Chest最新文献

Topic importance: As interstitial lung abnormalities (ILAs) are increasingly recognized on imaging and in clinical practice, identification and appropriate management are critical. We propose an algorithmic approach to the identification and management of patients with ILAs.

Review findings: The radiologist initially identifies chest CT scan findings suggestive of an ILA pattern and excludes findings that are not consistent with ILAs. The next step is to confirm that these findings occupy > 5% of a nondependent lung zone. At this point, the radiologic pattern of ILA is identified. These findings are classified as non-subpleural, subpleural nonfibrotic, and subpleural fibrotic. It is then incumbent on the clinician to ascertain if the patient has symptoms and/or abnormal pulmonary physiology that may be attributable to these radiologic changes. Based on the patient's symptoms, physiological assessment, and risk factors for interstitial lung disease (ILD), we recommend classifying patients as having ILA, at high risk for developing ILD, probable ILD, or ILD. In patients identified as having ILA, a multidisciplinary discussion should evaluate features that indicate an increased risk of progression. If these features are present, serial monitoring is recommended to be proactive. If the patient does not have imaging or clinical features that indicate an increased risk of progression, then monitoring is recommended to be reactive. If ILD is subsequently diagnosed, the management is disease specific.

Summary: We anticipate this algorithmic approach will aid clinicians in interpreting the radiologic pattern described as ILA within the clinical context of their patients.

Background: COPD inhaler regimens should be appropriate for the patient's peak inspiratory flow (PIF) and should ideally consist of single or similar device(s).

Research questions: In a subspecialized COPD clinic: (1) What is the prevalence of patients with suboptimal PIF and with inappropriate device(s) for measured PIF? (2) Are there patient-related risk factors associated with suboptimal PIF? (3) What is the prevalence of patients with non-single inhaler therapy (SIT)/nonsimilar devices? (4) Does point-of-care PIF affect clinical decision-making?

Study design and methods: In this single-center real-world observational study, PIF was measured systematically at every outpatient visit in a subspecialized COPD clinic, and point-of-care results were provided to the clinician. Coprimary outcomes were the prevalence of outpatients with suboptimal PIF and with inappropriate devices for measured PIF. Secondary outcomes were patient-related risk factors associated with suboptimal PIF, the prevalence of non-SIT/nonsimilar devices, the prevalence of regimens consisting of either inappropriate device(s) for measured PIF and/or non-SIT/nonsimilar devices, and the effect of point-of-care PIF on clinical decision-making.

Results: Suboptimal PIF was identified in 45 of 161 participants (28%), and inappropriate device(s) for measured PIF were identified in 18 participants (11.2%). Significant associations were observed between suboptimal PIF and age (1.09; 95% CI, 1.04-1.15), female sex (10.30; 95% CI, 4.45-27.10), height (0.92; 95% CI, 0.88-0.96), BMI (0.90; 95% CI, 0.84-0.96), and FEV₁ (0.09; 95% CI, 0.03-0.26). After adjustment for age and sex, the association between suboptimal PIF and BMI, but not height, remained significant. Non-SIT and/or nonsimilar devices were identified in 50 participants (31.1%). Regimens consisting of either inappropriate device(s) for measured PIF and/or non-SIT/nonsimilar devices were observed in 59 participants (36.6%). Inhaler prescription changes were observed in this latter group (3.39; 95% CI, 1.76-6.64), as well as in patients with suboptimal PIF who already had SIT/similar regimens (2.93; 95% CI, 1.07-7.92).

Interpretation: Suboptimal PIF and inappropriate devices for measured PIF are highly prevalent among outpatients from a subspecialized COPD clinic. Female sex, reduced FEV₁, and low BMI are important, readily identifiable risk factors for suboptimal PIF, and point-of-care PIF can inform clinical decision-making.

Background: It remains uncertain how long pure ground-glass nodules (pGGNs) detected on low-dose CT (LDCT) imaging should be followed up. Further studies with longer follow-up periods are needed to determine the optimal follow-up duration for pGGNs.

Research question: What is the percentage of enlarging nodules among pGGNs that have remained stable for 10 years?

Study design and methods: This was a retrospective cohort study originating from participants with pGGNs detected on LDCT scans between 1997 and 2006 whose natural courses were reported in 2013. We re-analyzed all the follow-up data until July 2022. The study participants were followed up per our institutional guidelines until they were no longer a candidate for definitive treatment. The growth of the pGGNs was defined as an increase in the diameter of the entire nodule by ≥ 2 mm or the appearance of new solid portions within the nodules.

Results: A total of 89 patients with 135 pGGNs were followed up for a median of 193 months. Of 135 pGGNs, 23 (17.0%) increased in size, and the median time to the first detection of a size change was 71 months. Of the 23 growing pGGNs, 122 were detected on the first LDCT scan and 13 were newly detected on the follow-up CT scan. An increase in size was observed within 5 years in 8 nodules (34.8%), between 5 and 10 years in 12 nodules (52.2%), and following 10 years in 3 nodules (13.0%). Fifteen nodules were histologically confirmed as adenocarcinoma by surgery. Among the 76 pGGNs stable for 10 years, 3 (3.9%) increased in size.

Interpretation: Among pGGNs that remained stable for 10 years, 3.9% eventually grew, indicating that some pGGNs can grow even following a long period of stability. We suggest that pGGNs may need to be followed up for > 10 years to confirm growth.

Background: Obesity hypoventilation syndrome (OHS) is associated with high morbidity and mortality. There are few data on whether there are gender differences in outcomes.

Research question: Is female gender associated with worse outcomes in ambulatory and hospitalized patients with OHS?

Study design and methods: Post hoc analyses were performed on 2 separate OHS cohorts: (1) stable ambulatory patients from the 2 Pickwick randomized controlled trials; and (2) hospitalized patients with acute-on-chronic hypercapnic respiratory failure from a retrospective international cohort. We first conducted bivariate analyses of baseline characteristics and therapeutics between genders. Variables of interest from these analyses were then grouped into linear mixed effects models, Cox proportional hazards models, or logistic regression models to assess the association of gender on various clinical outcomes.

Results: The ambulatory prospective cohort included 300 patients (64% female), and the hospitalized retrospective cohort included 1,162 patients (58% female). For both cohorts, women were significantly older and more obese than men. Compared with men, baseline Paco₂ was similar in ambulatory patients but higher in hospitalized women. In the ambulatory cohort, in unadjusted analysis, women had increased risk of emergency department visits. However, gender was not associated with the composite outcome of emergency department visit, hospitalization, or all-cause mortality in the fully adjusted model. In the hospitalized cohort, prescription of positive airway pressure was less prevalent in women at discharge. In unadjusted analysis, hospitalized women had a higher mortality at 3, 6, and 12 months following hospital discharge compared with men. However, after adjusting for age, gender was not associated with mortality.

Interpretation: Although the diagnosis of OHS is established at a more advanced age in women, gender is not independently associated with worse clinical outcomes after adjusting for age. Future studies are needed to examine gender-related health disparities in diagnosis and treatment of OHS.

Background: Pulmonary arteriovenous malformations (PAVMs) are direct connections between the pulmonary artery and vein, creating a right-to-left shunt (RLS). Embolization is indicated to prevent complications. Guidelines recommend follow-up chest CT scans to confirm persistent occlusion and embolization of all treatable PAVMs. Graded transthoracic contrast echocardiography (TTCE) after PAVM embolization may offer a reliable alternative in a subgroup of patients while preventing radiation exposure.

Research question: Can TTCE predict the need for additional embolotherapy in the postembolization population as accurately as it does in the treatment-naive population?.

Study design and methods: Since 2018, follow-up after PAVM embolization at our study institution includes both TTCE and chest CT scan after 6 to 12 months and every 3 to 5 years thereafter. Patients who underwent at least 1 follow-up TTCE and chest CT scan were included. The indication for additional embolotherapy was discussed in a multidisciplinary team meeting. The primary outcome was the indication for additional embolotherapy in each RLS grade. Additionally, the association between the RLS grade and indication for additional embolotherapy was investigated.

Results: A total of 339 patients with 412 embolization procedures were included; median time to follow-up TTCE was 7.5 months. An RLS was present in 399 postembolization TTCEs (97%): RLS grade 1 in 93 patients (23%), grade 2 in 149 patients (36%) and grade 3 in 157 patients (38%). In patients with RLS grades 0 and 1, no treatable PAVMs were found on CT scan. In patients with RLS grades 2 and 3, 22 (15%) and 72 (46%) underwent additional embolization.

Interpretation: This study shows chest CT scan might be forgone in patients with RLS grades 0 and 1 after PAVM embolization.

Background: Although it is generally accepted that aerobic exercise training does not change lung structure or function, some work suggests that greater pulmonary vascular structure and function is associated with higher exercise capacity (peak oxygen consumption [Vo₂peak]).

Research question: Is there a cross-sectional association between the pulmonary vasculature and Vo₂peak? We hypothesized that those with higher CT blood vessel volumes and capacity of the lungs for carbon monoxide (Dlco) would have higher Vo₂peak, independent of airflow limitation.

Study design and methods: Participants from the Canadian Cohort Obstructive Lung Disease (CanCOLD) study were categorized as follows: never smokers with normal spirometry (n = 263), ever smokers with normal spirometry (n = 407), and COPD: individuals with spirometric airflow obstruction (n = 334). Total vessel volume (TVV), volume for vessels < 5 mm² in cross-sectional area (BV5), and volume for vessels between 5 and 10 mm² in cross-sectional area (BV5-10) were generated from CT scans and used as indices of pulmonary vascular structure. Dlco was used as an index of pulmonary microvascular function. Vo₂peak was evaluated via incremental cardiopulmonary exercise testing.

Results: General linear regression models revealed that even after controlling for FEV₁, emphysema severity, and body morphology, Dlco, TVV, BV5, and BV5-10, were independently associated with Vo₂peak. Interaction effects were observed between COPD and TVV, BV5, and BV5-10, indicating a weaker association between pulmonary vascular volumes and Vo₂peak in COPD.

Interpretation: Our results suggest that pulmonary vascular structure and Dlco are independently associated with Vo₂peak, regardless of severity of airflow limitation and emphysema, suggesting that these associations are not limited to COPD.

Background: Multidisciplinary pulmonary embolism response teams (PERTs) streamline care of adults with life-threatening pulmonary embolism (PE). Given rarity of pediatric PE, developing a clinical, educational, and research PERT paradigm is a novel and underused concept in pediatrics.

Research question: Is a PERT feasible in pediatrics, and does it improve PE care?

Study design and methods: A strategy-to-execution proposal to launch a pediatric PERT was developed for institutional buy-in. Key stakeholders collectively implemented the PERT. Data were collected for the 2-year pre-PERT and post-PERT eras, and outcomes were compared.

Results: PERT implementation took 12 months. Our PERT, led by hematology, is composed of pediatric experts in emergency medicine, critical care, interventional cardiology, anesthesiology, and interventional radiology. Data on 30 patients pre-PERT and 31 patients post-PERT were analyzed. Pre-PERT, 10% (3 of 30), 13% (4 of 30), 20% (6 of 30), and 57% (17 of 30), and post-PERT, 3% (1 of 31), 10% (3 of 31), 16% (5 of 31), and 71% (22 of 31) were categorized as high-risk, intermediate-low-risk, intermediate-high-risk, and low-risk PE, respectively. Post-PERT, there were 13 unique PERT activations. PERT was activated on all eligible patients with PE and, additionally, on 4 low-risk PEs. Time to echocardiogram was shorter post-PERT (4.7 vs 2 hours, P = .0147). Anticoagulation was ordered (90 vs 54 minutes, P = .003) and given sooner (154 vs 113 minutes, P = .049) post-PERT. There were no differences in time to reperfusion therapies (12 hours pre-PERT vs 8.7 hours post-PERT, P = .10). Five of 6 (83.3%) eligible (intermediate-high and high-risk) patients received reperfusion therapies in the post-PERT era compared to 3 of 8 (37.5%) eligible patients in the pre-PERT era (P = .0001). There were no differences in major bleeding, mortality, or length of stay in either era.

Interpretation: The pediatric PERT paradigm was successfully created and adopted locally. Our PERT enhanced access to experts, facilitated timely advanced therapies, and held value for low-risk PE. The University of Texas Southwestern Medical Center and Children's Health System of Texas pediatric PERT may serve as a best practice model for streamlining care for pediatric PE.

Topic importance: This narrative review emphasizes the growing interest in palliative care for people with serious lung diseases such as COPD. It reflects on recent publications from the American Thoracic Society, the World Health Organization, and European Respiratory Society, with a focus on nonpharmacologic palliative care for people with COPD from both the health care professional and organizational perspective.

Review findings: The concept of palliative care has changed over time and is now seen as applicable throughout the entire disease trajectory according to need, in conjunction with any disease-modifying therapies. Palliative care should pay attention to the needs of the person with COPD as well as the informal caregiver. Timely integration of palliative care with disease-modifying treatment requires assessment of needs at the individual level as well as organizational changes. High-quality communication, including advance care planning, is a cornerstone of palliative care.

Summary: Therefore, services should be based on the understanding that palliative care is not only specific standardized actions and treatments, but rather a holistic approach that includes compassionate communication, treatment, and care addressing the patient and informal and formal caregivers. Living with and dying of COPD is much more than objective measurements. It is the sum of relationships with others and the experience of living in the best possible harmony with one's own values and hopes, despite having a serious illness.