Pulmonology最新文献

Background: Respiratory syncytial virus (RSV) is an important cause of lower respiratory tract infection, hospitalisation and death in adults.

Methods: Based on evidence regarding the impact of RSV on adult populations at risk for severe infection and the efficacy and safety of RSV vaccines, the Portuguese Society of Pulmonology, the Portuguese Association of General and Family Medicine, the Portuguese Society of Cardiology, the Portuguese Society of Infectious Diseases and Clinical Microbiology, the Portuguese Society of Endocrinology, Diabetes and Metabolism, and the Portuguese Society of Internal Medicine endorses this position paper with recommendations to prevent RSV-associated disease and its complications in adults through vaccination.

Conclusion: The RSV vaccine is recommended for people aged ≥50 years with risk factors (chronic obstructive pulmonary disease, asthma, heart failure, coronary artery disease, diabetes, chronic kidney disease, chronic liver disease, immunocompromise, frailty, dementia, and residence in a nursing home) and all persons aged ≥60 years. If it cannot be made available to this population, then the vaccine should be prioritised for individuals aged ≥75 years and those aged ≥50 years with risk factors. The vaccine should preferably be given between September and November and can be co-administered with the influenza vaccine. Ongoing studies on RSV vaccines may justify extending these recommendations in the future.

New ultrathin bronchoscopes (UTBs) enable the inspection and biopsy of small airways, potentially offering diagnostic advantages in sarcoidosis. In this prospective study, patients with suspected sarcoidosis underwent airway inspection with a UTB. Observed airway abnormalities were categorised into six predefined patterns. UTB-directed small airway biopsies (SABs) were collected from the upper lobes following a standardised procedure. We evaluated the prevalence and patterns of SAAs, as well as the diagnostic yield of UTB-directed SAB. Among 79 participants, 65 (82.3%) were diagnosed with sarcoidosis. Small airway abnormalities were identified in 26/65 (40%) patients, predominantly in those with parenchymal involvement on CT compared to those with lymphadenopathy only (58.1% VS. 23.5%, P = 0.005). The diagnostic yield of SABs for detecting granulomas was significantly higher in patients with SAAs than in those without (65.4% VS. 23.1%, P = 0.001) and in patients with parenchymal disease on CT compared to those without (54.8% VS. 26.5%, P = 0.02). Notably, random biopsies taken under direct visualisation from small airway carinas revealed peribronchiolar parenchyma in 23% of the patients. Small airway abnormalities are prevalent in sarcoidosis patients with parenchymal involvement, and biopsying these abnormalities yields a high rate of granuloma detection.

Importance: Prior study in healthy subjects has shown a reduction of partial pressure of arterial oxygen (PaO₂) by -1.60 kPa/kilometre of altitude gain. However, the association of altitude-related change in PaO₂ and altitude-related adverse health effects (ARAHE) in patients with chronic obstructive pulmonary disease (COPD) remain unknown.

Objective: To provide an effect size estimate for the decline in PaO₂ with each kilometre of altitude gain and to identify ARAHE in relation to altitude in patients with COPD. www.crd.york.ac.uk/prospero: CRD42020217938.

Data sources: A systematic search of PubMed and Embase was performed from inception to May 30, 2023.

Study selection: Peer-reviewed and prospective studies in patients with COPD staying at altitudes >1500 m providing arterial blood gases within the first 3 days at the target altitude.

Data extraction and synthesis: Aggregate data (AD) on study characteristics were extracted, and individual patient data (IPD) were requested. Estimates were pooled using random-effects meta-analysis.

Main outcome and measures: Relative risk estimates and 95 % confidence intervals for the association between PaO₂ and altitude in patients with COPD.

Results: Thirteen studies were included in the AD analysis, of which 6 studies (222 patients, 45.2 % female) provided IPD, thus were included in the quantitative analysis. The estimated effect size of PaO₂ was -0.84 kPa [95 %CI, -0.92 to -0.76] per 1000 m of altitude gain (I²=65.0 %, P < 0.001). In multivariable regression analysis, COPD severity, baseline PaO₂, age and time spent at altitude were predictors for PaO₂ at altitude. Overall, 37.8 % of COPD patients experienced an ARAHE, whereas older age, female sex, COPD severity, baseline PaO_2, and target altitude were predictors for the occurrence of ARAHE (area under ROC curve: 0.9275, P < 0.001).

Conclusions and relevance: This meta-analysis, providing altitude-related decrease in PaO₂ and risk of ARAHE in patients with COPD ascending to altitudes >1500 m, revealed a lower altitude-related decrease in PaO₂ in COPD patients compared with healthy. However, these findings might improve patient care and facilitate decisions about initiating preventive measures against hypoxaemia and ARAHE in patients with COPD planning an altitude sojourn or intercontinental flight, i.e. supplemental oxygen or acetazolamide.

Background: Non-invasive helmet respiratory support is suitable for several clinical conditions. Continuous-flow helmet CPAP systems equipped with HEPA filters have become popular during the recent Coronavirus pandemic. However, HEPA filters generate an overpressure above the set PEEP.

Methods: A lung simulator was used to mimic patient respiratory mechanics and effort. Compared to room air spontaneous breathing, the additional inspiratory effort attributable to helmet CPAP (ΔPmusHelmet) was recorded at different continuous-flow rates (30-150 L/min), PEEP levels (5, 10, 12.5 cmH2O) and respiratory rates (15, 20, 25, 30 breaths/minute), both with and without a HEPA filter at the outlet port.

Results: Helmet pressure swings during inspiration largely explained ΔPmusHelmet variations (p<0.001, Spearman's Rho=0.964). The lowest ΔPmusHelmet levels (0.2 [0; 0.4] cmH2O) were frequently recorded (>70%) at a 90 L/min flow rate. Higher ΔPmusHelmet levels were recorded when the continuous-flow was lower than the peak inspiratory flow (3.7 [3.1; 5.6] cmH2O, p<0.001) or when a HEPA filter was used (2.7 [2.2; 3.5], p<0.001). Increasing the flow rate resulted in higher overpressure levels, particularly with a HEPA filter (p<0.001). Overpressure levels correlated with ΔPmusHelmet (p<0.001, Spearman's Rho=0.598).

Conclusions: Helmet pressure swings below PEEP lead to additional inspiratory efforts. The HEPA filter acts as a flow resistor, generating an overpressure leading to increased respiratory effort. The continuous-flow rate should be titrated high enough to slightly exceed the peak inspiratory flow; however, further flow increase is not recommended as it leads to an increase in overpressure and helmet pressure swings below PEEP.

Introduction: Previous studies of anti-IL-5/IL-5(R) therapies in severe asthma found that response was mainly predicted by indicators of good baseline disease control. However, long-term response predictors remain unclear.

Methods: Responders to anti-IL-5/IL-5(R) therapy in the well-characterised, real-life, international German Asthma Net (GAN) registry were analysed using regression analyses. Response was defined by ≥50% reduction in exacerbations or corticosteroid dose, super-response by a complete stop of both, and remission additionally by controlled asthma (ACT score≥20).

Results: Seventy-seven percent of 347 patients (55% female, 56.6±12.3 years, follow-up 20.3±13 months) were responders and showed improved exacerbation rates, asthma control, and corticosteroid treatment reduction. Response was independently predicted by inhaled corticosteroid dose (odds ratio [OR] 1.5; p = 0.014), exacerbation rate (OR 1.2; p = 0.009), and treatment duration (OR 1.05, p = 0.023). Univariately, blood eosinophil counts notably predicted response (OR 12.4; p = 0.004). Super-response was inversely associated with corticosteroid dependence and depression. Remission was associated with the absence of systemic corticosteroids, better asthma control, and FEV1 in litre.

Conclusions: These results underscore that long-term anti-IL-5/IL-5(R) therapy reduces exacerbation and corticosteroid burden, especially in patients with severe disease and high type 2 inflammatory burden. Contrastingly, low baseline corticosteroid use and markers of good asthma control predicted remission and super-responder status.

Background: Administration of supplemental oxygen is a life-saving treatment in critically ill patients. Still, optimal dosing remains unclear during sepsis. The aim of this post-hoc analysis was to assess the association between hyperoxemia and 90-day mortality in a large cohort of septic patients.

Methods: This is a post-hoc analysis of the Albumin Italian Outcome Sepsis (ALBIOS) randomized controlled trial (RCT). Patients with sepsis who survived the first 48 h since randomization were included and stratified into two groups according to their average PaO₂ levels during the first 48 h (PaO_{2 0-48 h}). The cut-off value was established at 100 mmHg (average PaO_{2 0-48  h} >100 mmHg: hyperoxemia group; PaO_{2 0-48h}≤100: normoxemia group). The primary outcome was 90-day mortality.

Results: 1632 patients were included in this analysis (661 patients in the hyperoxemia group, 971 patients in the normoxemia group). Concerning the primary outcome, 344 (35.4%) patients in the hyperoxemia group vs. 236 (35.7%) in the normoxemia group had died within 90 days from randomization (p = 0.909). No association was found after adjusting for confounders (HR 0.87; CI [95%] 0.736-1.028, p = 0.102) or after excluding patients with hypoxemia at enrollment, patients with lung infection or including post-surgical patients only. Conversely, we found an association between lower risk of 90-day mortality and hyperoxemia in the subgroup including patients who had the lung as primary site of infection (HR 0.72; CI [95%] 0.565-0.918). Mortality at 28 days, ICU mortality, incidence of acute kidney injury, use of renal replacement therapy, days to suspension of vasopressor or inotropic agents, and resolution of primary and secondary infections did not differ significantly. Duration of mechanical ventilation and length of stay in ICU were significantly longer in patients with hyperoxemia.

Conclusions: In a post-hoc analysis of a RCT enrolling septic patients, hyperoxemia as average PaO₂>100 mmHg during the first 48 h was not associated with patients' survival.

Introduction and objectives: Chronic Mountain Sickness (CMS) syndrome, combining excessive erythrocytosis and clinical symptoms in highlanders, remains a public health concern in high-altitude areas, especially in the Andes, with limited therapeutic approaches. The objectives of this study were to assess in CMS-highlanders permanently living in La Rinconada (5100-5300 m, Peru, the highest city in the world), the early efficacy of acetazolamide (ACZ) and atorvastatin to reduce hematocrit (Hct), as well as the underlying mechanisms focusing on intravascular volumes.

Materials and methods: Forty-one males (46±8 years of age) permanently living in La Rinconada for 15 [10-20] years and suffering from CMS were randomized between ACZ (250 mg once-daily; N = 13), atorvastatin (20 mg once-daily; N = 14) or placebo (N = 14) uptake in a double-blinded parallel study. Hematocrit (primary endpoint) as well as arterial blood gasses, total hemoglobin mass (Hb_mass) and intravascular volumes were assessed at baseline and after a mean (±SD) treatment duration of 19±2 days.

Results: ACZ increased PaO₂ by +13.4% (95% CI: 4.3 to 22.5%) and decreased Hct by -5.2% (95% CI: -8.3 to -2.2%), whereas Hct remained unchanged with placebo or atorvastatin. ACZ tended to decrease Hb_mass (-2.6%, 95% CI: -5.7 to 0.5%), decreased total red blood cell volume (RBCV, -5.3%, 95% CI: -10.3 to -0.3%) and increased plasma volume (PV, +17.6%, 95% CI: 4.9 to 30.3%). Atorvastatin had no effect on intravascular volumes, while Hb_mass and RBCV increased in the placebo group (+6.1%, 95% CI: 4.2 to 7.9% and +7.0%, 95%CI: 2.7 to 11.4%, respectively).

Conclusions: Short-term ACZ uptake was effective to reduce Hct in CMS-highlanders living at extreme altitude >5,000 m and was associated with both an increase in PV and a reduction in RBCV.

Background and objectives: While adult chronic cough has high burden, its phenotypes, particularly those without aetiologically related underlying conditions, are understudied. We investigated the prevalence, lung function and comorbidities of adult chronic cough phenotypes.

Methods: Data from 3608 participants aged 53 years from the Tasmanian Longitudinal Health Study (TAHS) were included. Chronic cough was defined as cough on most days for >3 months in a year. Chronic cough was classified into "explained cough" if there were any one of four major cough-associated conditions (asthma, COPD, gastroesophageal reflux disease or rhinosinusitis) or "unexplained cough" if none were present. Adjusted regression analyses investigated associations between these chronic cough phenotypes, lung function and non-respiratory comorbidities at 53 years.

Results: The prevalence of chronic cough was 10% (95%CI 9.1,11.0%) with 46.4% being "unexplained". Participants with unexplained chronic cough had lower FEV₁/FVC (coefficient: -1.2% [95%CI:-2,3, -0.1]) and increased odds of comorbidities including obesity (OR=1.6 [95%CI: 1.2, 2.3]), depression (OR=1.4 [95%CI: 1.0, 2.1]), hypertension (OR=1.7 [95%CI: 1.2, 2.4]) and angina, heart attack or myocardial infarction to a lesser extent, compared to those without chronic cough. Participants with explained chronic cough also had lower lung function than both those with unexplained chronic cough and those without chronic cough.

Conclusions: Chronic cough is prevalent in middle-age and a high proportion is unexplained. Unexplained cough contributes to poor lung function and increased comorbidities. Given unexplained chronic cough is not a symptom of major underlying respiratory conditions it should be targeted for better understanding in both clinical settings and research.