Chest最新文献

A 72-year-old gentleman with metastatic pancreatic cancer was admitted to the ICU with increased oxygen demand and confusion, likely related to pulmonary metastases. In the presence of his son, the healthcare agent, and the team, the patient requested to be do-not-attempt-resuscitation and do-not-intubate (DNR/DNI) before losing decision-making capacity. When the patient's brother and another son heard of the code status change, they insisted on a return to Full Code. Although the youngest son (the healthcare agent) was present for the patient's request to be DNR/DNI, he declined to represent the patient's wishes and agreed with a return to Full Code. Numerous discussions over subsequent days revolved around the attempt to honor the patient's wishes in the setting of the surrogate's unwillingness or inability to make decisions in alignment with his father's wishes. This case reviews and analyzes the ethical options available to the clinical team in responding to requests for potentially inappropriate treatment at a patient's end of life, and explores the roles of relational autonomy, beneficence vs nonmaleficence, and holding the balance of clinicians' and ethicists' professional, legal, and ethical responsibilities.

Background: Evaluating expiratory airway function in infants is challenging, as the gold standard, the raised-volume rapid thoraco-abdominal compression technique is technically difficult and has a high failure rate.

Research question: Are measurements obtained during passive expiration from total lung capacity correlated with forced expiration measurements obtained by the raised-volume technique in infants?

Study design and methods: This observational retrospective analysis included infants born ≥ 36 weeks gestation who underwent pulmonary function testing using the raised-volume rapid thoraco-abdominal compression technique at Hadassah Medical Centre between January 2011 and December 2019. Technically acceptable forced and passive flow-volume curve measurements were included in the analysis.

Results: Out of 296 eligible infants, 276 (93%) had technically acceptable passive flow-volume curves while 226 (76%) had acceptable forced curves (p<0.001). The success rate of producing an acceptable curve was 70% for the passive curves and 39% for forced curves (p < 0.001). The Spearman correlation coefficients of vital capacity, expiratory volumes at 0.5 second, maximal expiratory flows, and expiratory flows at 50%, 75% and 85% of vital capacity were 0.92, 0.72, 0.83, 0.66, 0.67, 0.68, respectively (n= 226; p<0.001 for all). The correlation remained high regardless of the level of expiratory airway obstruction, gender or age. The mean inter-maneuver coefficients of variation were fairly low for both methods (5.2% vs 5.4%, p=NS).

Interpretation: The passive flow-volume curve offers reliable and reproducible data with high correlation to the forced flow-volume curve. Therefore, the passive flow-volume curve can serve as an alternative tool in evaluating expiratory airway function in infants.

Background: Chronic obstructive pulmonary disease (COPD) management is guided by the respiratory symptom burden, assessed using the modified Medical Research Council (mMRC) scale and/or COPD Assessment Test (CAT).

Research question: What is the ability of mMRC and CAT to detect abnormally high exertional breathlessness on incremental cardiopulmonary cycle exercise testing (CPET) in people with COPD?

Study design and methods: Analysis of people aged ≥40 years with post-bronchodilator FEV₁/FVC<0.70 and ≥10 smoking pack-years from the Canadian Cohort Obstructive Lung Disease study. Abnormal exertional breathlessness was defined as a breathlessness (Borg 0-10) intensity rating > upper limit of normal (ULN) at the symptom-limited peak of CPET using normative reference equations.

Results: We included 318 people with COPD (40% women), age 66.5±9.3 years (mean±SD), FEV₁ 79.5±19.0%predicted; 26% had abnormally low exercise capacity (V'O_2peak

Interpretation: In COPD, mMRC and CAT have low concordance with CPET and fail to identify many people with abnormally high exertional breathlessness.

Background: Recent treatment guidelines for chronic obstructive pulmonary disease (COPD) have replaced the long-acting beta₂-agonist and inhaled corticosteroid (LABA-ICS) combination with single-inhaler triple therapy that adds a long-acting muscarinic antagonist (LAMA-LABA-ICS). Yet, the corresponding trials reported numerically higher incidences of cardiovascular adverse events with triple therapy compared with LABA-ICS.

Research question: Does single-inhaler triple therapy increase the incidence of major adverse cardiovascular events, compared with LABA-ICS, in a real-world clinical practice setting?

Study design and methods: We identified a cohort of COPD patients, 40 years or older, treated during 2017-2021, from the United Kingdom's Clinical Practice Research Datalink. Among LAMA-naïve patients, initiators of single-inhaler triple therapy were matched 1:1 to LABA-ICS users on time-conditional propensity scores. They were compared on the incidence of major adverse cardiovascular events (MACE), defined as hospitalization for myocardial infarction or stroke, or all-cause-mortality, over one year.

Results: The cohort included 10,255 initiators of triple therapy and 10,255 matched users of LABA-ICS. The incidence rate of MACE was 11.3 per 100 per year with triple therapy compared with 8.7 per 100 per year for LABA-ICS. The corresponding adjusted hazard ratio (HR) of MACE with triple therapy was 1.28 (95% CI: 1.05-1.55), relative to LABA-ICS, though the increase was mainly in the first four months (HR 1.41; 95%CI: 1.14-1.74). The HR of all-cause death was 1.31 (95% CI: 1.06-1.62), while for acute myocardial infarction and stroke hospitalization it was 1.00 (95% CI: 0.56-1.79) and 1.06 (95% CI: 0.48-2.36), respectively, with triple therapy, relative to LABA-ICS.

Interpretation: In a real-world setting of COPD treatment, patients who initiated single-inhaler triple therapy had an increased incidence of MACE compared with similar patients treated with a LABA-ICS inhaler. This small increase was due to the all-cause mortality component, occurring mainly in the first four months after treatment initiation.

The Advanced Practice Respiratory Therapist (APRT) is a new healthcare practitioner trained to provide a scope of practice that exceeds that of the registered respiratory therapist (RRT) and is aligned with an advanced practice provider (APP) role. As part of a physician-led team, APRTs are trained to provide diagnostic and therapeutic patient care services in multiple settings across the health care spectrum, including critical care, acute and sub-acute inpatient care, and outpatient care such as preventative, ambulatory, and chronic care. Competency domains that must be included in accredited APRT education programs include medical knowledge, interpersonal and communication skills, patient care, professionalism, practice-based learning and improvement, and systems-based practice. Some of the individual competencies included in these domains must be incorporated into didactic coursework, some into laboratory and simulation activities, and all competencies must be incorporated into clinical coursework. Pre-clinical preparation of the APRT student includes coursework with other APP students and other health professions students, and courses created specifically to address the required competency domains. APRT students also complete a variety of patient simulations using standardized patients, task trainers, and patient simulators to ensure they are prepared to complete clinical education. The clinical courses include a minimum of 1,200 hours of supervised practice by a licensed physician in outpatient clinics, interventional pulmonology, inpatient pulmonary services, peri-operative services, and intensive care units. The APRT is trained to assess patients, develop care plans, order, evaluate and modify care based on each patient's response, and can be incorporated as a valuable member of the cardiopulmonary patient care team.

Introduction: Aspergillus sp. cause diverse clinical manifestations in bronchiectasis including Allergic bronchopulmonary aspergillosis (ABPA), Aspergillus sensitization (AS) and raised IgG indicating exposure or infection with Aspergillus.

Research question: What is the prevalence and clinical significance of Aspergillus-associated conditions in individuals with bronchiectasis?

Methods: Bronchiectasis patients enrolled into the EMBARC registry from 2015 to 2022 with laboratory testing for Aspergillus lung disease (total IgE, specific IgE to Aspergillus or Aspergillus skin test, IgG to Aspergillus and blood eosinophil counts) were included for analysis. Modified-ISHAM-ABPA working group criteria (2021) were used to define ABPA.

Results: 9953 patients were included. 608 (6.1%) were classified as having ABPA, 570 (5.7%) showed Aspergillus sensitization, 806 (8.1%) had raised Aspergillus-specific IgG without sensitisation, 184 (1.8%) were both sensitised to Aspergillus and had raised Aspergillus-specific IgG and 619 (6.2%) had eosinophilic bronchiectasis (elevated eosinophil counts without evidence of Aspergillus lung disease). The remaining 72.0% had negative Aspergillus serology. Patients with ABPA, Aspergillus sensitization, and raised Aspergillus-specific IgG had more severe disease, with worse lung function and more frequent exacerbations at baseline. During long-term follow-up, patients with raised Aspergillus-specific IgG had higher exacerbation frequency and more severe exacerbations. Aspergillus sensitization associated with increased exacerbations and hospitalisations only in patients not receiving inhaled corticosteroids.

Interpretation: Aspergillus lung disease is common in bronchiectasis. Raised IgG to Aspergillus is associated with significantly worse outcomes while ABPA and Aspergillus sensitization are associated with severe disease and exacerbations with a risk that is attenuated by inhaled corticosteroid use.

Background: The clinical and prognostic characteristics of mild-to-moderate chronic obstructive pulmonary disease (COPD) with and without emphysema remain inadequately investigated.

Research question: Do the clinical and prognostic characteristics differ between mild- to-moderate COPD with and without emphysema?

Study design and methods: We obtained clinical data of 989 participants with mild-to-moderate COPD from the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS). They were categorized into two groups based on their baseline %LAA_-950 of less than 5% on CT scans: those with emphysema (EC group) and those without emphysema (NEC group). Linear mixed-effects models were utilized to assess the differences in the decline of lung function, health-related quality of life, and quantitative CT indices between these two groups. Zero-inflated negative binomial regressions were employed to evaluate the rates of acute respiratory exacerbations between the groups.

Results: Among participants with mild-to-moderate COPD, 428 (43.3%) exhibited emphysema on CT scans. The annual decline in FEV₁ was -56.1 mL/year for the EC group and -46.9 mL/year for the NEC group, with a non-significant between-group difference of 9.1 mL/year (95% CI, -24.0 to 5.7 mL/year). The rate of emphysema progression in the EC group was significantly lower than in the NEC group (-0.173%; 95% CI, -0.252 to -0.094). The EC group also showed a more pronounced annual increase in the SGRQ score (0.9 points) compared to the NEC group. The EC group had a higher rate of acute respiratory exacerbations (0.36 per person-year) than the NEC group (0.25 per person-year), with a rate ratio of 1.42 (95% CI, 1.27 to 1.54).

Interpretation: Mild-to-moderate COPD with emphysema did not have accelerated rates of decline in FEV₁, but they experienced significantly worsen health-related quality of life and a higher rate of acute respiratory exacerbations. The non-emphysema subtype demonstrated increased emphysema progression.

Background: Oronasal masks are widely used for treating OSA with CPAP. However, oronasal CPAP is associated with lower effectiveness and lower adherence than nasal CPAP.

Research question: What is the impact of oral route and lateral position in patients well adapted to oronasal CPAP? Can these patients be switched to nasal CPAP?

Study design and methods: Patients with OSA on oronasal CPAP underwent 2 CPAP polysomnography (PSG) titrations in random order using an oronasal mask with 2 independent sealed compartments connected to two separate pneumotachographs. One study was done with the nasal and oral compartments opened and the other study with only the oral compartment opened. CPAP titration was done in the supine and lateral position. Finally, the patients were offered a nasal mask. A third PSG was performed using nasal CPAP.

Results: Twenty OSA patients (baseline AHI: 52 ± 21 events/h) adapted to oronasal CPAP were studied. Most patients (75%) were oronasal breathers on optimal CPAP. Oral CPAP was less effective to treat OSA than oronasal CPAP, evidenced by a higher residual AHI (2 (1 - 6.0) vs 12.5 (1.8 - 28.3); P = 0.003), despite a significantly higher CPAP level, (10 (9 - 10) vs 11 (10 - 12) cmH20; P = 0.003). The residual AHI was significantly lower in the lateral position for both oronasal and oral CPAP. Finally, patients (75%) agreed to change and preferred to continue on nasal mask, which resulted in lower CPAP and better OSA control.

Interpretation: The effectiveness of oronasal CPAP to abolish OSA is significantly decreased when patients are required to breathe exclusively through the mouth. Oronasal CPAP efficacy is significantly better in the lateral position. The transition to nasal mask results in higher CPAP effectiveness to treat OSA.