CHEST pulmonary最新文献

Background

Short-term increases in air pollution are associated with poor asthma and COPD outcomes. Short-term elevations in fine particulate matter (PM_2.5) due to wildfire smoke are becoming more common.

Research Question

Are short-term increases in PM_2.5 and ozone in wildfire season and in winter inversion season associated with a composite of emergency or inpatient hospitalization for asthma and COPD?

Study Design and Methods

Case-crossover analyses evaluated 63,976 and 18,514 patients hospitalized for primary discharge diagnoses of asthma and COPD, respectively, between January 1999 and March 2022. Patients resided on Utah’s Wasatch Front where PM_2.5 and ozone were measured by Environmental Protection Agency-based monitors. ORs were calculated using Poisson regression adjusted for weather variables.

Results

Asthma risk increased on the same day that PM_2.5 increased during wildfire season (OR, 1.057 per +10 μg/m³; 95% CI, 1.019-1.097; P = .003) and winter inversions (OR, 1.023 per +10 μg/m³; 95% CI, 1.010-1.037; P = .0004). Risk decreased after 1 week, but during wildfire season risk rebounded at a 4-week lag (OR, 1.098 per +10 μg/m³; 95% CI, 1.033-1.167). Asthma risk for adults during wildfire season was highest in the first 3 days after PM_2.5 increases, but for children, the highest risk was delayed by 3 to 4 weeks. PM_2.5 exposure was weakly associated with COPD hospitalization. Ozone exposure was not associated with elevated risks.

Interpretation

In a large urban population, short-term increases in PM_2.5 during wildfire season were associated with asthma hospitalization, and the effect sizes were greater than for PM_2.5 during inversion season.

Background

When administered as first-line intervention to patients admitted with acute hypercapnic respiratory failure secondary to COPD exacerbation in conjunction with guideline-recommended therapies, noninvasive ventilation (NIV) has been shown to reduce mortality and endotracheal intubation. Opportunities to increase uptake of NIV continue to exist despite inclusion of this therapy in clinical guidelines. Prior studies suggest that efforts to increase NIV use in acute exacerbation of COPD (AECOPD) need to account for the complex and interprofessional nature of NIV delivery and the need for interprofessional team coordination.

Research Question

We sought to develop an evidence-based interprofessional algorithm to apply NIV in AECOPD to improve the appropriate utilization of NIV in AECOPD.

Study Design and Methods

In this prospective qualitative descriptive study, subject matter expert physicians, nurses, and respiratory therapists practicing in a variety of clinical settings caring for patients with AECOPD were recruited for semistructured interviews. The Consolidated Criteria for Reporting Qualitative Research checklist was followed for interview development. Interview themes applicable to interprofessional collaborative practice were identified using deductive thematic analysis. An NIV algorithm based on recent society guidelines was constructed. Interprofessional team tasks appropriate for each phase of the NIV process were integrated into the algorithm.

Results

We present an interprofessional team-based algorithm for delivery of NIV in AECOPD inclusive of patient selection and initiation, titration, monitoring, and weaning of NIV. The goal is to increase appropriate uptake of NIV in the AECOPD population.

Interpretation

The identified roles and responsibilities of an interprofessional team could be integrated into an interprofessional education program pertaining to use and management of NIV for patients with AECOPD emphasizing collaborative best practice, interprofessional team communication, and support of professional autonomy when appropriate.

Case Presentation

A 28-year-old woman presented to the outpatient setting with right-sided intermittent chest pain for the past 8 months. For the past 3 months, she noticed breathlessness initially on exertion, which had progressed to dyspnea at rest. She also reported intermittent cramping abdominal pain, predominantly in the pelvis, that worsened during each menstrual cycle. She had regular menses and denied the use of any hormonal-based or barrier methods of contraception. She had never smoked. She was married and delivered a child 10 years ago. Two years before this presentation, she had undergone medical termination of pregnancy. A previous Pap smear of the cervix was normal. She denied any history of cough, hemoptysis, vomiting, diarrhea or hematemesis, dyspareunia, or post-coital bleeding. There was no relevant family history.

Case Presentation

A 69-year-old male with a history of ongoing tobacco use and long-standing history of seropositive rheumatoid arthritis on chronic immunosuppressive therapy (daily hydroxychloroquine, weekly methotrexate with etanercept) presented to the outpatient clinic with 6 weeks of weight loss, cough, and malaise. There was no history of recent infections, hospitalizations, or other significant changes to his health other than having a 3-month lapse in his rheumatoid arthritis medications due to prescription filling issues.

Background

Eccentric cycling exercise (ECC) allows training at low metabolic costs and may therefore be valuable for patients with precapillary pulmonary hypertension (PH) due to pulmonary vascular disease (PVD).

Research Question

What are the ventilatory and circulatory responses of ECC vs concentric cycling exercise (CON) in patients with PVD?

Study Design and Methods

This was a randomized controlled crossover trial in which patients diagnosed with PVD, defined as either pulmonary arterial or chronic thromboembolic PH, performed CON and ECC cycling tests at identical submaximal work rates, following stepwise incremental protocols. Oxygen uptake and additional cardiorespiratory responses were measured breath-by-breath by ergospirometry. Hemodynamic parameters (eg, systolic pulmonary arterial pressure [sPAP], tricuspid annular plain systolic excursion) were measured by echocardiography.

Results

Thirty-three patients (19 with pulmonary arterial hypertension and 14 with chronic thromboembolic PH; 13 female; mean age, 50 ± 15 years) were included. At identical work rates during ECC compared with CON, oxygen uptake was significantly lower by −200 mL/min (−40%; 95% CI, −272 to −129; P < .01), minute ventilation was significantly lower by −5.5 L/min (−30%; 95% CI, −9.2 to −3.1; P < .01), and sPAP was significantly lower by −12 mm Hg (−20%; 95% CI, −20 to −4; P < .01). Right ventricular-arterial coupling, as measured by tricuspid annular plain systolic excursion/sPAP, was 0.11 mm/mm Hg higher (31%; 95% CI, 0.04-0.18; P < .01). No adverse events occurred.

Interpretation

This study supports the hypothesis that ECC is a feasible and well-tolerated exercise modality for patients with PVD, with lower oxygen demand and a reduced load on the right ventricle. Future studies should investigate whether ECC improves exercise capacity, muscle force, and possibly hemodynamics during prolonged rehabilitation programs in patients with PVD.

Clinical Trial Registration

ClinicalTrials.gov; No.: NCT05186987; URL: www.clinicaltrials.gov

Background

Unexplained chronic cough (UCC) is characterized by persistent coughing without evident medical explanation.

Research Question

Does daily oral administration of natural capsaicin (chili) improve refractory coughing in patients with UCC?

Study Design and Methods

Forty-six patients (mean age, 60.5 years) with UCC participated in this crossover, randomized double-anonymized study. For 4 weeks, the participants took capsules containing pure capsaicin orally, and after a washout of 2 weeks, took placebo capsules for 4 weeks. A capsaicin inhalation cough test was used to assess the capsaicin inhalation concentration required to reach two coughs and the capsaicin inhalation concentration required to reach five coughs. The number of coughs in a 24-h period and the number of coughs per hour were recorded on four occasions using the Leicester Cough Monitor. Participants completed questionnaires with items on cough, cough-related symptoms, and quality of life.

Results

The mean values for capsaicin inhalation concentration required to reach two coughs and the capsaicin inhalation concentration required to reach five coughs increased after the capsaicin treatment period as compared with the first visit (baseline; P < .05 and P < .03, respectively), although they did not differ from the placebo recordings. Neither the capsaicin nor the placebo treatment significantly reduced the cough frequency, nor did they differ between the two treatment periods. When dividing the participants into low-cougher (≤ 400 coughs within 24 h) and high-cougher (> 400 coughs within 24 h) groups, the low coughers experienced a significantly better outcome from capsaicin, but not from placebo. The visual analog scale symptom scores improved after capsaicin treatment compared with baseline and placebo treatment in terms of the frequencies of coughing (P < .001), rhinitis (P < .03), and throat irritation (P < .01). The Leicester Cough Questionnaire scores improved after capsaicin treatment compared with baseline and compared with the placebo treatment group for all the domains (P < .01 for the total score).

Interpretation

In this study, capsaicin powder taken orally was found to be clinically effective and well tolerated by patients with UCC. The results suggest a future treatment for UCC.

Trial Registry

European Union Drug Regulating Authorities Clinical Trials Database; No.: EudraCT 2016-004463-39; URL: https://www.clinicaltrialsregister.eu

ClinicalTrials.gov; No.: NCT04125563; URL: www.clinicaltrials.gov

Background

Lung nodule incidence is increasing. Many nodules require biopsy to discriminate between benign and malignant causes. The gold standard for minimally invasive biopsy, CT scan-guided transthoracic needle biopsy (CT-TTNB), has not been compared directly with navigational bronchoscopy, a method that recently has seen rapid technological innovation and is associated with improving diagnostic yield and lower complication rates. Current estimates of the diagnostic usefulness of both methods are based largely on noncomparative data with significant risk for selection, referral, and publication biases.

Research Question

Is contemporary navigational bronchoscopy noninferior to CT scan-guided transthoracic needle biopsy for the diagnosis of indeterminate pulmonary nodules?

Study Design and Methods

Navigation Endoscopy to Reach Indeterminate Lung Nodules vs Transthoracic Needle Aspiration, a Randomized Controlled Study, is a multicenter, 1:1 randomized, parallel-group trial designed to ascertain whether electromagnetic navigational bronchoscopy with integrated digital tomosynthesis is noninferior to CT-TTNB for the diagnosis of peripheral lung nodules 10 to 30 mm in diameter with before testing probability of malignancy of at least 10%. The primary end point is diagnostic accuracy through 12 months of follow-up. Secondary end points include diagnostic yield, complication rate, procedure duration, need for additional invasive diagnostic procedures, and radiation exposure.

Results

This article describes the protocol and rationale for the Navigation Endoscopy to Reach Indeterminate Lung Nodules vs Transthoracic Needle Aspiration, a Randomized Controlled Study, designed to answer the study question.

Interpretation

The results of this rigorously designed trial will provide high-quality data regarding the management of lung nodules, a common clinical entity that often represents the earliest and most treatable stage of lung cancer. Several design challenges are described. Notably, all nodules are reviewed centrally by an independent interventional pulmonology and radiology adjudication panel relying on prespecified exclusions to ensure enrolled nodules are amenable to sampling by both methods while protecting against selection bias favoring either method. Conservative diagnostic yield and accuracy definitions with prespecified criteria for what nonmalignant findings may be considered diagnostic were chosen to avoid inflation of estimates of diagnostic usefulness.

Trial Registry

ClinicalTrials.gov; No.: NCT04250194; URL: www.clinicaltrials.gov