The prognostic significance of lung function in stable heart failure outpatients

Background

This study investigated the impact on all‐cause mortality of airflow limitation indicative of chronic obstructive pulmonary disease or restrictive spirometry pattern (RSP) in a stable systolic heart failure population.

Hypothesis

Decreased lung function indicates poor survival in heart failure.

Methods

Inclusion criteria: NYHA class II‐IV and left ventricular ejection fraction (LVEF) < 45%. Prognosis was assessed with multivariate Cox proportional hazards models. Two criteria of obstructive airflow limitation were applied: FEV₁/FVC < 0.7 (GOLD), and FEV₁/FVC < lower limit of normality (LLN). RSP was defined as FEV₁/FVC > 0.7 and FVC<80% or FEV₁/FVC > LLN and FVC <LLN.

Results

There where 573 patients in the cohort (85% of eligible patients in study period). Median follow‐up was 4.7 years and 176 patients died (31%). Age, NYHA class, smoking, body mass index and LVEF were independent prognostic factors (p<0.01). Obstructive airflow limitation increased mortality using both criteria (HR_GOLD 2.07 [95% CI 1.45–2.95] p<0.01 and HR_LLN 2.00 [1.40–2.84] p<0.01) and was an independent marker when using LLN criteria (HR 1.74 [1.17‐2.59] p=0.006). RSP was independently associated with mortality when defined as FVC < LLN (HR 1.54 [1.01–2.35] p=0.04) but not as FVC < 80%. Multivariate hazard ratios for a 10% decrease in predicted value of FEV1 or FVC were 1.42 (p<0.001) and 1.33 (p<0.001) in patients exhibiting airflow obstruction, and 1.36 (p=0.031) and 1.38 (p=0.041) in RSP.

Conclusions

Presence of obstructive airflow limitation indicative of COPD or RSP were associated with increased all‐cause mortality, however only independently when using the LLN definition.

     

Childhood measles contributes to post‐bronchodilator airflow obstruction in middle‐aged adults: A cohort study

Background and objective

Chronic obstructive pulmonary disease (COPD) has potential origins in childhood but an association between childhood measles and post‐bronchodilator (BD) airflow obstruction (AO) has not yet been shown. We investigated whether childhood measles contributed to post‐BD AO through interactions with asthma and/or smoking in a non‐immunized middle‐aged population.

Methods

The population‐based Tasmanian Longitudinal Health Study (TAHS) cohort born in 1961 (n = 8583) underwent spirometry in 1968 before immunization was introduced. A history of childhood measles infection was obtained from school medical records. During the fifth decade follow‐up (n = 5729 responses), a subgroup underwent further lung function measurements (n = 1389). Relevant main associations and interactions by asthma and/or smoking on post‐BD forced expiratory volume in 1 s/forced vital capacity (FEV₁/FVC; continuous variable) and AO (FEV₁/FVC < lower limit of normal) were estimated by multiple regression.

Results

Sixty‐nine percent (n = 950) had a history of childhood measles. Childhood measles augmented the combined adverse effect of current clinical asthma and smoking at least 10 pack‐years on post‐BD FEV₁/FVC ratio in middle age (z‐score: −0.70 (95% CI: −1.1 to −0.3) vs −1.36 (−1.6 to −1.1), three‐way interaction: P = 0.009), especially for those with childhood‐onset asthma. For never‐ and ever‐smokers of <10 pack‐years who had current asthma symptoms, compared with those without childhood measles, paradoxically, the odds for post‐BD AO was not significant in the presence of childhood measles (OR: 12.0 (95% CI: 3.4–42) vs 2.17 (0.9–5.3)).

Conclusion

Childhood measles infection appears to compound the associations between smoking, current asthma and post‐BD AO. Differences between asthma subgroups provide further insight into the complex aetiology of obstructive lung diseases for middle‐aged adults.

     

Multiple breath washout: A new and promising lung function test for patients with idiopathic pulmonary fibrosis

Background and objective

Idiopathic pulmonary fibrosis (IPF) is a devastating progressive lung disease affecting the parenchyma. Nitrogen multiple‐breath washout (N₂‐MBW) is a lung function test that measures ventilation inhomogeneity, a biomarker of small airway disease. We assessed clinical properties of N₂‐MBW in IPF.

Methods

In this prospective cohort pilot study, 25 IPF patients and 25 healthy controls were assessed at baseline and 10 patients at median 6.2 months later. Outcomes included the lung clearance index (LCI) from N₂‐MBW, forced vital capacity (FVC) from spirometry, diffusion capacity of the lungs for carbon monoxide (DL_CO), bronchiectasis score from computed tomography scans, the Gender–Age–Physiology (GAP score for IPF) stage and death or lung transplantation (LTx). Study end points were feasibility, repeatability, discriminative capacity and correlation with disease severity and structural lung damage.

Results

All patients were able to perform N₂‐MBW. LCI was repeatable and reproducible. Median (interquartile range (IQR)) LCI in IPF was 11.6 (10.1–13.8) in IPF versus 7.3 (6.9–8.4) in controls (P < 0.0001). LCI correlated with DL_CO corrected for haemoglobin (corrDL_CO; r = −0.49, P = 0.016), bronchiectasis score (r = 0.45, P = 0.024) and the GAP stage (r = 0.59, P = 0.002), but not with FVC. FVC was not related to bronchiectasis. During follow‐up, six patients died and one received LTx. LCI correlated with the latter compound outcome: hazard ratio (95% CI) was 2.43 (1.26; 4.69) per one LCI SD from the patient population.

Conclusion

N₂‐MBW is a feasible, reliable and valid lung function test in IPF. LCI correlates with diffusion impairment, structural airway damage and clinical disease severity. LCI is a promising surveillance tool in IPF that may predict mortality.

     

Vitamin D and respiratory health in the Busselton Healthy Ageing Study

Background and objective

The relationship between vitamin D and respiratory disease was examined by cross‐sectional analysis of a large community‐based sample.

Methods

Serum 25‐hydroxyvitamin D (25OHD) and history of respiratory disease, symptoms (recorded by questionnaire) and spirometry were measured in 5011 adults aged 45–69 years. Adjustments were made for age, sex, season and smoking (Model A), plus body mass index (BMI) and physical activity level (Model B), plus history of chronic diseases (Model C).

Results

Mean (SD) age was 58 (SD 6) years with 45% males, 10% current smokers and 12% taking vitamin D supplements. The prevalence of 25OHD level <50 nmol/L was 8.0%. In all the three models, 25OHD <50 nmol/L was significantly associated with asthma (Model C: odds ratio (OR): 1.32; 95% CI: 1.00, 1.73), bronchitis (1.54; 1.17, 2.01), wheeze (1.37; 1.10, 1.71) and chest tightness (1.42; 1.10, 1.83). Participants with vitamin D level > 100 nmol/L had higher forced vital capacity (FVC) in all the three models (1.17% higher, compared with the 50–100 nmol/L group in Model C).

Conclusion

Low levels of serum 25OHD were independently associated with asthma, bronchitis, wheeze and chest tightness after three levels of adjustment for potential confounders. Higher vitamin D levels were associated with higher levels of lung function.

     

Comparison of respiratory system impedance in asthma and COPD: A prospective observational study

Background and objective

A single assessment of within‐breath variations of respiratory system reactance (Xrs) at 5 Hz (ΔX5) measured by the forced oscillation technique (FOT) has been reported to be useful for the detection of pathophysiological changes in chronic obstructive pulmonary disease (COPD) and asthma. We examined longitudinal changes in respiratory system resistance (Rrs) and Xrs during tidal breathing between stable asthma and COPD patients in order to clarify the features of changes of respiratory system impedance and airflow limitation for these conditions.

Methods

Between April 2013 and September 2013, outpatients with a COPD or asthma diagnosis were recruited. We examined forced expiratory volume in 1 s (FEV₁) and FOT every 6 months until September 2015. Annual changes were estimated from the linear regression curve slope.

Results

We included 57 and 93 subjects with COPD and asthma, respectively. The median follow‐up period was 26 months (range: 24–29 months). Within‐breath analysis showed that the difference between mean Rrs at 5 Hz and 20 Hz was significantly lower, and ΔX5 more negative, in COPD than in asthma patients. With regard to annual changes, only ΔX5 was significantly different, more negative, in COPD than in asthma patients. Comparing between COPD subjects of Global Initiative Chronic Obstructive Lung Disease (GOLD) stage I/II and those with asthma, there were no significant differences in respiratory system impedance at enrolment, while annual change in ΔX5 was significantly more negative in mild COPD than in asthma patients.

Conclusion

ΔX5 may be useful for long‐term assessment of airflow limitation in COPD.

     

Defining ‘healthy’ in preschool‐aged children for forced oscillation technique reference equations

Background and objective

Selecting ‘healthy’ preschool‐aged children for reference ranges may not be straightforward. Relaxing inclusion criteria for normative data does not affect spirometry z‐scores. We therefore investigated the effect of similarly relaxing inclusion criteria in preschoolers on reference ranges for respiratory impedance (Zrs) using a modified forced oscillation technique (FOT).

Methods

The International Study of Asthma and Allergies in Childhood questionnaire classified 585 children into a healthy and five mutually exclusive groups. Zrs was measured between 4 and 26 Hz and resistance (R) and compliance (C) obtained by model fitting. Prediction models were determined using mixed effect models and z‐scores compared between healthy children and the five groups.

Results

Zrs data were obtained for 494 participants (4.30 ± 0.7 years) on 587 occasions. Comparison of the Zrs z‐scores between the healthy children and the health groups found significant differences in children with asthma, current wheeze and respiratory symptoms, but not in children born preterm or with early‐life wheeze. Adding these two groups to the healthy dataset had no significant effect on the distribution of z‐scores and increased the size of the dataset by 22.3%.

Conclusion

Our data suggest that preschool‐aged children born preterm or with early‐life wheeze can be included in FOT reference equations, while those with asthma, current wheeze and respiratory symptoms within 4 weeks of testing should be excluded. This more inclusive approach results in more robust FOT reference ranges.

     

Peripheral airway dysfunction and relationship with symptoms in smokers with preserved spirometry

Background and objective

Smokers develop respiratory symptoms and peripheral airway dysfunction even when spirometry is preserved. Multiple breath nitrogen washout (MBNW) and impulse oscillometry system (IOS) are potentially useful measures of peripheral airway function but they have not been compared in such subjects. We hypothesized that MBNW and IOS are jointly abnormal in smokers with normal spirometry and that these abnormalities relate to respiratory symptoms.

Methods

Eighty smokers with normal spirometry completed a symptom questionnaire, had ventilation heterogeneity in diffusion (Sacin) and convection‐dependent (Scond) airways and trapped gas volume at functional residual capacity as a percentage of vital capacity (%VtrFRC/VC) measured by MBNW. Respiratory resistance and reactance at 5 and 20 Hz were measured using IOS.

Results

Respiratory symptoms were reported in 55 (68%) subjects. Forty (50%) subjects had at least one abnormal MBNW parameter, predominantly in Sacin. Forty‐one (51%) subjects had at least one abnormal IOS parameter, predominantly in resistance. Sixty‐one (76%) subjects had an abnormality in either MBNW or IOS. Chronic bronchitis symptoms were associated with an increased Scond, while wheeze was associated with lower spirometry and an increased resistance. Abnormalities in MBNW and IOS parameters were unrelated to each other.

Conclusions

Respiratory symptoms and peripheral airway dysfunction are common in smokers with normal spirometry. Symptoms of chronic bronchitis related to conductive airway abnormalities, while wheeze was related to spirometry and IOS. The clinical significance of abnormalities in peripheral airway function in smokers remains undetermined.

     

The importance of symptoms in the longitudinal variability of clusters in COPD patients: A validation study

Background and objective

Cluster analysis has been utilized to explore phenotypic heterogeneity in chronic obstructive pulmonary disease (COPD). To date, little is known about the longitudinal variability of clusters in COPD patients. We aimed to evaluate the 2‐year cluster variability in stable COPD patients.

Methods

We evaluated the following variables in COPD patients at baseline and 2 years later: age, gender, pack‐year history, body mass index (BMI), modified Medical Research Council (MMRC) scale, 6‐min walking distance (6MWD), spirometry and COPD Assessment Test (CAT). Patient classification was performed using cluster analysis at baseline and 2 years later. Each patient’s cluster variability after 2 years and its parameters associated with cluster change were explored.

Results

A total of 521 smokers with COPD were evaluated at baseline and 2 years later. Three different clusters were consistently identified at both evaluation times: cluster A (of younger age, mild airway limitation, few symptoms), cluster B (intermediate) and cluster C (of older age, severe airway limitation and highly symptomatic). Two years later, 70% of patients were unchanged, whereas 30% changed from one cluster to another: 20% from A to B; 15% from B to A; 15% from B to C; 42% from C to B and 8% from C to A. 6MWD, forced expiratory volume in 1 s (FEV₁) % and CAT were the principal parameters responsible for this change.

Conclusion

After 2 years of follow‐up, most of the COPD patients maintained their cluster assignment. Exercise tolerance, lung function and quality of life were the main driving parameters in those who change their cluster assignment.

     

Increased risk of acute coronary syndrome in patients with bronchiectasis: A population‐based cohort study

Background and objective

There are few studies on the relationship between bronchiectasis and acute coronary syndrome (ACS). We conducted a population‐based cohort study to assess whether bronchiectasis was associated with an increased risk of ACS.

Methods

We identified 3521 patients diagnosed with bronchiectasis between 2000 and 2010 (bronchiectasis cohort) and frequency matched them with 14 084 randomly selected people without bronchiectasis from the general population (comparison cohort) according to sex, age and index year using the Longitudinal Health Insurance Database. Both cohorts were followed until the end of 2010 to determine the ACS incidence. Hazard ratios of ACS were measured.

Results

Based on 17 340 person‐years for bronchiectasis patients and 73 639 person‐years for individuals without bronchiectasis, the overall ACS risk was 40% higher in the bronchiectasis cohort (adjusted hazard ratio (HR) = 1.40; 95% CI: 1.20–1.62). Compared with those in the comparison cohort with one respiratory infection‐related emergency room (ER) visit per year, the ACS risk was 5.46‐fold greater in bronchiectasis patients with three or more ER visits per year (adjusted HR = 5.46, 95% CI: 4.29–6.96). Patients with bronchiectasis and three or more respiratory infection‐related hospitalizations per year had an 8.15‐fold higher ACS risk (adjusted HR = 8.15, 95% CI: 6.27–10.61).

Conclusion

Bronchiectasis patients, particularly those experiencing frequent exacerbations with three or more ER visits and consequent hospitalization per year, are at an increased ACS risk.

     

Segmentectomy versus lobectomy in early non‐small cell lung cancer of 2 cm or less in size: A population‐based study

Background and objective

Standard surgical management for early stage lung cancer is lobectomy with mediastinal lymph node dissection. The feasibility of limited resection remains controversial; we retrospectively assessed lung cancer‐specific survival (LCSS) and overall survival (OS) in early stage non‐small cell lung cancer (NSCLC) to evaluate whether segmentectomy is comparable to standard lobectomy.

Methods

Patients with primary NSCLC of 20 mm or less who were diagnosed from 2000 to 2014 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. To compare the two surgical interventions, a propensity score analysis was performed between lobectomy and segmentectomy.

Results

Of the 15 358 patients analysed, there were 14 549 lobectomies and 809 segmentectomies. The 5‐year OS was 76% for the lobectomy group and 74.4% for the segmentectomy group. There were no significant differences in OS or LCSS among patients who underwent lobectomy versus segmentectomy, as demonstrated by the propensity‐matched hazard ratio (HR) for OS (HR: 1.195, 95% CI: 0.993–1.439) and LCSS (HR: 1.124, 95% CI: 0.860–1.469). The inverse propensity‐weighted analysis also supported these results. Segmentectomy was more likely to be performed in elderly patients. In the subset of patients aged ≥75 years, the segmentectomy group demonstrated comparable OS (HR: 1.17, 95% CI: 0.87–1.58, P = 0.31) and LCSS (HR: 0.94, 95% CI: 0.59–1.51, P = 0.81), compared with the lobectomy group.

Conclusion

Equivalent OS and LCSS were demonstrated in patients with primary NSCLC of 20 mm or less without lymph node or distant metastasis.

     

Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single‐centre experience

Background and objective

Malignant pleurisy is associated with advanced oncological disease and dyspnoea is the most common presenting symptom. Pleurodesis is the preferred palliative and supportive treatment option, targeting symptom relief. The identification of clinical and endoscopic features that determine the success of talc pleurodesis in malignant pleurisy could guide clinical decision‐making.

Methods

All symptomatic patients with malignant pleurisy subjected to talc pleurodesis through medical thoracoscopy between January 2012 and December 2015 were included. Univariate and multivariate analyses were performed to identify factors associated with successful pleurodesis.

Results

Of the 155 patients, 122 (78%) were classified as having a successful pleurodesis based on clinical and radiological criteria. Factors associated with unsuccessful pleurodesis (univariate analysis) were the presence of pleural adhesions (odds ratio (OR): 0.43 (95% CI: 0.19–0.96); P = 0.04), extensive spread of pleural lesions (OR: 0.17 (95% CI: 0.05–0.59); P = 0.001), the use of systemic corticosteroids (OR: 0.28 (95% CI: 0.10–0.83); P = 0.02) and a prolonged time period between the clinical diagnosis of the pleural effusion and the moment of pleurodesis (OR: 0.14 (95% CI: 0.06–0.32); P < 0.0001). The latter being associated with failure of pleurodesis in a multivariate analysis (OR: 0.08 (95% CI: 0.01–0.25); P < 0.0001). Chest ultrasound prior to pleurodesis showed a sensitivity of 91% and a specificity of 88% in predicting the success of pleurodesis.

Conclusion

The success rate of pleurodesis in malignant pleurisy could potentially be enhanced by correct patient selection and early referral for pleurodesis. Ultrasonic assessment of pleural adhesions and potential lung expansion prior to pleurodesis is useful in clinical decision‐making.

     

Can Exercise Improve Cognitive Symptoms of Alzheimer's Disease?

Objectives

To examine the effects of exercise training on cognitive function in individuals at risk of or diagnosed with Alzheimer's disease (AD ).

Design

Meta‐analysis.

Setting

PubMed, Scopus, ClinicalTrials.gov, and ProQuest were searched from inception until August 1, 2017.

Participants

Nineteen studies with 23 interventions including 1,145 subjects with a mean age of 77.0 ± 7.5 were included. Most subjects were at risk of AD because they had mild cognitive impairment (64%) or a parent diagnosed with AD (1%), and 35% presented with AD .

Intervention

Controlled studies that included an exercise‐only intervention and a nondiet, nonexercise control group and reported pre‐ and post‐intervention cognitive function measurements.

Measurements

Cognitive function before and after the intervention and features of the exercise intervention.

Results

Exercise interventions were performed 3.4 ± 1.4 days per week at moderate intensity (3.7 ± 0.6 metabolic equivalents) for 45.2 ± 17.0 minutes per session for 18.6 ± 10.0 weeks and consisted primarily of aerobic exercise (65%). Overall, there was a modest favorable effect of exercise on cognitive function (d₊ = 0.47, 95% confidence interval (CI ) = 0.26–0.68). Within‐group analyses revealed that exercise improved cognitive function (d_+w = 0.20, 95% CI  = 0.11–0.28), whereas cognitive function declined in the control group (d_+w = ?0.18, 95% CI  = ?0.36 to 0.00). Aerobic exercise had a moderate favorable effect on cognitive function (d_+w = 0.65, 95% CI  = 0.35–0.95), but other exercise types did not (d_+w = 0.19, 95% CI  = ?0.06–0.43).

Conclusion

Our findings suggest that exercise training may delay the decline in cognitive function that occurs in individuals who are at risk of or have AD , with aerobic exercise possibly having the most favorable effect. Additional randomized controlled clinical trials that include objective measurements of cognitive function are needed to confirm our findings.

     

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

Objectives

To examine the effect of an emergency department (ED )‐based transitional care nurse (TCN ) on hospital use.

Design

Prospective observational cohort.

Setting

Three U.S. (NY , IL , NJ ) ED s from January 1, 2013, to June 30, 2015.

Participants

Individuals aged 65 and older in the ED (N = 57,287).

Intervention

The intervention was first TCN contact. Controls never saw a TCN during the study period.

Measurements

We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30‐day admission (any admission on Days 0–30) and 72‐hour ED revisits.

Results

A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: ?9.9% risk of inpatient admission, 95% confidence interval (CI ) = ?12.3% to ?7.5%; site 2: ?16.5%, 95% CI = ?18.7% to ?14.2%; site 3: ?4.7%, 95% CI = ?7.5% to ?2.0%). Participants with TCN contact had greater risk of a 72‐hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7–2.3%; site 2: 1.4%, 95% CI = 0.7–2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: ?7.8%, 95% CI = ?10.3% to ?5.3%; site 2: ?13.8%, 95% CI = ?16.1% to ?11.6%).

Conclusion

Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.

     

Epidemiology,treatment, disposition and outcome of patients with acute exacerbation of COPD presenting to emergency departments in Australia and South East Asia: An AANZDEM study

Background and objective

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a common presentation to emergency departments (ED) but data regarding its epidemiology and outcomes are scarce. We describe the epidemiology, clinical features, treatment and outcome of patients treated for AECOPD in ED.

Methods

This was a planned sub‐study of patients with an ED diagnosis of AECOPD identified in the Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study. The AANZDEM was a prospective, interrupted time series cohort study conducted in 46 ED in Australia, New Zealand, Singapore, Hong Kong and Malaysia over three 72‐h periods in May, August and October 2014. Primary outcomes were patient epidemiology, clinical features, treatment and outcomes (hospital length of stay (LOS) and mortality).

Results

Forty‐six ED participated. There were 415 patients with an ED primary diagnosis of AECOPD (13.6% of the overall cohort; 95% CI: 12.5–14.9%). Median age was 73 years, 60% males and 65% arrived by ambulance. Ninety‐one percent had an existing COPD diagnosis. Eighty percent of patients received inhaled bronchodilators, 66% received systemic corticosteroids and 57% of those with pH < 7.30 were treated with non‐invasive ventilation (NIV). Seventy‐eight percent of patients were admitted to hospital, 7% to an intensive care unit. In‐hospital mortality was 4% and median LOS was 4 days (95% CI: 2–7).

Conclusion

Patients treated in ED for AECOPD commonly arrive by ambulance, have a high admission rate and significant in‐hospital mortality. Compliance with evidence‐based treatments in ED is suboptimal affording an opportunity to improve care and potentially outcomes.

     

Diagnostic utility of surgical lung biopsies in elderly patients with indeterminate interstitial lung disease

Background and objective

Idiopathic pulmonary fibrosis (IPF) is increasingly diagnosed by clinical and computed tomography (CT) criteria; however, surgical lung biopsy (SLB) may still be required in patients who lack definite CT features of usual interstitial pneumonia (UIP). We reviewed a cohort of elderly patients who underwent SLB, to evaluate the benefit of SLB in diagnosing idiopathic interstitial pneumonia (IIP).

Methods

We searched the pathology records of Mayo Clinic for ambulatory patients at least 75 years old, who underwent SLB between 2000 and 2012 for indeterminate IIP. Histologic slides were reviewed and clinical data were extracted from the record.

Results

A total of 55 patients (35 male) were enrolled. Median (interquartile range) age was 77 (76–80) years. Forced vital capacity was 70 (61–76)% and diffusing capacity of the lungs for carbon monoxide was 48 (42–54)% of predicted. In total, 37 (67%) patients had IPF, including 61% of those with HRCT findings inconsistent with UIP. Thirty‐day mortality was 10% and 90‐day mortality was 15%.

Conclusion

The high mortality rate of SLB complicates the risk–benefit analysis in elderly patients with IIP. The expected value of the SLB is probably highest when the HRCT features are inconsistent with UIP, due to the frequent (39%) retrieval of patterns other than UIP.

     

External beam radiation therapy combined with airway stenting leads to better survival in patients with malignant airway obstruction

Background and objective

Malignant airway obstruction (MAO), a common complication of patients with advanced lung cancer, causes debilitating dyspnoea and poor quality of life. Two common interventions used in the treatment of MAO include bronchoscopy with airway stenting and external beam radiotherapy (EBRT). Data are limited regarding their clinical effectiveness and overall effect on survival.

Methods

A retrospective chart review of patients treated with airway stenting and/or EBRT at the Johns Hopkins Hospital for MAO between July 2010 and January 2017 was reviewed. Demographics, performance status, cancer histology, therapeutic intervention and date of death were recorded. Survival was calculated using cox regression analysis.

Results

Of the 606 patients who were treated for MAO, 237 were identified as having MAO and included in the study. Sixty‐eight patients underwent rigid bronchoscopy and stenting, 102 EBRT and 67 a combined approach. Patients who underwent stenting hand an increased hazard ratio (HR) of death in comparison to those who received combination therapy (HR: 2.12, 95% CI: 1.02, 4.39), while there was a trend towards significance in the EBRT alone group in comparison to the combination therapy group (HR: 1.62, 95% CI: 0.93, 2.83).

Conclusion

In this retrospective analysis, combination therapy with stenting and EBRT led to better survival in comparison to stenting or EBRT alone. Prospective cohort trials are needed to confirm these results.

     

Impact of limb weakness on extubation failure after planned extubation in medical patients

Background and objective

Limb muscle weakness is associated with difficult weaning. However, there are limited data on extubation failure. The objective of this cohort study was to evaluate the association between limb muscle weakness according to the Medical Research Council (MRC) scale and extubation failure rates among patients in a medical intensive care unit (ICU).

Methods

All consecutive medical ICU patients who were mechanically ventilated for more than 24 h and who were weaned according to protocol were prospectively registered, and limb muscle weakness was assessed using the MRC scale on the day of planned extubation. Association of limb muscle weakness with extubation failure within 48 h following planned extubation was evaluated with logistic regression analysis.

Results

Over the study period, 377 consecutive patients underwent planned extubation through a standardized weaning process. Extubation failure occurred in 106 (28.1%) patients. Median scores on the MRC scale for four limbs were lower in patients with extubation failure (14, interquartile range (IQR) 12–16) than in patients without extubation failure (16, IQR 12–18; P = 0.024). In addition, extubation failure rates decreased significantly with increasing quartiles of MRC scores (P for trend <0.001). In multivariable analysis, MRC scores ≤10 points were independently associated with extubation failure within 48 h (adjusted OR 2.131, 95% CI: 1.071–4.240, P = 0.031).

Conclusion

Limb muscle weakness assessed on the day of extubation was found to be independently associated with higher extubation failure rates within 48 h following planned extubation in medical patients.

     

Oesophageal diameter is associated with severity but not progression of systemic sclerosis‐associated interstitial lung disease

Background and objective

It is unknown whether oesophageal disease is associated with systemic sclerosis‐associated interstitial lung disease (SSc‐ILD) severity, progression or mortality.

Methods

High‐resolution computed tomography (HRCT) scans from 145 SSc‐ILD patients were scored for fibrosis score, oesophageal diameter and presence of hiatal hernia. Fibrosis asymmetry was calculated as: (most affected side − least affected side)/(most affected side + least affected side). Mixed effects models were used for repeated measures analyses.

Results

Mean fibrosis score was 8.6%, and most patients had mild‐to‐moderate physiological impairment. Every 1 cm increase in oesophageal diameter was associated with 1.8% higher fibrosis score and 5.5% lower forced vital capacity (FVC; P ≤ 0.001 for unadjusted and adjusted analyses). Patients with hiatal hernia had 3.9% higher fibrosis score, with persistent differences on adjusted analysis (P = 0.001). Oesophageal diameter predicted worsening fibrosis score over the subsequent year (P = 0.02), but not when adjusting for baseline fibrosis score (P = 0.16). Oesophageal diameter was independently associated with mortality (P = 0.001). Oesophageal diameter was not associated with asymmetric disease or radiological features of gross aspiration.

Conclusion

Oesophageal diameter and hiatal hernia are independently associated with SSc‐ILD severity and mortality, but not with ILD progression or asymmetric disease. Oesophageal disease is unlikely to be a significant driver of ILD progression in SSc.

     

Nasal high flow therapy and PtCO2 in stable COPD: A randomized controlled cross‐over trial

Background and objective

Hypercapnia is associated with worse clinical outcomes in exacerbations of COPD. The present study aimed to determine the effects of nasal high flow (NHF) therapy on transcutaneous partial pressure of carbon dioxide (PtCO₂) in stable COPD patients.

Methods

In a single‐blind randomized controlled cross‐over trial, 48 participants with COPD were allocated in random order to all of four 20 min interventions: NHF at 15 L/min, 30 L/min and 45 L/min or breathing room air with each intervention followed by a washout period of 15 min. The primary outcome measure was PtCO₂ at 20 min, adjusted for baseline PtCO₂. Secondary outcomes included respiratory rate at 20 min, adjusted for baseline.

Results

The mean (95% CI) change in PtCO₂ at 20 min was −0.6 mm Hg (−1.1 to 0.0), P = 0.06; −1.3 mm Hg (−1.9 to 0.8), P < 0.001; and −2.4 mm Hg (−2.9 to −1.8), P < 0.001; for NHF at 15 L/min, 30 L/min and 45 L/min compared with room air, respectively. The mean (95% CI) change in respiratory rate at 20 min was −1.5 (−2.7 to −0.3), P = 0.02; −4.1 (−5.3 to −2.9), P < 0.001; and −4.3 (−5.5 to −3.1), P < 0.001; breaths per minute compared with room air, respectively.

Conclusion

NHF results in a small flow‐dependent reduction in PtCO₂ and respiratory rate in patients with stable COPD.

     

BMI predicts exercise induced bronchoconstriction in asthmatic boys

Background

Exercise induced bronchoconstriction (EIB) is a frustrating morbidity of asthma in children. Obesity has been associated with asthma and with more severe EIB in asthmatic children.

Objectives

To quantify the effect of BMI on the risk of the occurrence of EIB in children with asthma.

Methods

Data were collected from six studies in which exercise challenge tests were performed according to international guidelines. We included 212 Children aged 7‐18 years, with a pediatrician‐diagnosed mild‐to‐moderate asthma.

Results

A total of 103 of 212 children (49%) had a positive exercise challenge (fall of FEV₁ ≥ 13%). The severity of EIB, as measured by the maximum fall in FEV₁, was significantly greater in overweight and obese children compared to normal weight children (respectively 23.9% vs 17.9%; P = 0.045). Asthmatic children with a BMI z‐score around +1 had a 2.9‐fold higher risk of the prevalence of EIB compared to children with a BMI z‐score around the mean (OR 2.9; 95%CI: 1.3‐6.1; P < 0.01). An increase in BMI z‐score of 0.1 in boys led to a 1.4‐fold increased risk of EIB (OR 1.4; 95%CI: 1.0‐1.9; P = 0.03). A reduction in pre‐exercise FEV₁ was associated with a higher risk of EIB (last quartile six times higher risk compared to highest quartile (OR 6.1 [95%CI 2.5‐14.5]).

Conclusions

The severity of EIB is significantly greater in children with overweight and obesity compared to non‐overweight asthmatic children. Furthermore, this study shows that the BMI‐z‐score, even with a normal weight, is strongly associated with the incidence of EIB in asthmatic boys.