Annals of the American Thoracic Society最新文献

Rationale: In cystic fibrosis (CF), body composition alterations are observed. The prevalence of obesity in CF is increasing, with evidence suggesting a subsequent increase in cardiometabolic risk. We sought to assess body composition using analytic morphomics from ultra-low-dose thoracic computed tomography (CT) scans in patients with CF on the triple CFTR (cystic fibrosis transmembrane conductance regulator) modulator therapy elexacaftor/tezacaftor/ivacaftor (ETI). Objectives: Our objective was to use analytical morphomics on routine ultra-low-dose CTs to assess patterns of change in body composition in patients with CF on ETI therapy. Methods: Forty-two patients with CF on ETI who had baseline and follow-up ultra-low-dose thoracic CT imaging were retrospectively analyzed. The CTs were acquired at a radiation dose equivalent to two frontal chest X-rays using our previously published acquisition parameters. The Bhalla score was used as a marker of structural lung disease severity. Analytic morphomics variables, including cross-sectional area and attenuation of pectoralis muscle, visceral fat (epicardial and upper abdominal), and subcutaneous fat, were extracted using the validated image segmentation software CoreSlicer. Paired-samples mean testing (Wilcoxon matched-pairs signed-rank test) and Spearman rank correlation analyses were performed. Results: Total Bhalla scores significantly improved over time in patients on ETI (P < 0.0001). In addition, body composition also changed, with an increase in the cross-sectional area of subcutaneous and epicardial visceral fat (P < 0.0001 and P = 0.0062, respectively). In those with a normal BMI at follow-up, epicardial and subcutaneous fat had also increased significantly in the interval (P = 0.0066 and P = 0.0002, respectively). Conclusions: In CF, ETI produced a significant improvement in structural lung disease over time; however, it also resulted in an increase in visceral and subcutaneous fat. The analytic morphomics methodology presented herein may help identify those patients for aggressive primary prevention strategies and permit the creation of more personalized nutritional plans.

Rationale: Survivors of severe coronavirus disease (COVID-19) frequently have persistent radiologic abnormalities beyond one year. Scant data exist for long-term outcomes of COVID-19. Objectives: To characterize a longitudinal multiethnic cohort of COVID-19 survivors 3 years after infection; to identify clinical factors associated with post-COVID-19 fibrotic-like abnormalities; to describe changes in radiologic abnormalities at 4 months, 15 months, and 3 years; and to describe histopathologic features of lung parenchyma from participants with fibrotic-like abnormalities at 3 years. Methods: One hundred two survivors of severe or critical COVID-19 (50% mechanically ventilated, all requiring oxygen supplementation) from a single-center, prospective, longitudinal, multiethnic cohort completed inspiratory and expiratory high-resolution chest imaging, pulmonary function testing, and physical performance testing 3 years after hospitalization. More than 70% participated in earlier follow up visits at 4 and/or 15 months. Factors associated with persistent fibrotic-like abnormalities were examined using multivariable logistic regression with covariate-balanced propensity scores to estimate adjusted associations. For subjects with more than one imaging study, changes in ground-glass opacities, reticulations, and traction bronchiectasis were semiquantitatively analyzed and qualitatively assessed. Five participants with post-COVID-19 fibrosis scores in the top quartile underwent transbronchial biopsy for histopathologic analysis. Results: Fibrotic-like abnormalities, including reticulations and traction bronchiectasis, were present in 61% of survivors of severe or critical COVID-19. In adjusted analyses, fibrotic-like abnormalities were positively associated with male sex, lower body mass index (BMI), shorter leukocyte telomere length, increased severity of illness and mechanical ventilation; they were negatively associated with Black race. Participants with fibrotic-like abnormalities were more likely to have reduced diffusion capacity and reduced 6-minute-walk distance. Reticulations, as assessed by semiquantitative analysis, modestly improved across all time points, even between 15 months and 3 years. Qualitatively, most participants had stable fibrotic-like abnormalities across all time points, with 9% improving from 15 months to 3 years and none worsening. Lung parenchyma from transbronchial biopsies of five individuals with elevated fibrotic scores showed small airway histopathology, consistent with air trapping during expiration, and infrequent interstitial thickening and fibrosis. Conclusions: Despite modest improvements in radiologic fibrotic-like abnormalities 3 years after hospitalization, their continued presence and their association with reduced diffusion capacity and reduced walk distance highlight the long-term consequences of severe COVID-19, which may require further monitoring.

Rationale: Pleural effusions commonly cause dyspnea. However, the drainage of pleural effusions does not reliably result in dyspnea relief. Objectives: To evaluate the predictive value of thoracic ultrasound and clinical parameters for dyspnea relief after thoracentesis. Methods: This prospective, multicenter observational study enrolled adult patients undergoing therapeutic thoracentesis. Predrainage ultrasound assessment included visual (shape and motion) and measurable (displacement, velocity, and thickening fraction) diaphragmatic parameters. The primary study outcome was dyspnea improvement, defined as ⩾14-mm change in visual analog scale score 15 minutes after drainage. Univariate analysis was performed to identify predictors of response. Results: Of 103 effusions drained, 83% (86/103) achieved clinically meaningful dyspnea relief. Predrainage flat or everted diaphragm appearance strongly predicted symptom improvement (odds ratio, 7.92; 95% confidence interval, 2.49-25.2; P < 0.001). Other diaphragmatic parameters (displacement, velocity, and thickening fraction) did not reliably distinguish responders from nonresponders. Responders had greater predrainage dyspnea by visual analog scale scores than nonresponders (66 vs. 38 mm; P < 0.001). Conclusions: In symptomatic pleural effusions, predrainage dyspnea severity and a flat or everted diaphragm shape predicted dyspnea relief after thoracentesis. Additional diaphragmatic measurements, including displacement, velocity, and thickening fraction, did not aid in predicting dyspnea relief after pleural drainage.

Although health effects of ambient air pollution are well established in the general population, the impact of exposure in working populations remains poorly understood. Outdoor workers are disproportionately exposed to ambient air pollution, particularly with increasing wildfire smoke events and global climate change. An international interdisciplinary group of experts including worker representation assembled to review the current state of knowledge regarding the impact of occupational air pollution exposure on worker health and develop recommendations for research and actions to evaluate, mitigate, and regulate occupational air pollution exposure. The group identified health risks likely resulting from air pollution based on studies of the general population, noting that additional risks may be encountered from coexposures, as well as exertion increasing the work of breathing. High-risk groups were identified, including agricultural workers, construction workers, and wildland firefighters; others working in warehouses and indoor spaces are likely at risk via ambient air pollutant infiltration. It was estimated that at least 20 million outdoor U.S. workers are exposed to air pollution at work, which limits productivity and increases absenteeism. Participants recommended using air quality to guide work modifications and adoption of the hierarchy of exposure controls as a model to reduce exposures, as used by some states and proposed by the National Institute for Occupational Safety and Health for agricultural and other outdoor workers. Existing research supports the urgent need for policies to protect workers from exposure. Research gaps remain, including medical surveillance strategies, improved technology to protect workers, and studies specifically evaluating the impacts of occupational air pollution exposure.

Rationale: Barriers to recognizing and treating acute respiratory distress syndrome (ARDS) exist. Prior studies have not investigated whether these barriers differ between academic and community settings or whether there were differences in critical care clinicians' reported ARDS management strategies during the coronavirus disease (COVID-19) pandemic. Objectives: Grounded in the Consolidated Framework for Implementation Research, we sought to determine whether there are differences between academic and community critical care clinicians in their team- and intensive care unit (ICU)-based culture; interprofessional communication; knowledge, attitudes, and perceived barriers to ARDS recognition and management; and ICU organization and ARDS management associated with the COVID-19 pandemic. Methods: Multidisciplinary survey from September 2020 to April 2021 of critical care physicians, nurses, advanced practice providers, and respiratory therapists (RTs) in six academic and nine community hospitals across the United States and Canada. Individual item and cumulative domain scores were compared between academic and community clinicians. Statistical adjustment was performed for multiple comparisons. Results: A total of 1,906 clinicians responded to at least one survey item (53% response rate). Mean (standard deviation [SD]) culture scores were higher for community physicians versus academic physicians (5.3 [1.8] vs. 4.4 [2.0]; P < 0.001) and community nurses versus academic nurses (4.4 [2.2] vs. 3.8 [2.1]; P = 0.007). Academic nurses and RTs had higher knowledge scores than community nurses and RTs (P < 0.001 for each comparison). Community physicians, nurses, and RTs reported higher mean (SD) number of changes in ICU organization and practice during the COVID-19 pandemic than academic clinicians (e.g., community physicians: 13.7 [2.7] changes vs. academic physicians: 11.8 [4.3] changes; P = 0.001). Although academic physicians, nurses, and RTs were approximately twice as likely to care for patients with ARDS daily or several days per week compared with community clinicians, ARDS management, attitudes, and belief in evidence was similar between academic and community clinicians in most respects. Conclusions: A large, multidisciplinary survey identified differences between academic and community critical care clinicians' culture and knowledge in the care of patients with ARDS. The COVID-19 pandemic had a greater impact on community ICU organization and ARDS management. Multifaceted implementation strategies should target implementation barriers differently in academic and community settings.

Rationale: Obesity is the most important risk factor for obstructive sleep apnea (OSA). However, the complex relationship between obesity and upper airway anatomy (craniofacial structure, soft tissues, and airway caliber) has not been robustly examined in patients with OSA. Objectives: To evaluate the relationship between obesity, on the basis of body mass index (BMI), and upper airway anatomic structures in adult patients with moderate or severe OSA. Methods: In this cross-sectional study, 583 patients with apnea-hypopnea index ≥15 events/h (mean age, 53.7 ± 10.4 yr; 81.0% men) were included from the Iceland Sleep Apnea Cohort. Airway sizes, soft tissue volumes, and craniofacial dimensions were quantified using three-dimensional magnetic resonance imaging. We examined how upper airway anatomy was associated with BMI using linear regression (continuous BMI) and analysis of covariance (BMI categories), adjusting for age, sex, and apnea-hypopnea index. Results: Most upper airway anatomy was significantly associated with BMI among patients with OSA. Higher BMI was associated with a different airway shape, including larger minimum anteroposterior distance at both the retropalatal and retroglossal regions and smaller minimum lateral distance in the retropalatal region. All pharyngeal soft tissues were larger with greater BMI, including the volumes of the tongue (and tongue fat), soft palate (and soft palate fat), lateral walls, fat pads, epiglottis, and pterygoids. Patients with lower BMIs had smaller craniofacial measures (e.g., distances between hyoid, retropogonion, and third cervical vertebrae, intramandibular volume, and nasooropharyngeal areas) and more retrognathia. BMI was only weakly associated with the proportion of mandibular space occupied by soft tissues (with no difference among BMI groups), suggesting comparable intraoral "crowdedness" among patients with OSA at different degrees of obesity, albeit for different reasons. Conclusions: The present results support associations between obesity and airway shape, soft tissue volumes, and craniofacial measures among patients with moderate to severe OSA. These relationships provide insights into anatomic traits leading to OSA in lean and obese patients and can inform more personalized treatment options.

Background: The impact of Elexacaftor/Tezacaftor/Ivacaftor (ETI) on provision of airway samples, chronic infection definitions, and Pa isolation frequency/abundance in those with established chronic Pa infection pre-ETI is unknown.

Methods: Retrospective cohort study of 211 pwCF at Royal Brompton with Leeds defined chronic Pa infection in either -1 or -2 years pre-ETI. Electronic patient records were analysed 5 years pre- (-5 to -1) and 2 years post- (+1 and +2) ETI for: number/type of airway samples provided per person per year (pppy), Pa (mucoid/non-mucoid) culture results (to calculate isolation frequency); Pa abundance (log-transformed median CFU/ml).

Results: 148 patients had complete data; 136 provided 1 airway sample per year. Year -1 coincided with covid-19 pandemic; comparisons are made from year -2 to years +1 and +2, finding sustained reduction in: samples provided pppy (years, mean[SD]: -2, 8.0[4.5]; +1, 3.0[2.5], p<0.0001; +2, 2.9[2.2], p<0.0001), proportion of people meeting Standards of Care of 4 samples pppy (years: -2, 90%; +1, 31%; +2; p<0.0001); proportion of Pa positive samples (years: -2, 84.1%; +1, 66.1%, p<0.0001; +2, 58.3%, p<0.0001); proportion exhibiting mucoid phenotype (years: -2, 62.1%; +1, 48.4%, p<0.001; +2, 43.6%, p<0.0001); median mucoid and non-mucoid Pa abundance (1-2 log CFU/ml).

Conclusion: Introduction of ETI coincides with reduced sample provision pppy; a minority of patients now meet Standards of Care (4 samples pppy), challenging the use of current chronic infection definitions. Use of ETI, even in those with established chronic Pa and mucoid phenotype, coincides with reduced Pa isolation frequency/abundance.