Chest最新文献

Case presentation: A 51-year-old man presented with chest tightness, exertional dyspnea, and occasional chest pain for 2 years. The patient visited his local hospital initially, and CT scan revealed a ground glass opacity (GGO) located in the right upper lobe (Fig 1A). He was diagnosed as having pulmonary infection and treated with levofloxacin for 12 days. A repeated chest CT scan 14 days later demonstrated a progressed solid nodule with surrounding ground glass opacity (Fig 1B). With a suspicion of carcinoma in situ, right upper lobectomy was performed via video-assisted thoracoscopic surgery at the local hospital. However, the histologic examination did not show any evidence of malignancy, and the symptoms persisted. Fourteen months later, his dyspnea worsened with extremely low exercise tolerance. The patient denied other symptoms (eg, rash, fever, joint pain, aphthous stomatitis, genital ulceration, other symptoms of arteritis). His appetite was decreased but without significant weight loss. He did not smoke and had a history of fully recovered cerebral infarction 9 months ago. There was no family history of respiratory diseases. After 4 months, a CT pulmonary angiography scan revealed filling defects at the left pulmonary artery and left inferior pulmonary artery (Fig 2A). A vascular narrowing was detected at the left superior pulmonary artery. Accompanied with an increased D-dimer level (> 10 mg/L; normal range, 0-0.5 mg/L), a diagnosis of pulmonary embolism was made. The patient was treated with warfarin, and his symptom of dyspnea was partially relieved. He came to our hospital for further treatment 4 months later.

Background: Patients with COPD frequently demonstrate pulmonary hypertension (PH). Severe PH in patients with COPD, identified by pulmonary vascular resistance (PVR) of > 5 Wood units (WU), is closely linked to impaired transplant-free survival. The impact of PH-targeting pharmacotherapy in this context remains unclear.

Research question: Is PH-targeted therapy associated with improved transplant-free survival in patients with COPD and PH?

Study design and methods: This study included Pulmonary Vascular Research Institute GoDeep meta-registry patients with COPD and PH and available right heart catheterization at diagnosis. We investigated PH-targeted therapy prevalence and its association with transplant-free survival using diverse statistical methods, including Cox regression and subgroup analyses based on PH severity, comorbidities, and pulmonary function test results. Immortal time bias was addressed through a landmark approach.

Results: As of December 2023, the GoDeep meta-registry included 26,981 patients (28% in PH group 1, 13% in PH group 2, 12% in PH group 3, 10% in PH group 4, 2% in PH group 5, 26% undefined, and 9% control participants). Of these, 836 patients had a diagnosis of COPD with PH and were included in this analysis, with median age of 66 years (interquartile range [IQR], 59-73 years), FEV₁ of 51% predicted (IQR, 34%-69% predicted), mPAP of 35 mm Hg (IQR, 28-44 mm Hg), PVR of 5 WU (IQR, 4-8 WU), cardiac index of 2.5 L/min/m² (IQR, 2.0-2.9 L/min/m²), and mostly World Health Organization functional class III were included. Five-year transplant-free survival was 42%, significantly worse than in group 1 PH. A multivariable Cox proportional hazards model identified PVR, but not FEV₁, as a major predictor of outcome. Four hundred eighteen patients (50%) received phosphodiesterase-5 inhibitor (PDE5i) therapy, which was associated with significantly reduced mortality: hazard ratio of 0.65 (IQR, 0.57-0.75) for the entire cohort of patients with COPD and PH and of 0.83 (IQR, 0.74-0.94) when performing landmark analysis. This PDE5i effect was reproduced robustly when performing subgroup analyses for patients with moderate to severe PH, various comorbidities, and supplemental oxygen requirement and when assessing the impact of unobserved confounders.

Interpretation: Patients with COPD and PH exhibit poor transplant-free survival, with PVR being a predictor of mortality. In this meta-registry, PDE5i therapy was associated with a significant reduction in mortality across all tested models.

There are physician shortages in the United States including in the cardiopulmonary specialty. Nonphysician advanced practice providers, including nurse practitioners or physician assistants, have been proposed to meet some more routine patient care needs. A supplementary provider called an advanced practice respiratory therapist (APRT) has been proposed. Such personnel start as respiratory therapists followed by training in a graduate degree program. The Commission on Accreditation for Respiratory Care has published a set of standards for such an education program, and one program has begun to train APRTs. The Commission on Accreditation for Respiratory Care requires each accredited program to publish its outcomes. The respiratory therapy credentialing board, the National Board for Respiratory Care, has undertaken stewardship of assessing APRT education program outcomes. The research question asks whether there is national support to develop a standardized assessment of graduates' performances near the end of an APRT education program. This paper describes methods used during this study of the nascent APRT role, which informed decisions of an advisory committee as they considered what content to assess and how to design the measurement instrument. The study exposed a set of survey-derived metrics about potential content signaling whether there was endorsement among physicians, nonphysician advanced practice providers, and APRT graduates. Metrics are described from these and other subgroups plus the committee's decisions are explained about what content to assess and how. Most of the surveyed content was endorsed for being part of the APRT role; therefore, the committee proceeded to make design decisions about the outcome assessment.

Background: The terminology of a do not resuscitate (DNR) order can be confusing and controversial for patients at the end of life. We examined whether changing the name to beneficial care only (BCO) would increase patient acceptance.

Research question: Would individuals be more willing to forgo full code (FC) status and accept a no-CPR order if the order title was BCO?

Study design and methods: We conducted a cross-sectional survey of 599 adults residing in the United States, presenting participants with a hypothetical scenario of a terminal patient. One-half were given a choice between FC and DNR status, and one-half were given a choice between FC and BCO status. The 20-item survey included multiple-choice responses and one free-response question.

Results: In our nationally representative survey of US participants who were 50% female and 26% non-White (99% response rate, 599 of 600), there was no difference in participant preference for BCO or DNR overall (P = .7616) and across participant sociodemographic characteristics. Although themes of participant reasons for choosing against CPR were similar for both DNR and BCO preferences, including harms imposed by CPR, lack of quality of life, trust in the medical team, and avoidance of suffering, two additional themes appeared only for BCO responses, including CPR would be useless and the patient would continue to receive beneficial care.

Interpretation: We found no statistically significant difference in preference between BCO and DNR orders for a terminally ill patient. These findings suggest changing the terminology of DNR to BCO may not lead to changes in decisions to forgo CPR. The additional themes identified with the use of BCO support the concept that BCO terminology conveys to the recipient that all beneficial care will continue to be provided to the patient.

Background: The prevalence of chronic respiratory diseases is increasing globally. There is evidence that those with spirometric impairment, and no evidence of obstruction, termed preserved ratio impaired spirometry (PRISm), have increased risk of morbidity and mortality, compared to those with normal lung function. There remain several gaps in characterizing PRISm.

Research questions: What is the prevalence, risk factors and clinical outcomes associated with PRISm globally?

Study design and methods: In this systematic review a comprehensive search using MEDLINE, Web of Science, CINHAL, and CENTRAL databases was conducted to include epidemiological studies with no language or data restrictions. Two reviewers independently screened citations and shortlisted full-text articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and data was extracted. Quality was assessed with the Effective Public Health Practice Project tool.

Results: 52 studies met the inclusion criteria with 33 studies included in the meta-analysis. Pooled PRISm prevalence was 12% (95% CI: 0.10, 0.15) with greater prevalence in low-and middle-income countries (LMICs) compared to high-income countries (19% vs. 11%). Comorbid diabetes was a significant risk factor associated with PRISm but data for female sex and smoking were mixed. PRISm was associated with increased all-cause (OR 1.41, 95% CI:1.08, 1.83, p=0.02), cardiovascular (OR 1.84, 95% CI:1.31, 2.58, p<0.01), and respiratory mortality (OR 1.82, 95% CI:1.08, 3.05, p=0.03). PRISm was not associated with a reduced lung cancer diagnosis (p=0.46). Quality assessment analysis revealed 34.6% (n=18) studies were rated "strong," 42.3% (n=22) "moderate," and 23.1% (n=12) "weak." Studies conducted LMICs had lower quality ratings.

Interpretation: Individuals with PRISm have increased risk of all-cause, cardiovascular, and respiratory mortality. Recognizing and targeting modifiable PRISm risk factors may reduce the growing burden of PRISm and transition to obstructive lung disease globally. Additional studies are needed in LMICs that have unique risk factors a disease trajectory.