BMJ Open Respiratory Research最新文献

Background: While anti-interleukin (IL) 5 therapy has been shown to be efficacious to reduce exacerbation rates (ERs) in patients with severe eosinophilic asthma and might also benefit patients with coexisting chronic obstructive pulmonary disease (COPD), it is unknown whether anti-IL5 therapy reduces all types of exacerbations in heterogeneous (smoking) real-life patients.

Methods: Adults initiating mepolizumab or benralizumab between 2017 and 2019 were identified in Belgian nationwide data. The ER in the year before anti-IL5 therapy initiation was compared to the year after. Exacerbations were classified as severe (hospitalised) exacerbations or moderate (outpatient) exacerbations treated with antibiotics, oral corticosteroids (OCS) or the combination.

Results: Among 807 patients initiating anti-IL5 therapy, severe ER was 40±4 exacerbations per 100 patient years pretreatment versus 17±3 post-treatment initiation (p<0.001, relative risk reduction (RRR) -56%, number needed to treat (NNT)=4) and significantly reduced both in patients without COPD (n=616, ER_pre=15±2, ER_post=6±1, p<0.001, NNT=11) as with coexisting COPD (n=191, ER_pre=119±12, ER_post=53±9, p<0.001, NNT=2). For moderate exacerbations, ERs were significantly reduced for all types of exacerbations in both patients with or without COPD, except for OCS only-treated exacerbations in patients with coexisting COPD (p=0.288). Current smoking reduced anti-IL5 effectiveness on OCS-treated exacerbations (NNT >1), although current smokers with coexisting COPD still had a great reduction in hospitalisations (ER_pre=152±23, ER _post=55±18, p<0.001, NNT=1, RRR=-64%).

Conclusions: In this nationwide cohort study, treatment targeting eosinophilic inflammation was significantly associated with reduced moderate and severe exacerbations, with seemingly less impact on corticosteroid-treated exacerbations in (current smoking) patients with coexisting COPD, but still a large number of hospitalisations were prevented.

Background: The inherent unpredictability of COVID-19 has compelled clinicians to seek early predictors of in-hospital mortality. This study explored the association between mechanical power and in-hospital mortality in mechanically ventilated COVID-19 patients and provides an evidence-based foundation for mortality prediction.

Study design and methods: A multi-centre, retrospective analysis of 600 mechanically ventilated COVID-19 patients aged 18-98 years at 16 Texas Health Resources hospitals between 2020 and 2023 was conducted. Peak inspiratory pressure, static compliance, plateau pressure, driving pressure and mechanical power were analysed for association with in-hospital mortality. Mechanical power was further categorised to provide clinicians with a straightforward approach for mortality prediction.

Results: The overall in-hospital mortality was 57% (53% to 60%). All five parameters were strongly associated with mortality after adjusting for confounders. In the first 24-hours of mechanical ventilation, 72 patients with mechanical power below 10 J/min had a mortality of 31% (20% to 42%), 159 patients with mechanical power between 10 J/min and 15 J/min had a mortality of 47% (39% to 55%), and 369 patients with mechanical power greater than 15 J/min had a mortality of 66% (61% to 71%). Patients still intubated on day 7 had a 2.1% increase in mortality for each J/min increase in mechanical power.

Conclusion: Mechanical power in the first 24 hours of mechanical ventilation in COVID-19 patients is associated with in-hospital mortality and is useful for clinical prognostication.

Background: Inhalers are essential for managing asthma and chronic obstructive pulmonary disease; however, their environmental effects vary significantly. Pressurised metered-dose inhalers (pMDIs) contain potent greenhouse gases (GHGs), resulting in a much higher carbon footprint (CF) than non-propellant inhalers (NPIs). Consequently, reducing the use of pMDIs is seen as an important contribution to reduce the healthcare sector's effect on climate change. This study analyses inhaler dispensing trends in Germany, estimates their resulting CF and quantifies the potential GHG savings from increased NPI use.

Methods: Dispensing data at the expense of statutory health insurances, covering nearly 90% of the German population, were analysed from 2013 to 2022 across three age groups. Annual dispensing shares and CF estimates based on life cycle assessment-derived CF values were calculated for four inhaler types: pMDIs with hydrofluorocarbon (HFC)-134a, pMDIs with HFC-227ea, dry powder inhalers (DPIs), and soft mist inhalers (SMIs). Two scenario calculations estimated the potential GHG savings.

Results: Between 2013 and 2022, the total number of dispensed defined daily doses of inhalers increased by 14%, with no significant shift towards lower-emission inhalers (2013, 55% NPIs; 2022, 52% NPIs). Consequently, the total CF increased from 459 kilotonnes of carbon dioxide equivalent (kt CO₂eq) in 2013 to 525 kt CO₂eq in 2022 (+14%). More than 95% of the inhaler-related CF was attributable to pMDIs. A GHG-saving scenario assuming 85% NPI use among patients aged 10-79 years projected an annual CF reduction of 55% (288 kt CO₂eq).

Conclusion: Despite climate neutrality goals, inhaler-related CF has continued to rise because of stable pMDI usage rates. The substantial potential for GHG reduction highlights the necessity and feasibility of a sustainable change in clinical prescription practice. Our insights could support the promotion of climate-friendly inhalers across other European countries with similar prescription patterns.

Background: High blood or sputum eosinophil counts are linked to poor clinical outcomes in chronic obstructive pulmonary disease (COPD), yet the value of combining both for the assessment of clinical prognosis remains unclear. In this study, we explore the value of combined blood and sputum eosinophil counts for assessing COPD outcomes.

Methods: Patients were divided into four groups by blood (≥300 cells/µL) and sputum (≥3%) eosinophil counts (low blood and low sputum, low blood and high sputum, high blood and low sputum, high blood and high sputum). Spirometry, questionnaires, CT scans, impulse oscillometry, blood laboratory tests and induced sputum tests were performed at baseline. Spirometry and follow-up questionnaires were performed annually. Poisson regression was used to compute the relative risk (RR) for acute exacerbation. The mixed-effects model was used to assess annual lung function decline.

Results: Compared with the low blood and low sputum eosinophils group, the high blood and high sputum eosinophils group had poorer lung function, more severe airway resistance and worse emphysema and air trapping at baseline. The high blood and high sputum eosinophils group had higher risks of cough (adjusted OR=1.87, 95% CI 1.20 to 2.92, p=0.006) and wheezing (adjusted OR=2.19, 95% CI 1.32 to 3.64, p=0.002). The low blood and high sputum eosinophils group had higher risks of phlegm (adjusted OR=1.53, 95% CI 1.04 to 2.24, p=0.029) and dyspnoea (adjusted OR=1.68, 95% CI 1.13 to 2.50, p=0.010). The high blood and high sputum eosinophils group demonstrated higher total (adjusted RR=1.36, 95% CI 1.15 to 1.60, p<0.001) and moderate-to-severe (adjusted RR=1.42, 95% CI 1.14 to 1.76, p=0.001) exacerbation risks. There was no significant difference in annual lung function decline among the groups.

Conclusion: Elevated blood and sputum eosinophil counts are linked to worse lung function and a higher exacerbation risk in patients with COPD.

Background: Antibiotics are widely used to manage acute asthma exacerbations, despite little evidence for their effectiveness. This study assesses the added value of antibiotics alongside oral corticosteroids (OCSs) in treating asthma exacerbations.

Methods: This retrospective cohort study included individuals from the Netherlands between 1994 and 2022 from the IADB.nl pharmacy dispensing database. Individuals had to be 16-45 years old, use inhaled asthma medication and have a first recorded prednisone/prednisolone (OCS) dispense of ≥30 mg/day for 3-14 days. Patients were compared regarding treatment failure (a new dispense of OCS or antibiotics, 15-30 days after initial dispense), based on whether or not they were dispensed antibiotics (AB) alongside their first recorded OCS dispense. Regression analyses with inverse probability of treatment weighting were used to adjust for various confounders.

Results: Of the 5401 individuals included, 38% received antibiotics alongside the first-recorded OCS dispense, with a decreasing trend from 47% in 2009 to 24% in 2020. The OR for treatment failure was 1.36 (95% CI 0.81 to 2.16) for AB+OCS versus OCS-only. The HR for a new exacerbation within 31-365 days of follow-up was 1.20 (95% CI 0.92 to 1.56) for AB+OCS versus OCS-only. The lack of beneficial effect of AB was consistent across subcohorts.

Conclusions: This study found no reduction in treatment failure, nor in risk of subsequent exacerbation, from adding AB to OCS for treating acute asthma exacerbations. We suggest that antibiotics should not be used in primary care settings to treat acute asthma exacerbation unless there are clear signs of bacterial infection.

Background: Bronchiolitis is associated with asthma persisting until adulthood. While bronchial hyper-reactivity (BHR) is a hallmark of asthma, its occurrence and characteristics after bronchiolitis have been less studied. We aimed to study if BHR differed between young adults hospitalised for bronchiolitis in infancy and control subjects with no such history. Further, we sought to study whether any association between asthma and BHR differed between these two groups.

Methods: This Norwegian historical cohort study included 186 young adults hospitalised for respiratory syncytial virus positive or negative bronchiolitis in infancy during 1996-2001 and 139 matched control subjects. BHR was assessed at 17-20 years by methacholine provocation tests and recorded as dose-response slopes (DRS). Outcomes were analysed by mixed effects regression models.

Results: DRS was higher in the post-bronchiolitis group than in the control group (regression coefficient (β) 0.37; 95% CI 0.01 to 0.73; p=0.045). In both groups combined, current asthma was positively associated with DRS (β 0.98; 95% CI 0.50 to 1.45; p<0.001). Stratified analyses showed that the effect (β) of asthma on BHR was 0.80 (95% CI 0.21 to 1.38; p=0.008) in the post-bronchiolitis group and 1.40 (95% CI 0.58 to 2.23; p=0.001) in the control group. The difference in the association between asthma and BHR across the two groups was not statistically significant (p=0.191 for interaction).

Conclusions: BHR at age 17-20 years was higher in subjects hospitalised for bronchiolitis in infancy than in control subjects. The association between asthma and BHR was not found to differ between the post-bronchiolitis group and the control group, although a possible stronger association in the control group may warrant further study.

Background: We assessed the coverage of molecular drug susceptibility testing (mDST) among patients with pulmonary multidrug/rifampicin-resistant tuberculosis (MDR/RR-TB) in South Korea and identified factors influencing the lack of mDST implementation.

Methods: This retrospective study included patients with pulmonary MDR/RR-TB who initiated tuberculosis (TB) treatment between January 2015 and September 2021. Data were obtained from the K-TB-N cohort, an integrated national TB database linking three datasets. We assessed mDST coverage, temporal trends and factors associated with the lack of mDST implementation. mDST was defined as the use of the Xpert MTB/RIF assay or line probe assay (LPA) for isoniazid and rifampicin (first-line LPA).

Results: In total, 4637 patients were included in the analysis. Of the 4637 patients, 1342 (28.9%) did not undergo mDST; whereas, 3295 (71.1%) underwent mDST. Over the study period, a statistically significant annual increase in mDST coverage was observed, escalating from 49.1% in 2015 to 96.9% in 2021 (p<0.001). Throughout the study, the coverage of the Xpert MTB/RIF assay remained lower than that of LPA (22.1% vs 64.2%, p<0.001). Multivariable logistic regression analysis identified several factors independently associated with a decreased likelihood of mDST being conducted, including TB treatment initiation in secondary general hospitals, small hospitals or primary clinics, as well as in non-public-private mix (PPM) participating institutions. In addition, transfers between PPM-participating and non-participating institutions during the treatment period and sputum acid-fast bacilli smear-negative status were significantly associated with lower mDST uptake.

Conclusion: Although the increasing mDST coverage is a positive development, further efforts are needed to achieve nationwide and universal implementation, particularly for the Xpert MTB/RIF assay, in South Korea.

Background: Chronic respiratory diseases, particularly chronic obstructive pulmonary disease (COPD), are the eighth leading cause of death in Taiwan. Although COPD management has advanced in the previous two decades, mortality trends remain unclear. The present study analysed COPD mortality rates in Taiwan from 2002 to 2022.

Methods: COPD mortality and population data were obtained from Taiwan's National Health Statistics and the Ministry of the Interior's Demographic Yearbook. For comparison, global COPD mortality data were sourced from the WHO mortality database. A joinpoint analysis was conducted to assess trends in age-specific and age-standardised mortality rates across sex, region or country.

Results: From 2002 to 2022, Taiwan had 100 147 deaths attributed to COPD. The age-standardised mortality rate decreased with an annual average percentage change (AAPC) of -3.79%, which was more pronounced in women (AAPC: -4.28%) than in men (AAPC: -3.79%). The largest decline occurred from 2016 to 2022, with an AAPC of -7.70%. Most COPD-related deaths occurred among older individuals, with significant reductions in mortality rates observed among men aged ≥60 years and among women aged ≥50 years. A downward trend in COPD mortality rates was noted in most counties from 2016 to 2022, although patterns varied. The overall COPD mortality rate has declined in most countries since 2002, including Taiwan, which ranks third in Asia in terms of reductions in COPD mortality rates during this period.

Conclusion: From 2002 to 2022, COPD mortality rates in Taiwan declined considerably across sexes and regions, although patterns varied. In Asia, Taiwan's reduction in the rate of COPD mortality ranks third behind those of the Republic of Korea and Singapore. The reductions observed in COPD mortality rates in Taiwan may be attributable to tobacco control initiatives and nationwide COPD care programmes.

Background: Health is a fundamental issue in politics and an area where governments hold significant levers of influence. Countries in Europe have seen increased support for populist political parties, with some evidence linking support for these parties to health metrics. We aimed to establish if there is an association between health metrics and patterns of voting in England, particularly in relation to a recently established political party, Reform UK, in the 2024 general election.

Methods: We conducted a cross sectional ecological study with data from all constituencies in England (n=543). We conducted Pearson correlations and linear regression between the proportion of eligible votes for Reform UK and estimated prevalence of 20 common non-communicable diseases, including obesity, chronic obstructive pulmonary disease (COPD), asthma, type 2 diabetes and depression.

Results: Constituencies electing Reform members of parliament (MPs) (n=5/543) had the highest average prevalence of asthma (7.44%) and COPD (2.85%). Across the country, adjusting for age, sex and deprivation, a 10% increase in the party's vote share was associated with a +0.261% (95% CI 0.213% to 0.309%) prevalence of COPD, a +0.113% (95% CI 0.026% to 0.201%) prevalence of asthma and a +1.479% (95% CI 1.239% to 1.720%) increase in obesity prevalence.

Conclusions: At a constituency level, poor health, in particular conditions associated with breathlessness, was associated with a greater proportion of votes for Reform UK.

Introduction: There is significant potential for respiratory infections, such as tuberculosis (TB) and COVID-19, to overlap but little is known about such co-infection. We aimed to study the impact of active TB and latent TB on the incidence of severe COVID-19 in a large cohort of individuals in a setting of low TB endemicity.

Methods: Clinical data of patients admitted to hospital with acute SARS-CoV-2 were merged with a database of patients with a history of previous or current active TB, latent TB or healthy controls. We assessed the incidence of COVID-19 in these groups, length of hospital stay, admission to the intensive care unit (ICU) and in-hospital mortality.

Results: COVID-19 incidence among individuals with current active TB was 6.2% (12/194) and previous active TB 0.67% (30/4496). In contrast, the incidence in previously treated latent TB was 0.09% (4/4542) and among TB contacts 0.24% (34/13 391). There were similar rates of ICU admission and mortality among individuals with COVID-19 and current active TB, TB contacts and other patients. No individuals with previously treated latent TB and COVID-19 were admitted to the ICU or died.

Conclusions: Individuals with a history of latent TB seem to be at reduced risk of severe COVID-19 and have better outcomes than those with active TB and even uninfected controls. Further studies are required to understand the mechanistic basis of this observation.