndelag hospital records and the Norwegian Patient Registry.

Results

During a mean follow-up of 17.3 ± 5.3 years, 2619 participants (4.5%) had a first stroke. Not controlled asthma was associated with a modest increased risk of stroke (adjusted HR 1.34, 95%CI 1.03–1.73). Subgroup analyses revealed that the respective association was stronger among those with history of smoking (HR 1.48, 95%CI 1.10–2.00) and males (HR 1.55, 95%CI 1.12–2.16) while absent in non-smokers (HR 1.02, 95%CI 0.61–1.70) and females (HR 1.05, 95%CI 0.69–1.60). Likewise, active asthma was associated with similar increased stroke risk among smokers and males and absent in non-smokers and females.

Conclusions

Symptomatic and active asthma was associated with a modest increased relative risk for ischemic stroke in smokers and males. Future studies should clarify the difference in risks and mechanisms between different phenotypes of asthma.

Background

Asthma is a chronic airway inflammatory disease with various degrees of severity. Exacerbations are commonly seen in uncontrolled asthma and their treatment involves oral corticosteroids use with a lot of side effects.

Objective

The aim of the study was to identify easily available predictors for future exacerbations in patients with asthma.

Methods

This is a prospective study on 250 consecutive patients with asthma with a successful sputum induction. Exacerbation rate in the following year was assessed by telephone interview. Logistic regression was used to test the relationship between the binary outcomes (<1 or ≥1 exacerbation, <2 or ≥2 exacerbations) and a set of covariates including demographic, clinical, functional and inflammatory characteristics such as FeNO, sputum and blood cell counts. The results were then applied and validated in a new cohort of 1450 patients.

Results

Sputum and blood eosinophils were able to identify patients presenting ≥1 or ≥2 exacerbations with the same discriminative power (AUC:0.65 and 0.64 respectively). The multiple regression analysis identified that exacerbations in the previous year (OR = 9.3), treatment with high doses ICS (OR = 27.1), blood eosinophils (cells/mm³, OR = 1.8) and FEV₁/FVC (OR = 0.93) were independent predictors of exacerbations in the year following the visit with an AUC of 0.93 for this model. Frequent exacerbations (≥2) were also predicted by exacerbations in the previous year (OR = 10.5), treatment with high doses ICS (OR = 39.2) and blood eosinophils (OR = 3.5) with an AUC of 0.95 for the model.

Conclusion

Blood and sputum eosinophils have similar predictive value for future exacerbations. Prediction could be improved by combining this information with lung function, ICS dose and history of previous exacerbations.

Background

Hospitalisations for an exacerbation of chronic obstructive pulmonary disease (COPD) impair exercise tolerance, muscle strength and participation in physical activity. Earlier studies of exercise training in this population often initiate training late in the admission and have not combined aerobic and resistance exercise.

Objective

In adults hospitalised with an exacerbation of COPD, to determine the effects of aerobic and resistance exercise, initiated within 48 h of admission, on exercise tolerance, peak quadriceps muscle force (QMF_peak), functional performance and physical activity.

Methods

Thirty-eight patients (mean ± SD age 64 ± 7yr; FEV₁ 33 ± 14%pred) were randomised to a control group (CG; n = 18) or an exercise group (EG; n = 20). Both groups received usual care (airway clearance and encouragement to mobilise). Those in the EG participated in twice daily walking and resistance exercise. Outcome measures comprised the 2-min walk distance (2MWD), QMF_peak, performance on the Sit-To-Stand-Test (STST), Timed Up and Go (TUG) and physical activity measured using wearable technology.

Results

Median [interquartile range] length of stay in the CG and EG were 7 [6 to 8] and 8 [6 to 9] days. Compared with the CG, those in the EG demonstrated greater gains in 2MWD (mean between-group difference; 95% confidence interval 13 m; 3 to 23) and QMF_peak (2.8 kg; 0.3 to 5.3). No between-group differences were seen in performance on the STST (1 repetition; −1 to 2), TUG (−0.8s; −0.2 to 0.4) and or daily steps (1462 steps; −469 to 3393).

Conclusion

Exercise initiated early during a hospitalisation for exacerbation of COPD optimised exercise tolerance and QMF_peak.

Clinical trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry; ACTRN12612000745842; URL: www.anzctr.org.au.

Right heart catheterization (RHC) is needed to diagnose pulmonary hypertension (PH). Traditional hemodynamic determinations may be insufficient to identify early stages of the disease and the mechanism of PH, confidently allocate patients to the pre- and/or postcapillary groups of the disease and guide certain treatment decisions (e.g. use of calcium channel blockers). In this review, we discuss the role of established (pulmonary vasodilatory, exercise and rapid fluid infusion challenges) and promising maneuvers (passive leg raising, intrathoracic pressure estimation, temporary exclusion of arteriovenous dialysis accesses and dobutamine infusion) that help interrogate the pulmonary vasculature during RHC, with a focus on describing rationale for use, indications, contraindications, protocols and implications of different responses.

Introduction

Small airway dysfunction (SAD) is a pathophysiological characteristic of chronic obstructive pulmonary disease (COPD). Excess ventilation and dynamic hyperinflation (DH) are two main pathophysiological traits and limiting factors of COPD patients while exercising. We aimed to ascertain whether or not SAD, assessed by the multiple breath nitrogen washout (MBNW), may predict exercise ventilatory inefficiency and DH.

Methods

Fifty stable COPD patients were prospectively studied and underwent MBNW and incremental cardio-pulmonary exercise test (CPET). Indices of conductive (S_cond) and acinar (S_acin) ventilation heterogeneity as well as minute ventilation/CO₂ production (V_E/VCO₂) linear relationship and the change in inspiratory capacity (IC) were analyzed.

Results

S_acin was significantly and directly related to V_E/VCO₂ slope and inversely related to IC change and to peak O₂ uptake (p < 0.01 for all correlations). No significant correlation was found between S_cond and CPET parameters. The regression equation generated by stepwise multiple regression analysis for the V_E/VCO₂ slope and IC change, as dependent variables, included only S_acin, as independent variable. This model accounted for 31% and 36% of the total variance for the V_E/VCO₂ slope and IC change, respectively.

Conclusion

Our study shows the value of the SAD as determinant of the excess ventilation and DH during exercise in patients with stable COPD.