Monitoring pulmonary function in asthma and COPD: point-of-care testing

Analysis of clinical characteristics of different types of lung function impaiement in TDL patients

AIM

The clinical characteristics associated with pulmonary function decline in patients with Tuberculosis-destroyed lung (TDL) remain uncertain. We categorize them based on the pattern of pulmonary function impairment, distinguishing between restrictive spirometric pattern (RSP) and obstructive spirometric pattern (OSP). We aim to compare the severity of these patterns with the clinical characteristics of TDL patients and analyze their correlation.

METHOD

We conducted a retrospective analysis on the clinical data of TDL patients who underwent consecutive pulmonary function tests (PFT) from November 2002 to February 2023. We used the lower limit formula for normal values based on the 2012 Global Lung Function Initiative. We compared the clinical characteristics of RSP patients with those of OSP patients. The characteristics of RSP patients were analyzed using the tertiles of forced vital capacity percentage predicted (FVC% pred) decline based on PFT measurements, and the characteristics of OSP patients were analyzed using the tertiles of forced expiratory volume in 1 s percentage predicted (FEV1% pred) decline.

RESULT

Among the RSP patients, those in the Tertile1 group (with lower FVC% pred) were more likely to have a higher of body mass index (BMI), spinal deformities, and C-reactive protein (CRP) compared to the other two groups (P for trend < 0.001, 0.027, and 0.013, respectively). Among OSP patients, those in the Tertile1 group (with lower FEV1% pred) showed an increasing trend in cough symptoms and contralateral lung infection compared to the Tertile 2-3 group (P for trend 0.036 and 0.009, respectively).

CONCLUSION

For TDL patients, we observed that Patients with high BMI, a higher proportion of spinal scoliosis, and abnormal elevation of CRP levels were more likely to have reduced FVC. Patients with decreased FEV1% pred have more frequent cough symptoms and a higher proportion of lung infections on the affected side.

Changes in Thrombelastography in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease and the Relationship with Lung Function

Purpose

To analyze the changes in thrombelastography (TEG) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and the relationship with indicators related to lung function.

Methods

100 patients with AECOPD admitted to our hospital from May 2021 to May 2022 were selected as the AE group, and another 80 patients with a stable phase of COPD in the same period were selected as the SP group. Fresh blood specimens were collected from both groups, and TEG-related indicators (R value, K value, α-angle, MA value) were measured using the TEG technique, and lung function-related indicators (FEV1, FVC, FEV1/FVC, FEV1%) were measured using a lung function meter, and the correlation between TEG-related indicators and lung function-related indicators was analyzed.

Results

Patients in the AE group had lower R and K values and higher α-angle and MA values than those in the SP group, all with statistically significant differences (P < 0.05). Patients in the AE group had lower FEV1, FVC, FEV1/FVC, and FEV1% levels than those in the SP group, all with statistically significant differences (P < 0.05). Correlation analysis showed that the R value in TEG of AECOPD patients was positively correlated with pulmonary function-related indicators (FEV1, FVC, FEV1/FVC, FEV1%) (r = 0.565, 0.529, 0.447, 0.527, all P < 0.001); K value was positively correlated with pulmonary function-related indicators (FEV1, FVC, FEV1/FVC, FEV1%) (r = 0.512, 0.567, 0.459, 0.439, all P < 0.001); α-angle was inversely correlated with pulmonary function-related indicators (FEV1, FVC, FEV1/FVC, FEV1%) (r = -0.498, -0.372, -0.408, -0.424, all P < 0.001); MA value was inversely correlated with lung function-related indicators (FEV1, FVC, FEV1/FVC, FEV1%) (r = -0.459, -0.429, -0.394, -0.403, all P < 0.001).

Conclusion

There is a correlation between TEG-related indicators and lung function-related indicators in AECOPD patients, both of which can guide the diagnosis and treatment process of the disease and are worthy of clinical promotion. The clinical registration number is EA2021086.

A Review of Portable Electronic Spirometers: Implications for Asthma Self-Management

PURPOSE OF REVIEW

Although portable electronic spirometers allow for at-home lung function monitoring, a comprehensive review of these devices has not yet been conducted. We conducted a systematic search and review of commercially available portable electronic spirometers designed for asthma patient use.

RECENT FINDINGS

All devices (N = 16) allowed for monitoring of basic lung function parameters, but only 31% provided in-app videos on how to perform breathing maneuvers. Most devices (63%) provided graphical representations of lung function results, but only 44% gave immediate feedback on the quality of the breathing maneuver. Several devices (25%) were FDA-approved and cost ranged from US$99 to $1390. Information on data security (63%), measurement accuracy (50%), and association with patient outcomes (0%) was commonly limited. This review found that providers' ability to make informed decisions about whether asthma patients may benefit from portable electronic spirometers is limited due to lack of patient outcome data.

An evaluation of a multi-site community pharmacy-based chronic obstructive pulmonary disease support service

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is a progressive chronic condition that can be effectively managed by smoking-cessation, optimising prescribed therapy and providing treatment to prevent chest infections from causing hospitalisation. The government agenda in the UK is for community pharmacists to become involved in chronic disease management, and COPD is one area where they are ideally located to provide a comprehensive service. This study aims to evaluate the effect of a community pharmacy-based COPD service on patient outcomes.

METHODS

Patients in one UK location were recruited over a 10-week period to receive a community pharmacy-based COPD support service consisting of signposting to or provision of smoking-cessation service, therapy optimisation and recommendation to obtain a rescue pack containing steroid and antibiotic to prevent hospitalisation as a result of chest infection. Data were collected over a 6-month period for all recruited patients. Appropriate clinical outcomes, patient reported medication adherence, quality of life and National Health Service (NHS) resource utilisation were measured.

KEY FINDINGS

Three hundred six patients accessed the service. Data to enable comparison before and after intervention was available for 137 patients. Significant improvements in patient reported adherence, utilisation of rescue packs, quality of life and a reduction in routine general practitioner (GP) visits were identified. The intervention cost was estimated to be off-set by reductions in the use of other NHS services (GP and accident and emergency visits and hospital admissions).

CONCLUSIONS

Results suggest that the service improved patient medicine taking behaviours and that it was cost-effective.

Diagnostic point-of-care tests in resource-limited settings

The aim of diagnostic point-of-care testing is to minimise the time to obtain a test result, thereby allowing clinicians and patients to make a quick clinical decision. Because point-of-care tests are used in resource-limited settings, the benefits need to outweigh the costs. To optimise point-of-care testing in resource-limited settings, diagnostic tests need rigorous assessments focused on relevant clinical outcomes and operational costs, which differ from assessments of conventional diagnostic tests. We reviewed published studies on point-of-care testing in resource-limited settings, and found no clearly defined metric for the clinical usefulness of point-of-care testing. Therefore, we propose a framework for the assessment of point-of-care tests, and suggest and define the term test efficacy to describe the ability of a diagnostic test to support a clinical decision within its operational context. We also propose revised criteria for an ideal diagnostic point-of-care test in resource-limited settings. Through systematic assessments, comparisons between centralised testing and novel point-of-care technologies can be more formalised, and health officials can better establish which point-of-care technologies represent valuable additions to their clinical programmes.

4-1BB ligand-mediated imbalance of helper 17 T cells and regulatory T cells in patients with allergic asthma

OBJECTIVES

To investigate the presence of 4-1BB ligand (4-1BBL) in the peripheral blood of patients with allergic asthma and evaluate its role in controlling the balance between helper 17 T (T(h)17) and regulatory T (T(reg)) cells.

METHODS

Soluble 4-1BBL (s4-1BBL) was quantified by enzyme-linked immunosorbent assay in plasma from patients with asthma (n = 45) and from healthy control subjects (n = 35). The proportion of monocytes positive for membrane-bound 4-1BBL (m4-1BBL) was determined by flow cytometry. Peripheral blood mononuclear cells from patients with asthma were incubated with anti-4-1BB monoclonal antibody in vitro. Concentrations of interleukin (IL)-17 and transforming growth factor (TGF)-β(1) in the culture supernatant were analysed.

RESULTS

Plasma s4-1BBL concentrations and the proportion of m4-1BBL-positive monocytes were significantly lower in patients with asthma than in control subjects. The culture supernatant concentration of TGF-β(1) was increased and that of IL-17 was decreased by incubation with anti-4-1BB monoclonal antibody.

CONCLUSIONS

Both soluble and membrane-bound 4-1BBL were reduced in patients with allergic asthma compared with control subjects. 4-1BBL/4-1BB signalling may play an important role in allergic asthma by regulating the T(h)17/T(reg) balance.

Adherence to current guidelines for chronic obstructive pulmonary disease (COPD) among patients treated with combination of long-acting bronchodilators or inhaled corticosteroids

Background

To estimate the potential cost savings by following the current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline recommendations in patients being treated for chronic obstructive pulmonary disease (COPD) with the combination of long-acting β₂-agonist (LABA), long-acting muscarinic antagonist (LAMA) or inhaled corticosteroids (ICS).

Methods

The Geisinger Health System (GHS) database was utilized to identify subjects between January 1, 2004 to March 12, 2007. The index date was based on the first prescription of a LAMA plus LABA, LAMA plus LABA/ICS, or LABA plus ICS. Patients were included in the study if they: had a COPD diagnosis; had data representative of treatment 12 months prior to and 12 months post index date; were 40 years of age or over; had no prior diagnosis for asthma; and had pulmonary function test (PFT) data. We examined the baseline characteristics of these patients along with their healthcare resource utilization. Based on PFT data within 30 days of the index date, a subgroup was classified as adhering or non-adhering to GOLD guidelines.

Results

A total of 364 subjects could be classified as adhering or non-adherent to current GOLD guidelines based on their PFT results. The adherent subgroup received COPD medications consistent with current GOLD guidelines. Of the LAMA plus LABA cohort, 25 patients adhered and 39 patients were non-adherent to current GOLD guidelines. In the cohort of LABA plus ICS, 74 patients were adherent and 180 patients non-adherent to current GOLD guidelines. In the cohort of LAMA plus LABA/ICS, 21 patients were adherent and 25 patients non-adherent to current GOLD guidelines. GOLD adherence was associated with mean total cost of all services savings of $5,889 for LAMA plus LABA, $3,330 for LABA + ICS, and $10,217 for LAMA plus LABA/ICS cohorts.

Conclusion

Staging of COPD with a PFT and adherence to current GOLD guidelines was associated with lower costs in subjects with moderate to severe COPD. Appropriate use of LAMA plus LABA, LABA plus ICS, and LAMA plus LABA/ICS has economic as well as clinical benefits for patients and payers.

Can peak expiratory flow measurements differentiate chronic obstructive pulmonary disease from congestive heart failure?

Dyspneic patients are commonly encountered by Emergency Medical Service (EMS). Frequent causes include Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Measurement of peak expiratory flow rate (PEFR) has been proposed to help differentiate COPD from CHF. This prospective, cohort, pilot study was conducted to determine if PEFR in patients with an exacerbation of COPD were significantly different than CHF. Included were patients presenting with dyspnea plus a history of COPD and/or CHF. A PEFR was measured, values were compared to predicted average, and a percentage was calculated. Twenty-one patients were enrolled. Six had a diagnosis of COPD, 12 CHF; 3 had other diagnoses. Mean percentage of predicted PEFR with COPD was 26.36%, CHF 48.9% (P = 0.04). Patients presenting with acute COPD had significantly lower percentage of predicted PEFR than those with CHF. These results suggest that PEFR may be useful in differentiating COPD from CHF. This study should be expanded to the prehospital setting with a larger number of subjects.

Medication changes prior to hospitalization for obstructive lung disease: a case-crossover study

BACKGROUND

Hospitalizations have always been seen as a solid outcome parameter in pharmacoepidemiology. However, the period leading to hospitalization and prehospital management of the patient are equally important.

OBJECTIVE

To evaluate medication changes in the period prior to hospitalization for obstructive lung disease and to quantify the association between medication use and the risk of hospitalization.

METHODS

We conducted a case-crossover study using the PHARMO record linkage system, which contains drug dispensing data from community pharmacies and hospital admission data. Patients included in the study were adults hospitalized for obstructive lung disease between 2005 and 2007. The index date of the case period was the date of hospitalization, and control moments were set at 3, 6, 9, and 12 months before admission. For each patient, all prescriptions prior to the date of hospitalization were identified. Medication use was ascertained in a 90-day time window prior to each case or control moment.

RESULTS

We identified 1481 patients who were hospitalized for obstructive lung disease. It appeared that respiratory medication use increased in the 90 days prior to hospitalization. Hospitalization was associated with the use of 3 or more respiratory drugs (OR 2.2; 95% CI 1.8 to 2.8), systemic glucocorticoids (OR 4.5; 95% CI 3.8 to 5.4), and antibiotics (OR 3.1; 95% CI 2.7 to 3.6).

CONCLUSIONS

The use of systemic glucocorticoids, antibiotics, and other respiratory drugs increased prior to hospitalization for obstructive lung disease. These results could be indicative of the development and/or treatment of an exacerbation. There is a need for markers to detect exacerbations in an early phase in order to start treatment as early as possible and possibly prevent hospitalizations for obstructive lung disease.

ABCs of Asthma

Asthma results from chronic airway inflammation involving a diversity of activated cells including mast cells, eosinophils, T-lymphocytes, neutrophils, macrophages, and epithelial cells. These cells release proinflammatory cytokine mediators that augment and regulate airway inflammation, leading to airway hyperresponsiveness responsible for the chronic asthma symptoms of dyspnea, wheezing, and chest tightness. It is hypothesized, but unproven, that inflammatory effects can lead to irreversible structural and functional airway changes. Early intervention with anti-inflammatory agents mitigates inflammatory changes, reverses airway obstruction, and may possibly prevent progression of airway remodeling. Current asthma guidelines recommend that initial management should be based on pretreatment assessments of asthma severity as determined by measures of clinical and spirometric impairment in individual patients; subsequent adjustments of pharmacotherapy and avoidance recommendations should be performed at regular follow-up visits and guided by frequent assessments of asthma control. Physicians and providers should continually educate asthmatic patients about proper use of asthma controller medications, avoidance of asthma triggers, and self-management of asthma exacerbations.

Monitoring flow rates and retention of inhalation techniques using the in-check dial device in adult asthmatics

The In-Check-Dial (Alliance Tech Medical, Granburg, TX) was used to determine adequacy of inhalation techniques and teaching of two different devices. Retention of adequate techniques, was assessed in 234 moderate to severe asthmatics. Inhalation techniques were assessed at periodic follow-ups divided into less than 1 month return visit, between 1 and 3 months, 3 to less than 6 months, and 6 months to less than 1 year. Proper inhalation techniques worsened at greater than 3 months after the last instruction. The use of the In-Check-Dial is a useful tool in teaching proper technique and monitoring the patient's ability to correctly use inhalation devices.

Stepwise Approach to Developing Point-of-Care Testing Services in the Community/Ambulatory Pharmacy Setting

OBJECTIVE

To provide a stepwise approach to development and implementation of a point-of-care testing (POCT) patient care service.

SETTING

Community and ambulatory care pharmacy practice.

PRACTICE DESCRIPTION

To provide community and ambulatory pharmacists with the steps involved in integrating POCT services into their pharmacy practice site.

PRACTICE INNOVATION

Authors used various resources to detail the process of implementing pharmaceutical care in community or ambulatory pharmacy settings in combination with individual practice experiences. The five steps involved in developing a POCT service include conducting a needs assessment, researching and organizing information, developing program materials, implementing the service, and evaluating the service. The narrative description of each step is illustrated by a case study example.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS/CONCLUSION

POCT patient care services are a valuable addition to a pharmacy's services, benefiting patients, health care providers, and the pharmacy. This article presents a structured, deliberate approach with resources that can be used to develop a successful POCT service within a community or ambulatory pharmacy setting.

Agreement Between Pneumotachograph and PiKo-1 Measurements of PEF and FEV1

OBJECTIVE

To assess how well values for peak expiratory flow (PEF) and forced expiratory volume in 1 second (FEV1) agree when measured with the PiKo-1 device and with a conventional pneumotachograph.

PATIENTS AND METHODS

This randomized, single-blind study included 40 patients who attended the clinic for lung function testing. The 2 measurement devices were the Masterlab pneumotachograph and the PiKo-1. A correction factor estimated by the manufacturer was applied to the measurements taken with the PiKo-1.

RESULTS

The values obtained with the 2 devices differed by a mean of 5.8218 L/min for PEF (95% confidence interval [CI], -9.4809 to 21.1387) and 0.001 L for FEV1 (95% CI, -0.0616 to 0.0636). The intraclass correlation coefficient was 0.9652 (95% CI, 0.9336-0.9819) for PEF and 0.9876 (95% CI, 0.9761-0.9936) for FEV1.

CONCLUSIONS

The PiKo-1 is a simple and easy-to-use device that can be very useful for monitoring and assessing the severity of obstructive pulmonary diseases. The results must be corrected for altitude and the estimated correction factor should be applied.

Pulmonary function electronic monitoring devices: a randomized agreement study

STUDY OBJECTIVES

To compare in a clinical setting the within-session reproducibility of two pulmonary function electronic monitoring devices (PiKo-1; Ferraris Respiratory Europe; Hereford, UK; and Spirotel; MIR; Rome, Italy) with one mechanical device (Mini-Wright Peak-Flow Meter; Clement-Clarke International; Harlow, Essex, UK), and to evaluate the accuracy of these devices using as reference an office pneumotachograph.

DESIGN, SETTING, AND PARTICIPANTS

After detailed instructions, adults without airways diseases and patients with stable asthma attending an outpatient clinic performed four sets of expiratory maneuvers, one set for each device, in a strictly random order. Each set comprised three maneuvers with 2 to 3 min of rest between them.

MEASUREMENTS

Reproducibility of FEV1 and peak expiratory flow (PEF) was assessed by a coefficient of variation (CV) and intraclass correlation coefficient (ICC), and accuracy was assessed by ICC and limits of agreement.

RESULTS

Of the 38 participants evaluated, 71% were women and 61% had asthma. Ages ranged from 18 to 58 years, and FEV1 ranged from 1.2 to 4.8 L. In all monitoring devices, CV was < 6% and ICC was > 0.94 for the reproducibility of both FEV1 and PEF measurements. The accuracy of the PiKo-1 device was better for FEV1 (ICC = 0.98) than for PEF (ICC = 0.90). The Spirotel device had similar results for FEV1 and PEF (ICC = 0.95). The Mini-Wright device had the lowest accuracy (ICC = 0.87), particularly for PEF values < 500 L/min.

CONCLUSIONS

These low-cost and easy-to-use electronic monitoring devices showed a very good reproducibility and were in agreement with the pneumotachograph. Therefore, the PiKo-1 and Spirotel devices seem adequate for both screening and monitoring. However, prospective studies are still needed to assess their long-term reproducibility and usability and, particularly, the effects on the improvement of respiratory care.

Hyperpolarized 3He MRI in asthma measurements of regional ventilation following allergic sensitization and challenge in mice--preliminary results

RATIONALE AND OBJECTIVES

Quantitative regional measurement of physiological parameters of lung may improve both early detection of asthma and its response to treatment by elucidating the characteristics of airway obstruction. Recent emergence of hyperpolarized helium-3 magnetic resonance imaging as a sensitive pulmonary imaging tool has shown great potential in capturing important structural and functional aspects of normal and diseased lungs. The objective of this study was to investigate regional ventilation changes in the mouse lung following allergen sensitization and challenge.

MATERIALS AND METHODS

A murine model of allergic airway inflammation was created in mice following allergen challenge using Af and IgE-mediated asthma. The creation of model was verified using pulmonary function test and histology. Regional fractional ventilation was then measured in the animals using hyperpolarized 3He MRI on a pixel-by-pixel basis with a planar resolution of 0.24 mm. The sensitized and healthy animals were then compared statistically to assess the potential sensitivity of this technique in detection of such pulmonary abnormalities.

RESULTS

In this work, we have demonstrated for the first time the quantitative measurement of regional ventilation in normal and asthmatic mice. Results of this study show significant changes in regional ventilation in murine model of allergic airway sensitization compared with that in normal control animals.

CONCLUSION

Further development of this technique can potentially serve as a quantitative marker to investigate the physiology of allergen-induced airway hyperresponsiveness and to assist in disease treatment and prevention.