BMJ Open Respiratory Research最新文献

Background: UK General Internal Medicine (GIM) registrars are traditionally expected to be able to perform pleural procedures out-of-hours (OOH) if required. Pleural exposure for GIM registrars has declined, with procedures increasingly performed by specialists in-hours. Pleural procedures can cause significant harm. We explored the role of the GIM registrar in performing OOH pleural procedures, with particular focus on competence and confidence.

Methods: An anonymous survey was distributed to GIM registrars and respiratory consultants across the UK.

Results: Responses were received from 391 non-respiratory GIM registrars and 93 respiratory consultants. 37% of registrars reported being 'signed-off' as independent in chest drain insertion for pneumothorax. 69% had not done a pleural procedure for at least a year. Regarding perceived confidence for OOH chest drain insertion for pneumothorax, 42% reported no confidence to perform the procedure even if directly supervised, with only 11% feeling confident to proceed unsupervised. Consultants rated the pleural competence of an average non-respiratory GIM registrar; only 4% felt they could perform the procedure unsupervised. Common themes in the free text included anxiety surrounding pleural procedures, patient safety concerns, insufficient available training opportunities to maintain competency and differing opinions on the evolving role of the medical registrar and who should be expected to perform OOH pleural procedures.

Conclusions: The majority of UK GIM registrars are neither confident nor perceived by trainers as competent to independently perform OOH chest drain insertion. This has implications for patient safety and service delivery, informing broader discussions regarding GIM training, curriculum and the need to establish local OOH pleural pathways.

Introduction: Since the inflammatory response increases the production and accumulation of mucus in the airways during respiratory infections, conventional and unconventional techniques of secretion removal are used. High-frequency chest wall oscillation is an effective strategy for secretion removal; however, it presents barriers due to the high cost. In Brazil, the Expector was developed using a kangaroo-vest interface as an accessible alternative; however, studies are needed to evaluate the use of Expector in infants. The aim of this study was to assess the feasibility and usability of the Expector device in healthy infants.

Methods and analysis: For this feasibility randomised controlled clinical trial, 30 participants aged 3-6 months will be divided into three groups. Two experimental groups will use the Expector device (kangaroo baby-carrier version) with different configurations of the minivibrating motors (ie, totally activated and upper half of motors activated). The device will be deactivated for the control group. The following parameters will be assessed before the test, every 5 min during 15 min of device use and for 15 min after its use: heart rate, respiratory rate, peripheral oxygen saturation, pulmonary auscultation, sleep/wakefulness state, pain and parental satisfaction. Data will be described using measures of central tendency and dispersion and absolute and relative frequencies. Statistical analysis will be performed using correlation and intra- and intergroup comparisons. This study will generate preliminary evidence regarding the feasibility of Expector (kangaroo baby-carrier version) for infants and allow randomised and controlled studies using this technology.

Ethics and dissemination: The Ethics Committee of the Faculty of Health Sciences of Trairi of the Federal University of Rio Grande do Norte approved this study (Number 5636504). Findings will be disseminated through peer-reviewed journal publications, scientific conference presentations and knowledge translation to the public via social media.

Trial registration number: This feasibility randomised controlled clinical trial was registered in the Brazilian Registry of Clinical Trials (REBEC) (Number RBR-5r8v8qz).

Background: The metabolic score of visceral fat (METS-VF) is linked to chronic obstructive pulmonary disease (COPD) incidence, while its association with mortality and adverse outcomes in patients with COPD remains unclear.

Materials and methods: We analysed 7246 participants with COPD from the UK Biobank and 869 from US National Health and Nutrition Examination Survey (US NHANES) (1999-2018). METS-VF was categorised into quartiles. In UK Biobank, outcomes included all-cause, cardiovascular disease (CVD), COPD-specific mortality, pulmonary heart disease (PHD), pulmonary embolism (PE) and heart failure (HF); in NHANES, only all-cause and CVD mortality were evaluated. UK Biobank analyses used Cox models, restricted cubic splines, Kaplan-Meier curves, time-dependent receiver operating characteristic (ROC) curves and mediation analysis (C reactive protein (CRP), white blood cell count (WBC), platelet count (PLT)). NHANES served as an external validation cohort using survey-weighted Cox models, subgroup and sensitivity analyses and time-dependent ROC for the two mortality outcomes.

Results: In UK Biobank, restricted cubic splines identified non-linear associations of METS-VF with all-cause and CVD mortality, with a common inflection point at 7.03, and linear associations with secondary outcomes. Compared with the lowest quartile, the highest METS-VF quartile showed significantly higher risks of all-cause mortality (HR 1.467), CVD mortality (HR 3.000), COPD-specific mortality (HR 1.952), PHD (HR 3.505), PE (HR 2.301) and HF (HR 2.567). Similar positive associations were observed in NHANES, where the highest METS-VF quartile remained significantly associated with all-cause mortality (HR 3.337) and CVD mortality (HR 3.011). Time-dependent ROC analyses demonstrated modest but stable discrimination across follow-up in both cohorts. Mediation analyses showed that CRP and WBC partially mediated the associations of METS-VF with mortality and cardiopulmonary outcomes, whereas PLT did not exhibit significant mediation effects.

Conclusions: Elevated METS-VF is consistently associated with increased long-term risks of mortality and cardiopulmonary complications in COPD across independent discovery and validation cohorts. METS-VF may serve as a practical prognostic biomarker for risk stratification in the clinical management of COPD.

Objectives: Paediatric acute respiratory distress syndrome (PARDS) is a heterogeneous condition and identifying a specific biomarker remains a challenge. We aimed to validate the association of plasma soluble receptor for advanced glycation end-products (sRAGE) and angiopoietin-2 (Ang-2) with PARDS diagnosis, and its prognostic performance.

Methods: This prospective observational study included children with PARDS and non-PARDS critical illness. Plasma sRAGE and Ang-2 levels were measured using enzyme-linked immunosorbent assays. Comparisons were made between PARDS versus non-PARDS critical illness and survivors versus non-survivors. Multivariable logistic regression was used to determine the association between biomarkers and intensive care unit (ICU) mortality after adjusting for age and the Pediatric Index of Mortality 3 score.

Results: 93 and 117 patients with PARDS and non-PARDS critical illness, respectively, were included in this study. Plasma sRAGE was higher in PARDS versus non-PARDS critical illness (2981 (1027 to 6198) vs 1575 (864 to 2994) pg/mL; p=0.002) and in non-survivors vs survivors (5323 (1647 to 8261) vs 1601 (864 to 3572); p<0.001). Plasma Ang-2 was elevated in non-survivors versus survivors (3054 (1760 to 6808) vs 1748 (845 to 3868); p=0.002), though there was no difference between PARDS and non-PARDS groups. In the multivariable model, sRAGE demonstrated an independent association with PARDS diagnosis (adjusted OR (aOR) 1.01 95% CI 1.01 to 1.02; p=0.003) and ICU mortality (aOR 1.02 (95% CI 1.01 to 1.03); p<0.001), whereas there was no association observed with Ang-2.

Conclusion: Within an ICU cohort, only sRAGE demonstrated an association with the diagnosis of PARDS and ICU mortality, which remained after controlling for confounders.

Diagnosis of complicated parapneumonic pleural effusion (CPPE), empyema and uncomplicated parapneumonic pleural effusion (UPPE) is vital in therapeutic management.

Objective: To measure the pleural fluid concentrations of soluble triggering receptor expressed on myeloid cell-1 (sTREM-1), procalcitonin (PCT) and C reactive protein (CRP) to provide information for diagnosing and discriminating between CPPE and UPPE.

Methods: Retrospective data analysis from February 2016 to December 2017, focused on pleural fluid analysis of patients with infectious (PPE, empyema and tuberculosis) and non-infectious (malignant and transudates) effusions.

Results: Over 224 pleural fluid samples collected, 29 were empyema, 48 CPPE, 31 UPPE, 35 tuberculous, 47 malignant and 34 transudates. The levels of sTREM-1 and PCT were significantly higher in empyema (3658±1474 and 1704±1027) and CPPE (2651±1058 and 841±667) and lower in transudates (p<0.001). CRP levels were significantly higher in empyema (88.8±61.5) and CPPE (83.8±42.6) than in other groups (p<0.001), with no difference between them.

Conclusion: The study demonstrated higher sTREM-1, PCT and CRP levels in empyema and CPPE and lower levels in transudates. Both sTREM-1 and CRP showed a higher than 70% diagnostic accuracy between infectious and non-infectious pleural effusions and between CPPE and UPPE; however, not superior to LDH pleural fluid levels.

Introduction: Understanding the influence of environmental and socioeconomic factors, collectively known as the exposome, on severe exacerbation risks in chronic obstructive pulmonary disease (COPD) and asthma is crucial for enhancing patient care.

Methods: We assessed the impact of the exposome on COPD and asthma severe exacerbations in France between 2018 and 2022, combining data from the French National Hospital Discharge Programme de Médicalisation des Systèmes d'Information database and open data for multiple environmental exposition. Using a retrospective matched case-control design, 473 990 patients with COPD and 187 332 patients with asthma were matched for sex, birth year and date of first hospitalisation. Conditional logistic regressions were performed to quantify ORs of exacerbations within the studied population.

Results: In a multivariate model, exposure to extreme cold temperatures and exceeding WHO standards for nitrogen dioxide (NO₂), fine particulate matter and ozone increased the odds of COPD exacerbation. Only exceeding NO₂ was related to an increased risk of asthma exacerbation. Patients with COPD or asthma living in urban or artificial areas or near livestock farms were much more likely to have a severe exacerbation, whereas those living near water, wetlands or green spaces were protected from this risk. Higher poverty rates and long-term tobacco smoking were linked to a greater likelihood of COPD exacerbations.

Conclusions: The study highlights how exposome factors influence bronchial diseases and underscores the benefit of open-access data for advancing research. COPD and asthma exacerbations account for numerous deaths and cost billions and will increase with global warming, identifying modifiable environmental risk factors, improving patient care and helping shape valuable public health policies.

Background: People who smoke are at increased risk of unfavourable tuberculosis treatment outcomes compared with those who do not, but the pathways that explain this disparity are unclear.

Objective: To estimate the difference in a successful end-of-treatment outcome by smoking status among people with multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB) and to examine if this difference changes if people who smoked had the same retention in treatment as those who did not smoke.

Design and methods: Using data from the prospective endTB Observational Study, we estimated the difference in treatment success by cigarette smoking status, adjusting for baseline confounders including demographics, social history and comorbidities. To examine how this difference changed if everyone was retained in treatment, we censored participants who were lost to follow-up and applied inverse probability of censoring weights to simulate this scenario.

Results: Among 1786 participants in 12 countries, 539 (30.2%) reported smoking at least one cigarette daily. People who smoked were more frequently found in post-Soviet countries and had a complex social history (eg, incarceration and substance use) and infectious comorbidities (eg, hepatitis C). At the end of treatment, 73.5% of people who smoked and 80.3% of people who did not smoke had treatment success (risk difference in percentage points: -6.8, 95% CI -11.1 to -2.6). After adjusting for baseline confounders, the risk difference was similar (-5.2 percentage points), but the 95% CI was less precise (-14.1 to 3.2). When simulating a scenario in which everyone was retained in treatment, the risk difference was attenuated (-1.9 percentage points; 95% CI -11.1 to 4.7).

Conclusion: People who smoked had a lower frequency of MDR/RR-TB treatment success than those who did not smoke. Eliminating loss to follow-up reduced this difference by smoking status, suggesting that pathways related to retention in treatment were a major driver of this disparity.

Background: This study characterised the use and perceptions of cannabis and vaping in people with cystic fibrosis (CF) and CF transmembrane conductance regulator (CFTR)-related disorder followed by a large Canadian adult CF clinic. It also aimed to assess whether cannabis legalisation in Canada affected perceived benefits and harms, and whether media attention regarding e-cigarette or vaping product use-associated lung injury (EVALI) affected perceptions of vaping.

Methods: An electronic questionnaire was emailed to all clinic patients on 23 April 2021, and remained open until 28 October 2021.

Results: 110 individuals completed the questionnaire, of whom 43% identified as a current user of cannabis. As a result of legalisation, 14% of respondents reported change in their perceptions of cannabis, primarily related to decreased stigma and increased awareness of medical indications and potential side effects. Cannabis was reported as being used medically for 85% of current users, with stress, insomnia/lack of sleep, and anxiety being the most common symptoms treated; the majority reported it to be somewhat or very effective to manage symptoms. Overall, 33% of respondents had tried vaping, but only 7% considered themselves current vapers. For 45% of respondents, the 2019 EVALI epidemic was reported to have changed perceptions of potential short-term and long-term effects associated with vaping, with increased awareness of potential harms.

Conclusions: Cannabis use was common, with a reported increase since its legalisation in this population. EVALI media attention was reported to increase awareness for potential harms associated with vaping. CF healthcare providers are well positioned to provide education and support so patients can make informed decisions about cannabis use and vaping.

Introduction: Progressive pulmonary fibrosis (PPF) is a debilitating progression of pulmonary fibrosis in patients with interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). Oral pirfenidone has been studied in non-IPF ILDs, but in smaller academic studies, it did not achieve a statistically significant change in the primary endpoint. Increased systemic exposure with oral administration may lead to substantial adverse events and limit its utility. Clinical data support inhaled pirfenidone for the treatment of PPF with improved tolerability compared with orally administered pirfenidone.

Methods and analysis: Approximately 300 patients with PPF will be randomised 2:1:2 to one of three treatment arms: AP01 100 mg two times per day, AP01 50 mg two times per day or placebo two times per day by oral inhalation using the investigational eFlow Nebuliser System (PARI Pharma GmbH, Germany). The primary endpoint is the change from baseline in forced vital capacity at week 52. The main secondary endpoints are change in quality of life measurements from baseline to 52 weeks, time to disease progression and change in lung fibrosis scores based on high-resolution CT from baseline to 52 weeks.

Trial registration number: NCT06329401.

Introduction: A significant proportion of patients with asthma remain uncontrolled despite treatment with inhaled corticosteroids and bronchodilators. Multiple reasons exist for this. Suboptimal inhaler adherence, inadequate inhaler technique and continuous exposure to allergens are often found to contribute to poor asthma control. Additionally, symptoms from some comorbid conditions, such as obesity, GORD and deconditioning, may be perceived as arising from asthma. The first priority should always be to confirm if asthma is the cause of the patients' current symptoms.

Methods & analysis: In this protocol paper, we describe the design of a prospective cohort replicate study. We will test the hypothesis that digitally acquired data on lung function and medication use can better establish that asthma is the cause of symptoms, rather than guideline-recommended practice. Patients with clinician-diagnosed asthma who remain uncontrolled despite inhaled corticosteroid treatment will be enrolled. Over 26 weeks and five visits, lung function, markers of T2 inflammation and symptoms will be repeatedly assessed. The 'ground truth' diagnosis for each patient will be established using a multimodal template comprised of lung function, T2 inflammation data, response to treatment, assessment of alternative diagnoses and patient outcome over time.The primary aim of this study is to compare guideline-recommended methods to diagnose asthma with a novel metric derived from digitally measured lung function in combination with T2 inflammation, which has been developed in an independent cohort of patients with severe asthma and a healthy control group. In secondary analysis, we will assess the direct costs and cost-effectiveness of this approach.

Ethics & dissemination: The trial was approved by the Beaumont Hospital's Research & Ethics Committee, REC number 21/89. Participants completed an informed, written consent form. Data will be analysed, anonymised and reported in relevant peer-reviewed journals and at national and international conferences. Data will be anonymised prior to publication.

Trial registration number: NCT05357274.