Annals of the American Thoracic Society最新文献

Electrical impedance tomography (EIT) is a radiation-free, noninvasive method of measuring the regional behavior of the lung that may be particularly suited to neonatal medicine. It is used more and more commonly in neonatology, particularly in the research setting. To harmonize efforts in terms of scientific and clinical use of this novel technology, we summarize the current knowledge on EIT use in both term and preterm infants and delineate potential future perspectives in this state-of-the-art article. We describe the current use in research and practice in neonatal medicine, including the following areas: 1) the cardiopulmonary transition immediately after birth; 2) changes in airway management, including the use of different interfaces, endotracheal intubation, extubation to noninvasive respiratory support and (endotracheal) suctioning; 3) surfactant administration; 4) different body positions; 5) different modes of invasive and noninvasive respiratory support; 6) evaluation of acute pulmonary pathologies; 7) the predictive value of using EIT in neonatology; and 8) the assessment of pulmonary perfusion. In summary, EIT is a very valuable research tool in neonatal medicine, where it allows us to understand physiological principles and pathogenesis of disease more deeply. It may also be useful for selected clinical situations in neonatology, including major acute lung pathologies, because it allows accurate and noninvasive assessment of intrapulmonary volume changes in neonates. However, there are still some barriers to widespread implementation in clinical practice.

Rationale: Engaging patients and families in critical care research is recognized as best practice. The extent of engagement in critical care trials in Australia and New Zealand is unknown after introduction of national guidelines in 2016. Objectives: To assess the extent of patient and family engagement in adult critical care research studies endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG). Methods: Prospective studies endorsed between January 2017 and December 2023 or previously endorsed and still recruiting during this period were included. The study design included a two-stage process: 1) retrospective independent assessment of patient and family engagement in study protocols, progress reports, and manuscripts and 2) prospective self-reported survey of study principal investigators and project managers to understand priority of engagement, types of activities, barriers, and facilitators. Both stages assessed engagement using a modified version of an existing tool developed by the Canadian Critical Care Trials Group (CCCTG) Patient and Family Partnership Committee. The Guidance for Reporting Involvement of Patients and Public 2 tool was also used in stage 1. Results: Stage 1 was a retrospective analysis using the CCCTG and Guidance for Reporting Involvement of Patients and Public 2 tools. Of the 35 studies reviewed in stage 1, patient and family engagement was infrequently reported (reported in eight protocols submitted to ANZICS CTG for endorsement [8 of 35; 23%], reported in one trial progress report [1 of 34; 3%] and in one protocol publication [1 of 17; 6%], and not reported in the 10 primary trial publications [0 of 10; 0%]). Stage 2 involved survey responses using the CCCTG tool. Twenty-eight (80%) of 35 studies had at least one survey response. Respondents for 20 of these studies (20 of 28; 71%) reported undertaking some form of patient and family engagement. The most common facilitator of engagement was staff engagement experience (12 of 28; 43%), and lack of resources (12 of 28; 43%) was identified as a key barrier. Conclusions: This study identified low rates of reported patient and family engagement in clinical trial protocols and manuscripts via independent appraisal compared with a high self-reported rate of engagement activities among studies endorsed via the ANZICS CTG. This study highlighted the importance of adequate resourcing for engagement activities, including experienced personnel and funding.

Rationale: Continuous positive airway pressure (CPAP) is the standard of care for obstructive sleep apnea (OSA), but adherence remains a major clinical challenge. Clinical variables are insufficient to fully predict the adherence profile in an individual. Objectives: To determine the association between self-efficacy, determined using the Self-Efficacy Measure for Sleep Apnea (SEMSA)-15 questionnaire, and 1-year CPAP adherence and adherence trajectories in individuals with newly diagnosed OSA. Methods: This prospective, multicenter, observational cohort study was conducted in France; the study started in May 2021, and recruitment finished in December 2022. All participants were adults with OSA referred to a home care provider for CPAP therapy and agreed to the use of their data for research purposes. At baseline, participants completed the SEMSA-15 (to assess self-efficacy), Deprivation in Primary Care Questionnaire (to assess precariousness), and the Health Literacy Questionnaire. CPAP adherence was determined based on objective telemonitoring data and was calculated as mean device use during the first 15 days after therapy initiation or during the 30 days preceding the 90-day and 1-year follow-up. CPAP adherence trajectories were determined using group-based trajectory modeling. Results: A total of 293 individuals were included (70% male; median age 55 yr; median apnea-hypopnea index, 43 events per hour). The median SEMSA-15 total score was significantly higher in adherent versus nonadherent individuals (3.1 vs. 2.8; P < 0.01). After adjustment for confounding variables, the SEMSA-15 score was significantly associated with CPAP adherence at 15 days (odds ratio [OR], 4.08; 95% confidence interval [CI], 2.13-7.79), 90 days (OR, 2.63; 95% CI, 1.39-5.01), and 1 year (OR, 3.14; 95% CI, 1.71-5.79). The SEMSA-15 score was also significantly associated with having a better CPAP adherence trajectory (OR, 2.84; 95% CI, 1.61-5.04). Conclusions: Self-efficacy (based on the SEMSA-15 score) could facilitate the early identification of individuals who are likely to have low adherence and/or be at risk of CPAP therapy termination. Clinical trial registered with www.clinicaltrials.gov (NCT04894175).

Rationale: Pulmonary hypertension (PH) is associated with significant morbidity and mortality. Ground-glass opacities (GGOs) are common in Group 1 PH, but their clinical significance is unclear. Objectives: We sought to characterize the clinical features and outcomes of patients with Group 1 PH with and without GGOs in the PVDOMICS study, a prospective multicenter cohort study aimed at deep phenotyping PH. Methods: Patients with incident and prevalent PH were enrolled across seven U.S. centers. We included patients with Group 1 PH and excluded those with parenchymal lung disease or without chest imaging, resulting in a cohort of 242 patients. Results: GGOs were common among patients with Group 1 PH (43% prevalence), associated with female sex, younger age, prostanoid use, and longer disease duration. GGOs were more common among patients with familial pulmonary arterial hypertension and pulmonary veno-occlusive disease. GGOs were associated with established markers of disease severity, including echocardiographic (right ventricular systolic pressure and tricuspid annular plane systolic excursion), biomarkers (N-terminal pro B-type natriuretic peptide), and worse hemodynamics (higher mean pulmonary artery pressure, pulmonary vascular resistance, and pulmonary artery wedge pressure). GGOs were associated with worse transplant-free survival (hazard ratio, 2.49; 95% confidence interval = 1.43-4.32; P = 0.001) and had independent prognostic value for predicting transplant-free survival after adjusting for European Society of Cardiology and European Respiratory Society risk stratification (hazard ratio, 2.19; 95% confidence interval = 1.20-3.99; P = 0.01). Conclusions: Overall, GGOs were associated with specific clinical characteristics and disease phenotypes, as well as worse hemodynamics, longer disease duration, prostanoid use, and worse survival. Future studies evaluating the pathophysiology and "omic" correlates of GGOs are warranted. Clinical trial registered with www.clinicaltrials.gov (NCT02980887).

Rationale: The term "persistent critical illness" (PerCI; defined as an ICU stay of ⩾10 or more days) refers to the condition of a growing group of patients in the intensive care unit (ICU) whose critical illness persists into chronicity. These patients account for a disproportionate amount of resources, yet long-term functional outcomes are unknown. Objectives: We sought to compare death or new disability at 6 months in ICU patients with and without Methods: We performed a secondary analysis of a multicenter, prospective cohort study that was conducted in six metropolitan ICUs. Participants were adults admitted to an ICU who received more than 24 hours of mechanical ventilation. Patients who died before Day 10 were excluded from the control group. The primary outcome was death or new disability at 6 months, adjusted for various covariates, with new disability defined as a ⩾10% increase from baseline as measured with the World Health Organization Disability Assessment Schedule 2.0. We included various secondary outcomes (e.g., quality of life, cognition, mental health, return to work) to assess recovery holistically at 3 and 6 months. A significance level of 0.01 was used to compensate for multiplicity. Results: Of 888 total enrolled patients, 799 survived to Day 10. Of these, the primary outcome was available in 670 (84%) patients, 188 with PerCI and 482 in the control group. The primary outcome was present in 124/171 (72.5%) of patients with PerCI and 246/457 (53.8%) of the control group: adjusted risk difference, 10.70; 95% confidence interval (CI) = 0.47-20.90; P = 0.040. At 6 months, the mortality rate was higher in the PerCI group compared with the control group: 76/252 (30.2%) and 57/547 (10.4%), respectively (adjusted risk difference, 15.04; 95% CI = 9.65-20.39; P < 0.001). In survivors, 48/95 (50.5%) of the PerCI group developed a new disability, compared with 100/311 (32.2%) in the control group (adjusted risk difference, 9.98; 95% CI = -0.27, 20.20; P = 0.056). Assessment of secondary outcomes showed several differences at 3 months that were reduced by 6 months, and residual differences were largely related to physical function. Conclusions: Patients with PerCI had a similar incidence of death or new disability at 6 months. However, an assessment of secondary outcomes showed significant recovery in survivors of PerCI between 3 and 6 months.

Rationale: There are insufficient data to inform the management of central sleep apnea (CSA) in patients with heart failure with reduced ejection fraction (HFrEF). Nocturnal oxygen therapy (NOT) has been postulated to benefit CSA patients with HFrEF but has not been rigorously studied. Objectives: To compare NOT with sham NOT (control) in heart failure (HF) patients receiving guideline-based HF therapy on the composite outcome of first occurrence of either mortality due to any cause, a lifesaving cardiovascular intervention, or an unplanned hospitalization for worsening HF, together with other secondary outcomes. Methods: A multisite, double-blind, sham-controlled randomized clinical trial was conducted from September 2019 to December 2021, when the study was terminated prematurely because of slow enrollment. Cox proportional-hazards regression models were used to analyze time-to-event outcomes. Results: Ninety-eight participants (mean left ventricular ejection fraction, 27.8 ± 9.6%; mean central apnea-hypopnea index, 30.6 ± 18.2 events/h) were randomized and followed for an average of 10.8 ± 6.3 months. A total of 22 events met the criteria for the primary composite endpoint. The hazard ratio comparing the NOT group with the control group according to time to first event, adjusted for the stratification factor (hospitalization for HF in the past 12 mo and/or elevated outpatient brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide concentration) was 1.46 (95% confidence interval, 0.65-3.29). No group differences in changes in patient-reported outcomes (HF-specific quality of life [Kansas City Cardiomyopathy Questionnaire], sleep disturbance and sleep-related impairment [Patient-reported Outcomes Measurement Information System], generic health [EQ-5D], or mood [Patient Health Questionnaire-8]) were observed at 6 months. Polysomnography showed improved indices of sleep-disordered breathing (apnea-hypopnea index, central apnea-hypopnea index, and time at oxygen saturation < 90%) with oxygen compared with room air. Conclusions: Although NOT improves CSA and overnight oxygenation, this prematurely terminated study does not provide support for the clinical effectiveness of NOT in patients with CSA and HFrEF. Clinical trial registered with www.clinicaltrials.gov (NCT03745898).