CHEST pulmonary最新文献

Case Presentation

A 76-year-old female with a history of estrogen receptor-positive/progesterone receptor-positive/HER2-negative breast cancer presented to the pulmonary clinic with severe exertional dyspnea. She had no known history of cardiopulmonary disease and was in her usual state of health until 3 months prior to her presentation when she was diagnosed with a breast cancer recurrence in an axillary lymph node with associated osseous metastases. Subsequently, she had developed rapidly progressive exercise intolerance, orthopnea, and lower extremity edema.

Background

Sex-based differences are important in the development and progression of pulmonary arterial hypertension. However, it is not established whether these differences are generalizable to all forms of pulmonary hypertension (PH).

Research Question

What are the sex-based differences in right ventricle (RV) function and transplant-free survival in patients with PH from the Redefining Pulmonary Hypertension Through Pulmonary Vascular Disease Phenomics (PVDOMICS) cohort?

Study Design and Methods

Patients with PH enrolled in the PVDOMICS cohort study underwent right heart catheterization, cardiac MRI, and echocardiography. A multivariable linear regression model was used to investigate the interactive effect between sex and pulmonary vascular resistance (PVR) on RV ejection fraction (RVEF). Effects of sex, RVEF, and PVR on transplant-free survival were assessed using a Cox proportional hazards model.

Results

Seven hundred fifty patients with PH (62.8% female) were enrolled, including 397 patients with groups 2 through 5 PH. Patients with group 1 PH were predominantly female (73.4%). Male patients showed multiple markers of worse RV function with significantly lower RVEF (adjusted difference, 5.5%; 95% CI, 3.2%-7.8%; P < .001) on cardiac MRI and lower RV fractional shortening (adjusted difference, 4.0%; 95% CI, 2.3%-5.8%; P < .001) and worse RV free-wall longitudinal strain (adjusted difference, 2.4%; 95% CI, 1.2%-3.6%; P < .001) on echocardiography. Significant interaction was noted between PVR and sex on RVEF, with the largest sex-based differences in RVEF noted at mild to moderate PVR elevation. Male sex was associated with decreased transplant-free survival (adjusted hazard ratio, 1.46; 95% CI, 1.07-1.98; P = .02), partially mediated by differences in RVEF (P = .003).

Interpretation

In patients with PH in the PVDOMICS study, female sex was more common, whereas male sex was associated with worse RV function and decreased transplant-free survival, most notably at mild to moderate elevation of PVR.

Trial Registry

ClinicalTrials.gov; No.: NCT02980887; URL: www.clinicaltrials.gov

Background

Accurate measurement of cardiac output (CO) is critical in the evaluation and monitoring of pulmonary hypertension (PH). We assessed the accuracy of thermodilution (TD) CO vs direct Fick (DF) CO among patients with PH and evaluated whether the method of CO measurement affected diagnosis or risk assessment.

Research Question

Does using Thermodilution CO as compared to Direct Fick CO alter hemodynamic risk status in PH?

Study Design and Methods

We included patients who had undergone a right heart catheterization with both TD CO and DF CO measurements at University of California, Los Angeles between January 2021 and January 2023. Based on the cardiac index, patients were classified into low-, intermediate-, or high-risk hemodynamic status according to the European Society of Cardiology/European Respiratory Society guidelines.

Results

The analysis included 116 patients with PH. Of the patients, 55% were on PH therapy at the time of catheterization. The median age was 59 years (25th-75th percentile, 50-69), and 63% were female. The median TD CO and DF CO were 4.6 L/min (25th-75th percentile, 3.6-6.0) and 5.3 L/min (25th-75th percentile, 4.2-7.0) (P = .007), respectively. Bland-Altman analysis revealed a mean bias of −0.64 L/min. Median DF pulmonary vascular resistance and TD pulmonary vascular resistance were 4.7 Wood units (25th-75th percentile, 2.7-6.6) and 5.6 Wood units (25th-75th percentile, 3.0-8.0), respectively. Among patients with a low TD cardiac index, almost 40% had a preserved DF cardiac index. There was 78% agreement between DF and TD hemodynamic risk status. Using TD over DF reclassified 8% of patients with precapillary PH (n = 101) from low-risk into intermediate- or high-risk hemodynamic status. TD had a sensitivity of 97% for appropriately risk stratifying patients into intermediate-/high-risk status but a specificity of 73%. Overall, there was a strong correlation between DF CO and TD CO (concordance correlation coefficient, 0.81; 25th-75th percentile, 0.74-0.86).

Interpretation

Hemodynamic risk status was concordant between TD and DF measurements in almost 80% of patients. Oxygen consumption measurement should be considered if available on index right heart catheterization in patients with PH to aid in hemodynamic risk stratification or in whom strict pulmonary vascular resistance calculations are required.

Background

Lung function declines over the course of adulthood; however, a consensus on the normal range of decline in an individual’s lung function is lacking.

Research Question

What is the normal range and the upper limit of normal (ULN) decline in lung function in adults without prior tobacco use, occupational dust exposure, or a known diagnosis or symptoms of cardiopulmonary disease?

Study Design and Methods

A retrospective analysis of healthy individuals who have never smoked (N = 1,305) from the Framingham Heart Study with repeated lung function meeting standards for acceptability and reproducibility was conducted. Longitudinal change was derived using a linear mixed effects model and estimated to a 6-year interval. The ULN decline was defined as the 95th percentile.

Results

The mean follow-up between spirometry examinations was 5.5 years, whereas the mean follow-up between diffusing capacity for carbon monoxide studies was 5.9 years. Decline in FEV₁, FVC, and D accelerated with age, whereas decline in FEV₁/FVC decelerated with age. Decline varied with sex, age, and height. Over a 6-year period, the ULN decline in FEV₁ ranged from 383 to 667 mL, and the ULN decline in Dlco ranged from 3.6 to 9.5 mL/min/mm Hg. Overall, male individuals had faster absolute rates of decline than female individuals, whereas relative (%) rates of decline were similar between sexes.

Interpretation

Lung function decline is nonlinear and accelerates with age. In this cohort, the ULN decline over 6 years often exceeded current guidelines for interpreting significant longitudinal change in lung function.

Background

Racial differences in lung cancer screening (LCS) eligibility and outcomes persist despite recent expansion of the US Preventive Services Task Force criteria and greater recognition of screening disparities.

Research Question

What is the annual screening adherence rate for US Preventive Services Task Force-eligible Asian American individuals receiving LCS through a centralized screening program?

Study Design and Methods

Individuals screened through a centralized LCS program were identified retrospectively using the Jefferson LCS Program Registry. Sociodemographic and clinical data were extracted from the prospectively maintained registry. Frequency statistics were compared by race including among Asian American subgroups, and multivariate logistic regression was carried out for annual adherence with LCS.

Results

Among 2,257 individuals in the study cohort, 122 participants (5.4%) self-identified their race as Asian American. Compared with other racial groups, Asian American individuals had significant differences in sex distribution, educational attainment, and insurance status. The most common Asian American race subgroups were Chinese American, Korean American, and Vietnamese American, and significant differences in cigarette smoking intensity were seen between these groups. Among currently smoking individuals, Asian American individuals reported interest in tobacco counseling and pharmacotherapy treatment at rates similar to those of other races. Asian American individuals had significantly lower odds of adherence (adjusted OR, 0.42; 95% CI, 0.26-0.69) with annual screening than other races, even after adjustment for age, sex, educational attainment, smoking status, and COPD.

Interpretation

Asian American individuals in our centralized LCS program have increased rates of lung cancer-related factors including low educational attainment, high smoking prevalence, low tobacco cessation, and low annual LCS adherence compared with other racial groups. This gap highlights the need for greater focus on culturally tailored early detection strategies for this underserved population.

Pulmonary function tests (PFTs) are imperative to the diagnosis of people with respiratory symptoms and lung disease and to disease management. PFTs require expertise to obtain both high-quality tests and proficiency in test interpretation. In this review, we provide recommendations for obtaining high-quality test results in an efficient and cost-effective manner guided by available evidence and expert opinion. The medical director plays a critical role in pulmonary laboratory operations and ultimately is responsible for laboratory performance. Responsibilities of the medical director are reviewed and discussed. Quality control is an underappreciated part of the pulmonary laboratory that is that is necessary high-quality tests. What constitutes a complete PFT and the order that tests are performed may differ among laboratories. We suggest an approach to the performance of spirometry, bronchodilator-responsiveness testing, diffusing capacity, lung volumes, and tests of respiratory muscle strength that maximizes clinical usefulness and laboratory efficiency. Appropriate resources, time, and expertise are needed to run an efficient pulmonary function laboratory capable of performing high-quality testing.

Background

Care management programs for chronic lung disease attempt to reduce hospitalizations, yet have not reliably achieved this goal. A key limitation of many programs is that they target patients with characteristics associated with hospitalization risk, but do not specifically modify the mechanisms that lead to hospitalization.

Research Question

What are the common mechanisms underlying known patient-level risk characteristics leading to hospitalizations for acute exacerbations of chronic lung disease?

Study Design and Methods

We conducted a qualitative study of patients admitted to the University of Pennsylvania Health System with acute exacerbations of chronic lung disease between January and September 2019. We interviewed patients, their family caregivers, and their inpatient and outpatient clinicians about experiences leading up to the hospitalization. We analyzed the interview transcripts using triangulation and abductive analytic methods.

Results

We conducted 69 interviews focused on the admission of 22 patients with a median age of 66 years (interquartile range, 60-70 years), of whom 16 patients (73%) were female and 14 patients (64%) were Black. We interviewed 22 patients, 14 caregivers, 19 inpatient clinicians, and 14 outpatient clinicians. We triangulated the available interview data for each patient admission and identified the underlying mechanisms of how several known patient characteristics associated with risk actually led to hospitalization. These mechanisms included limited capacity for home management of acute symptom changes, barriers to accessing care, chronic functional limitations, and comorbid behavioral health disorders. Importantly, many of the clinical, social, and behavioral mechanisms underlying hospitalizations were present for months or years before the symptoms that prompted inpatient care.

Interpretation

Care management programs should be built to target specific clinical, social, and behavioral mechanisms that directly lead to hospitalization. Upstream interventions that reduce hospitalization risk are possible given that many contributory mechanisms are present for months or years before the onset of acute exacerbations.