Research advances and clinical management of bronchiectasis: Chinese perspective

Epidemiological characteristics of patients with invasive pulmonary aspergillosis infected with Aspergillus fumigatus from a tertiary hospital in Ningxia, China

Invasive pulmonary aspergillosis (IPA) is a severe fungal infection primarily caused by Aspergillus fumigatus, representing a significant burden on public health. This study aims to address the limitations in the epidemiological characteristics, risk factors and diagnostic approaches for IPA by identifying clinical characteristics, laboratory findings, and chest CT imaging features that distinguish IPA from Aspergillus fumigatus colonization (AFC). We conducted a retrospective analysis of 249 hospitalized patients, including 77 with IPA and 172 with AFC, at Ningxia Medical University General Hospital from January 2018 to December 2023. Our findings revealed that patients with IPA exhibited higher rates of hemoptysis, dyspnea, and fever compared to those with AFC. Laboratory results indicated elevated levels of galactomannan (GM), white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and platelet count in IPA patients. Chest computed tomography imaging studies showed higher incidences of cavity, consolidation, ground-glass opacity, and halo sign in IPA patients. Voriconazole was the primary treatment for 75.3% of IPA patients, who also had longer hospital stays and higher treatment costs. Multivariate logistic regression identified GM, ESR, chronic obstructive pulmonary disease (COPD), and hypertension as significant risk factors for IPA. Our study highlights the necessity of developing enhanced diagnostic models that integrate GM and ESR biomarkers to improve the specificity and sensitivity of IPA diagnosis. These findings provide valuable insights for early diagnosis and optimized treatment strategies, potentially improving patient outcomes and reducing healthcare costs.

Psychometric Validation and Determination of the Minimal Clinically Important Difference for the Bronchiectasis Health Questionnaire in Adults with Bronchiectasis

Rationale: The Bronchiectasis Health Questionnaire (BHQ) is a concise, self-administered, and disease-specific instrument for measuring health-related quality of life in bronchiectasis. Objectives: We sought to investigate the psychometric properties of a simplified Mandarin BHQ and determine the minimum clinically important difference (MCID) as a reliable clinical endpoint for assessing the efficacy of bronchiectasis treatments. Methods: A longitudinal, randomized controlled trial cohort of 357 patients treated with tobramycin inhalation solution or saline inhalation for Pseudomonas aeruginosa infection and a cross-sectional observational cohort of 436 patients with bronchiectasis were analyzed. Psychometric analyses encompassed convergent validity, known-groups validity, internal consistency, test-retest reliability, and responsiveness. Both anchor-based and distribution-based approaches were utilized to calculate the MCID for therapeutic response. Results: There were significant positive correlations between scores on the BHQ and those on the Quality of Life-Bronchiectasis Respiratory Symptom Scale, with correlation coefficients of 0.698 in the trial cohort and 0.567 in the clinical cohort (both Ps < 0.0001). Known-groups validity indicated significant differences in BHQ scores stratified by baseline Bronchiectasis Severity Index. BHQ scores correlated modestly with both forced expiratory volume in 1 second percent predicted and exacerbation frequency within the previous year. In the trial cohort, the BHQ demonstrated excellent internal consistency (Cronbach's α = 0.893) and test-retest reliability (intraclass correlation coefficient = 0.853). An 8-point improvement in scores on the Quality of Life-Bronchiectasis Respiratory Symptom Scale corresponded to a mean increase of 5.49 points in BHQ scores after 4-week treatment. The MCID for BHQ was consistently 3 points. Conclusions: The BHQ (MCID: 3 points) represents a clinically meaningful tool for evaluating therapeutic intervention outcomes and patient-centered outcomes in patients with bronchiectasis.

Baseline characteristics of patients in the Chinese Bronchiectasis Registry (BE-China): a multicentre prospective cohort study

BACKGROUND

Bronchiectasis is a disease with a global impact, but most published data come from high-income countries. We aimed to describe the clinical characteristics of patients with bronchiectasis in China.

METHODS

The Chinese Bronchiectasis Registry (BE-China) is a prospective, observational cohort enrolling patients from 111 hospitals in China. Data on demographics, comorbidities, and aetiological testing results were collected from adult patients with bronchiectasis at baseline and annual follow-up. Patients who met the inclusion criteria (age ≥18 years; received chest high-resolution CT in the past year showing bronchiectasis affecting one or more lung lobes; and clinical history consistent with bronchiectasis, including chronic cough, daily sputum production, and history of exacerbations) were included. Patients with known cystic fibrosis were excluded. To investigate variations according to different economic regions, two groups were compared based on whether per capita disposable income of residents was greater than US$5553. Clinical characteristics were compared with the European (EMBARC) registry and other national registries.

FINDINGS

Between Jan 10, 2020, and March 31, 2024, 10 324 patients from 97 centres were included in the study. Among 9501 participants with available data, the most common cause of bronchiectasis was post-infective disease (4101 [43·2%] patients), followed by idiopathic (2809 [29·6%] patients). 6676 (70·0%) of 9541 patients with available data had at least one exacerbation in the year before enrolment and 5427 (57·2%) of 9489 patients with available data were hospitalised at least once due to exacerbations. Treatments commonly used in high-income countries, such as inhaled antibiotics and macrolides, were infrequently used in China. Implementation of airway clearance in China was scarce, with only 1177 (12·2%) of 9647 patients having used at least one method of airway clearance. Compared with upper-middle-income regions, patients from lower-middle-income regions were younger (61·0 years [SD 14·0] vs 63·9 years [14·2]) with a higher proportion of pulmonary comorbidities (521 [17·8%] of 2922 patients vs 639 [8·6%] of 7402 with chronic obstructive pulmonary disease and 194 [6·6%] of 2922 patients vs 364 [4·9%] of 7402 patients with asthma), a higher tuberculosis burden (442 [16·0%] of 2768 patients vs 715 [10·6%] of 6733 patients), more severe radiological involvement (1160 [42·4%] of 2736 patients vs 2415 [35·4%] of 6816 patients with cystic bronchiectasis), more exacerbations (median 1·4 [IQR 0-2] in both groups; mean 1·4 [SD 1·6] vs 1·2 [1·4] in the previous year) and hospitalisations (1662 [60·6%] of 2743 patients vs 3765 [55·8%] of 6746 patients hospitalised at least once in the previous year), and poorer quality of life (median 57·4 [IQR 53·5-63·1] vs 58·7 [54·8-64·8] assessed by the Bronchiectasis Health Questionnaire).

INTERPRETATION

The clinical characteristics of patients with bronchiectasis in China show differences compared with cohorts in Europe and India. Bronchiectasis is more severe with a higher burden of exacerbations in lower-income regions. The management of patients with bronchiectasis in China urgently needs standardisation and improvement.

FUNDING

National Natural Science Foundation of China, Innovation Program of the Shanghai Municipal Education Commission, Program of the Shanghai Municipal Science and Technology Commission, and Program of the Shanghai Shenkang Development Center.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Risk factors for readmission within one year after acute exacerbations of bronchiectasis in a Chinese tertiary hospital: a retrospective cohort study

BACKGROUND

Frequent exacerbations of bronchiectasis lead to poor quality of life, impaired lung function, and higher mortality rates. This study aims to evaluate the risk factors associated with readmission within one year due to acute exacerbation of bronchiectasis (AEB).

METHODS

A retrospective cohort study was performed on 260 patients with bronchiectasis who were hospitalized in the respiratory and critical care department of a tertiary hospital in China. Univariate and multivariate Cox analyses were used to evaluate the risk factors for readmission within one year.

RESULTS

Readmission within one year was found in 44.6% of 260 patients hospitalized with acute exacerbation of bronchiectasis. The risk factors associated with readmission included age over 65 years (HR = 3.66; 95% CI: 2.30 to 5.85), BMI < 18.5 kg/m2 (HR = 1.71; 95% CI: 1.16 to 2.51), respiratory intensive care unit (RICU) stay during admission (HR = 2.06, 95% CI: 1.16-3.67), involvement of 3 or more lobes on chest high-resolution computed tomography (HRCT) (HR = 1.85; 95% CI, 1.22 to 2.80), chronic Pseudomonas aeruginosa (PA) colonization (HR = 2.29; 95% CI: 1.54 to 3.38), and positive sputum culture results within 24 h after admission (HR = 1.93; 95% CI: 1.27 to 2.94). Long-term oral antibiotics use after discharge was associated with decreased hazard of readmission (HR = 0.34; 95% CI: 0.20 to 0.59).

CONCLUSIONS

Patients with bronchiectasis have a high rate of readmission, which is linked to varieties of risk factors, and identifying these risk factors is importance for effectively managing patients with bronchiectasis.

Association of short-term exposure to ambient air pollution and temperature with bronchiectasis mortality: a nationwide time-stratified case-crossover study

BACKGROUND

Ambient pollution and non-optimal temperature are major risk factors for respiratory health. However, the relationships between short-term exposure to these factors and bronchiectasis mortality remain unknown.

METHODS

A nationwide, time-stratified case-crossover study across Mainland China was conducted from 2013 to 2019. Records of bronchiectasis deaths were extracted from the National Death Registration Reporting Information System. Daily concentrations of fine particulate matter (PM2.5), coarse particulate matter (PM2.5-10), nitrogen dioxide (NO2), ozone (O3), and daily temperature were obtained from high-resolution prediction models. We utilized conditional logistic regression model and distributed lag nonlinear model to explore the associations of these exposures with bronchiectasis mortality.

FINDINGS

We included a total of 19,320 bronchiectasis deaths. Air pollutant was associated with bronchiectasis mortality within the first 3 days after exposure and the exposure-response relationships were almost linear. An interquartile range increase in PM2.5, PM2.5-10, and O3 was associated with increments of 3.18%, 4.14%, and 4.36% in bronchiectasis mortality at lag 02 d, respectively. Additionally, lower temperature was associated with higher odds of bronchiectasis mortality. Compared to referent temperature (23.6 °C), the odds ratio for bronchiectasis mortality associated with extremely low temperature (P1: -13.4 °C) was 1.54 (95% CI: 1.05, 2.25).

INTERPRETATION

This national study provides compelling evidence, and highlights the necessity and importance of reducing air pollution exposures and keeping warm for susceptible populations.

FUNDING

National Natural Science Foundation of China (81925001; 82330070); Innovation Program of Shanghai Municipal Education Commission (202101070007-E00097); Program of Shanghai Municipal Science and Technology Commission (21DZ2201800); Program of Shanghai Shenkang Development Center (SHDC12023110); and Major Project of National Health Commission of China.

Autologous transplantation of P63+ lung progenitor cells in patients with bronchiectasis: A randomized, single-blind, controlled trial

Non-cystic fibrosis bronchiectasis is a progressive respiratory disease with limited treatment options, prompting the exploration of regenerative therapies. This study investigates the safety and efficacy of autologous P63+ progenitor cell transplantation in a randomized, single-blind, controlled, phase 1/2 trial. Thirty-seven patients receive bronchoscopic airway clearance (B-ACT) (n = 19) or B-ACT plus P63+ progenitor cells (n = 18). Results show that compared to the control group, the change in DLCO levels from baseline to 24 weeks post therapy is significantly higher in the cell treatment group (p value = 0.039). Furthermore, the patients in the cell treatment group demonstrate significantly reduced lung damaged area, improved SGRQ score, and ameliorated BSI and FACED scores within 4-12 weeks post therapy. Transcriptomic analysis reveals that progenitor cells with higher expression of P63 gene have better therapeutic efficacy. These findings suggest that P63+ progenitor cells may offer a promising therapeutic approach for bronchiectasis. This study was registered at ClinicalTrials.gov(NCT03655808).

Improving the Diagnosis and Treatment of Paediatric Bronchiectasis Through Research and Translation

Bronchiectasis, particularly in children, is an increasingly recognised yet neglected chronic lung disorder affecting individuals in both low-to-middle and high-income countries. It has a high disease burden and there is substantial inequity within and between settings. Furthermore, compared with other chronic lung diseases, considerably fewer resources are available for children with bronchiectasis. The need to prevent bronchiectasis and to reduce its burden also synchronously aligns with its high prevalence and economic costs to health services and society. Like many chronic lung diseases, bronchiectasis often originates early in childhood, highlighting the importance of reducing the disease burden in children. Concerted efforts are therefore needed to improve disease detection, clinical management and equity of care. Modifiable factors in the causal pathways of bronchiectasis, such as preventing severe and recurrent lower respiratory infections should be addressed, whilst also acknowledging the role played by social determinants of health. Here, we highlight the importance of early recognition/detection and optimal management of bronchiectasis in children, and outline our research, which is attempting to address important clinical knowledge gaps discussed in a recent workshop. The research is grouped under three themes focussing upon primary prevention, improving diagnosis and disease characterisation, and providing better management. Our hope is that others in multiple settings will undertake additional studies in this neglected field to further improve the lives of people with bronchiectasis. We also provide a resource list with links to help inform consumers and healthcare professionals about bronchiectasis and its recognition and management.

A phase 4 multicentre, 2×2 factorial randomised, double-blind, placebo-controlled trial to investigate the efficacy and safety of tobramycin inhalation solution for Pseudomonas aeruginosa eradication in bronchiectasis: ERASE

Chronic Pseudomonas aeruginosa (PA) infection significantly contributes to morbidity and mortality in bronchiectasis patients. Initiating antibiotics early may lead to the eradication of PA. Here we outline the design of a trial (ERASE; NCT06093191) assessing the efficacy and safety of inhaled tobramycin, alone or with oral ciprofloxacin, in bronchiectasis patients with a new isolation of PA. This multicentre, 2×2 factorial randomised, double-blind, placebo-controlled, parallel-group trial includes a 2-week screening period, a 12-week treatment phase (with a combination of ciprofloxacin or a placebo at initial 2 weeks) and a 24-week follow-up. 364 adults with bronchiectasis and a new PA isolation will be randomly assigned to one of four groups: placebo (inhaled saline and ciprofloxacin placebo twice daily), ciprofloxacin alone (750 mg ciprofloxacin and inhaled saline twice daily), inhaled tobramycin alone (inhaled 300 mg tobramycin and ciprofloxacin placebo twice daily) or a combination of both drugs (inhaled 300 mg tobramycin and 750 mg ciprofloxacin twice daily). The primary objective of this study is to assess the proportion of patients successfully eradicating PA in each group by the end of the study. Efficacy will be evaluated based on the eradication rate of PA at other time points (12, 24 and 36 weeks), the occurrence of exacerbations and hospitalisations, time to first pulmonary exacerbations, patient-reported outcomes, symptom measures, pulmonary function tests and the cost of hospitalisations. To date no randomised trial has evaluated the benefit of different PA eradication strategies in bronchiectasis patients. The ERASE trial will therefore generate crucial data to inform future clinical guidelines.

Association of blood total immunoglobulin E and eosinophils with radiological features of bronchiectasis

BACKGROUND

Our study aimed to investigate whether serum total IgE and blood eosinophils were associated with radiological features of bronchiectasis in a Chinese cohort.

METHODS

We retrospectively enrolled bronchiectasis patients who visited Peking University Third Hospital from Jan 1st, 2012 to Oct 7th, 2021. The clinical, laboratory and chest CT characteristics were analyzed in association with serum total IgE level and blood eosinophil count.

RESULTS

A total of 125 bronchiectasis patients were enrolled, with 50.4% (63/125) female, and a mean age of 62.4 ± 14.1 years. The median serum total IgE level and blood eosinophil count were 47.7 (19.8, 123.0) KU/L and 140 (90, 230) cells/µl, respectively. In patients with a higher than normal (normal range, 0-60 KU/L) total IgE (43.2%, n = 54), more lobes were involved [4 (3, 5) vs. 3 (2, 4), p = 0.008], and mucus plugs were more common (25.9% vs. 9.9%, p =0.017) on HRCT, as compared to those with a normal level of total IgE. The higher IgE group was more likely to have bilateral involvement (p = 0.059), and had numerically higher Smith and Bhalla scores, but the differences were not statistically significant. In patients with an eosinophil count ≥ 150 cells/µl (49.6%, n = 62), the number of lobes involved was greater [4 (3, 5) vs. 3 (2, 4), p = 0.015], and the Smith and Bhalla scores were higher [9 (5, 12) vs. 6 (3, 9), p = 0.009, 7 (5, 11) vs. 5 (3, 9), p = 0.036]. The Smith score was correlated positively with the eosinophil count (r = 0.207, p = 0.020). Fractional exhaled nitric oxide (FeNO) was correlated with total IgE (r = 0.404, p = 0.001) and eosinophil count (r = 0.310, p = 0.014).

CONCLUSIONS

Our study demonstrated that serum total IgE and the blood eosinophil count were associated with the radiological extent and severity of bronchiectasis, necessitating further investigation on the role of T2 inflammation in structural abnormalities of this heterogeneous disease.

The BED-Pro Tool: facilitating the detection of bronchiectasis exacerbations

The Bronchiectasis Exacerbation Diary is an eight-item patient-reported outcome instrument for detecting exacerbations in bronchiectasis https://bit.ly/3k2IH4p.

Necroptosis-related subtypes are associated with bronchiectasis in pulmonary non-tuberculous mycobacteria-infected patients: a perspective based on transcriptomic analysis

The aim of this study was to explore the potential mechanisms responsible for the different manifestations of bronchiectasis in patients with pulmonary non-tuberculous mycobacteria (pNTM) infection. We found that the necroptosis level increased significantly after NTM infection. Further, the 31 pNTM-infected patients were classified into two subtypes based on necroptosis-related genes (NRGs) by unsupervised cluster analysis. After that, we compared the differences in clinical parameters, immune cell infiltration, and gene expression between the two subtypes. We observed that the high-necroptosis subtype possessed higher CT scores for bronchiectasis extent (P = 0.008) and severity (P = 0.023). And, more neutrophil infiltration in the high-necroptosis subtype was demonstrated both by the CIBERSORT algorithm and by blood neutrophil count (P = 0.001). Next, 688 differentially expressed genes (DEGs) between two subtypes were identified. To explore the portion in DEGs that might contribute to bronchiectasis, we intersected the DEGs with two gene modules. These two gene modules were identified as the most associated with CT scores for bronchiectasis extent and severity by weighted gene co-expression network analysis (WGCNA). Ninety-three intersection genes were obtained. Finally, 7 hub genes including ACSL1, ANXA3, DYSF, HK3, SLC11A1, STX11, and TLR4 were further screened out by machine learning algorithms and protein-protein interaction network analysis. These results suggested that the differential levels of necroptosis in pNTM patients might lead to differential extent and severity of bronchiectasis on radiographic imaging. This process might be associated with neutrophil infiltration and the involvement of seven hub genes.

Diagnosis values of Dectin-1 and IL-17 levels in plasma for invasive pulmonary aspergillosis in bronchiectasis

Background

Among immunocompetent patients, patients with bronchiectasis are considered to be a high-risk group for invasive pulmonary aspergillosis (IPA). Early diagnosis and treatment can improve the prognosis of patients.

Objectives

We aimed to investigate the diagnostic value of Dectin-1 and IL-17 for diagnosing IPA with bronchiectasis.

Methods

We retrospectively collected data on patients with bronchiectasis who had been hospitalized in the Third Affiliated Hospital of Soochow University between September 2018 to December 2021. Dectin-1, IL-17 and GM were measured by enzyme-linked immunosorbent assays.

Results

A total of 129 patients were analyzed in the study, of whom 33 had proven or probable IPA with bronchiectasis. The remaining 96 patients served as controls. The plasma Dectin-1 and IL-17 levels in the IPA group were significantly higher than that in the control group (P=0.005; P<0.001). The plasma GM, BALF GM, plasma Dectin-1 and IL-17 assays had sensitivities of 39.4%, 62.5%, 69.7% and 78.8%, respectively, and specificities of 89.2%, 91.5%, 72.9% and 71.9%, respectively. The sensitivity of Dectin-1 and IL-17 in plasma was higher than that in plasma and BALF GM. while the specificity is lower than that of plasma and BALF GM. The diagnostic sensitivity and specificity of plasma GM combined with IL-17 for IPA in bronchiectasis were greater than 80%. The combination of plasma GM and IL-17 can improve the sensitivity of the GM test, but does not reduce the diagnostic specificity. The plasma Dectin-1 and IL-17 showed positive linear correlations with the bronchiectasis severity Index (BSI) score in linear regression.

Conclusions

Plasma Dectin-1 and IL-17 levels were significantly higher in bronchiectasis patients with IPA. The sensitivity of Dectin-1 and IL-17 was superior to that of GM for the diagnosis of IPA in patients with bronchiectasis. The combination of GM and IL-17 in plasma is helpful for the diagnosis of IPA in bronchiectasis patients who cannot tolerate invasive procedures.