Evaluation of clinical methods for rating dyspnea

A prospective, multicenter, randomized controlled trial evaluating anticoagulation alone vs anticoagulation plus computer assisted vacuum thrombectomy for the treatment of intermediate-high-risk acute pulmonary embolism: Rationale and design of the STORM-PE study

BACKGROUND

Therapeutic anticoagulation (AC) is standard care for pulmonary embolism (PE). Endovascular therapy with mechanical thrombectomy (MT) is commonly performed for PE and well-studied in single-arm trials. The efficacy benefit of MT over AC alone in a randomized fashion remains unstudied.

METHODS AND RESULTS

STORM-PE (ClinicalTrials.gov Identifier: NCT05684796) is a post-market, international, open-label trial conducted in partnership with The Pulmonary Embolism Response Team Consortium. Up to 100 patients with confirmed acute intermediate-high-risk PE demonstrated by right ventricular (RV) dysfunction with a right-to-left ventricular (RV/LV) ratio ≥1.0 and elevated cardiac biomarkers will be randomized 1:1 to receive AC alone or AC plus computer assisted vacuum thrombectomy (CAVT) with the Indigo Aspiration System (Penumbra Inc.). The primary outcome is a mean change in RV/LV ratio at 48 hours, assessed by computed tomographic pulmonary angiography (CTPA) and adjudicated by a blinded, independent imaging Core Lab. Additional endpoints are composite major adverse events, functional outcomes (6-minute walk test, New York Heart Association classification, post-venous thromboembolism functional status scale, modified Medical Research Council Dyspnea Scale, Borg Scale), quality of life (Pulmonary Embolism Quality of Life Questionnaire and EQ-5D-5L), mortality, and symptomatic PE recurrence through 90 days. A Clinical Events Committee will adjudicate adverse events for causality and attribution and an independent Data Safety Monitoring Board will oversee the study. STORM-PE is funded by Penumbra Inc.

CONCLUSIONS

The STORM-PE trial will help inform future guidelines and standards of care related to frontline treatment using mechanical thrombectomy with CAVT for patients with acute intermediate-high-risk PE.

TRIAL REGISTRATION

STORM-PE, NCT05684796, is registered at https://clinicaltrials.gov/study/NCT05684796.

Association of Patient-Reported Outcome Patterns and Major Clinical Factors with Frailty in Stable COPD

Purpose

Chronic obstructive pulmonary disease (COPD) exhibits heterogeneous symptom profiles across individuals. This study aimed to identify subgroups of patients with stable COPD according to physiological, psychological, and environmental symptoms; assess differences in their characteristics; and examine the association of symptom patterns with frailty.

Patients and Methods

We analyzed data from the second wave of a cohort study involving patients with COPD reassessed 6 months after hospitalization for acute exacerbations. Frailty and patient-reported outcomes were measured using the FRAIL and Modified COPD-Patient-Reported Outcome (mCOPD-PRO) scales. Latent profile analysis identified subgroups based on mCOPD-PRO symptom patterns. Differences across symptom severity subgroups were assessed using post-hoc trend analyses and chi-square tests for trends. Multinomial logistic regression quantified the magnitude of differences between subgroups. The relationship between subgroups, clinical factors, and frailty was examined through linear regression.

Results

Among 308 patients with stable COPD, three subgroups were identified: "low-symptom" (27.9%), "moderate-symptom" (51.3%), and "severe-symptom" (20.8%). Body mass index, Global Initiative for Chronic Obstructive Lung Disease stage (GOLD), COPD Assessment Test (CAT) score, modified Medical Research Council (mMRC) score, and physical activity exhibited significant linear trends across subgroups of increasing symptom severity. Frailty scores differed significantly: 0.50 ± 0.78 in the low-symptom group, 1.34 ± 0.96 in the moderate-symptom group, and 2.72 ± 0.95 in the severe-symptom group. Multivariate analysis identified severe-symptom group (β coefficient [β]=0.62, 95% confidence interval [CI]: 0.21-1.03), rural residence (β=0.21, 95% CI: 0.04-0.39), GOLD (β=0.23, 95% CI: 0.07-0.39), mMRC (β=0.17, 95% CI: 0.03-0.31), and CAT score (β=0.04, 95% CI: 0.02-0.06) associated with frailty.

Conclusion

Patients with stable COPD can be categorized based on patient-reported outcomes, with differences in demographic and disease characteristics across subgroups. Patients with severe COPD symptoms revealed higher levels of frailty compared to those with low symptoms.

Respiratory post COVID sequelae: the role of pulmonary function impairment, fatigue and obesity in dyspnea and the impact of SPA rehabilitation

BACKGROUND

Respiratory COVID-19 post-acute sequelae (PASC) may persist for extended periods following recovery.

METHODS

Patients with PASC who were referred for Salus Per Aquam (SPA) therapy were enrolled in the study.

AIM

To categorize patients based on the presence of dyspnea and fatigue, with a specific focus on obesity, chronic respiratory conditions, and predictors of rehabilitation outcomes.

RESULTS

From July-November 2021, 327 consecutive patients were enrolled at the spa center. Among these, 31% had been previously hospitalized, 5% had required noninvasive or invasive mechanical ventilation. Approximately one-third of the cohort underwent DLCO testing, which was abnormal in 56.3% of cases. Patients with impaired DLCO had significantly higher dyspnea rates compared to those with normal DLCO (88.9% vs. 64.3%, p < 0.0001). Dyspneic patients were more likely to have one or more comorbidities (p < 0.001), be obese (p = 0.005), and have a history of chronic respiratory disease (p = 0.0009). Patients reporting fatigue also had higher rates of dyspnea (91.2% vs. 61.5%, p < 0.0001), were more frequently obese (p = 0.03), had more comorbidities (p = 0.02), and had a greater history of hospitalization (p = 0.02). No improvement in dyspnea/fatigue was observed post-SPA treatment among patients with DLCO impairment and obese. However, patients with chronic respiratory conditions reported benefit.

CONCLUSIONS

Dyspnea in PASC is complex and multifactorial. The findings suggest that SPA rehabilitation may be particularly beneficial for alleviating fatigue and enhancing overall well-being in selected subgroups of patients with PASC.

Prolonged disturbances in citrulline metabolism following resistance exercise in COPD

BACKGROUND & AIMS

Disturbances in arginine (ARG) and protein metabolism, as well as in gut function have been observed in response to an endurance exercise session in patients with Chronic Obstructive Pulmonary Disease (COPD). We studied whether resistance exercise also affects the acute response in arginine (role in nitric oxide synthesis), citrulline (CIT, marker of gut health), and (muscle) protein metabolism differently in COPD as compared to healthy older adults.

METHODS

Patients with stable moderate to severe COPD (n = 24) and healthy controls (n = 25) completed a high-intensity resistance exercise session in the postabsorptive state. We administered a pulse of multiple stable isotopes of amino acids before, and 1 h and 24 h post-resistance exercise to assess the whole body production (WBP) and intracellular productions by compartmental analysis of ARG and CIT, and of tau-methylhistidine (TauMETHIS), phenylalanine (PHE), tyrosine (TYR), and PHE > TYR conversion as markers of muscle (myofibrillar) protein breakdown and whole body (net) protein breakdown, respectively. Muscle fatigue was determined by assessing the decay in peak leg extension torque post-resistance exercise.

RESULTS

COPD patients overall exhibited lower WBP ARG (p < 0.0001), CIT (p < 0.0001), PHE (p = 0.0001), TYR (p < 0.0001), and tau-METHIS (p = 0.0004) compared to controls. Resistance exercise did not change WBP of PHE, tau-METHIS, or PHE > TYR conversion, despite prolonged muscle fatigue in COPD. WBP CIT was increased at 1- and 24-h post-exercise in both groups (p < 0.003). Plasma CIT concentrations were reduced in both groups (p < 0.006) and remained lower at 24 h post-exercise in COPD only (p < 0.05) despite a third less work performed.

CONCLUSIONS

Both COPD and healthy participants exhibited upregulated whole-body citrulline production following resistance exercise. However, in COPD, this increase was insufficient to counteract the sustained reduction in plasma citrulline concentration, despite performing significantly less work during the exercise session. This prolonged disturbance in citrulline metabolism in COPD points to a potential exercise-induced enterocyte dysfunction, highlighting a novel area for understanding the impact of resistance exercise on gut health in this population.

CLINICAL TRIAL REGISTRY

Trial registration ClinicalTrials.gov: NCT02780219.

A Randomized, Double-Blinded, Placebo-Controlled Study of the Use of Traditional Chinese Medicine for Treating Patients With Mild/Moderate Chronic Obstructive Pulmonary Disease

AIM

Chronic obstructive pulmonary disease (COPD) is a critical disease, with lung function closely linked to disease severity. This study aimed to evaluate the clinical efficacy of treatments for stable COPD in patients with pulmonary function Grades I and II.

PATIENTS AND METHODS

We conducted a multicenter, randomized, double-blind, placebo-controlled trial (registration number: NCT01486186). A total of 502 patients were randomly assigned to an experimental group (n = 251, treated with Bufei, Bufei Jianpi, and Bufei Yishen granules based on traditional Chinese medicine [TCM] syndromes) and a control group (n = 251, treated with a Chinese medicine-based placebo). Acute exacerbations (AEs), lung function, clinical symptoms, 6-min walking distance (6MWD), and dyspnea were assessed over 12 months of treatment and 12 months of follow-up.

RESULTS

A total of 432 patients, including 214 and 218 patients in the experimental and control groups, respectively, completed the trial. The early treatment group had fewer AEs (p < 0.05), better clinical symptom scores (p < 0.05), longer 6MWD (p < 0.05), and better Modified Medical Research Council (mMRC) scores than the control group (p < 0.05). No significant differences were found in forced vital capacity (FVC) and forced expiratory volume in first second (FEV1%) between the two groups, but there was a significant difference in FEV1 and the annual rate of FEV1 decline between the groups over 2 years (p < 0.05).

CONCLUSION

Treatment with TCM for stable COPD significantly reduced AEs, increased the 6MWD, and alleviated dyspnea in patients with pulmonary function Grades I and II. FEV1 was improved, and the slower FEV1 decline indicates a potential benefit in mitigating disease progression.

Correlation between the repositioning error measured and subjectively assessed by healthy subject during shoulder flexion

INTRODUCTION

Assessment of proprioception is useful for clinician practice. The feeling is not retained for the proprioceptive assessment while it is used for dyspnoea or perception of effort with visual analogue scale. Proprioception assessment is often complicated and costly, making it unsuitable for clinical practice. The aim of this study is twofold, 1) to evaluate the correlation between the outcomes of a visual analogue scale and a joint position sense error and 2) to validate the use of an affordable inertial measurement unit.

METHODS

Correlation coefficients between angular joint position error and the feeling of error measured with a visual analogue scale were computed. Data were collected using a smartphone's IMU and the Phyphox application. A total of 30 subjects were divided in two groups ("test group" and "error group"). Each subject performed six arm flexion movements for a total of 90 acquisitions per group.

RESULTS

The "error group" had good capabilities in error detection as 100% of them detected two out of three errors (false positioning). Pearson correlation coefficients were 0.85 (p < 0.001), 0.76 (p < 0.005) and 0.91 (p < 0.005) depending on the shoulder flexion angle ranges.

CONCLUSION

The positive correlation between error in perception of joint position and the values of the visual analogue scale shows that the subjects' sensation could be used to assess proprioception, as the perceptive scale is a complementary piece of data to the quantitative assessment in order to have a patient-centred approach.

Generic and disease-specific self-care instruments in older patients affected by multiple chronic conditions: A descriptive study

AIMS

To describe and compare generic and disease-specific self-care measures in patients with multiple chronic conditions (MCCs) in the three dimensions of self-care maintenance, monitoring, and management.

DESIGN

Multicentre cross-sectional study.

METHODS

Patients aged 65 and over with MCCs. We used Self-Care of Chronic Illness Inventory to measure generic self-care, Self-care of Diabetes Inventory to measure self-care in diabetes mellitus, Self-Care of Heart Failure (HF) Index to measure self-care in HF, and Self-Care of Chronic Obstructive Pulmonary Disease Inventory to measure self-care in chronic lung diseases.

RESULTS

We recruited 896 patients. Multimorbid patients with diabetes had lower scores on the self-care maintenance scale, and diabetic patients in insulin treatment on the generic management scale than on the disease-specific instrument. Multimorbid patients with HF or chronic lung diseases scored higher on generic self-care maintenance and monitoring scales than disease-specific ones. There was a partial consistency between the generic and disease-specific self-care maintenance and management. Inadequate behaviours were recorded in disease-specific self-care monitoring rather than generic ones.

CONCLUSIONS

Older patients affected by MCCs scored differently in the generic and disease-specific instruments, showing inadequate self-care in some of the three self-care dimensions.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The choice between generic and disease-specific instruments to use in clinical practice and research should be made considering the specific aims, settings, patients characteristics, and knowledge of the different performance of the instruments by users.

IMPACT

No study has described and compared generic and specific self-care measures in patients affected by MCCs. Knowing these differences can help nurses choose the most suitable measure for their aims, context, and patients and plan generic and disease-specific self-care educational interventions for those behaviours in which MCCs patients perform poorly.

PATIENT CONTRIBUTION

Patients were informed about the study, provided informed consent, and answered questionnaires through interviews.

Effect of traditional Chinese medicine combined with conventional Western medicine for patients with severe/very severe chronic obstructive pulmonary disease: a multi-center, randomized, double-blind, controlled study

BACKGROUND

Traditional Chinese medicine (TCM) is widely used in the management of chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the clinical efficacy of comprehensive therapy based on TCM patterns for patients with stable, severe to very severe COPD.

METHODS

A multicenter, randomised, double-blind, placebo-controlled trial was conducted. Eligible patients were randomly allocated in equal proportions to two groups: the trial group, which received TCM-based therapy with Bu-Fei Jian-Pi, and Bu-Fei Yi-Shen, and Yi-Qi Zi-Shen granules tailored to TCM syndromes, and the control group, which received a placebo resembling Chinese medicine. Both groups also received conventional Western medicine as part of their treatment. Acute exacerbations (AEs), lung function, dyspnea scores, the 6-min walking test (6MWT), and the COPD assessment test (CAT) were assessed over 12 months of treatment, with an additional 12 months of follow-up.

RESULTS

A total of 467 patients were included in the analysis with 228 in the experimental group and 239 in the control group. The Chinese herbal granules group significantly reduced AEs (0.63 vs. 1.03 events, P = 0.002), improved mMRC scores (-0.17 points, 95% CI -0.30 to -0.03; P = 0.015), 6MWT (29.24 m, 95% CI 10.71-47.77; P = 0.002), and CAT (-3.11 points, 95% CI -4.13 to -2.09, P < 0.001), compared with the control group. No significant differences were observed between the two groups in terms of FVC (l) and FEV1 (both in litres and as percentage).

CONCLUSION

Comprehensive therapy based on TCM patterns demonstrated efficacy in patients with severe to very severe COPD, reducing the frequency of AEs, improving dyspnea and exercise capacity, and alleviating symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02270424. Registered 17 October 2014, https://clinicaltrials.gov/study/NCT02270424?id=NCT02270424&rank=1 .

A Multidimensional Diagnostic Approach for Chronic Obstructive Pulmonary Disease

Importance

Individuals at risk for chronic obstructive pulmonary disease (COPD) but without spirometric airflow obstruction can have respiratory symptoms and structural lung disease on chest computed tomography. Current guidelines recommend COPD diagnostic schemas that do not incorporate imaging abnormalities.

Objective

To determine whether a multidimensional COPD diagnostic schema that includes respiratory symptoms and computed tomographic imaging abnormalities identifies additional individuals with disease.

Design, Setting, and Participants

This cohort study included 2 longitudinal cohorts: the Genetic Epidemiology of COPD (COPDGene), which enrolled 10 305 participants between November 9, 2007, and April 15, 2011, with longitudinal follow-up through August 31, 2022; and the Canadian Cohort Obstructive Lung Disease (CanCOLD), which enrolled 1561 participants between November 26, 2009, and July 15, 2015, with follow-up through December 31, 2023.

Exposure

Exposure included the new multidimensional COPD diagnostic schema, defined by (1) major diagnostic category: presence of the major criterion (airflow obstruction based on postbronchodilator forced expiratory volume in the first second of expiration [FEV1]/forced vital capacity ratio <0.70) and at least 1 of 5 minor criteria (emphysema or bronchial wall thickening on computed tomography, dyspnea, poor respiratory quality of life, and chronic bronchitis); or (2) minor diagnostic category: presence of least 3 of 5 minor criteria (which must include emphysema and bronchial wall thickening for individuals with respiratory symptoms potentially due to other causes).

Main Outcomes and Measures

All-cause mortality, respiratory cause-specific mortality, exacerbations, and annualized change in FEV1.

Results

Among 9416 adults in COPDGene (mean [SD] age at enrollment, 59.6 [9.0] years; 5035 [53.5%] were men; 3071 [32.6%] were Black; 6345 (67.4%) were White; 4943 [52.5%] currently smoked), 811 of 5250 individuals (15.4%) without airflow obstruction were newly classified as having COPD by minor diagnostic category, and 282 of 4166 individuals (6.8%) with airflow obstruction were classified as not having COPD. Reclassified individuals with a new COPD diagnosis had greater all-cause mortality (adjusted hazard ratio, 1.98; 95% CI, 1.67-2.35; P < .001) and respiratory-specific mortality (adjusted hazard ratio, 3.58; 95% CI, 1.56-8.20; P = .003), more exacerbations (adjusted incidence rate ratio, 2.09; 95% CI, 1.79-2.44; P < .001), and more rapid FEV1 decline (adjusted β = -7.7 mL/y; 95% CI, -13.2 to -2.3; P = .006) compared with individuals classified as not having COPD. Among individuals with airflow obstruction on spirometry, those no longer classified as having COPD based on this new diagnostic schema had outcomes similar to those without airflow obstruction. Among 1341 adults in CanCOLD, individuals newly classified as having COPD experienced more exacerbations (adjusted incidence rate ratio, 2.09; 95% CI, 1.25-3.51; P < .001).

Conclusions and Relevance

A new COPD diagnostic schema integrating respiratory symptoms, respiratory quality of life, spirometry, and structural lung abnormalities on computed tomographic imaging newly classified some individuals as having COPD. These individuals had an increased risk of all-cause and respiratory-related death, frequent exacerbations, and rapid lung function decline compared with individuals classified as not having COPD. Some individuals with airflow obstruction without respiratory symptoms or evidence of structural lung disease were no longer classified as having COPD.

Albuterol Digihaler in COPD Disease Management: A Real-World Study to Assess Digihaler Inhalation Parameters, Thresholds and Their Use to Identify Deterioration in Clinical Practice

Purpose

Despite increasing awareness, chronic obstructive pulmonary disease (COPD) exacerbations are often unrecognized, not reported or not treated. Assisting patients and caregivers to better identify deteriorations in COPD can help improve care. This study was designed to collect usage and inhalation parameters from albuterol Digihaler devices and its associated Digihaler dashboard, to identify potential inhalation parameters and alerts that might predict worsening COPD.

Patients and Methods

Real-time rescue albuterol Digihaler (albuterol sulfate) results for peak inspiratory flow (PIF), rescue inhaler usage and inhalation volume (InV) were assessed in 20 COPD patients over 6 months. Alert thresholds from device measurements were analyzed for 14 days prior to all COPD deteriorations defined by a COPD exacerbation or an acute worsening in COPD assessment test (CAT) score.

Results

Eleven subjects experienced 22 COPD exacerbations, and 16 subjects experienced 40 CAT score worsening over 6 months' time. No demographic or physiologic differences were identified comparing patients with or without exacerbations or CAT score worsening. Falls in PIF and increases in rescue inhaler usage were weak predictors of impending exacerbations, while a higher percentage (36%) of subjects had a fall in InV prior to an exacerbation. No notable changes in inhaler parameters were associated with deteriorating CAT scores, and no changes in lung function were observed over the study. A combination of 3 alert thresholds was present in 59% of patients within the 2 weeks prior to a COPD exacerbation.

Conclusion

Our study suggests that alert thresholds based on Digihaler device-measured physiologic parameters may have value in a predictive model for clinical deterioration in COPD.

Impact of Severe Dyspnea on Mortality and Disability: A 9-Year Cohort Study of Older Adults in Japan

OBJECTIVES

We investigated the association of severe dyspnea and frailty with all-cause mortality and disability in Japanese community-dwelling older adults.

DESIGN

A 9-year follow-up cohort study.

SETTING AND PARTICIPANTS

We enrolled 3499 community-dwelling adults aged ≥65 years without disabilities or residence in care facilities who completed a baseline survey in 2013.

METHODS

Dyspnea was assessed via a questionnaire on severe dyspnea during daily activities, and frailty status was determined using the Kihon Checklist. Disability was defined as new long-term care insurance certification. Cox proportional hazard models were used to calculate hazard ratios for mortality and disability. Fine-Gray regression models were used to calculate subdistribution hazard ratios for disability while accounting for mortality as a competing risk and adjusting for confounders. Both analyses were stratified by frailty status.

RESULTS

Severe dyspnea was present in 240 participants (6.9%). Overall, the incidence rate of mortality was 6.37 and 2.55 per 100 person-years, and that of disability was 9.96 and 5.06 in the dyspnea and no-dyspnea groups, respectively. Severe dyspnea was associated with a hazard ratio of 1.67 (95% CI, 1.35-2.07) for mortality and 1.38 (95% CI, 1.14-1.67) for incident disability in the frailty group. After accounting for death as a competing risk using the Fine-Gray regression model, the subdistribution hazard ratio for new disability associated with severe dyspnea was 1.38 (95% CI, 1.12-1.70) in the frailty group.

CONCLUSIONS AND IMPLICATIONS

Severe dyspnea was associated with an increased risk of both mortality and incident disability, particularly among participants in the frailty group. These findings highlight the heightened vulnerability of frail older adults to dyspnea-associated adverse outcomes.

Effect of telerehabilitation on post-COVID-19 individuals with long-term dyspnea: A randomized controlled study

ObjectiveThis study aimed to determine the effectiveness of telerehabilitation in managing ongoing dyspnea and associated issues following coronavirus disease 2019 (COVID-19), and observe changes over time.DesignThe study included 36 participants who previously had COVID-19 but continued to experience dyspnea (mean age, 42.44 ± 15.51 years). The participants were randomly allocated into three groups: telerehabilitation (TRG), home exercise (HEG), and control (CG). Dyspnea level, exercise capacity, muscle oxygenation, respiratory function, and fatigue were evaluated at baseline, at 6th, and at 12th weeks. Telerehabilitation was performed supervised and synchronously via video-calls.ResultsAt the 6-week assessment, TRG showed significant improvements in dyspnea, fatigue (p < 0.001), exercise capacity (p = 0.001), and respiratory muscle strength (p < 0.001). By the 12th week, these gains were maintained, with no further changes from week 6. In HEG, dyspnea and fatigue improved at weeks 6 and 12 (p < 0.001), with no additional changes between these time points. In CG, only dyspnea improved at both assessments (p < 0.001); other parameters remained unchanged. TRG achieved greater benefits compared to CG in reducing dyspnea and fatigue at week 6 (p = 0.001 and p = 0.003, respectively), but no group differences were found at week 12 (p > 0.05). No changes in muscle oxygenation were observed in any groups or evaluation points (p > 0.05).ConclusionsTelerehabilitation effectively improved and sustained dyspnea, fatigue, respiratory muscle strength, and exercise capacity in patients with post-COVID, while home-based exercises only reduced dyspnea and fatigue. Supervised and structured telerehabilitation may be a viable approach to managing post-COVID-19 symptoms.

Risk Factors and Predictors for Persistent Dyspnea Post-COVID-19: A Systematic Review

The most frequently reported post-coronavirus disease of 2019 (COVID-19) symptoms include shortness of breath, fatigue, and cognitive disturbances, with reports of persistent dyspnea ranging between 26% and 41%. There is an urgent need to understand the risk factors and predictors for persistent COVID-19 dyspnea in individuals at all levels of COVID-19 illness severity, to enable the implementation of targeted interventions for those likely to be most affected with persistent dyspnea. Thus, the purpose of this systematic review is to explore the risk factors and predictors that are associated with persistent dyspnea in the post-COVID-19 population. This review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and registered prospectively in PROSPERO as CRD42023466713. A search strategy was conducted across PubMed, CINAHL, Web of Science, and EMBASE databases, that included studies conducted from 2020 to March 2024. The Covidence platform was used for screening studies, scoring methodologic quality, and performing data extraction using a two-step independent review process. This review included 33 studies, addressing 83,920 participants across 20 countries. The strongest predictive risk factors for persistent dyspnea included the following: female sex, elevated body mass index, pulmonary comorbidities, pre-existing anxiety and depression, pre-COVID-19 physical limitations, the severity of the COVID-19 illness, and socioeconomic differences. Potential risk factors included increased age, smoking history, and COVID-19 variant type. The presence of biomarkers for persistent dyspnea in the post-COVID-19 population can be used by clinicians to prospectively identify those individuals who should be flagged. Early identification may then be leveraged for timely referral for prophylactic and rehabilitative interventions for dyspnea. A personalized plan to target those risk factors that are modifiable should follow.

Vocal Impact in Patients With Unilateral Diaphragmatic Paralysis

OBJECTIVES

This study aimed to investigate the possible vocal impact confirmed by diagnostic tests, the degree of perception of possible vocal impairment by patients with Unilateral Diaphragmatic paralysis (UDP) and its correlation with ventilatory weakness.

METHODS

The researchers conducted an analytical, observational and case-control study with 70 individuals, including 35 UDP patients and 35 healthy patients in a control group, who underwent the following assessments: 1) Self-assessment of voice handicap (VHI-10); 2) Self-Assessment of Quality of Life (SF-36); 3) Self-Assessment of Dyspnea (MRC); 4) Objective vocal measures (Maximum Phonation Time (MPT) in /a/, /s/, /z/ and glottal-to-noise excitation ratio); 5) Functional respiratory pressures (Spirometry and maximum ventilatory pressures); 6) General degree of dysphonia - G on the GRBAS Scale. The sex, age and body mass index (BMI) of the individuals were the variables used to match the sample of this study.

RESULTS

When compared with controls, patients with UDP had a restrictive functional pattern and inspiratory weakness, with symptoms of dyspnea and worsening quality of life. When associated with a possible vocal impact, these patients had voice handicap and decreased MPT values for all phonemes, especially /a/. There was also a correlation between vocal performance and inspiratory weakness. However, it should be noted that, despite having vocal impairment, many patients did not report the perception of this fact, somehow neglecting such impairment.

CONCLUSIONS

In addition to the expected weakness of the ventilatory muscles, patients with UDP had clinically verified vocal impact, and those who had greater inspiratory weakness also had greater voice impairment. Finally, it is relevant that not all patients perceived such vocal impact, which showed a very reduced perception of this impairment in patients with UDP.

SPACO+: a mixed methods protocol to assessing the effectiveness of an educative intervention in patients with Long Covid

BACKGROUND

The management of many chronic diseases requires a multidisciplinary and holistic approach. Long Covid is a recent, poorly understood disease with several symptoms. Most recommendations suggest a multidisciplinary approach. While there are a few programs aimed to the management of Long Covid, to our knowledge very few were assessed. The SPACO + study therefore aims to evaluate an innovative program which combines the methods used in therapeutic education and in personalized multifactorial intervention for management of Long Covid. Here, we present the protocol of our study, which aims to evaluate the effectiveness of an educational intervention in terms of changes in quality of life at 6 months in comparison with standard clinical practice in patients suffering from Long Covid.

METHODS

To achieve our objectives, we have planned to carry out a prospective, multicentre, two-arm randomized controlled trial with a convergent parallel mixed methods design. Two countries are involved in this study: France and Cameroon. The study concerns patients aged 18 and over, who have been infected with Covid-19. They must also be diagnosed as having Long Covid in accordance with the WHO definition. The number of subjects required for the study is 400 individuals. Participants will be randomly assigned to either the intervention or control group using a dynamic randomization process to ensure balanced group characteristics. The SPACO + program is an educative intervention with individual follow-up by a nurse dedicated to the program. The SPACO + program offers five workshops, two of which are compulsories. Patients take part in the other workshops according to their needs. The program includes an 8 - 10 weeks intervention period. Each session lasts two hours and includes breaks (pacing). The main outcome measure will be quality of life, evaluated through the SF-36. Primary and secondary outcomes, with few exceptions, are assessed before the intervention ("T0"), at 8 weeks ("T1" corresponding to the end of SPACO + program's session period) and then 3 months later ("T2").

DISCUSSION

If the SPACO + program is effective and accepted by professionals and patients, it could be disseminated in other regions to assess its transferability. The medico-economic evaluation will also make it possible to assess the benefits provided.

TRIAL REGISTRATION

This trial is registered under the number NCT05787366 (March 24, 2023). Protocol Version N°3.0 (May 31, 2024).

Effects of Oral Doxofylline and Procaterol on Chronic Obstructive Pulmonary Disease: A Randomized Crossover Study

Background: Oral bronchodilators may serve as an adjunctive therapy in patients with chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the effects of oral doxofylline and oral procaterol on lung function and clinical symptoms in COPD patients. Methods: A crossover randomized controlled trial was conducted in patients with clinically stable COPD. Participants first received either doxofylline or procaterol for 4 weeks, followed by a 1-week washout period. Assessments included the modified Medical Research Council (mMRC) dyspnea scale, COPD assessment test (CAT) scores, and 6-minute walking distance (6MWD). Pulmonary function was evaluated using spirometry with bronchodilator (BD) testing and all adverse events were recorded. Results: Twenty patients were randomly assigned to begin treatment with either doxofylline or procaterol. Their mean age was 71.7 ± 9.4 years. After four weeks of treatment, the doxofylline group showed significantly greater improvement in pulmonary function parameters (post-BD peak expiratory flow and post-BD forced expiratory flow 25-75) compared to the procaterol group. However, there were no significant differences in mMRC scores, CAT scores, or 6MWD between the two groups. More neurological adverse events were observed in the doxofylline group compared to the procaterol group (35% vs. 5%, p = 0.044). Conclusions: Doxofylline improved pulmonary function in COPD patients but did not provide superior functional performance compared to procaterol. Neurological adverse events were more frequently associated with doxofylline. Doxofylline may serve as an adjunctive therapy to enhance pulmonary function in COPD patients, but caution is advised due to its potential side effects.

Accuracy of Accuhaler, Ellipta, and Turbuhaler Testers in Patients with Chronic Obstructive Pulmonary Disease

Background: Peak inspiratory flow rate (PIFR) measurement is an essential tool for assessing the effectiveness of inhaler therapy in chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the accuracy of three different inhaler testers compared to the In-Check DIAL® device. Methods: A cross-sectional study was conducted in clinically stable COPD patients. Participants performed PIFR measurements using the In-Check DIAL® device and three inhaler testers (Accuhaler, Ellipta, and Turbuhaler). Optimal PIFR was defined as ≥60 L/min. Minimum PIFR was defined as ≥30 L/min. Results: A total of 82 COPD patients (93.9% male) were included, with a mean age of 73.3 ± 8.8 years. Post-bronchodilator forced expiratory volume in one second was 69.2 ± 21.0%. The prevalence of optimal PIFR was 78%, 74%, and 52% for the Accuhaler, Ellipta, and Turbuhaler testers, respectively. For detecting optimal PIFR, the Accuhaler tester demonstrated an accuracy of 80.5%, sensitivity of 100%, and specificity of 11.1%. The Ellipta tester showed an accuracy of 78.1%, sensitivity of 100%, and specificity of 14.3%, while the Turbuhaler tester achieved an accuracy of 56.1%, sensitivity of 100%, and specificity of 7.7%. All devices showed excellent accuracy (>95%), sensitivity (>98%), and specificity (100% except for the Turbuhaler tester) in detecting minimum PIFR. Conclusions: The majority of COPD patients achieved optimal PIFR across the three different devices, with the highest prevalence observed for the Accuhaler tester. All three inhaler testers demonstrated excellent accuracy in assessing PIFR in COPD patients, suggesting their potential as reliable alternatives to the In-Check DIAL® device in clinical practice.

Predicting Outcomes using DIGital TechnologY in patients with Interstitial Lung Disease (PRODIGY-ILD): Protocol for a Prospective Cohort Study

INTRODUCTION

Interstitial lung disease (ILD) patients may develop a progressive phenotype usually characterised by progressive pulmonary fibrosis. While this condition is life-limiting, wide variations in its clinical course have made it difficult to predict the rate of disease progression, onset of acute exacerbations and mortality. New approaches are needed to predict the clinical course of ILD, to enable treatment planning, evaluation and clinical trial design. Advances in digital health technologies have facilitated the ability to collect 'real-time' data to monitor diseases. These data, including physiological measures, activity indices and patient-reported outcomes, may be useful as components of new outcome predictors. The objective of this study is to first deploy comprehensive data collection enabling deep profiling of patients with ILD and to use these data to develop better predictors of outcome. Finally, these predictions will be evaluated based on real observed outcomes for individual patients.

METHODS AND ANALYSIS

This study is a prospective cohort study with 50 participants.

INCLUSION CRITERIA

Age 18 years or older with a diagnosis of ILD and the ability to provide written informed consent.

EXCLUSION CRITERIA

Age under 18 years or unwilling to wear a smartwatch for the duration of the study. Participants will be provided with a smartwatch to passively collect biometric data. These data will be combined with clinical history and course, in addition to a set of patient-reported outcome measures. Participants will be followed for 3 years to assess the rate of disease progression, occurrence of acute exacerbations and mortality. Initial data will be used to develop clinical prediction models. These models will be further evaluated for accuracy using regular follow-up data.

ETHICS AND DISSEMINATION

This study was approved by the St. Vincent's University Hospital Research Ethics Committee, Dublin, Ireland (reference no: RS23-023). Results will be presented at medical conferences and disseminated via peer-reviewed journals.

Climate Anxiety and COPD: Unveiling Its Impact on Patients' Quality of Life Through a Multivariate Lens

OBJECTIVE

To examine the impact of climate anxiety on the quality of life (QoL) of patients with COPD. It also explores how climate anxiety interacts with clinical factors, such as disease severity and comorbidities, to influence QoL.

DESIGN

Cross-sectional.

METHODS

A total of 270 COPD patients were recruited using a convenience sampling method. Data were collected through structured interviews and clinical assessments, incorporating the Climate Anxiety Scale, the St. George's Respiratory Questionnaire and the BODE Index. Hierarchical multiple regression analysis was performed to determine the predictors of QoL.

RESULTS

The study found a statistically significant association between climate anxiety and both QoL (r = 0.81, p < 0.01) and COPD severity (r = 0.76, p < 0.01). COPD severity (B = 4.68, p < 0.01) and climate anxiety (B = 0.28, p < 0.01) were predictors of QoL. Among the covariates, former smokers, older patients and multiple comorbidities reported significantly worse QoL (B = 4.80, p = 0.03; B = 0.43, p < 0.01; B = 0.85, p = 0.02, respectively). Collectively all predictors explained 86% of the variance in QoL.

CONCLUSION

Climate anxiety significantly contributes to reduced QoL in COPD patients, beyond disease severity and demographic factors. Addressing psychological distress in COPD management is essential to improving patient outcomes.

IMPLICATIONS FOR PRACTICE

Nurses should recognise climate anxiety as a key variable influencing COPD management. Incorporating climate anxiety screening into nursing assessments and providing targeted interventions can enhance patient support and improve overall COPD care.

IMPACT

Climate anxiety is an emerging concern in COPD. While previous research has focused on physical and clinical determinants of COPD-related QoL, climate anxiety remains underexplored. This study provides new evidence that climate anxiety is a predictor of poorer QoL, highlighting the need for holistic nursing interventions that address both physical and psychological health.

REPORTING METHOD

This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

PATIENT OR PUBLIC CONTRIBUTION

Patients with COPD were involved in this study.

Ashwagandha (Withania somnifera (L.) Dunal) for promoting recovery in long covid: protocol for a randomised placebo-controlled clinical trial (APRIL Trial)

BACKGROUND

Long covid describes a syndrome of persistent symptoms following COVID-19 and is responsible for substantial healthcare and economic burden. Currently, no effective treatments have been established. Ashwagandha (Withania somnifera (L.) Dunal) is a medicinal herb traditionally used in India for its immune-strengthening and anti-inflammatory properties. Withanolides, a family of steroid-derived molecules unique to Ashwagandha, have been shown to modulate inflammatory pathways in animal models, and several small randomised trials in humans support its effectiveness for reducing symptoms that are also associated with long covid. Therefore, this study aims to assess whether Ashwagandha is effective and safe for improving functional status and reducing symptom burden in adults living with long covid.

METHODS

A randomised double-blind placebo-controlled trial will be performed at participating general practice (GP) surgeries and long covid clinics across the UK. Individuals diagnosed with long covid will be screened for eligibility and then randomised 1:1 to take 1000 mg daily of Ashwagandha root extract tablets (standardised to <0.9% withanolides) or matching placebo tablets for 3 months (target, n = 2500). Monthly online surveys will be performed to collect patient-reported outcomes, and monthly safety monitoring, including liver function tests, will be conducted by clinical site teams. The primary outcome of the Post-COVID Functional Status Scale score at 3 months will be assessed by baseline-adjusted ordinal logistic regression, according to a pre-published statistical analysis plan. The secondary outcomes included validated quality of life and long covid symptom scales, work status and productivity and adverse events. The trial has been approved as a Clinical Trial of an Investigational Medicinal Produce by the Medicines and Healthcare Regulatory Authority and by the NHS Research Ethics Committee and Health Research Authority.

DISCUSSION

Treatments for long covid are urgently needed. This trial will robustly evaluate the safety and efficacy of a candidate treatment with a promising efficacy and safety profile. If found to be effective, the findings will likely influence treatment guidelines and improve health outcomes in those living with long covid.

TRIAL REGISTRATION NUMBER

This trial was pre-registered on 15/08/2022: ISRCTN12368131.

A Smartphone App Self-Management Program for Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial of Clinical Outcomes

BACKGROUND

Chronic obstructive pulmonary disease (COPD) negatively impacts clinical health outcomes, resulting in frequent exacerbations, increased hospitalizations, reduced physical activity, deteriorated quality of life, and diminished self-efficacy. Previous studies demonstrated that a self-management program tailored for adults with COPD improves self-management decisions, resulting in a positive effect on clinical health outcomes. Limitations of these studies include issues regarding heterogeneity among interventions used, patient population characteristics, outcome measures, and longitudinal studies. Limited studies focused on the use of a comprehensive self-management program using a smartphone app for adults with COPD over 12 months.

OBJECTIVE

This study aimed to explore the effectiveness of a smartphone app self-management program and monthly phone calls compared with standard respiratory outpatient care on clinical health outcomes in adults with COPD.

METHODS

This was a 3-arm parallel pilot randomized controlled trial (RCT) that included 92 participants. Participants were randomized into intervention arm 1, which included a self-management smartphone app and monthly phone calls (n=31); intervention arm 2, which included a self-management smartphone app (n=31); and arm 3, which was standard respiratory outpatient care (n=30). All arms received standard respiratory outpatient care. The primary outcome was a binary indicator equal to 1 if participants reported attendance to a general practitioner (GP) and or a hospital setting as a result of an exacerbation and 0 otherwise. This indicator was recorded at 6 months and 12 months from the baseline. Secondary outcomes included engagement, breathlessness, physical activity, health-related quality of life, and self-efficacy.

RESULTS

There was a statistically significant difference (P=.03), indicating fewer exacerbations in the intervention arm 2 compared with the control arm at 6 months in the hospital setting. The intervention arms had a statistically significant difference indicating a lower risk of developing an exacerbation at 6 months in both the GP (P=.01) and hospital setting (P=.006) compared to the control arm. Furthermore, intervention arm 1 demonstrated a statistically significant difference in exercise capacity at 6 and 12 months (P=.02 and P=.03). The intervention arm 2 illustrated a statistically significant difference in step count (P=.009) compared to the control arm. The majority of participants (60%, 33/55) used the app over the 12-month period.

CONCLUSIONS

This study demonstrated that a smartphone app self-management program had a positive effect on clinical health outcomes for participants with COPD in comparison to standard respiratory outpatient care. This study illustrated benefits such as reduced exacerbations resulting in fewer hospitalizations, improved exercise capacity, and physical activity among the intervention arms. This was a single-center study, which was limited in power to demonstrate significant effects on all measured outcomes but paves the way for a larger, fully powered multicenter trial exploring the effect of a smartphone app self-management program on clinical health outcomes in adults with COPD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05061810; https://clinicaltrials.gov/study/NCT05061810.

Core characteristics, and effectiveness of mobile health interventions on dyspnoea and quality of life in older persons with chronic obstructive pulmonary disease: A systematic review and meta-analysis of randomised controlled trials

AIM

To systematically review the core characteristics, and effectiveness of mobile health interventions (MHIs) on dyspnoea and quality of life (QoL) in older persons with chronic obstructive pulmonary disease (COPD).

METHODS

A comprehensive search was conducted from inception to 21 February 2023 in Chinese and English databases, with an updated search performed on 30 April 2024. Randomised controlled trials (RCTs) involving MHIs with four core functions - customisation, self-monitoring, alerts, and goal-setting - in older persons with COPD were included. Two reviewers independently identified the core characteristics of MHIs using the Template for Intervention Description and Replication (TIDieR) checklist. The Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were used to assess the methodological quality of RCTs and the overall quality of evidence.

RESULTS

28 RCTs were included, with 43% of studies adequately reported core characteristics of MHIs according to the TIDieR checklist. Meta-analysis suggested that MHIs may alleviate dyspnoea and improve disease-specific QoL questionnaires (CRQ and CCQ) and generic-related QoL questionnaires (SF-36 and EQ-5D), but not other disease-specific QoL questionnaires (SGRQ and CAT). Subgroup analyses showed that multi-component MHIs were effective in improving dyspnoea. Dyspnoea showed statistically significant improvement at 3 months, 6 months and 12 months, whereas QoL improved at 4 months (SGRQ), 2 months (CAT) and 6 months (CAT).

CONCLUSION

Reporting on the core characteristics of MHIs is currently incomplete, and it is recommended that healthcare professionals develop and report multi-component MHIs based on the TIDieR checklist to help alleviate dyspnoea and enhance QoL in older persons with COPD.

Assessment of sub-maximal aerobic capacity in North African patients with chronic hepatitis B: a pilot case-control study

Background

Studies assessing sub-maximal aerobic capacity in non-cirrhotic chronic hepatitis B (CHB) patients are scarce. This study aimed to evaluate sub-maximal aerobic capacity in CHB patients compared to apparently healthy participants (control-group (CG)).

Methods

A 6-min walk test (6MWT) was performed. The 6-min walk distance (6MWD) was recorded, along with heart-rate (HR), oxy-hemoglobin saturation (SpO 2), blood-pressure, and dyspnea ( ie ; visual analogue scale) at rest (Rest) and at the end (End) of the 6MWT. Additionally, the 6-min walk work (6MWW), and estimated cardiorespiratory and muscular chain age were calculated. Signs of physical intolerance were determined including abnormal 6MWD ( ie ; 6MWD < lower limit of normal), chronotropic insufficiency (ie ; HREnd < 60% of maximal predicted HR (MPHR)), high dyspnea ( ie ; dyspneaEnd > 5), and desaturation ( ie ; drop in SpO 2 > 5 points).

Results

Compared to the CG (n=28), the CHB-group (n=26) exhibited significantly lower 6MWD by 61 meters (8%), lower 6MWW by 10%, and lower HR End by 21% (when expressed in bpm) and 17% (when expressed in %MPHR). The CHB-group, compared to the CG, included higher percentages of participants with chronotropic insufficiency and abnormal 6MWD (23.08% vs. 3.57%, and 34.61% vs. 3.57%, respectively). The CHB-group was 8.1 and 14.3 times more likely to have chronotropic insufficiency and abnormal 6MWD than the CG, respectively. CHB accelerated the aging of the cardiorespiratory and muscular chain by 11 years.

Conclusion

Non-cirrhotic CHB may contribute to reduced submaximal aerobic capacity and acceleration of cardiorespiratory and muscular chain aging.

Depression and Anxiety as Moderators for a Behavioral Treatment for Dyspnea in Advanced Lung Cancer

CONTEXT

Dyspnea (breathlessness) is a distressing and disabling symptom affecting over 70% of patients with advanced lung cancer. Although dyspnea treatments are limited, recent research on a brief, nurse-led behavioral intervention for dyspnea in patients with advanced lung cancer demonstrated improvements in dyspnea-related functioning compared to usual care.

OBJECTIVES

We examined whether depression and anxiety moderate the efficacy of a brief behavioral intervention for dyspnea in advanced lung cancer.

METHODS

This secondary analysis of a randomized controlled trial examined a two-session, nurse-led behavioral intervention for dyspnea in 247 patients with advanced lung cancer. Patients self-reported dyspnea-related functioning (Modified Medical Research Council Dyspnea Scale), multidimensional dyspnea (Cancer Dyspnea Scale), and depression and anxiety (Hospital Anxiety and Depression Scale [HADS]) at baseline and post-treatment (8 weeks later). The PROCESS macro tested depression and anxiety as treatment moderators for dyspnea and probed interactions when P's < 0.15 using the Johnson-Neyman procedure due to reduced power in testing moderators.

RESULTS

Baseline depressive symptoms moderated the intervention's impact on dyspnea functioning (b = -0.074, P = 0.075), with significant benefits observed in those reporting >6 on baseline scores of the HADS-Depression subscale. Any post-treatment improvement on the HADS-Anxiety subscale (b = 0.069, P = 0.135) and improvements of at least 3 on the HADS-Depression subscale (b = 0.671, P = 0.009) significantly enhanced outcomes for total dyspnea and dyspnea functioning, respectively.

CONCLUSIONS

Patients with elevated baseline depression and improved distress may benefit more from this intervention for dyspnea. Considering treatment moderators helps optimize resources, but additional research on treatment adaptations is needed to enhance care for all.

High-Flow Oxygen Therapy to Support Inpatient Pulmonary Rehabilitation During Very Severe Hepatopulmonary Syndrome Recovery Post Liver Transplant: A Case Report

This case study reports the novel use of inpatient pulmonary rehabilitation (PR) with near-maximal high-flow oxygen therapy in a patient recovering from very severe hepatopulmonary syndrome (HPS) following liver transplantation. HPS is a rare condition where advanced liver disease alters lung microvasculature through intrapulmonary vascular dilatation (IPVD) and angiogenesis. Platypnoea-orthodeoxia (postural dyspnoea with concurrent blood oxygen desaturation) is characteristic of HPS due to redirection of blood flow to the basal lung where IPVDs are more prominent, secondary to gravity. Currently, the only definitive treatment is liver transplantation, which allows normalization of oxygenation over an extended period, typically within 1 year. Pulmonary rehabilitation is an effective intervention for improving dyspnoea, health-related quality of life (HRQoL), and exercise capacity in people with chronic respiratory disease. Despite this, little is known of the effect PR has on individuals recovering from HPS post liver transplant. The aim is to describe an inpatient PR program for a patient recovering from HPS. This case study describes a 27-year-old male with "very severe" HPS who undertook inpatient PR 5 months posttransplant. The patient completed an 8-week program of twice-weekly PR supported by high-flow oxygen therapy (fraction of inspired oxygen of 90%). He performed aerobic and resistance exercises for the upper and lower limbs in recumbent, seated, and standing positions. The patient improved in exercise capacity on the 1-min sit-to-stand test (+4 repetitions), lower limb strength on the 5-repetition sit-to-stand test (-3.4 s) and in HRQoL outcomes assessed. Following rehabilitation, the patient still had a high burden of respiratory symptoms and required continuous high-flow oxygen therapy. This case study demonstrates that inpatient PR, modified for HPS-associated platypnoea-orthodeoxia and supported by high-flow oxygen therapy, is safe and effective and therefore feasible for other HPS patients.

Long COVID in ARDS Survivors: Insights from a Two-Year-Follow-Up Study After the First Wave of the Pandemic

Objectives: To compare the health status, exercise capacity, and health-related quality of life (HRQoL) in survivors of COVID-19-associated acute respiratory distress syndrome (ARDS) at 8, 12, and 24 months post-diagnosis. Methods: We conducted a prospective, single-center follow-up study embedded within a larger multicenter cohort of adults with COVID-19 who required hospital admission. Eligible participants underwent clinical interviews, physical examinations, chest radiography, and the 6-min walk test (6MWT). Standardized scales were used to assess post-traumatic stress disorder (PTSD), anxiety, depression, and HRQoL. Results: Out of 1295 patients with COVID-19, 365 developed ARDS, of whom 166 survived. After excluding deaths and loss to follow-up, 95 patients were monitored for 24 months. Over 60% of patients had persistent symptoms, though significant improvements were recorded in quality of life and physical recovery. More than 70% recovered their previous physical capacity, but 15% did not return to their usual lifestyle habits. Symptoms such as arthralgia and fatigue decreased, but cognitive issues, such as memory loss and insomnia, persisted. Radiological improvements were noted, although pulmonary function remained impaired. The prevalence of PTSD and anxiety decreased, while depression remained stable at around 30%. Conclusions: Long COVID continues to impose significant physical, mental, and social challenges. Symptoms like fatigue and anxiety have a profound impact on daily life. Strategies are urgently needed to help patients regain health and resume their normal lives.

Long-term outcomes of post-acute sequelae of SARS-CoV-2 infection: a cohort study protocol

Introduction

Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) presents a multifaceted interplay of demographic, clinical, environmental, and socioeconomic factors. Quantification at the individual level of these factors remains underexplored. Our study aims to address this knowledge gap by analyzing the long-term health implications of PASC, utilizing a comprehensive integration of spatiotemporal, clinical, environmental, and socioeconomic data.

Methods and analysis

The study will enroll over 4,000 confirmed COVID-19 patients from Gansu Provincial Hospital, treated from December 2022 to May 2023, as the baseline. These patients are spread across 14 cities in Gansu Province, with geographic coordinates ranging from 92°13'E to 108°46'E and 32°31'N to 42°57'N. Follow-ups will be conducted via structured telephone interviews at 24, 36, and 48 months post-discharge, from 2024 to 2027, to assess PASC and long-term health outcomes. Participants will be categorized into three age groups: children and teenagers (birth to 18 years), adults (18-65 years), and the older adult (over 65 years). Environmental and socioeconomic data corresponding to each case are also integrated. The primary objective is to assess the persistence and long-term health outcomes of PASC symptoms. Secondary objectives focus on evaluating the acute infection phase, its progression, and the efficacy of medical management strategies in influencing PASC trajectories. Mixed-effects models will be utilized to evaluate the impact of various factors on PASC, while spatiotemporal analyses will explore the correlations between environmental and socioeconomic conditions and the diagnosis and recovery trajectories of PASC.

Ethics and dissemination

The Gansu Provincial Hospital's research ethics committee has approved this study protocol. Participation will be voluntary, with informed consent obtained from all participants. Study results will be published in peer-reviewed journals.

Clinical trial registration

ChiCTR2400091805.

The Canadian Lung Outcomes in Users of Vaping Devices (CLOUD) Study: protocol for a prospective, observational cohort study

INTRODUCTION

The rapid growth in popularity of e-cigarettes over the past decade has prompted concerns about their impact on long-term respiratory health. Small airway injury is suspected to be a direct consequence of e-cigarette use and may be quantifiable by novel structural and functional diagnostic modalities.

METHODS AND ANALYSIS

In a multicentre observational longitudinal study, participants will be enrolled in either an adolescent (ages ≥12 and <19 years) or an adult arm (≥19 years old) and followed over 3 years across three time points (baseline, 18 months and 36 months). In the adolescent arm, a total of 50 e-cigarette and 50 non-e-cigarette users will be enrolled across 4 sites. In the adult arm, a total of 100 e-cigarette users, 100 non-e-cigarette users, and an additional 100 combustible cigarette-only users and 100 dual combustible cigarette-e-cigarette users will be enrolled across 5 sites. Participants will undergo respiratory questionnaires, pulmonary function tests, oscillometry, cardiopulmonary exercise testing, hyperpolarised 129-xenon gas MRI and blood collection. In adolescent participants only, multiple breath washout and induced sputum collection will be performed. Adult participants will also undergo inspiratory/expiratory chest CT and bronchoscopy. The primary endpoint will be a composite of small airway dysfunction according to oscillometry, cardiopulmonary testing and/or chest imaging parameters.

ETHICS AND DISSEMINATION

This protocol has been approved by The University of British Columbia-Providence Health Care Research Ethics Board (Certificate H24-00374). The use of hyperpolarised 129-xenon gas in this study has been approved by Health Canada (Certificate HC6-024-c291776). Written documentation of informed consent will be required prior to study initiation. We will seek to enrol adolescent participants who are capable of providing informed consent with an optional support statement from a parent encouraged but not required. Study findings will be disseminated to medical/scientific audiences through scientific conferences and published manuscripts respecting the Strengthening the Reporting of Observational Studies in Epidemiology statement, to youths through outreach events at high schools and community programmes and through social media, and to adults through lung health community events.

TRIAL REGISTRATION NUMBER

NCT06819969.

The first comparative analysis of open and robotic tracheobronchoplasty for excessive central airway collapse†

OBJECTIVES

Tracheobronchoplasty is an operation to treat excessive central airway collapse by stabilizing the posterior tracheal membrane. In 2020, our institution transitioned from the traditional open approach to the robotic-assisted tracheobronchoplasty in select patients. This retrospective cohort study compares postoperative complications and short-term outcomes for patients undergoing open versus robotic tracheobronchoplasty at a high-volume complex airway centre.

METHODS

A retrospective review of all patients who underwent open tracheobronchoplasty (2018-2020) and robotic tracheobronchoplasty (2020-2023) was conducted.

RESULTS

During the study period, 43 and 69 patients underwent robotic and open tracheobronchoplasty, respectively. Robotic tracheobronchoplasty had longer median operative times than open (8.4 vs 6.2 h; P ≤ 0.01). Both median intensive care unit (ICU) length of stay (1.0 vs 3.0 days, P ≤ 0.01) and hospital length of stay (5.0 vs 7.0 days, P ≤ 0.01) were shorter after robotic tracheobronchoplasty. There were no significant differences in major or minor complications, total Clavien-Dindo Score, estimated blood loss, discharge to home, and 30-day readmission. The robotic group had two reoperations during the index hospitalization and three conversions to open. There were no mortalities in either group. Short-term (3-month) functional and quality-of-life outcomes were equivalent between groups.

CONCLUSIONS

In selected patients with severe and symptomatic excessive central airway collapse, robotic tracheobronchoplasty is a safe and feasible alternative to the traditional open approach. Patients undergoing robotic tracheobronchoplasty have shorter ICU and total hospital stays with equivalent complication rates. As the robotic approach becomes more prevalent, further comparative outcomes are necessary with longer follow-up to ensure durability of the robotic-assisted repair.

Post COVID symptom burden in patients supported with extracorporeal membrane oxygenation: A prospective 2-year follow-up analysis

OBJECTIVES

A systematic characterization of the long-term sequelae after the severest form of COVID-19 requiring ECMO-therapy is lacking. Here, we present 2-year follow-up data of COVID-19 ECMO survivors, and analyze the cardiopulmonary, neurocognitive, psychological, and functional status, plus health-related quality of life (HRQL).

METHODS

From 04/2020 to 09/2021, 60 COVID patients were supported with ECMO. Survival to discharge was 40.0% (n = 24), and 6-month survival was 33.3% (n = 20). Follow-ups were performed via phone and mail using validated tools. Six-month outcomes have been published before.

RESULTS

At 2 years, 20 patients were alive. N = 19 agreed to participate in this study (median age 57.0 (45.0-63.0) years, 21.1% female). The cardiopulmonary status was satisfactory (78.9% in NYHA level I-II). Altogether, 84.2% were vastly independent in daily life. However, 47.4% still showed cognitive impairment, 21.1% moderate, 15.8% severe depression, and 15.8% posttraumatic stress disorder symptoms. HRQL subscale results were similar to 6 months, but patients self-rated their overall health significantly better (70.0% (50.0%-80.0%) vs 50.0% (30.0%-80.0%), p = 0.04). The number of patients working was increasing. Social life remained markedly affected.

CONCLUSIONS

Two-year outcomes in COVID-19 ECMO patients were stable to improving as compared to 6-month results. However, long-term impairments affected all aspects of life. Long COVID specifically, and post ECMO sequelae in general need to be characterized further to enable maximum recovery.

Pleural Irregularities: A new ultrasound marker for lung involvement in primary Sjögren's disease

OBJECTIVES

Lung ultrasound (LUS) has been proposed as a useful tool for the assessment of interstitial lung disease (ILD) in connective tissue diseases. However, there are no studies investigating the significance of pleural irregularities (PI) on LUS in primary Sjögren's disease (SjD) patients. The aim of this study was to explore the role of PI for the assessment of SjD-related lung involvement.

METHODS

All primary SjD patients who had undergone a chest CT-scan in the lasts 2 months from the start of the study were enrolled, including both SjD patients with known ILD and SjD patients without known lung involvement who underwent a chest CT due to clinical indications other than ILD screening. LUS was performed for all patients and PI total and partial scores were assigned from 0 (normal) to 2 (major changes). Based on CT-scans results SjD patients were divided into 5 groups: normal CT-scan, non SjD-related lung abnormalities, SjD-related non-ILD lung abnormalities, established ILD, newly diagnosed ILD.

RESULTS

Nineteen SjD patients with established ILD and 42 without known lung involvement who had undergone a CT-scan were included. Among the latter, CT allowed the diagnosis of 4 new ILD cases. Both total and postero-inferior PI scores were comparable between established ILD and newly diagnosed ILD patients and significantly higher compared to patients with normal CT-scan and SjD related non-ILD lung abnormalities. The AUC for ILD diagnosis was significantly higher for the PI postero-inferior score compared to the PI total score. A cut-off score of 15 for the PI postero-inferior score resulted in a sensitivity of 86.6% and specificity of 84.2% for SjD-ILD diagnosis. Both PI total and postero-inferior scores strongly correlated with HRCT Warrick score (r=0.809 and r=0.854). The correlation between PFT and both total and postero-inferior PI scores was higher than that observed between PFT and the Warrick HRCT score.

CONCLUSIONS

PI may represent a valid tool for the assessment of lung involvement in SjD, particularly for the screening of ILD. PI assessment limited to postero-inferior lung fields seem to maintain good diagnostic accuracy, allowing to save time in clinical practice.

Characterizing COPD phenotypes with a targeted signaling lipids metabolomics approach

AIMS

This study aimed to elucidate clinically-relevant classifications of COPD using a targeted metabolomics approach focusing on signaling lipids.

MATERIALS AND METHODS

Using a targeted LC-MS/MS platform, 166 metabolites including free fatty acids, prostaglandins, isoprostanes, lysophospholipids, endocannabinoids, and bile acids were profiled in a cohort of 49 COPD patients. The study integrated metabolomic data with clinical parameters to identify key metabolites and related pathways for various COPD classification systems including Global Initiative for Chronic Obstructive Lung Disease (GOLD) grading stages, Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF, Royal Dutch Society for Physiotherapy) profiles, and Systemic (SYS) subtypes and explored the association of these classification systems.

KEY FINDINGS

The GOLD stages showed correlations with 15 metabolites, including lysophospholipids, oxylipins, and bile acids. KNGF profiles were linked to 13 metabolites, predominantly lysophospholipids, while SYS subtypes were associated with 9 metabolites, mainly oxylipins. A specific cluster of oxylipins, including HETEs and HDoHEs, was notably correlated to prognostic factors of COPD.

SIGNIFICANCE

This study identified distinct metabolic patterns associated with GOLD stages, KNGF profiles, and SYS subtypes. Additionally, the findings indicate that 14-HDoHE/DHA may serve as a potential biomarker for COPD exacerbation and suggest possible therapeutic targets for COPD, including pathways involving lipoxygenases, G-protein coupled receptors, and the Farnesoid X receptor.

The effectiveness of functional inspiratory muscle training on exercise capacity and peripheral muscle strength in patients with essential hypertension: a three-arm randomized controlled trial

BACKGROUND

The effect of inspiratory muscle training (IMT) applied along with function in Hypertension (HT) patients is uncertain. In this study, it was to determine the effectiveness of functional IMT (F-IMT) on functional lower and upper exercise capacity, mobility, peripheral and respiratory muscle strength, blood pressure, fatigue, physical activity, and quality of life (HRQoL) in HT patients.

METHODS

Prospective, randomized controlled, assessor-blinded, parallel three-armed trial. Forty-five patients with HT were divided into F-IMT group (IMT with 50% maximal inspiratory pressure (MIP)/4 weeks + exercise and IMT with 50% MIP/4 weeks, n = 15), IMT group (MIP 50%, n = 15) and control group (CG, breathing exercises, n = 15). 6-min walking test (6-MWT), 6-min pegboard ring test (6PBRT), 1-min sit to stand test (1STS), mobility, peripheral muscle strength, MIP, maximal expiratory pressure (MEP), systolic& diastolic blood pressure (SBP, DBP), fatigue, physical activity, and HRQoL were evaluated before and after 8 weeks of training.

RESULTS

Increases in 6-MWT were higher in F-IMT (p < 0.001). 6PBRT, 1STS, quadriceps femoris strength were improved and SBP reduced in F-IMT and IMT than CG (p < 0.001). Mobility, handgrip, HRQoL, and physical activity level increased within groups (p < 0.05). MIP increased within F-IMT and IMT; MEP, fatigue, DBP improved only within F-IMT (p < 0.05).

CONCLUSIONS

F-IMT is more effective in enhancing exercise capacity, reducing fatigue and DBP, and improving MEP. Both IMT and F-IMT show similar benefits for upper extremity exercise capacity, quadriceps femoris strength, SBP, and MIP. Mobility, HRQoL, and physical activity levels are increased with F-IMT, IMT, and breathing exercises.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06343246 (03/29/2024).

Comparison of Chest High-Resolution Computed Tomography Findings in Patients with Anti-Melanoma Differentiation-Associated Gene 5 Antibody-Positive and Antibody-Negative Progressive Pulmonary Fibrosis with Polymyositis/Dermatomyositis

Background/Objectives: This study compared chest high-resolution computed tomography (HRCT) findings between patients with anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive and antibody-negative progressive pulmonary fibrosis (PPF) with polymyositis/dermatomyositis (PM/DM). Methods: Of the 85 patients with PM/DM-interstitial lung disease (ILD), 17 were anti-MDA5 antibody-positive, and 68 were antibody-negative. Among these, 5 anti-MDA5 antibody-positive and 9 antibody-negative cases met the criteria for PPF and were enrolled in the study. The chest HRCT findings and the duration from treatment initiation to the appearance of key fibrotic changes were analyzed. Results: In the anti-MDA5-positive group, all patients were diagnosed with PPF within 6 months of treatment initiation, compared to only 22.2% in the anti-MDA5-negative group. While there was no difference between the anti-MDA5 antibody-positive and antibody-negative groups in terms of chest HRCT findings associated with PPF, the duration to the appearance of increased traction bronchiectasis and bronchiolectasis, and new ground-glass opacity with traction bronchiectasis was significantly shorter in the anti-MDA5-positive group (p = 0.016 and p = 0.023, respectively). The appearance of new fine reticulations and increased coarseness of reticular abnormalities tended to be shorter in the anti-MDA5 antibody-positive group than in the antibody-negative group. Conclusions: Pulmonary fibrosis in patients with anti-MDA5 antibody-positive ILD can rapidly progress within 6 months, despite immunosuppressive therapy. Frequent HRCT monitoring and early combination therapy with antifibrotic agents are crucial for managing the progression of fibrosis.

Outcomes from the Victorian Healthy Homes Program: a randomised control trial of home energy upgrades

OBJECTIVES

The Victorian Healthy Homes Program investigated the impact of thermal home upgrades on energy and health outcomes in vulnerable, older individuals over winter in Victoria, Australia.

DESIGN

A staggered parallel-group randomised control trial design of 984 (764 per protocol (PP)) vulnerable households and 1313 (1015 PP) individuals. The intervention group received their upgrade prior to their winter of recruitment, and the control group received their upgrade after the winter of their recruitment.

SETTING

Western Melbourne (metropolitan) and the Goulburn Valley (regional) in Victoria, Australia.

PARTICIPANTS

1000 households were recruited: 800 from western Melbourne (metropolitan) and 200 from the Goulburn Valley (regional).

INTERVENTION

A thermal comfort and home energy efficiency upgrade of up to $AUD3500 per household.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the change in indoor temperature over winter and the secondary outcomes were changes in quality of life, healthcare use and costs, self-reported health measures, energy use and costs and humidity.

RESULTS

A relatively low-cost and simple home upgrade (average cost $A2809) resulted in reduced gas consumption (-25.5 MJ/day) and increased indoor winter temperatures (average daily increase of 0.33°C), and a reduction of exposure to cold conditions (<18°C) by an average of 0.71 hours (43 min) per day. The intervention group experienced improved mental health as measured by the short-form 36 mental component summary and social care related quality of life measured by the Adult Social Care Outcomes Toolkit, less breathlessness and lower overall healthcare costs (an average of $A887 per person) over the winter period.

CONCLUSIONS

The home upgrades significantly increased average winter indoor temperature, improved mental health and social care-related quality of life and made householders more comfortable while yielding reductions in overall healthcare use and costs.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry: ACTRN12618000160235.

Neuroleptics used in critical COVID associated with moderate-severe dyspnea after hospital discharge

Dyspnea is a prominent symptom in patients with long COVID due to its high prevalence and significant clinical impact. However, the influence of commonly used medications in critically ill patients on long-term dyspnea remains unclear. This study aimed to identify risk factors and assess the impacts associated with moderate to severe dyspnea in COVID-19 survivors. This study evaluated patients admitted to a university hospital between April 2020 and April 2021. Data were collected on clinical preconditions, hospital and ICU stays, and the use of corticosteroids, neuroleptics, neuromuscular blockers, midazolam, fentanyl, and noradrenaline. Post-discharge evaluations were conducted at 1 and 12 months, assessing dyspnea, frailty, quality of life, functional capacity, anxiety, and depression. Descriptive statistics, including frequencies and percentages, were used, and logistic regression analysis was performed to identify factors associated with moderate to severe dyspnea at 1 and 12 months post-discharge. Statistical significance was defined as P < 0.05. A total of 100 patients were prospectively included in the study; all underwent the 1-month evaluation, and 63 completed the 12-month evaluation. Limiting dyspnea, defined as an mMRC score > 1, was observed in 56.6% of patients at 1 month and 33.9% at 12 months post-discharge. Independent factors associated with limiting dyspnea at 1 month included the total dose of neuroleptics administered during hospitalization and the presence of pre-existing comorbidities. The use of corticosteroids, neuromuscular blockers, midazolam, fentanyl, and noradrenaline showed no significant association with limiting dyspnea. Dyspnea at 1 month post-discharge was an independent risk factor for the persistence of limiting dyspnea at 12 months. Patients with limiting dyspnea at 12 months exhibited higher levels of depression, anxiety, and frailty, alongside reduced quality of life and functionality. Patients with severe COVID-19 exhibit a high prevalence of limiting dyspnea in the long term. The total dose of neuroleptics administered during hospitalization and the presence of comorbidities were independently associated with limiting dyspnea after discharge. At 12 months post-discharge, individuals with persistent limiting dyspnea frequently demonstrated additional physical and mental health impairments, underscoring the need for comprehensive evaluation and management to mitigate the burden of long-term disabilities.

The Prevalence and Severity of Dyspnea in Young Saudi Female Adults: A Cross-sectional Study

Background

Dyspnea impacts daily activities; women tend to report a higher perception of dyspnea and experience greater emotional distress compared to men. Therefore, the study aims to assess the prevalence and severity of dyspnea among Saudi women aged 18 to 35 years and explore associated risk factors.

Method

A quantitative cross-sectional study was conducted in Saudi Arabia. The data were collected using an electronic online questionnaire survey. The questionnaire consisted of participants' demographic data, and the status of factors associated with dyspnea, such as body mass index, physical activity, and smoking status. Using the modified Medical Research Council (mMRC) dyspnea scale is another option. The modified Medical Research Council (mMRC) dyspnea scale was used in a descriptive analysis to characterize the prevalence and score of dyspnea.A Mann-Whitney U test and Chi-square tests were conducted to determine the differences and associations according to the dyspnea risk factors. A p-value of <0.05 determined the statistical significance.

Results

A total of 554 participants were recruited. The overall prevalence of dyspnea was reported by 115 (21%) participants, with a mean score of 1.42 (SD 1.38) on the MRC Dyspnea Scale. The majority of participants were from the central region (74%) and aged 18 to 24 years (65.5%). No statistically significant differences were found between participants with and without dyspnea in terms of body mass index (22.6 [19.6-25.6] vs 22.8 [20.1-26.2], p=0.68, respectively), passive smoking status (p=0.07), or physical activity level (p=0.37).

Conclusion

The study concludes that approximately one in five young females experienced dyspnea, suggesting that this symptom may be quite prevalent. However, no significant association was found between dyspnea and factors such as body mass index, passive smoking, or physical activity levels.

Examining recovery trajectories of physical function, activity performance, cognitive and psychological functions, and health related quality of life in COVID-19 patients treated in ICU: a Swedish prospective cohort study

PURPOSE

To investigate the recovery trajectories of physical function, activity performance, cognitive and psychological functions, and health related quality of life, as well as potential interaction effects, in individuals with COVID-19 treated in an intensive care unit (ICU).

METHODS

This prospective cohort study included patients with confirmed COVID-19 infection, treated in an ICU. Clinical assessments and self-ratings of functioning, disability and health were performed > 1 month and > 12 months after discharge from hospital.

RESULTS

Among the 65 included individuals (mean age 56.6, SD 11) significant improvements in physical and psychological function were observed over time, although not reaching population norms. Cognition remained unchanged (MoCA median 27, IQR 4). At the 12-month follow-up, physical limitations in activity (RAND-36) were found to be associated with dyspnea (mMRC-Dyspnea), mental and physical fatigue (MFI-20), and walking endurance (6-minute walk test) (r2 0.509 p < 0.001). Role limitations due to physical health (RAND-36) was found to be associated with physical and mental fatigue (MFI-20) and pain (r2 0.530 p < 0.001).

CONCLUSION

Despite improvements in functioning and health in this group of predominantly younger age recovery did not reach population norms. These results highlight persistent impairments and activity limitations that may necessitate long-term healthcare interventions.

Interventions for the management of post-COVID-19 condition (long COVID): protocol for a living systematic review and network meta-analysis

BACKGROUND

Up to 15% of survivors of COVID-19 infection experience long-term health effects, including fatigue, myalgia and impaired cognitive function, termed post-COVID-19 condition or long COVID. Several trials that study the benefits and harms of various interventions to manage long COVID have been published and hundreds more are planned or are ongoing. Trustworthy systematic reviews that clarify the benefits and harms of interventions are critical to promote evidence-based practice.

OBJECTIVE

To create and maintain a living systematic review and network meta-analysis addressing the benefits and harms of pharmacologic and non-pharmacologic interventions for the treatment and management of long COVID.

METHODS

Eligible trials will randomise adults with long COVID to pharmacologic or non-pharmacologic interventions, placebo, sham or usual care. We will identify eligible studies by searching MEDLINE, EMBASE, CINAHL, PsycINFO, AMED and CENTRAL from inception, without language restrictions.Reviewers will work independently and in duplicate to screen search records, collect data from eligible trials, including trial and patient characteristics and outcomes of interest and assess risk of bias. Our outcomes of interest will include patient-reported fatigue, pain, postexertional malaise, changes in education or employment status, cognitive function, mental health, dyspnoea, quality of life, physical function, recovery and serious adverse events.For each outcome, when possible, we will perform a frequentist random-effects network meta-analysis. When there are compelling reasons to suspect that certain interventions are only applicable or effective for a subtype of long COVID, we will perform separate network meta-analyses. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach will guide our assessment of the certainty of evidence.We will update our living review biannually, on the publication of a seminal trial, or when new evidence emerges that may change clinical practice.

CONCLUSION

This living systematic review and network meta-analysis will provide comprehensive, trustworthy and up-to-date summaries of the evidence addressing the benefits and harms of interventions for the treatment and management of long COVID. We will make our findings available publicly and work with guideline-producing organisations to inform their recommendations.

ETHICS AND DISSEMINATION

The study describes the protocol for a systematic review that uses data from published trial reports. Therefore, the study is exempt from ethics review. We intend to deposit all data in a public repository and publish each iteration of the living review online.

Balneotherapy for the treatment of post-COVID syndrome: a randomized controlled trial

BACKGROUND

Post-Acute COVID Syndrome (PACS) is a complex disorder that currently lacks effective evidenced-based therapies to manage it. This randomized controlled trial aims to evaluate the effects of balneotherapy (BT) on PACS symptomatology.

METHODS

Ninety-eight adults with PACS visited at Hospital del Mar Research Institute, Barcelona (Spain) were included to the study. Participants in the intervention group (n = 51) were allocated to 12 sessions of BT and aquatic exercises delivered in one month while the control group (n = 47) did not. The primary outcome was to evaluate the absolute change in questionnaire scores between baseline and two follow-up points: immediately after balneotherapy (or one-month post-baseline for the control group) and 2 months post-baseline. The following scales/questionnaires were employed: Post-COVID-19 functional status scale, mMRC dyspnea Scale, SF-36, Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), Memory failures in everyday life following severe head injury, and Visual Analogic Scale (VAS).

RESULTS

Forty-seven patients in the BT group and 43 in the control group completed the study. The majority of participants were middle-aged women (> 84%; mean age 48 years), and the most prevalent symptoms were fatigue, musculoskeletal pain, and neurocognitive impairment (> 88%). Noteworthy, the vast majority did not undergo a severe primary infection (ICU admissions < 3%). After BT, significant improvement was detected in the BT group vs. the control group in various SF-36 domains, PSQI total score (Beta-coefficient [95%CI] 2.641 [1.15;4.12]; p -value = 0.003), HAD's anxiety subscale (Beta-coefficient [95%CI] 1.72 [0.40;3.03;p-value = 0.023), and VAS (Beta-coefficient [95%CI] 1.625 [0.32;2.96]; p-value = 0.026). Among these, SF-36's energy/fatigue and pain subscales exhibited the most prominent changes with a Beta-coefficient [95%CI] of -17.45 [-24.23;-10.66] and - 21.634 [-30.48;-12.78], respectively (p-value < 0.0001). No severe adverse effects were reported during BT although seventeen patients reported mild and transient worsening of preexisting symptoms, particularly fatigue/post-exertional malaise mainly in the first sessions of BT.

CONCLUSION

Balneotherapy comprise an effective therapeutic modality that can alleviate several symptoms that characterize PACS, particularly musculoskeletal pain and fatigue. However, the sustainability of these effects over time remains uncertain, as evidenced by the loss of some between-group differences at the one-month follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05765591 (13/03/2023).

Postacute COVID-19 fatigue, dyspnea and reduced activity in children and adolescents

BACKGROUND

This study aimed to quantify fatigue, dyspnea, and physical activity and identify associated factors in children and adolescents with postacute COVID-19 syndrome.

METHODS

A prospective cohort study included 74 participants aged 6-18 years with postacute COVID-19 symptoms and 120 age- and sex-matched controls without SARS-CoV-2 antibodies. Participants completed questionnaires assessing fatigue, dyspnea, and physical activity and underwent pulmonary function tests.

RESULTS

Children with postacute COVID-19 syndrome reported significantly greater fatigue (parent-rated scores: mean 67.9 vs. 82.4, p < 0.001; child-rated scores: 73.7 vs. 83.0, p < 0.001), increased dyspnea (mMRC grades 3-4: 10.9% vs. 4.1%, p = 0.001), and lower physical activity (median 787.8 vs. 1658.5 MET*min/week, p < 0.001) than controls. They also had a higher prevalence of mixed (8.1% vs. 1.7%, p = 0.029) and restrictive lung disease (29.7% vs. 10.8%, p = 0.001). Older age and COVID-19 were identified as risk factors for fatigue and reduced activity. Fatigue correlated with reduced physical activity but not with pulmonary function.

CONCLUSION

Children and adolescents with postacute COVID-19 syndrome, particularly older individuals, experience greater fatigue and reduced physical activity than controls. These findings highlight the importance of quantifying postacute COVID-19 symptoms and their associations with physiological assessments.

IMPACT

This prospective, age- and sex-matched cohort study revealed that children and adolescents with postacute COVID-19 syndrome perceived higher fatigue levels, had higher dyspnea scores, had a greater prevalence of mixed lung and restrictive lung disease, and exhibited less physical activity than their control counterparts. Fatigue correlated with reduced physical activity but was not consistently correlated with pulmonary function test results. This study highlights the importance of quantifying postacute COVID-19 symptoms and exploring the associations between individual symptoms and the impact of coronavirus infection on various systems, including the neurological, musculoskeletal, cardiopulmonary, and immune systems.

Relationship of Pulmonary Vascular Structure and Function With Exercise Capacity in Health and COPD

BACKGROUND

Although it is generally accepted that aerobic exercise training does not change lung structure or function, some work suggests that greater pulmonary vascular structure and function are associated with higher exercise capacity (peak rate of oxygen consumption [V˙o2peak]).

RESEARCH QUESTION

Is there a cross-sectional association between the pulmonary vasculature and V˙o2peak? We hypothesized that those with higher CT blood vessel volumes and pulmonary diffusing capacity for carbon monoxide (Dlco) would have higher V˙o2peak, independent of airflow limitation.

STUDY DESIGN AND METHODS

Participants from the Canadian Cohort Obstructive Lung Disease (CanCOLD) study were categorized as follows: participants with normal spirometry who had never smoked (n = 263), participants with normal spirometry who had ever smoked (n = 407), and COPD: individuals with spirometric airflow obstruction (n = 334). Total vessel volume (TVV), volume for vessels < 5 mm2 in cross-sectional area (BV5), and volume for vessels between 5 and 10 mm2 in cross-sectional area (BV5-10) were generated from CT scans and used as indices of pulmonary vascular structure. Dlco was used as an index of pulmonary microvascular function. V˙o2peak was evaluated via incremental cardiopulmonary exercise testing.

RESULTS

General linear regression models revealed that even after controlling for FEV1, emphysema severity, and body morphology, Dlco, TVV, BV5, and BV5-10, were independently associated with V˙o2peak. Interaction effects were observed between COPD and TVV, BV5, and BV5-10, indicating a weaker association between pulmonary vascular volumes and V˙o2peak in COPD.

INTERPRETATION

Our results suggest that pulmonary vascular structure and Dlco are independently associated with V˙o2peak, regardless of severity of airflow limitation and emphysema, suggesting that these associations are not limited to COPD.

One-year trajectories of physical and mental health-related quality of life, fatigue and dyspnoea in COVID-19 survivors

PURPOSE

A substantial number of people experience a persisting impact on health-related quality of life (HRQoL) after COVID-19. The current study aims to identify different trajectories of physical and mental HRQoL, fatigue severity, and dyspnoea severity following hospitalisation with COVID-19, and associated factors of these trajectories.

METHODS

500 patients with COVID-19 were followed for one year in a longitudinal cohort study. Self-reported outcomes were measured at 3, 6, 9, and 12 months after hospitalisation. Distinct trajectories were characterised using Growth Mixture Modelling. Sociodemographic and clinical correlates of trajectories were investigated using multivariable (multinomial) logistic regression analyses.

RESULTS

Three trajectories ('stable high' (16%), 'improving' (40%), and 'stable low' (44%)) were found for physical HRQoL, and four ('stable high' (43%), 'improving' (14%), 'middle declining' (17%), and 'low' (26%)) for mental HRQoL. Older age, overweight and obesity, lower education, and comorbidities were associated with 'low' physical HRQoL. Younger age was associated with 'low' mental HRQoL. Four fatigue trajectories ('no fatigue' (15%), 'improving' (40%), 'low-severe' (27%), and 'high-severe' (18%)) were found. Participants either experienced almost never ('no dyspnoea', 75%) or almost always ('severe', 25%) dyspnoea. High co-occurrences between low HRQoL and severe fatigue and dyspnoea symptom trajectories were found.

CONCLUSION

A substantial number of COVID-19 survivors continue to struggle with reduced HRQoL over time. However, large variations in these physical and mental HRQoL trajectories exist, and trajectories are associated with persisting COVID-19-related symptoms or pre-hospitalised health status. Regular measurement of HRQoL and post-COVID symptoms may help identify those that may benefit from timely interventions.

Exercise capacity, dyspnea, and quality of life 6 months after exercise-based rehabilitation in patients with persistent dyspnea following pulmonary embolism

Background

Exercise is safe and effective in the short-term following pulmonary embolism. To date, little is known about the long-term effects.

Objectives

The aim of the study was to investigate whether the effects of exercise-based rehabilitation are maintained 6 months after completion in patients with persistent dyspnea following pulmonary embolism when compared with usual care.

Methods

A 2-center, randomized controlled trial compared 8 weeks of exercise-based rehabilitation with usual care. Patients were reassessed postintervention and 6 months later. Exercise capacity was measured with the incremental shuttle walk test (ISWT). Dyspnea was assessed with the Shortness of Breath Questionnaire, and health-related quality of life was assessed with disease-specific (Pulmonary Embolism Quality of Life Questionnaire) and generic questionnaires.

Results

In total, 159 of 211 randomized patients attended follow-up 6 months postintervention. The significant improvement on the ISWT in the rehabilitation group was maintained at the 6-month follow-up (96 m; SE: 15 m; 95% CI: 66, 127). There were no changes on the ISWT in the control group at either time point. From postintervention to 6×-month follow-up, the rehabilitation group had further improvements in dyspnea compared with the control group (-3 points; SE: 1.4; 95% CI: -6, -1; P = .02). Health-related quality of life improved in both groups although superior improvements were seen in the rehabilitation group.

Conclusion

The improvement in exercise capacity after 8 weeks of exercise-based rehabilitation in patients with pulmonary embolism and persistent dyspnea was maintained at the 6-month follow-up, while no improvement was observed in the control group, highlighting the relevance of offering rehabilitation to these patients.

Diffusion capacity and static hyperinflation as markers of disease progression predict 3-year mortality in COPD: Results from COSYCONET

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) exhibits diverse patterns of disease progression, due to underlying disease activity. We hypothesized that changes in static hyperinflation or KCO % predicted would reveal subgroups with disease progression unidentified by preestablished markers (FEV1, SGRQ, exacerbation history) and associated with unique baseline biomarker profiles. We explored 18-month measures of disease progression associated with 18-54-month mortality, including changes in hyperinflation parameters and transfer factor, in a large German COPD cohort.

METHODS

Analysing data of 1364 patients from the German observational COSYCONET-cohort, disease progression and improvement patterns were assessed for their impact on mortality via Cox hazard regression models. Association of biomarkers and COPD Assessment test items with phenotypes of disease progression or improvement were evaluated using logistic regression and random forest models.

RESULTS

Increased risk of 18-54-month mortality was linked to decrease in KCO % predicted (7.5% increments) and FEV1 (20 mL increments), increase in RV/TLC (2% increments) and SGRQ (≥6 points), and an exacerbation grade of 2 at 18 months. Decrease in KCO % predicted ≥7.5% and an increase of RV/TLC ≥2% were the most frequent measures of 18-month disease progression occurring in ~52% and ~46% of patients, respectively. IL-6 and CRP thresholds exhibited significant associations with medium- and long-term disease measures.

CONCLUSION

In a multicentric cohort of COPD, new markers of current disease activity predicted mid-term mortality and could not be anticipated by baseline biomarkers.

Five-Repetition Sit-to-Stand Test as Predictor of Mortality in High Risk COPD Patients

OBJECTIVE

To determine if adding performance on the five-repetition sit-to-stand test (5-STS) to chronic obstructive pulmonary disease (COPD) high-risk criteria, proposed by the Spanish COPD guidelines (GesEPOC), affects mortality prognosis.

METHODS

Observational study of COPD outpatients involved prospective follow-up for 5 years. Patients were classified based on 5-STS performance and risk criteria proposed by GesEPOC version 2021. Outcome measures were 5-year mortality timing and rate. Kaplan-Meier curves and univariate and multivariate Cox proportional-hazard analyses, analysis of variance, and univariate and multivariate linear and logistic regression models were used.

RESULTS

One hundred and thirty-seven patients were included. Mean age was 66±8.3 years, and 87.6% were men. Of them, 115 (83.9%) were classified as high risk, 43 (34.4%) of whom had poor performance on the 5-STS. Overall mortality at 5 years was 27% and was significantly higher in the high-risk (29.6%) compared with the low-risk (13.6%) group. Among high-risk patients, mortality at 5 years was significantly worse with poor 5-STS performance (60.5%) compared with non-poor performance (11.1%). Poor performance on the 5-STS was independently associated with increased 5-year mortality risk (HR 4.70; 95% CI: 1.96-11.27) in a model adjusted for history of heart disease and dyspnea.

CONCLUSION

Among high-risk COPD patients, those with poor performance on the 5-STS have a significantly higher mortality at 5 years than those with non-poor 5-STS performance.

A Comparison of GOLD and STAR Severity Stages in Individuals With COPD Undergoing Pulmonary Rehabilitation

BACKGROUND

Alongside the recognized Global Initiative for Obstructive Lung Disease (GOLD) classification, the Staging of Airflow Obstruction by Ratio (STAR) severity scheme has been proposed for categorizing COPD.

STUDY QUESTION

What are the agreement and utility of the GOLD and STAR classifications in patients with severe COPD entering the rehabilitation setting?

STUDY DESIGN AND METHODS

Medical records were reviewed in this multicenter retrospective study, examining key functional variables and their changes in a large cohort of patients with COPD undergoing pulmonary rehabilitation.

RESULTS

A total of 1,516 participants (33.7% female participants; median age, 72.0 years) were included in the analysis. Compared with GOLD, the use of the STAR classification resulted in a different disease severity category for 53.4% of patients. An unweighted Cohen's kappa of 0.25 and a Bangdiwala B value of 0.24 indicated a fair agreement between the 2 classifications. Higher weighted agreement measures (0.47 and 0.78, respectively) suggested that discrepancies between the classifications mainly occurred for contiguous stages. GOLD exhibited superior discrimination between stages for chronic respiratory failure, whereas STAR exhibited better performance in detecting hyperinflation. In terms of their application within pulmonary rehabilitation settings, GOLD exhibited superior performance compared with STAR in identifying the minimal clinically important difference in 6-min walking distance and modified Medical Research Council score. Accordingly, GOLD but not STAR acted as an independent predictor for achieving a minimal clinically important difference in modified Medical Research Council score (OR, 1.48; 95% CI, 1.12-1.94; P = .005) and also independently predicted changes in the Braden scale score (β = 0.154; P = .004).

INTERPRETATION

STAR exhibited a more uniform gradation of disease severity and enhanced performance in detecting hyperinflation, but our preliminary findings do not endorse its utilization in the rehabilitation setting.

Self-reported dyspnea and interest in a respiratory muscle training program among callers to the New York State Quitline

INTRODUCTION

Cigarette smoking is an important risk factor in the development of dyspnea. Programs designed to strengthen the respiratory muscles can improve dyspnea in people with or without lung disease. As a first step in understanding the feasibility of offering a respiratory muscle training (RMT) program to people who are seeking help to try to quit smoking, we asked callers who contacted the New York State Quitline about their dyspnea and potential interest in a home-based RMT program.

METHODS

Consecutive callers who contacted the New York State Quitline (n=1019) between 19 May and 9 June 2023 completed the Modified Medical Research Council (mMRC) dyspnea scale and reported their level of interest in RMT. Participants were categorized as: high breathlessness (HB: 0-1), or low breathlessness (LB: 2-4). We examined characteristic differences between participants who reported HB versus LB and examined differences in level of interest in home-based RMT.

RESULTS

Those with HB were older [mean (SD): 61.3 (12.5) vs 53.6 (15.0) years, p<0.001], had more cumulative years of smoking [38.8 (15.1) vs 28.8 (15.4) years, p<0.001], smoked more cigarettes per day [19.3 (10.5) vs 17.3 (8.8), p<0.01], reported more disability (p<0.001) and chronic health conditions (78.5% vs 53.9%, p<0.001). Those with HB also expressed greater interest in RMT [7.8 (3.3) vs 6.2 (4.1), p<0.001].

CONCLUSIONS

These preliminary findings suggest that about 20% of quitline callers report clinically significant levels of breathlessness and most respondents, regardless of their level of breathlessness, report interest in a home-based RMT program, underscoring a potential opportunity to offer this program along with cessation support.

Risk factors for interstitial lung disease in early rheumatoid arthritis and external validation of screening strategies: Baseline results of SAIL-RA

Background

Risk factors and screening strategies for rheumatoid arthritis-associated interstitial lung disease (RA-ILD) have received limited evaluation in patients with early RA. We investigated RA-ILD prevalence, risk factors, and the performance of proposed RA-ILD screening methodologies in a multicenter, prospective study of patients with early RA.

Methods

Participants with early RA, defined as being within two years of RA diagnosis, were enrolled at five US sites and assessed with high-resolution computed tomography (HRCT) chest imaging, pulmonary function tests, and autoantibodies. RA-ILD presence was determined through independent HRCT review by thoracic radiologists. We investigated RA-ILD risk factors using multivariable logistic regression and reported the predictive performance of RA-ILD screening strategies (ANCHOR-RA, 2023 ACR/CHEST, Four Factor Score, and ESPOIR).

Results

Among 172 participants (74% female, 82% seropositive, median RA duration 0.79 years, mean age 55.3 years), 19 (11%) had ILD on HRCT. Moderate/high RA disease activity by DAS28ESR (OR 7.00 [1.95, 25.1]) and age ≥60 years (OR 3.87 [1.33, 11.3]) were associated with RA-ILD. Sensitivity and specificity of screening strategies ranged from 0.32-0.95 and 0.32-0.81, respectively. The number of early RA patients needing screening to detect one ILD case ranged from 3.6 to 6.4.

Discussion

In this prospective, multicenter study, ILD prevalence in early RA was 11%. Disease activity and older age were strongly associated with ILD in early RA, and several proposed ILD screening strategies performed showed promise for enabling ILD screening in early RA.