CHEST pulmonary最新文献

Background

Sex assigned at birth is currently used to calculate predicted normative values for oxygen consumption during cardiopulmonary exercise testing (CPET) in transgender and gender-diverse (TGD) patients. It is unclear if this is physiologically valid once gender-affirming hormonal therapy (GAHT) has been instituted.

Research Question

What are the changes in functional aerobic capacity (FAC) and % predicted peak oxygen consumption ($\dot{V}$o₂peak) when gender is used, instead of sex assigned at birth (SAB), to estimated normative predicted values among TGD patients aged > 14 years who are receiving GAHT?

Study Design and Methods

We retrospectively analyzed 16 referred TGD patients (eight transgender men and eight transgender women) receiving GAHT at the time of the test. Data collected and analyzed included the following: clinical indication for CPET, biometrics (age, height, and weight), CPET parameters (treadmill, Mayo Clinic protocol, without chest binder), chest imaging, echocardiographic results, and hemoglobin levels.

Results

In transgender women, the use of gender congruent normative predictive values, instead of SAB, significantly increased FAC (mean ± SE for SAB and gender, respectively, 69.70% ± 4.35% vs 87.82% ± 5.15%; P ≤ .0001) and % predicted Vo₂peak (mean ± SE for SAB and gender, respectively, 66.53% ± 4.17% vs 89.69% ± 5.60%; P ≤ .0001). In transgender men, the use of gender congruent normative predictive values showed that both FAC and % predicted Vo₂peak significantly decreased (approximately 20% and 25%, respectively). Deconditioning was the most frequent CPET finding among transgender men.

Interpretation

Among TGD individuals receiving GAHT, the use of gender to calculate normative values affects % predicted peak exercise oxygen consumption and FAC significantly. Body composition changes after GAHT require regular monitoring of muscle strength, lean body mass, and aerobic capacity. Cardiopulmonary symptoms among TGD patients should be assessed with these variables in mind, especially in the presence of chronic cardiac and pulmonary diseases.

Background

After COVID-19, some patients present with ongoing symptoms (eg, breathlessness, exercise limitations), even after mild acute infection.

Research Question

What is the exercise capacity of patients diagnosed with long COVID and does it change from baseline to 1-year follow-up?

Study Design and Methods

This retrospective case series included patients with persistent symptoms after a confirmed diagnosis of COVID-19. Exercise capacity was examined by cardiopulmonary exercise testing (CPET), and parameters related to performance, ventilation, circulation, and gas exchange were compared with predicted values. A subgroup of patients was retested 1 year after baseline, and self-reported physical fitness was assessed at follow-up.

Results

In total, 169 patients completed baseline CPET and 41 patients completed 1-year follow-up. Mean maximum workload was 172 W (95% CI, 161-182), with 19% not achieving at least 84% predicted workload. Mean peak oxygen uptake was 24.4 mL/kg/min (95% CI, 23.1-25.7), and 36% had a value below % predicted. Oxygen uptake/workload slope below the normal threshold of 8.4 mL/min/W was observed in 54% of patients. The 1-year follow-up results showed no statistically significant changes in any of the CPET parameters, which correspond to lack of improvement in self-reported physical fitness.

Interpretation

Patients with long COVID demonstrated lowered peak oxygen uptake, oxygen uptake/workload slope, and/or ventilatory equivalent for carbon dioxide, but different parameters were lowered in different patients, illustrating a heterogeneous study population. No improvements in any parameters were found at 1-year follow-up.

Background

The Envisia Genomic Classifier (EGC) is a clinically validated molecular diagnostic test identifying usual interstitial pneumonia (UIP), increasing the diagnostic confidence for idiopathic pulmonary fibrosis in patients with interstitial lung disease (ILD).

Research Question

What is the association of the EGC and lung cryobiopsy on clinical management decisions in patients with fibrotic ILD?

Study Design and Methods

Retrospective analysis of patients at multimedical centers. We assessed the change in management strategy after EGC and cryobiopsy. We evaluated the association between genomic UIP classification and disease progression using the American Thoracic Society definition of progressive pulmonary fibrosis (method 1), or combined end point of death from any cause, lung transplant, or ≥ 10% relative decline in FVC (method 2).

Results

In patients that were EGC positive for UIP (gcUIP+), 78.6% were diagnosed with idiopathic pulmonary fibrosis. Cryobiopsy and EGC test results changed management strategy for 59.5% of patients in the cohort that were gcUIP+, and 21.4% of patients that had indeterminate cryobiopsy interpretations were gcUIP+, leading to a change in treatment strategy of an additional 16.7%. There was a decrease in follow-up without treatment from 64.3% to 11.9% (P < .001). Utilization of immunosuppressive drugs decreased from 23.8% to 9.5% (P = .06), and there was an increase in treatment with antifibrotics drugs from 11.9% to 71.4% (P < .001). A Kaplan-Meier curve of disease progression did not reach statistical significance on multivariable analysis (method 1: hazard ratio, 1.4; 95% CI, 0.4-4.2; P = .55; method 2: hazard ratio, 1.3; 95% CI, 0.8-2.1; P = .29). In analysis of EGC positivity for UIP, patients who were not prescribed antifibrotics showed disease progression compared with patients who were EGC negative for UIP (hazard ratio, 1.8; 95% CI, 0.99-3.4; P = .053)

Interpretation

This study suggests that combined EGC and cryobiopsy are associated with change in therapeutic strategy in patients with undiagnosed ILD. The EGC might serve as a predictor for disease progression in patients not treated with antifibrotics.

Cerebral palsy is the most common motor disability in childhood with increasing survival rates into adulthood. Pulmonary complications are a leading cause of morbidity and mortality in this population. However, adult pulmonologists are rarely trained on how to receive these patients into their practice, including how best to identify and manage pulmonary complications. Quality studies on pulmonary complications in cerebral palsy, both in the adult and pediatric population, are lacking, but we review the available literature to provide an approach for the adult pulmonologist in identifying risk factors for pulmonary complications including aspiration, impaired airway clearance, airways disease, neuromuscular scoliosis and restrictive chest wall disease, sleep-disordered breathing, and hypoventilation. We provide a framework to help manage these pulmonary complications and plan and organize successful multidisciplinary transition of pulmonary care from adolescence to adulthood, largely extrapolating from small pediatric studies, studies on neurodevelopmental disorders in general, international guidelines, and clinical experiences, until more quality studies on this topic are available.

Background

Standard-of-care treatment options for stage I non-small cell lung cancer (NSCLC) include surgery and stereotactic body radiation therapy (SBRT). Notwithstanding a lack of prospective evidence demonstrating superior long-term survival with either of these treatments, evidence-based guidelines currently recommend only surgery for patients with operable disease and to limit SBRT for patients with inoperable disease.

Research Question

Do surgery or SBRT lead to superior survival rates for operable stage I NSCLC?

Study Design and Methods

A phase 3 randomized clinical trial was designed to compare the overall survival (OS) rates after surgery or SBRT for stage I NSCLC. Eligible participants must have biopsy-confirmed NSCLC measuring ≤ 5 cm in maximum diameter located > 1 cm from the trachea, proximal bronchial tree, esophagus, and spinal cord. Participants must be staged with fluorodeoxyglucose PET scans with mandatory biopsies of all radiographic areas concerning for regional or distant metastatic disease. The planned accrual is 670 patients to detect a 10% absolute benefit in 5-year OS with surgery or SBRT. Secondary outcome measures include patient-reported quality of life, respiratory function, health state utilities, patterns of lung cancer relapse, and causes of mortality by independent adjudication.

Results

The study was initiated in April 2017 with a planned ramp-up phase at six Veterans Affairs medical centers. Adapted recruitment interventions contributed to overcoming historical barriers to randomizing eligible participants between surgery and SBRT, and the study was expanded to 16 sites in May 2019. As of July 5, 2023, 280 of 670 planned participants have been enrolled.

Interpretation

The final results are expected to clarify the role of SBRT in lieu of surgery for patients with operable stage I NSCLC and to facilitate more informed discussions about these treatment options.

Trial Registry

ClinicalTrials.gov; No.: NCT02984761; URL: www.clinicaltrials.gov

Background

Pediatric sleep-disordered breathing (SDB) disproportionately affects children with low socioeconomic status (SES). The multilevel risk factors that drive these associations are not well understood.

Research Question

What are the associations between SDB risk factors, including individual health conditions (obesity, asthma, and allergies), household SES (maternal education), indoor exposures (environmental tobacco smoke [ETS] and pests), and neighborhood characteristics (neighborhood disadvantage), and pediatric SDB symptoms?

Study Design and Methods

Cross-sectional analyses were performed on 303 children (aged 6-12 years) enrolled in the Environmental Assessment of Sleep Youth study from 2018 to 2022. Exposures were determined by caregiver reports, assays of measured settled dust from the child’s bedroom, and neighborhood-level Census data (deriving the Childhood Opportunity Index to characterize neighborhood disadvantage). The primary outcome was the SDB-related symptom burden assessed by the OSA-18 questionnaire total score. Using linear regression models, we calculated associations between exposures and SDB-related symptom burden, adjusting for sociodemographic factors, then health conditions, indoor environment, and neighborhood factors.

Results

The sample included 303 children (39% Hispanic, Latino, Latina, or Spanish origin; 30% Black or African American; 22% White; and 11% other). Increasing OSA-18 total scores were associated with low household SES after adjustment for demographic factors, and with asthma, allergies, ETS, pests (mouse, cockroach, and rodents), and an indoor environmental index (sum of the presence of pests and ETS; 0-2) after adjusting for sociodemographic factors. Even after further adjusting for asthma, allergies, and neighborhood disadvantage, ETS and pest exposure were associated with OSA-18 (ETS: β = 12.80; 95% CI, 7.07-18.53, also adjusted for pest; pest exposure: β = 3.69; 95% CI, 0.44-6.94, also adjusted for ETS).

Interpretation

In addition to associations with ETS, a novel association was observed for indoor pest exposure and SDB symptom burden. Strategies to reduce household exposure to ETS and indoor allergens should be tested as approaches for reducing sleep health disparities.

Case Presentation

A 78-year-old man is admitted to the ICU for acute respiratory distress requiring endotracheal intubation. The patient was in his usual state of health and had seen his primary care physician earlier that day for a routine visit and influenza immunization. Later in the evening, the patient developed acutely worsening shortness of breath. He had no fever or chills, worsening cough, purulent sputum, wheezing, stridor, chest pain, palpitation, or known sick contacts. Family members noted that his face looked puffy, but he did not have lip or tongue swelling, difficulty swallowing, odynophagia, or a new rash. On ambulance arrival, the patient was noted to have significant respiratory distress. He was subsequently intubated at the scene and transferred to the hospital for further evaluation and management. The patient was known to have paroxysmal atrial fibrillation and COPD requiring 2 to 4 L of oxygen via nasal cannula at baseline. Social history was notable for prior use of tobacco. Family history was negative for allergies, pulmonary disease, and malignancy. The patient was last hospitalized for COPD exacerbation > 1 year prior to this admission. Otherwise, he remained adequately adherent to his COPD treatment.

Topic Importance

Ulcerative colitis and Crohn’s disease are multisystem illnesses that primarily affect the gut, but present with various extraintestinal manifestations. The pathogenesis behind these clinical features is poorly understood, and pulmonary manifestations of inflammatory bowel disease (IBD) are no exception. Research has suggested an intricate interplay between the mucosal immune system and the microbiotic environment between the gut and the lung, often termed the gut-lung axis. This dysregulated communication is demonstrated in a wide range of pulmonary complications involving the large and small airways, lung parenchyma, serosal tissues, and pulmonary vasculature; fistulous connection between the gastrointestinal tract and thoracic cavity; and drug toxicities. Most of these diseases have been well documented in case reports to respond to corticosteroid treatment regimens. However, a notable lack of treatment recommendations guiding the dosage and duration of steroid use and managing the disease refractory to therapy are available. In addition, the progressive and debilitating disease often remains a therapeutic challenge.

Review Findings

This review sheds light on the different strategies documented to treat the spectrum of pulmonary complications of IBD, including novel therapeutic approaches using immunomodulatory therapy, and summarizes their clinical and radiologic features with pathologic correlation.

Summary

Although their existence is well documented, further research is needed to develop evidence-based guidelines for diagnosing, managing, and preventing pulmonary complications of IBD.

Background

Point-of-care ultrasonography (POCUS) machines may use deep learning, a subfield of artificial intelligence (AI), to improve image interpretation and acquisition in real time. The impact of AI on POCUS learning is unknown.

Research Question

Do AI-enhanced devices equipped with deep learning aid in cardiac image acquisition and interpretation among POCUS novices?

Study Design and Methods

We conducted a single-center investigation from 2021 through 2022. Internal medicine trainees (N = 43) with limited POCUS experience were randomized to receive a POCUS device with (Echonous; n = 22) or without (Butterfly; n = 21) AI functionality for 2 weeks while on inpatient rotations. AI device functionality included guidance for optimal probe placement to acquire an apical four-chamber (A4C) view and ejection fraction estimations based on deep learning. Participants used the devices at their discretion for patient-related care after randomization. The primary outcome was the time to acquire A4C images on a standardized patient. Secondary outcomes included A4C image quality using a validated scale, image quiz performance, and attitudes. Measurements were performed at randomization and at 2-week follow-up using the same standardized patient.

Results

Both AI and non-AI groups showed similar scan times and image quality scores at baseline. At follow-up, the AI group showed faster scan times (57 s [interquartile range (IQR), 32-75 s] vs 85 s [IQR, 50-172 s]; P = .01), higher image quality scores (4.5 [IQR, 2-5.5] vs 2 [IQR, 1-3]; P < .01), and more accurately identified reduced systolic function on the image quiz (85% vs 50%; P = .02) vs the non-AI group. The AI group used the devices more than the non-AI group (median, 5.5 times [IQR, 4-10 times] vs 2 times [IQR, 0-4 times]; P < .01). Trust in the AI features did not change during the intervention.

Interpretation

POCUS devices with deep learning functionality may improve A4C image acquisition and interpretation by novices. Future studies are needed to determine the extent that AI impacts POCUS learning.