BMJ Open Respiratory Research最新文献

Background: Chronic obstructive pulmonary disease (COPD) is linked to an increased risk of falls, however, there is no accurate method for predicting falls in this population. This study aimed to develop and internally validate a clinical prediction model for falls in individuals with COPD.

Methods: A secondary analysis was conducted using data from a recent fall prevention trial. Participants with COPD who reported a 12-month history of falls, concerns with balance or recent near falls were tracked for falls over 12 months prospectively. Baseline data included demographics and measures of balance, mobility and health status. A predictive model was developed using backward-selected multivariate logistic regression with fall status (no falls versus ≥1 fall) as the dependent variable and 17 baseline candidate predictors as independent variables. Using the bootstrap resampling method for internal validation, model performance was assessed for discrimination by the concordance (c) statistic and calibration by the expected to observed (E:O) ratio, calibration in the large (CITL) and calibration slope. The final model was adjusted for optimism using the bootstrap shrinkage factor.

Results: Of 178 participants (mean age 73±9 years; 83 females), 74 (42%) reported ≥1 fall over 12 months, totalling 188 falls. The predictive model identified three factors associated with 12-month future falls: reporting a 12-month history of ≥2 falls (OR=3.59, CI (1.65 to 7.82)), more chronic conditions (OR=1.14, CI (1.01 to 1.28)) and worse Timed Up and Go Dual-Task test scores (OR=1.04, CI (1.00 to 1.09)). The final prediction model achieved acceptable discrimination (c-statistic=0.69, CI (0.61 to 0.78)) and calibration (E:O ratio=1.01, CITL=-0.01 and calibration slope=0.93).

Conclusions: A history of ≥2 falls, having more chronic conditions and impaired mobility under cognitive demand predicts future falls in individuals with COPD. The prediction model showed acceptable internal validation. External validation is needed to confirm these findings.

Trial registration number: NCT02995681; clinicaltrials.gov.

Background: The prevalence of infection with non-tuberculous mycobacteria (NTM) has been increasing in people with cystic fibrosis (pwCF) over the past 30 years. Emerging reports of beneficial effects of CFTR modulators, particularly elexacaftor/tezacaftor/ivacaftor (ETI), on the rates of NTM acquisition and persistence are encouraging. In this observational study, we evaluate the impact of the introduction of ETI on the prevalence of NTM infection within a cohort of pwCF living in sub-tropical Queensland, Australia.

Methods: We examined the impact of ETI introduction on rates of NTM isolation in pwCF attending an adult CF centre and two large regional clinics providing CF care. Data on NTM infection were collected for a minimum of 2 years pre- and post-initiation of ETI.

Results: In total, 271 (84.2%) were commenced on ETI with 33 (12.2%) of these pwCF isolating an NTM species on one or more occasion. The number of pwCF isolating Mycobacterium abscessus (Mabs) remained static across the 4-year period of analysis. However, there was a trend towards declining numbers of pwCF isolating either Mycobacterium intracellulare or other NTM species across the surveillance period.

Conclusions: ETI therapy was not associated with reduced rates of NTM isolation from sputum over the first 2 years of treatment. However, at a species level, two distinct patterns of change were seen with a trend towards a reduction in the isolation of M. intracellulare, while the rates of Mabs isolation remained unchanged. The reasons for this remain unclear at present but highlight the need for ongoing vigilance with screening for NTM in the setting of ETI therapy.

Introduction: The COVID-19 pandemic significantly impacted primary healthcare for chronic disease patients, including those with chronic obstructive pulmonary disease (COPD). Information about whether virtual or remote consultations were effective or acceptable to patients with COPD is sparse. E-consultation and telephone triage strategies were deployed, with the vast majority of triaged consultations taking place over the phone or through video calls. This study explored the views of patients with COPD and providers on the effects of the pandemic on their health and healthcare, and barriers to/enablers of remote consultations.

Methods: 12 semi-structured interviews with open-ended questions were conducted via telephone/Zoom among patients with COPD and healthcare professionals (HCPs) in the West Midlands, UK. Patients with COPD were recruited from the Birmingham Lung Improvement StudieS (BLISS) cohort. HCPs were approached via an advert distributed through general practitioner practices that were part of the BLISS cohort; brief adverts were disseminated to several professional organisations throughout the West Midlands area and social media. Interviews were analysed using Braun and Clarke's six steps of thematic analysis.

Results: Three major themes around coping and life adjustment, NHS service accessibility and healthcare inequalities related to e-health literacy.

Conclusion: Post-pandemic priorities should include enhancing remote consultation training for providers, with a focus on rapport-building and care delivery. Equally important are providing flexible healthcare access, continuity of care and targeted support for vulnerable patients with COPD to maintain essential services during crises.

The British Thoracic Society responded to a call from the pleural community to establish a new Training Standard for pleural procedures, relevant to all health care professionals. This should be seen as an enhancement to aspects of existing curricula and be supportive in giving clarity to learners and trainers about expectations for training and practice in pleural procedures.

Introduction: An increase in airway isolates of non-tuberculous mycobacteria (NTM) has been observed, particularly in patients with previous lung damage. Inhaled corticosteroids may increase the risk of NTM lung disease. NTM isolation is of therapeutic importance, especially when macrolides are used. There are few data on the actual prevalence of NTM isolation in patients with chronic obstructive pulmonary disease (COPD).

Objective: To determine the prevalence of NTM isolation and NTM pulmonary disease according to the ATS/ERS/IDSA 2020 criteria in patients with high-risk COPD. As a secondary objective, we sought to identify risk factors for NTM isolation and developing NTM pulmonary disease in patients with COPD.

Methods: Prospective multicentre observational study based on the collection of three sputum samples in a year, for standard, mycobacteria and fungi cultures, in patients with high-risk COPD (postbronchodilator forced expiratory volume in 1 s<50% and/or ≥2 exacerbations in the previous year), with a 12-month follow-up. Patients with at least two good-quality samples were included.

Results: 305 patients were initially selected, of which only 258 had at least two valid samples. NTM was isolated in 15% of patients (n=39), though only 8 (3%) met the ATS 2020 criteria for NTM disease. The most commonly isolated species was mycobacterium avium complex (MAC). Multivariate analysis identified the following risk factors for NTM isolation: low body weight, alpha-1 antitrypsin (AAT) deficiency, inhaled corticosteroids and cancer. NTM disease was only associated with body mass index <21.

Conclusions: NTM isolation is more common than expected in patients with COPD and may have implications for treatment. It is associated with low body weight, AAT deficiency, inhaled corticosteroid use and cancer.

Background: The 2023 Global initiative for chronic Obstructive Lung Disease (GOLD) recommendations advocate long-acting beta₂ agonist (LABA) and long-acting muscarinic antagonist (LAMA) combinations (LABA-LAMA) for the initial pharmacological treatment of patients with chronic obstructive pulmonary disease (COPD) with multiple exacerbations. However, this choice, rather than combinations of LABA and inhaled corticosteroids (LABA-ICS), no longer recommended in GOLD, was based on randomised trials that excluded patients with multiple prior exacerbations.

Research question: What is the comparative effectiveness of initiating COPD treatment with LABA-ICS versus LABA-LAMA inhalers, particularly in patients with multiple COPD exacerbations, in a real-world clinical practice setting?

Study design and methods: We identified a cohort of patients with COPD, 40 years of age or older, from the United Kingdom's Clinical Practice Research Datalink. Treatment-naïve initiators of single-inhaler LABA-ICS or LABA-LAMA, with no prior asthma, LABA, LAMA or ICS use, were compared on the incidence of moderate or severe COPD exacerbation over 1 year, after adjustment by propensity score weighting.

Results: The study cohort included 20 750 initiators of LABA-ICS inhalers and 16 594 of LABA-LAMA. The overall adjusted HR of a first moderate or severe exacerbation with LABA-ICS relative to LABA-LAMA was 1.03 (95% CI 0.98 to 1.08). Among patients with two or more prior exacerbations, the HR of exacerbation with LABA-ICS versus LABA-LAMA was 0.89 (95% CI 0.81 to 0.97), while it was 1.07 (95% CI 1.00 to 1.15) among patients with no prior exacerbations. The HR was 0.92 (95% CI 0.86 to 0.99) among those with forced expiratory volume in 1 s (FEV₁)≥50% predicted.

Interpretation: In a real-world clinical practice setting of COPD treatment, initiating therapy with LABA-ICS inhalers may be more effective than LABA-LAMA inhalers among patients with multiple exacerbations, particularly those with FEV₁≥50% predicted, but less effective among those with no prior exacerbations and FEV₁<50% predicted. This study supports a targeted approach to initial therapy for COPD. .

Introduction: Despite the identification of multiple susceptibility loci by genome-wide association studies (GWAS), considerable chronic obstructive pulmonary disease (COPD) heritability remains unexplained.

Aim: To identify interaction networks of airway epithelial cell DNA methylation in COPD and further explore potential correlations with airway bacterial composition, as potentially collective regulators of biological pathways influencing COPD severity.

Methods: Using DNA isolated from bronchial airway brushings of 67 ever-smokers (>20 pack-years) from the SubPopulations and InteRmediate Outcomes Measures in COPD Study (SPIROMICS), we assessed proportion of DNA methylation (β) by epigenome-wide association study (EWAS) and examined associations of differentially methylated CpG probes (DMPs) with risk for moderate-to-severe COPD (N=34) versus absent or mild COPD (N=33). We tested co-methylation modules generated by Weighted Correlation Network Analyses (WGCNA) for associations with moderate-to-severe COPD and with bacterial genus-level relative abundances (16S rRNA sequencing).

Results: EWAS-identified nominally significant DMPs enriched for lung function GWAS loci. Eigengenes in six WGCNA modules were associated with moderate-to-severe COPD (false discovery rate <0.05). Four of those modules were enriched for forced expiratory volume in 1 s/forced vital capacity GWAS loci, and five overlapped with DMPs from EWAS. Overlapping CpG loci in three COPD-associated modules were adjacent to mucin genes; one had 10 genes highly ranked by connectivity with MUC5B, including important pathway genes: B3GNT6, DGKI and ITGA8. CpGs in an independent COPD-associated module showed the most correlations with Rothia, with directionality suggestive of negative associations with moderate-severe COPD.

Conclusions: Bronchial epithelial DNA methylation modules enriched for lung function GWAS loci associate with COPD severity in SPIROMICS. Potential module relationships to bronchial bacterial composition require further validation.

Background: High-flow nasal therapy (HFNT) is a widely used non-invasive respiratory support technique, but data on its clinical application remain limited. This study aimed to assess clinicians' self-reported practices, perceptions and barriers regarding HFNT use in acute and chronic respiratory failure.

Methods: A cross-sectional web-based survey was disseminated among members of the European Respiratory Society's respiratory intensive care, rehabilitation and chronic care, and allied respiratory professionals assemblies from September to November 2023. Descriptive analysis was performed, with results presented as frequencies and percentages.

Results: A total of 1176 clinicians from 104 countries participated, primarily pulmonologists (78.3%) and respiratory therapists (9.7%). HFNT was most commonly used for de novo acute respiratory failure (56.2%) and interstitial lung disease exacerbations (56.3%), with lower utilisation for chronic obstructive pulmonary disease with hypercapnia (47.4%) and trauma/atelectasis (41.5%). Despite guideline recommendations, 67% of respondents initiated HFNT only after conventional oxygen therapy failure. HFNT was also frequently used for symptom relief in palliative care, despite limited supporting evidence. Respiratory distress was the primary clinical trigger for HFNT initiation, while the ROX (Respiratory Rate-Oxygenation) index was rarely used to guide escalation of care (32%). Barriers to HFNT adoption included equipment costs (23%), lack of funding (22%) and limited clinician knowledge (18%). HFNT use increased during the COVID-19 pandemic (84%), but long-term application for chronic respiratory failure remained rare (16%).

Conclusions: This survey highlights significant variability in HFNT practices and a disconnect between guidelines and real-world implementation. Addressing financial and educational barriers may improve adherence to evidence-based recommendations.

Introduction: Effective management of chronic breathlessness requires understanding people's activity limitations. This study evaluated the extent to which chronic breathlessness limits people's self-reported everyday activities.

Methods: A web-based, cross-sectional survey (adults ≥18 years). Recruitment was through a marketing research company, stratified to the 2016 Australian Census for key demographics (age, sex, state/territory of residence, rurality). Self-reported measures included demographics, breathlessness limiting exertion (modified Medical Research Council (mMRC) breathlessness scale) and breathlessness impact (yes/no question; three most important activities affected). Impact was categorised as performing with difficulty/reduced/ceased.

Results: 7300 respondents were included (mean age 46.5 (SD 18.6); men 50.8%; mMRC ≥1 290.0%). 30.6% (648/2119) with mMRC ≥1 versus 2.6% (136/5181; p<0.001) with mMRC 0 reported activities affected; the proportions increased for each mMRC level.2342 activities were nominated with the most frequent being: high intensity sport, household chores and mobility. The order changed for mMRC 2 (household chores>high intensity sports>mobility) and mMRC 3-4 (mobility>household chores>high intensity sports). Breathlessness increased the likelihood of activities being reduced or ceased.In a logistic regression model exploring the WHO Disability Assessment Schedule, controlling for baseline factors, most affected domains were getting along (OR 2.5 (95% CI 1.5 to 4.2)), life activities (OR 1.8 (95% CI 1.2 to 2.7)) and participation (OR 6.4 (95% CI 4.2 to 9.9)).

Conclusion: Chronic breathlessness of every intensity above mMRC 0 affects people's ability to perform a range of everyday activities. The progressive loss of these activities is a key coping mechanism to avoid precipitating breathlessness and is mostly invisible to other people.

Background: Air pollution exacerbates chronic obstructive pulmonary disease (COPD), increasing hospitalisation and exacerbation rates. While inhaled therapy is a cornerstone of COPD management, pressurised metered-dose inhalers (pMDIs) significantly contribute to greenhouse gas (GHG) emissions. This study evaluates the interplay between air pollution exposure, inhaled therapy selection and COPD exacerbations to identify strategies that optimise clinical outcomes while reducing environmental impact.

Methods: A retrospective observational cohort study was conducted using COPD patient records (ICD-10: J44.0, J44.1, J44.8, J44.9) from the National Taiwan University Hospital Yunlin Branch (2016-2024). Patient visits, including outpatient, emergency and inpatient admissions, were analysed alongside air pollution data (PM_2.5, PM₁₀, NO₂, O₃, CO) from the Environmental Protection Administration. Regression models assessed the impact of inhaled therapies, short-acting β₂-agonists (SABAs), long-acting β₂-agonists (LABAs), long-acting muscarinic antagonists (LAMAs) and triple therapy (ICS/LABA/LAMA), on exacerbation rates and inhaler-associated carbon emissions.

Results: Higher PM_2.5 levels correlated with a 0.97% increase in COPD exacerbation rates (B=0.0291, p=0.0001). Triple therapy was significantly associated with reduced exacerbations (B=-0.0035, p=0.0003), whereas higher SABA use was associated with markers of poorer COPD control (B=7.145, p<0.001). The uptake of non-pMDIs, such as dry powder inhalers and soft mist inhalers, rose in 2020-2021 as hospitalisations declined. In 2022-2024, pMDI use and estimated emissions increased, while emergency room (ER) visits were unchanged and hospitalisations declined modestly. A 42% increase in non-pMDI prescriptions in 2020-2021 was associated with a decline in hospitalisations and emissions. However, a subsequent shift back to pMDIs in 2022-2024 coincided with an increase in exacerbations and increased carbon footprint.

Conclusion: In this single-centre retrospective study, higher ambient PM_2.5 was associated with higher COPD acute exacerbation (AE) rates, and greater use of triple therapy correlated with lower hospitalisations. Our inhaler carbon-footprint estimates quantify GHG differences between device types but were not linked to AE and should inform sustainability discussions rather than clinical effectiveness.