Annals of the American Thoracic Society最新文献

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.

Rationale: Dyspnea (breathlessness) commonly impacts patients with lung cancer, worsening depression, anxiety, quality of life, and functioning. Current treatments are limited. Objectives: To test the acceptability, feasibility, and preliminary efficacy of "Take a Breath" (TAB), a novel cognitive-behavioral treatment for dyspnea. Methods: A randomized controlled trial compared TAB with standard of care (SOC) in patients with lung cancer reporting at least moderate dyspnea (N = 45). TAB consisted of five 1-hour weekly individual sessions employing exposure-based interventions paired with pulse oximetry biofeedback, psychoeducation, and behavioral skills (e.g., pursed lip breathing). The Client Satisfaction Questionnaire-8 measured acceptability. Accrual, treatment retention, and homework completion measured feasibility. Primary outcomes were the American Thoracic Society Dyspnea Scale (dyspnea-related functioning) and Cancer Dyspnea Scale (dyspnea-related effort, discomfort, and anxiety). Secondary outcomes included depression (Patient Health Questionnaire-9), health-related quality of life (12-item Short Form Health Survey), physical activity (International Physical Activity Questionnaire Short Form), and functional status (Karnofsky performance status). Measurements occurred at baseline, midtreatment (3 wk), post-treatment (6 wk), and 1-month follow-up. Robust mixed-effects modeling tested group × time interactions. Results: TAB was at least "mostly satisfactory" for 75% of participants. The accrual was 25.6%, with 60% completing all sessions and an 88.7% homework completion rate. Intention-to-treat analysis revealed greater improvements in TAB than SOC for dyspnea-related functioning (Cohen's d = 0.82; P = 0.03) and anxiety (Cohen's d = 0.87; P < 0.01) at post-treatment and follow-up. TAB outperformed SOC in improving depressive symptoms, health-related quality of life, sedentary time, and performance status over time (all P < 0.05). Conclusions: TAB yielded symptom, psychological, and functional improvements, establishing its readiness for further testing as the first comprehensive cognitive-behavioral treatment for dyspnea and related sequelae. Clinical trial registered with www.clinicaltrials.gov (NCT05304793).

Deployed military personnel often develop respiratory symptoms and disorders due to exposure to particulate matter such as dust, blast materials, and burn pit emissions. A range of deployment-related respiratory diseases have been reported, including toxic lung injury, eosinophilic pneumonia, asthma, chronic obstructive pulmonary disease, bronchiolitis, and interstitial lung disease. The Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act of 222, which was enacted in 2022, expanded coverage of medical care for veterans and improved awareness of deployment-related respiratory diseases. This law added 23 diagnoses presumed to be connected to deployment but has failed to address issues related to the diagnosis of deployment-related respiratory disorders. Diagnosing some of the respiratory disorders associated with deployment can be challenging, as symptoms are often nonspecific. Veterans who present with respiratory symptoms should undergo a comprehensive assessment, including a detailed medical and exposure history, pulmonary function tests, imaging, and serologic screening for autoimmune disorders. A decision on whether a surgical lung biopsy should be performed should be made on a case-by-case basis on the basis of multidisciplinary review and an informed discussion with the patient. The clinical care team should discuss pharmacological and nonpharmacological treatment options with the patient and direct them to reliable sources of information. Long-term follow-up is essential to monitor for worsening of pulmonary function or symptoms. Further research is needed to characterize associations between deployment-related exposures and respiratory health outcomes and to inform better means of assessment and treatment of military veterans.

Rationale: Combined pulmonary fibrosis and emphysema (CPFE) is a unique phenotype with important prognosis and management implications in patients with idiopathic pulmonary fibrosis (CPFE-IPF) and other forms of fibrotic interstitial lung disease (CPFE-fILD). However, the epidemiology of CPFE is not well characterized, creating a barrier to clinical research needed to advance our understanding and management. Objectives: To investigate the incidence, prevalence, and long-term outcomes of CPFE among a regional cohort of veterans. Methods: We retrospectively reviewed records for veterans in the Veterans Affairs Mid-Atlantic Health Care Network (includes North Carolina and Virginia) with International Classification of Disease, Ninth Revision, codes for pulmonary fibrosis between January 1, 2008, and December 31, 2015. We stratified pulmonary fibrosis into IPF and fILD using diagnostic codes and chart review. We reviewed computed tomography reports and classified cases as having CPFE according to documented emphysema; a thoracic radiologist overread a subset of scans for validation. We calculated annual incidence and prevalence of CPFE and compared characteristics between veterans with CPFE and veterans with fibrosis without emphysema using chi-square tests, Mann-Whitney U tests, and paired t tests. We used Kaplan-Meier and Cox models to determine overall survival from diagnosis. Results: We identified 2,414 veterans with fILD. Among 1,880 veterans with IPF, 734 (39.0%) had CPFE-IPF; among 534 veterans with fILD, 194 (36.3%) had CPFE-fILD. Agreement between computed tomography reports and thoracic radiologist review was high (kappa = 0.78). Annual CPFE prevalence ranged from 71 to 100 per 100,000 veterans, and incidence ranged from 16 to 39 per 100,000 veterans. CPFE was associated with male sex, lower body mass index, greater tobacco history, higher forced vital capacity, reduced forced expiratory volume in 1 second/forced vital capacity ratio, reduced diffusing capacity of the lung for carbon monoxide, and increased oxygen use. CPFE was associated with increased mortality in unadjusted models. However, after adjustment for age, sex, and body mass index, CPFE was not associated with survival for CPFE-IPF versus IPF without emphysema (hazard ratio, 1.13; 95% confidence interval, 0.96-1.33) as well as CPFE-fILD versus fILD without emphysema (hazard ratio, 1.16, 95% confidence interval, 0.82-1.63). Conclusions: CPFE has a high incidence and prevalence among veterans with IPF and fILD and has a distinct phenotype with diagnostic and therapeutic implications. Further studies investigating diagnosis, treatment considerations, and long-term impacts in CPFE are merited.