Annals of the American Thoracic Society最新文献

Rationale: Excess weight contributes to impaired physical function among individuals with chronic obstructive pulmonary disease (COPD) and sleep apnea. Self-directed lifestyle-based weight management programs are an accessible option to promote weight loss and improve physical function, but their effectiveness has not been clearly demonstrated.

Objective: To test whether a self-directed lifestyle program improves 6-minute walk test (6MWT) distance among individuals with COPD and comorbid sleep apnea.

Study design and methods: We performed a subset analysis of participants previously enrolled in the INSIGHT-COPD randomized clinical trial (low-intensity lifestyle intervention vs. usual care) who self-reported a diagnosis of sleep apnea. Our primary outcome was between-group differences for change in 6MWT distance (minimally important difference [MID] 30 m). Secondary outcomes included between-group differences in weight (a loss of 3% defines meaningful reduction) and quality of life (SF-12 Physical Component Score [PCS], MID 3-3.5 points). We also tested whether sleep apnea modified the effect of the intervention across the entire INSIGHT-COPD population.

Measurements and main results: Among 285 participants with sleep apnea (141 randomly allocated to intervention, 144 to usual care), those randomized to intervention could walk further (difference in 6MWT distance of 25.5 m, 95% CI 8.2 m to 42.9 m; 23.4% vs. 20.1% had a MID increase in 6MWT distance) and had a greater reduction in weight (difference in weight of -2.4 kg, 95% CI -3.9 to -0.9 kg; 36.2% vs 23.6% had a 3% reduction in weight) at 12 months. The intervention group also reported a greater physical-function related quality-of-life (difference in SF-12 PCS of 1.78 pts, 95% CI 0.10 to 3.49) in comparison to usual care at 12 months.

Conclusions: Among patients with COPD and sleep apnea, a self-directed video-based weight management program led to favorable changes 6MWT distance compared to usual care, though this did not meet the threshold of a clinically important improvement. However, fewer participants in the intervention group saw a decline in 6MWT distance, and more achieved meaningful weight loss. To effectively improve function in this population, additional interventions beyond self-directed weight management will be necessary.

Rationale: Pulmonary artery (PA) dilation on CT has been associated with moderate-severe pulmonary hypertension (PH) using outdated diagnostic criteria. The association between PA size and mean PA pressure (mPAP) in mild PH and the prognostic implications of PA dilation remain unclear.

Objectives: To investigate associations between PA size, mPAP, and survival in subjects without significant lung disease aside from PH.

Methods: PA size on CT was measured for individuals with group 1 or 2 PH and matched controls in the Pulmonary Vascular Disease Phenomics cohort. Outcomes included mPAP on right heart catheterization (RHC) and time to heart and/or lung transplantation or death.

Measurements and main results: 691 subjects were included, with 595 undergoing RHC. PA diameter and PA:aorta ratio demonstrated significant association with mPAP (ρ = 0.557 and 0.564, respectively). Size increased incrementally from no PH to mild PH to moderate-severe PH for PA diameter (27.64 [95% CI 17.64-37.64] to 30.65 [18.99-42.31] to 36.00 [22.46-49.54] mm) and PA:aorta (0.89 [0.53-1.24] to 0.99 [0.63-1.35] to 1.19 [0.60-1.78]). PA diameter and PA:aorta demonstrated good discrimination of mPAP > 20 mmHg (AUC 0.834 and 0.816, respectively). Transplant-free survival decreased across the continuum of PA diameter and PA:aorta (p < 0.001). Adjusted hazard ratio of third versus first quartile values was 2.36 [1.58-3.54] for PA diameter and 2.24 [1.52-3.30] for PA:aorta.

Conclusions: In subjects without significant lung disease outside of PH, PA size on CT was associated with increased mPAP and decreased transplant-free survival across the spectrum of PH severity and demonstrated modest diagnostic discriminatory ability using updated hemodynamic criteria. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Rationale: Critically ill lung cancer patients are a growing, high-risk population. However, prognostic tools to guide intensive care unit (ICU) decision-making are limited.

Objective: To identify oncologic and critical illness factors associated with 90-day mortality following ICU admission in patients with lung cancer.

Methods: We conducted a retrospective cohort study of lung cancer patients admitted to the ICU across Mayo Clinic Health System between 2018 and 2024. The primary outcome was 90-day mortality. Two complementary Cox proportional hazards models were developed: a focused model including cancer-specific variables (stage, cause of critical illness, ECOG performance status prior to admission, code status at admission, and time since last systemic therapy) and a full model that added broader clinical factors (age and Sequential Organ Failure Assessment [SOFA] score). We also evaluated discharge disposition and transitions in code status.

Results: Among 528 patients, 90-day mortality was 58.7%. In the focused model (C-index 0.67), independent predictors of mortality included late-stage disease, cancer-specific reason for ICU admission, DNR/DNI status, and ECOG >1. In the full model (C-index 0.95), only age and SOFA score remained significant. Among early-stage patients, recent targeted or combination therapy was associated with higher mortality. Patients who changed code status during admission had high mortality (83%) and a low rate of discharge home (11%).

Conclusions: Lung cancer patients admitted to ICU experience high short-term mortality, with outcomes shaped by both oncologic status and the severity of acute illness. A dual-model approach suggests a risk hierarchy: cancer-specific factors inform baseline mortality risk with an ICU admission, but age and physiologic derangement are the dominant drivers of survival once critical illness develops. These findings support dynamic, multidisciplinary prognostication and underscore the need to integrate oncology and critical care expertise in ICU decision-making. Word count: 310.

Background: Patients with pulmonary hypertension due to interstitial lung disease (PH-ILD) have worse exercise capacity and survival than ILD patients without PH. Vasoreactivity with inhaled nitric oxide (NO) provides prognostic and therapeutic implications in pulmonary arterial hypertension, but little is known on its value in PH-ILD. We evaluated the pulmonary hemodynamic changes following inhaled NO and their association with outcomes in PH-ILD.

Methods: We measured pulmonary hemodynamics in patients with PH-ILD who underwent inhaled NO administration during right heart catheterization. We recorded baseline clinical, echocardiographic, and pulmonary function testing measures; and investigated the use of inhaled treprostinil as well as the rate of hospitalization, death and lung transplantation.

Results: In 120 patients (age 67 ± 11 years, 62% women), the administration of inhaled NO resulted in a median (IQR) decrease in mean pulmonary artery pressure (mPAP) of -3 (-5, -1) mmHg, p<0.001, and PVR of -0.8 (-1.8, -0.2) Wood units, p<0.001. The % change in mPAP and PVR were -6.3 (-10.9, -1.8) % and -16.8 (-27.3, -3.3) %, respectively. Factors associated with the % drop in PVR included baseline PVR (r= 0.30, p<0.001), cardiac output (r= -0.19, p=0.04), and WHO functional class (r=0.25, p=0.01). The median (IQR) follow-up was 14.5 (7, 25) months. During this time, 40 (33%) patients died, 8 (7%) underwent lung transplantation, and 76 (63%) experienced either hospitalization due to respiratory failure, transplantation, or death. The % drop in mPAP and PVR during inhalation of NO had no significant impact on these outcomes and was not associated with clinical response to inhaled treprostinil measured by changes in six-minute walk distance (6MWD) and forced vital capacity (FVC).

Conclusion: Inhaled NO caused a modest reduction in mPAP and PVR in patients with PH-ILD, but the acute hemodynamic response to inhaled NO, in our cohort, was not associated with outcomes or response to inhaled treprostinil therapy.

Rationale: Air pollution and pneumonia are both associated with respiratory morbidity and disproportionately impact resource-limited settings. However, the impact of air pollution on lung health in these settings is incompletely understood. We characterized the relationship between personal PM2.5 exposure and lung function among adults who have recovered from pneumonia in Kampala, Uganda.

Methods: Adults 18 to 60 years old who had recovered from pneumonia completed spirometry and diffusing capacity for carbon monoxide (DLco) testing following 48 hours of personal PM2.5 exposure measurement, between June 2021 and April 2023. We fit linear and logistic regression models to characterize the relationship between personal PM2.5 exposure and lung function. Models were adjusted for age, sex, smoking status, HIV, and socioeconomic status, and were assessed for effect modification using interaction terms and stratified models.

Results: Among 96 participants, median age was 32.5 years, 48% were women, 53% were people with HIV (PWH), and 9% were diagnosed with COPD. Median personal PM2.5 exposure was 67 µg/m3, although 67% of participants reported their home air quality as Excellent or Good. Personal PM2.5 exposure did not differ by sex, HIV serostatus, or type of pneumonia. In adjusted models, a 1 µg/m3 increase in PM2.5 was associated with decreased FEV1 (β=-3.16, 95%CI: -5.59, -0.74), FVC (β=-3.09, 95%CI: -5.51, -0.66) and DLco (β=-0.04, 95%CI: -0.06, -0.02), and with increased odds of COPD (aOR 1.01; 95%CI 1.00, 1.02). There was no evidence of effect modification by sex, HIV, TB pneumonia, or socioeconomic status.

Conclusion: Among adults who had recovered from pneumonia in Kampala, PM2.5 was associated with reduced lung function, highlighting the importance of air pollution exposure mitigation in improving chronic lung health among vulnerable populations in resource-limited settings. Future work must differentiate PM2.5 sources in these settings to inform regionally appropriate mitigation efforts.

Rationale: Post Intensive Care Syndrome is a significant challenge for survivors of critical illness. However, little is understood about fear of falls - the concern for falls.

Objective: This study sought to quantify the prevalence of fear of falls within the first year after hospital discharge and identify factors associated with high fear of falls.

Methods: Mixed methods approach. Fear of falls was assessed using the Falls Efficacy Scale International short form questionnaire with participants dichotomised into low/moderate (7-12) and high fear of falls (13-28). Persistence was defined as high fear of falls across at least two assessment time points. Data were also collected on physical parameters, frailty, cognition, mood, quality of life and physical activity levels. Participants were assessed at hospital discharge, 3, 6, and 12 months.

Results: A high fear of falls was reported in 66 participants in the first 12 months with 41% reporting persistent high fear. High fear primarily commenced at hospital discharge (79%). Hospital discharge factors associated with reduced odds of experiencing high fear of falls in the first 12 months were: higher cognition, strength; physical function; balance; and health-related quality of life. Whereas increased odds of experiencing high fear were: older age, comorbidities; ICU-delirium; frailty; delayed quadriceps time to peak force and mental health impairments. The final multivariate model found that ICU survivors who had ICU delirium were more likely to have high fear of falls (OR 4.67; 95%CI: 1.18-18.48) whilst those with better balance were less likely to do so (OR 0.83, 95%CI 0.74-0.94). High fear of falls was not predictive of physical activity or function at 6 months however it was a significant predictor of depression. Qualitative data highlighted participant concern for further incapacitation through injury and loss of independence. Perceived causes were reduced strength, balance and fatigue. Participants described strategies they adopted to reduce their risk of falling including environmental scanning, gait aid use, and slow deliberate movement.

Conclusions: Fear of falls is a significant and persistent challenge for ICU survivors. Modifiable discharge factors exist such as strength, physical function/balance, ICU-related delirium and mood which may be the target of future post hospital interventions.

Rationale: The pulmonary embolism response team (PERT) model was developed to facilitate multispecialty decision-making and expedite therapeutic interventions for patients with pulmonary embolism (PE). PERT implementation has previously been associated with survival benefit in some studies, although specific workflow components that confer survival benefit have not been identified. Objectives: To measure the effects of PERT workflow revisions based upon risk stratification on clinical outcomes in an existing PERT. Methods: As a quality improvement initiative, we implemented three specific workflow interventions to an existing PERT program at an academic medical center: 1) designating triage responsibility to a specific group of providers; 2) assigning guideline-based risk stratification to all calls at triage; and 3) establishing intensive care unit admission guidelines on the basis of risk stratification. We used electronic medical records to review clinical outcomes for all PERT calls for 2 years after implementing the revised workflow and compared these with outcomes for the preceding 2-year period. We used logistic regression to compare the odds of in-hospital mortality before and after the workflow revision, with multiple models adjusted for clinically relevant variables. Results: During the study period (2019-2023), there were 420 unique patient PERT activations with confirmed PE; 253 patients were managed using the revised workflow, and 167 patients were managed using the historical workflow. The proportion of patients meeting the primary endpoint of in-hospital death at 30 days after the workflow revisions was significantly lower than during the historical period (6.3% vs. 18.0%; P < 0.001). Logistic regression analysis demonstrated the revised-PERT workflow to have a protective effect against in-hospital mortality (odds ratio = 0.31; 95% confidence interval = 0.16-0.59; P < 0.001). This mortality benefit remained significant after adjustment for demographics, clinical factors, hemodynamic instability, Pulmonary Embolism Severity Index class, and stage in the Bova scoring system. The workflow revisions were also associated with increased use of advanced therapies but did not change the proportion of patients with major bleeding or length of stay in the intensive care unit or hospital. Conclusions: In an existing PERT program, implementation of three specific workflow revisions centered around risk stratification and level-of-care triage improved survival for patients with PE. These findings suggest that incorporation of a standardized approach and risk stratification are valuable components of the PERT response.