BMJ Open Respiratory Research最新文献

Objective: Care guidelines for cystic fibrosis (CF) recommend annual screening for anxiety and depression using standardised measures, the Patient Health Questionnaire (PHQ-9) and the Generalised Anxiety Disorder Scale (GAD-7). Research in other chronic illness groups such as diabetes has demonstrated that illness-specific distress predicts daily functioning above and beyond depression alone. To address the need for a measure of illness-specific distress, we developed and validated the CF Stress Questionnaire (CFSQ), which could serve as a meaningful adjunct to mental health screening.

Methods: We developed a CF-specific measure of perceived stress with multiple phases of input from our patient population. We then conducted a multisite CFSQ validation study with 200 adults with CF across 3 geographically diverse CF centres, to examine the CFSQ's factor structure, internal consistency, convergent validity and test-retest reliability.

Results: Results of item and subscale-level analyses indicate that all but one subscale met the established internal consistency cut-off of >0.6. In terms of convergent validity, the CFSQ and its subscales were moderately to highly correlated with the PHQ-9 (r=0.73 for total score, p<0.05) and the GAD-7 (r=0.66 for total score, p<0.05) and moderately correlated with quality of life as measured by the Cystic Fibrosis Questionnaire Revised (CFQ-R) Social (r=-0.59 for total score, p<0.05) and Treatment Burden subscales (r=-0.63 for total score, p<0.05). Subscales of the CFSQ were moderately correlated with the CFQ-R Emotional or Physical Functioning subscales, and weakly correlated with forced expiratory volume in 1 s per cent predicted or body mass index.

Conclusions: The CFSQ is a valid and reliable measure in terms of internal consistency and convergent validity with existing measures of mental health and quality of life commonly used in CF care and research.

Background: Malignant pleural effusion (MPE) is common, affecting approximately 15% of patients with cancer. Over recent years, there have been significant changes in both the diagnostic and therapeutic strategies for the condition, and recent epidemiological studies have shown improvements in survival across most major cancer types. However, it is currently unclear whether there has been an increase in survival in patients with MPE.

Methods: Medical records of patients diagnosed with MPE between 2015 and 2023 at Oxford University Hospitals were retrospectively reviewed. Patients were split into groups of equal size based on the date of MPE diagnosis and Kaplan-Meier survival analyses were performed. Subgroup analyses were conducted in patients with MPE by causative cancer type, performance status at diagnosis and treatment with systemic anti-cancer therapy. Cox regression analyses were carried out using the individual year of MPE diagnosis as an included variable.

Results: 742 patients with MPE were included. There was no improvement in survival length in patients managed in more recent years. This was consistent across effusions secondary to any primary malignancy; effusion secondary to lung cancer, mesothelioma or breast cancer; in patients with better performance status; and in patients who received systemic anti-cancer therapy.

Conclusions: Despite recent changes in the management of MPE and improving survival trends in cancer overall, survival time following the development of MPE appears to have remained stagnant over the 8-year time period under study. This suggests that MPE should potentially be considered as a discrete clinical entity, necessitating investigation of oncological therapies specifically targeted to the pleural space.

Objective: To examine diagnostic testing patterns for symptoms associated with lung cancer in Australian general practice.

Design: Retrospective cohort study using a linked primary care database.

Setting: Victorian general practices enrolled in the University of Melbourne's primary care data repository, Patron.

Participants: Deidentified patients aged 40 years and over who presented with symptoms associated with lung cancer between 2008 and 2022.

Main outcome measures: The proportion of patients who underwent pathology, imaging or referral or who were prescribed medication; differences across sociodemographic variables and the proportion of patients diagnosed with lung cancer.

Results: Between 33% and 53% of patients underwent no investigations. Among those investigated, blood tests were most common for fatigue (83%) and anorexia (69%), while X-rays were more commonly performed for chest infections (40%) and haemoptysis (38%). Two-thirds of patients with haemoptysis were investigated, but only 22% were referred for a chest CT scan. When medications were prescribed, antimicrobials were often used, particularly for chest infections (79%) and haemoptysis (67%), while beta-2 agonists were primarily prescribed for shortness of breath (46%). Ever-smokers exhibited only marginally higher odds of being investigated (OR 1.05). Patients with higher socioeconomic advantage were 1.39 times more likely to undergo investigation than those with the least advantage (p<0.001). Presenting multiple times increased the odds of testing. Overall, lung cancer was diagnosed in 0.15% of patients, with haemoptysis preceding the highest proportion of cases (23/727; 3.2%).

Conclusion: There is significant variation in diagnostic testing for lung cancer-related symptoms in Australian primary care. Future efforts should focus on optimising testing for high-risk symptoms, rationalising investigations for non-specific symptoms, implementing safety-netting for low-risk but not no-risk symptoms and addressing socioeconomic disparities in testing rates.

Background: Lung cancer with progressive bone metastases usually leads to skeletal-related events (SREs) and a reduced quality of life. Denosumab delays the onset of SREs and is associated with improved overall survival. However, other factors associated with overall survival in patients with lung cancer and bone metastases remain unclear. This study aimed to evaluate the survival benefit of denosumab use in patients with lung cancer and bone metastases and how other factors affect overall survival in these patients.

Methods: This retrospective cohort study included 622 patients with lung cancer treated at a southern Taiwan Medical Center between 2018 and 2022. The overall survival of patients with lung cancer and bone metastases treated with denosumab (n=90) was compared with that of patients who did not receive denosumab (n=212). Kaplan-Meier survival analysis and Cox proportional hazards models were used to evaluate the factors associated with the overall survival of these patients.

Results: Denosumab use was associated with improved overall survival among patients with lung cancer and bone metastases compared with untreated patients (HR 0.61, 95% CI 0.47 to 0.80, p<0.001, overall survival 455 days vs 172 days), particularly in patients who had received more than five cycles of treatment (HR 0.31, 95% CI 0.19 to 0.50, p<0.001). Systemic cancer treatments, such as tyrosine kinase inhibitors, chemotherapy and immunotherapy, were also associated with improved overall survival in these patients.

Conclusions: Denosumab usage, especially good compliance, for over five cycles in patients with lung cancer and bone metastases was associated with improved overall survival. Future studies should focus on strategies to improve adherence to denosumab treatment and maximise its clinical benefits.

Introduction: Evidence is growing for interventions beyond inhaled therapies in chronic obstructive pulmonary disease (COPD). Clinician attitudes and access to these therapies are crucial to informing COPD care pathways.

Aims: We sought to explore current attitudes, practices, future directions and challenges in the management of moderate to severe COPD among respiratory consultants in the Republic of Ireland (ROI).

Methods: A custom online survey was disseminated by email and text messaging to respiratory consultants in the ROI through the Irish Thoracic Society contact list.

Results: 37 responses were received (24.5% response rate), of which 36 were eligible for inclusion. Completion rate was 97.2% (n=35). Only 9 of 30 respondents (30%) reported sufficient access to pulmonary rehabilitation (PR), and 9 of 29 (31%) to a dedicated COPD multidisciplinary team (MDT). 10 of 29 respondents (34%) infrequently or never consider long-term non-invasive ventilation (LTNIV), despite 21 of 27 (78%) rating the quality of evidence for its benefit in reducing hospitalisations as moderate or high. 16 of 27 respondents (59%) infrequently or never consider lung volume reduction (LVR), despite 22 of 25 (88%) perceiving it to be moderately or highly beneficial towards improving quality of life. There was variable uncertainty regarding the evidence for biologics in COPD, with up to 11 of 24 respondents (46%) uncertain about Tezepelumab. Perceived challenges to integrating biologics into COPD care in the ROI included the absence of national drug reimbursement agreements, lack of dedicated COPD MDTs and administrative burden.

Conclusions: Our study highlights insufficient access to PR and COPD MDTs, variable attitudes towards LTNIV and LVR, and uncertainty around the role of biologics in COPD care. While the modest response rate may limit generalisability, our findings underscore the need to address infrastructural and systemic barriers to optimise care pathways for moderate to severe COPD in the ROI.

Background: The prognostic value of respiratory symptom profiles for predicting exacerbation risk and lung function decline remains unclear in mild-to-moderate chronic obstructive pulmonary disease (COPD).

Research question: Are respiratory symptom profiles associated with both exacerbation risk and lung function decline in mild-to-moderate COPD?

Study design and methods: This was a posthoc analysis of data from participants with mild-to-moderate COPD from the SubPopulations and InteRmediate Outcome Measures in COPD Study. Respiratory symptom profiles were identified through latent class analysis. Outcomes included exacerbation rates evaluated by zero-inflated negative binomial regressions, time-to-first exacerbation evaluated by Cox regression and longitudinal forced expiratory volume in 1 second (FEV₁) decline evaluated by linear mixed-effects models.

Results: Among the 954 participants with mild-to-moderate COPD, five distinct respiratory symptom profiles were identified. Compared with the 'minimal respiratory' profile, the 'productive cough' profile was associated with a higher rate of any respiratory exacerbations (relative ratio [RR] 1.84; 95% confidence interval [CI] 1.29 to 2.64) and severe respiratory exacerbations (RR 2.05; 95% CI 1.12 to 3.74). Similarly, the 'Wheeze' profile was associated with higher rates of any (RR 1.55; 95% CI 1.12 to 2.15) and severe exacerbations (RR 1.73; 95% CI 1.00 to 2.98). The 'nearly all respiratory symptoms' profile was associated with a higher rate of exacerbations (any exacerbation: RR 2.12; 95% CI 1.56 to 2.89; severe exacerbations: RR 2.07; 1.23 to 3.47) and an accelerated annual FEV₁ decline (-15.41 mL/year; 95% CI -30.33 to -0.51 mL/year). The 'dry cough' profile exhibited the lowest FEV₁ trajectory despite a non-significant annual decline.

Interpretation: Respiratory symptom profiles identifies distinct prognostic outcomes in mild-to-moderate COPD. The productive cough is associated with increased exacerbation risk, while the dry cough is associated with a lower lung function trajectory.

Trial registration number: NCT0196934.

Background: Hypersensitivity pneumonitis (HP) is an interstitial lung disease (ILD) caused by repeated exposure to inhaled antigens, leading to small airway and parenchymal inflammation. Diagnosis is based on a detailed clinical history, chest imaging and invasive tests such as bronchoalveolar lavage. Distinguishing HP from other ILDs is challenging. Respiratory oscillometry, a novel pulmonary function test (PFT), is highly sensitive to small airway abnormalities. Oscillometry measurement of reactance is strongly correlated with gender-age-physiology score, a prognostic tool used to predict mortality and disease severity in idiopathic pulmonary fibrosis (IPF).

Objective: To determine if oscillometry and standard PFT patterns are different in HP and IPF.

Methods: 39 HP (79.5% with fibrotic HP) were enrolled from October 2022 to December 2023 for oscillometry before clinically-indicated standard PFTs and compared with 39 age-matched and sex-matched patients with IPF who also had same day oscillometry and standard PFTs. The main oscillometry metrics of interest were R5-19 (the difference in resistance from 5 to 19 Hz, a metric of small airway function and ventilatory inhomogeneity that increases with worsening respiratory mechanics), X5 (reactance at 5 Hz) which primarily reflects respiratory elastance and AX (area of reactance), a summative measure of the respiratory system stiffness across a range of frequencies, that behaves similarly but in opposite direction to X5.

Results: Patients with HP exhibited higher residual volume/total lung capacity (RV/TLC), lower per cent predicted (%) forced expiratory volume in 1 s (FEV₁) and % predicted forced vital capacity (FVC) than IPF (p<0.05) while FEV₁/FVC and %TLC were similar. Oscillometry showed higher R5-19 in HP. RV/TLC ratio correlated with AX (r²=0.72), X5 (r²=0.66) and R5-19 (r²=0.64).

Conclusion: Gas trapping (RV/TLC>0.40) is a feature of HP not observed in IPF. The strong correlations of RV/TLC with AX, X5 and R5-19 suggest that oscillometry can provide non-invasive markers of small airway obstruction in HP that can differentiate it from IPF.

Introduction: People with pulmonary fibrosis (PF) experience gaps in care, educational resources and self-management strategies throughout their journey. We sought to identify gaps in care and information, determine essential information, examine sources of information and assess preferred modes of delivery for patient education and self-management (PESM) resources and interventions.

Methods: In this qualitative study, we conducted interviews with people with PF using predefined, literature-based categories ("staying well with PF", "keeping fit & strong with PF", "using oxygen therapy", symptom management "breathlessness", "cough", "fatigue", "anxiety, depression and panic") and categories derived from own experience ("sources of information", "preferred modes of education delivery"). Interviews were analysed using deductive-inductive content analysis.

Results: We interviewed 11 individuals with PF (one woman), median age of 73 years (range 52-80) and time since diagnosis ranging from 1 to 10 years. Interviews lasted 40-70 min. A priori-defined saturation was reached for each predefined topic. Patients with PF relied on healthcare professionals (HCPs) as their primary information source. However, for sensitive topics such as life expectancy, death or when time with HCPs was limited, they often turned to internet searches with little success. There was a need for guidance on managing antifibrotic side effects, including adaptation of nutrition. While exercise was valued, it lacked structure, particularly at home. Self-management strategies for cough and fatigue remained insufficient. Digital resources were considered beneficial but maintaining in-person interactions with HCPs is essential.

Conclusion: This in-depth analysis highlights how people with PF comprehend patient education content and which taught or self-acquired self-management techniques they implement in their lives, including beliefs and concerns. These insights are essential for refining current and future PESM programmes and support the creation of blended learning and digital resources, with HCPs offering guidance on their use, to further support people with PF in self-management.

Background and study aim: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a common metabolic and liver condition that leads to systemic inflammation. Obstructive airway diseases (OADs) are characterised by chronic airway inflammation, with small airway dysfunction (SAD) regarded as an early indicator. However, it is unknown whether MASLD contributes to SAD or the risk of acute exacerbation (AE) in OAD.

Methods: In this retrospective cohort study, 2572 patients who underwent spirometry, impulse oscillometry (IOS) and abdominal CT scans were enrolled. Patients were divided according to MASLD status to compare their pulmonary function and clinical outcomes, including OAD AE over a follow-up period of up to 6 years.

Results: 349 patients exhibited MASLD (13.6%). The peripheral airway resistance measured by IOS is significantly higher in MASLD patients (X5 values: -0.14 vs -0.16 kPa/(L/s), p=0.002; AX: 0.76 vs 0.89, p=0.044). After 6 years of follow-up, patients with both MASLD and SAD exhibited the highest rate of OAD AE (34.8%, p=0.016) of all groups, and the coexistence of MASLD and SAD remained an independent predictor of exacerbations after adjustment by logistic regression. Hepatic steatosis was also identified as a potential contributing factor of OAD AE.

Conclusion: MASLD is associated with a higher risk of SAD, and together they markedly increase OAD AE risk. Hepatic steatosis appears to be a major driver of this risk. These findings highlight the need for integrated management of patients with MASLD, addressing both liver and respiratory health to improve outcomes.

Background: The COVID-19 pandemic caused a major disruption in access to and use of health resources and facilities. There are limited longitudinal data from low-resource settings on the impact of pandemic mitigation strategies and medication use on asthma attacks in children.

Methods: We did a longitudinal study of risk factors for asthma attack recurrence among children aged 5-17 years presenting with an attack to emergency rooms in public hospitals in Ecuador. Children were followed for at least 12 months by monthly telemonitoring. Cox regression models for multiple recurrences were used to identify potential risk factors.

Results: 213 asthmatic children were recruited from May 2019 to March 2020 when recruitment was interrupted by a COVID-19 lockdown: 97% were followed for at least 12 months (median 419 days, IQRs 393-421 days). In multivariable analysis, the lockdown effect (adjusted HR 0.35, 95% CI 0.22 to 0.56, p<0.001) and use of inhaled corticosteroids (adjusted HR 0.64, 95% CI 0.43 to 0.93, p=0.020) were strongly protective against recurrence while short-acting β2 agonist use was associated with increased recurrence, particularly among children with a previous asthma diagnosis (interaction p=0.033). Other risk factors were household mould (adjusted HR 1.42, 95% CI 1.03 to 1.95, p=0.031) and number of prerecruitment emergency room visits (adjusted HR 1.05, 95% CI 1.00 to 1.11, p=0.040).

Conclusion: Our data show in a population of asthmatic children from marginalised urban neighbourhoods in Ecuador, that use of inhaled corticosteroids was protective against asthma attack recurrence as were mitigation strategies implemented during the COVID-19 pandemic to reduce transmission of respiratory viruses.