Annals of the American Thoracic Society最新文献

Background: Lung cancer screening (LCS) is vital for early detection of lung cancer. Many veterans live in rural areas far from VA medical centers but may receive VA-funded care locally through care in the community (CITC). LCS through CITC may lack the centralized support available at main VA campuses, placing veterans at risk for lower quality care.

Question: Does implementation of a centralized process for CITC LCS: reduce screening among ineligible individuals, improve timeliness of care and staff experience, decrease care fragmentation by recapturing imaging and consultative care within the VA, and increase appropriate imaging follow-up and specialty consultation for lung nodules identified through LCS?

Methods: We conducted a quality improvement initiative to incorporate centralized processes for veterans receiving LCS through CITC. A nurse coordinator served as implementation champion and was responsible for reviewing referrals, confirming eligibility for CITC and LCS, ensuring results were received back to the ordering medical center and ensuring follow-up was conducted according to Lung Imaging Reporting and Data System (LungRADS) guidelines. Quantitative data was compared pre- and post- implementation period for key outcomes (eligibility, timeliness, evaluation of high-risk nodules, care fragmentation). Qualitative data was obtained by interviewing participating staff.

Results: In the pre-implementation period, 6.3% (31/489) of patients who completed LCS were ineligible. In the post-implementation period, 14.3% (433/3023) of referred patients were ineligible, and 0 completed imaging. (P = 0.0001). The mean time between CT completion and results received by the ordering clinician or LCS coordinator decreased from 27.6 (19.7-35.5) days to 14.5 (9.3-19.8) days following program implementation (P = 0.0414), with improved guideline adherent follow-up including serial imaging or pulmonary consult for high-risk nodules. More consults were completed at the VA (vs CITC) following program initiation (11.1% vs 88.0%, P = 0.0001). Participating staff felt the implementation process was smooth and were satisfied with the centralized support.

Conclusion: Implementing a centralized LCS program for CITC patients resulted in improved guideline-adherent LCS, increased appropriate consultative care, decreased care fragmentation and improved staff experience. Other VA healthcare systems should consider implementing similar centralized CITC-LCS programs.

Rationale: Inspiratory muscle training (IMT) is a relatively new intervention for obstructive sleep apnea (OSA) with the aim of improving respiratory muscle strength and mitigating OSA-related symptoms. However, its effects on key clinical endpoints remains unclear.

Objectives: To evaluate the effects of IMT on OSA severity, sleep quality, respiratory function, and cardiovascular outcomes.

Methods: We systematically searched PubMed, EMBASE, CENTRAL, and Web of Science for randomized control trials (RCTs) assessing IMT in adults with OSA. Studies assessed IMT versus control/placebo with outcomes, including the apnea-hypopnea index (AHI), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), maximal inspiratory pressure (MIP), lowest oxygen saturation (LSaO2), blood pressure (BP), and body mass index (BMI).

Results: Ten RCTs (166 IMT vs. 157 control participants) found significant improvements in OSA with IMT across multiple domains. The intergroup difference in mean BMI reduction (mean difference [MD], -1.48; 95% credible interval [CI], -2.39 to -0.57), mean PSQI gain (-3.15; -3.69 to -2.62), mean LSaO2 gain (2.86; 1.01 to 4.71), mean ESS reduction (-3.18; -4.50 to -1.87), mean MIP gain (25.54; 11.09 to 40.00), the percentage of predicted values for forced vital capacity (FVC) (FVC%) predicted gain (17.20; 9.53 to 24.87), and mean systolic blood pressure (SBP) reduction (-6.63; -13.26 to -0.00) indicated the benefit of IMT over the control therapy. However, there was no significant improvement in AHI (1.00; -2.57 to 4.56). Heterogeneity primarily stemmed from differences in intervention protocols and baseline disease severity among the patients.

Conclusions: IMT resulted in clinically meaningful symptomatic benefits across OSA phenotypes by enhancing respiratory strength, sleep quality, and cardiovascular health. However, the lack of significant improvement in AHI suggests that IMT may not impact primary pathophysiological markers of OSA. Thus, IMT may be an adjunctive intervention, rather than a primary therapy, for reducing event frequency in OSA.

Rationale: Family members of patients in intensive care units (ICU) experience psychological distress both during and after the ICU stay. Yet, past interventions are few and largely ineffective.

Objective: We developed a flexible, tele-delivered psychotherapeutic intervention based on contemporary cognitive therapeutic methods and tested its feasibility in a one-arm pilot study. Although evaluated in family members of patients with COVID-19, the intervention was developed to be broadly applicable to mental health problems in ICU family caregivers.

Methods: Adult family members of patients with COVID-19 in five ICUs across Denmark received weekly sessions with clinical psychologists during the ICU stay and on a needs basis for eight weeks post-discharge. The intervention manual specified a catalog of treatment principles and methods from contemporary cognitive therapies. Questionnaires evaluating peritraumatic distress, anxiety, depression, stress, rumination, worry, and tolerance of uncertainty were administered at pre-intervention, post-intervention, six-, and twelve-month follow-up. Mixed-effects models estimated the change in mental health symptoms over time. A subset of family members and psychologists completed in-depth interviews post-intervention analyzed with thematic analysis.

Results: Of 43 eligible family members, 40 (93%) participated. Two withdrew consent during the intervention. On average, family members received 6 sessions (range: 0-15) over 9 to 118 days. Both the tele-delivery format and the intervention methods were found feasible and acceptable by family members as well as psychologists, and family members found the intervention beneficial in validating and addressing their evolving needs and helping them manage distress. Preliminary effects at post-intervention were large reductions in mental health symptoms for peritraumatic distress (Hedges' g = -0.86, 95% confidence interval (CI) = [-1.2 to -0.25]), anxiety (g = -2.46, [-2.36 to -1.51]), and depression (g = -1.77, [-2.5 to -0.88]), also seen at follow-up, together with medium improvements for perceived stress.

Conclusions: This tele-based psychotherapeutic intervention for family members of patients in ICUs was feasible and acceptable, and tele-delivered contemporary cognitive therapies present a promising approach for reducing peritraumatic distress, anxiety, and depression.

Trial registration: Clinicaltrials.gov (NCT04409821).

Objective: Assess the impact in primary care of the 2025 Global Obstructive Lung Disease (GOLD) comment to use pre-bronchodilator results when they do not demonstrate obstruction.

Materials and methods: Data from participants of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation (CAPTURE) study who had baseline pre- and post-bronchodilator (BD) spirometry were used to assess the pre-BD results ability to predict post-BD obstruction, defined as FEV1/FVC <0.70. Spirometry data were stratified into four groups: 1) consistent non-obstruction, 2) only post-BD obstruction-missed diagnosis, 3) consistent obstruction and 4) only pre-BD obstruction-over diagnosed. Sensitivity, specificity, positive and negative predictive value (PPV and NPV) of the pre-BD results to predict post-BD obstruction were calculated.

Results: 1,181 of 4,336 participants (27.2%) were included in this study because they met the study's criteria for pre- and post-BD spirometry: pre-BD obstruction (FEV1/FVC <0.70) or FEV1 < 80% predicted. Of the 1,181, 701 (59.4%) had consistent non-obstruction with 26 (2.2%) having only post-BD obstruction-missed diagnosis of COPD by pre-BD, while 273 (23.1%) had consistent obstruction. 181 (15.3% of the 1181 or 4.2% of the 4,336) had only pre-BD obstruction-overdiagnosis of COPD. Pre-BD sensitivity for post-BD obstruction (labelled COPD) was 91.3% (95%CI 87.5-94.2%) with specificity 79.5% (95%CI 76.7-82.1%), NPV 96.4% (95%CI 94.8-97.7%) and PPV 60.1% (95%CI 55.5-64.7%).

Conclusions: Using the 2025 GOLD recommendations in these primary care patients with pre-BD spirometry showing obstruction or an FEV1 < 80% predicted resulted in few missed diagnoses of COPD or obstruction. Our data confirm that non-obstructive pre-BD results may be used routinely in primary care.

Background: While several biologics are approved in the U.S. for the treatment of severe asthma in children aged ≥6 years, important knowledge gaps persist regarding their real-world effectiveness. Here, we examine their real-world effectiveness and whether it differs by age of treatment initiation, biologic agent, or early-childhood asthma risk factors and characteristics.

Methods: Retrospective cohort of 122 children with moderate/severe asthma treated with a biologic by pediatric subspecialists between December 2019 and December 2024. Piecewise generalized linear mixed-effects models were used to examine biologic clinical benefit, defined as the change in the odds of severe asthma exacerbations before vs. after treatment initiation.

Results: The cohort (52% female, 59% African American, mean age 10 ± 4 years at biologic initiation) was prescribed dupilumab (64%), omalizumab (29%), or mepolizumab (8%) and had 10 years median follow-up. Biologics led to significant reductions in severe exacerbations (adjusted OR = 0.47 [95%CI = 0.28, 0.80]); this benefit was more pronounced with younger age at initiation: aOR = 0.46 [95%CI = 0.26, 0.80] in ≤11-years-olds, versus aOR = 0.56 [95%CI: 0.27, 1.89] in those ≥12 years. Similarly, benefit was more pronounced among patients with early childhood polysensitization (aOR = 0.32 [95%CI = 0.14, 0.74] than those without (aOR = 0.59 [95%CI = 0.30, 1.19]) and patients with a moderate/high burden of early-childhood asthma risk factors (aOR = 0.39 [95%CI = 0.21, 0.70]) than those with low burden (aOR = 0.90 [95%CI = 0.32, 2.57]). We found no significant differences by biologic agent.

Conclusion: Biologics may be more effective with earlier treatment initiation, especially among children with early polysensitization or multiple early-childhood risk factors. Screening for these risk factors may help inform targeted early initiation of biologics for asthma.

Rationale: There is a critical gap in our understanding of how treatment with continuous positive airway pressure (CPAP) modulates vascular inflammation in patients with obstructive sleep apnea (OSA). We have shown that the effects of CPAP treatment on cardiovascular outcomes in OSA vary between individuals (heterogeneity of treatment effects [HTE]). In this study, we evaluate HTE on vascular inflammation in OSA patients undergoing CPAP therapy.

Methods: We recruited adults with moderate-to-severe OSA (respiratory disturbance index, RDI ≥15) who underwent 18F-FDG Positron Emission Tomography/Magnetic Resonance Imaging (PET/MRI) at baseline and after 3 months of CPAP. We measured vascular inflammation in the carotid arteries and aorta, using standardized uptake values (SUV). Carotid SUVmax was the primary outcome. We used multivariable linear regression and linear mixed-effects models to evaluate associations between OSA metrics and vascular inflammation at baseline, and after CPAP. We explored HTE using k-means clustering to identify distinct clusters based on changes in carotid vascular inflammation after CPAP treatment.

Results: 180 patients completed baseline imaging, and 135 returned for follow-up. OSA severity and hypoxic burden were significantly associated with vascular inflammation, though this association was attenuated after adjusting for cardiovascular risk factors. There were no significant changes in vascular inflammation after CPAP. However, significant HTE was observed, with three distinct clusters of patients: those showing a decrease in carotid vascular inflammation (-16.6% [CI -19.8%,-13.3%]), an increase (+24.2% [CI 19.3%, 29.2%]), or no significant change (-1.18% [CI -3.7%, 1.4%]) in inflammation post-CPAP. Patients with no change or an increase in vascular inflammation post-CPAP were more likely to have a history of smoking (P = 0.009) and a higher baseline delta heart rate (P = 0.012) compared to those with a decrease in vascular inflammation post-CPAP.

Conclusion: Although CPAP therapy did not uniformly reduce vascular inflammation in OSA patients, there was substantial heterogeneity in treatment responses across participant clusters. Differences in baseline lifestyle and polysomnographic features between these clusters may provide insight into factors driving variability in subclinical cardiovascular disease and treatment outcomes in OSA.