Interstitial Lung Diseases

Predicting New-onset Exertional and Resting Hypoxemia in Fibrotic Interstitial Lung Disease

Rationale: Hypoxemia in fibrotic interstitial lung disease (ILD) indicates disease progression and is of prognostic significance. The onset of hypoxemia signifies disease progression and predicts mortality in fibrotic ILD. Accurately predicting new-onset exertional and resting hypoxemia prompts appropriate patient discussion and timely consideration of home oxygen. Objectives: We derived and externally validated a risk prediction tool for both new-onset exertional and new-onset resting hypoxemia. Methods: This study used ILD registries from Canada for the derivation cohort and from Australia and the United States for the validation cohort. New-onset exertional and resting hypoxemia were defined as nadir oxyhemoglobin saturation < 88% during 6-minute-walk tests, resting oxyhemoglobin saturation < 88%, or the initiation of ambulatory or continuous oxygen. Candidate predictors included patient demographics, ILD subtypes, and pulmonary function. Time-varying Cox regression was used to identify the top-performing prediction model according to Akaike information criterion and clinical usability. Model performance was assessed using Harrell's C-index and goodness-of-fit (GoF) likelihood ratio test. A categorized risk prediction tool was developed. Results: The best-performing prediction model for both new-onset exertional and new-onset resting hypoxemia included age, body mass index, a diagnosis of idiopathic pulmonary fibrosis, and percent predicted forced vital capacity and diffusing capacity of carbon monoxide. The risk prediction tool exhibited good performance for exertional hypoxemia (C-index, 0.70; GoF, P = 0.85) and resting hypoxemia (C-index, 0.77; GoF, P = 0.27) in the derivation cohort, with similar performance in the validation cohort except calibration for resting hypoxemia (GoF, P = 0.001). Conclusions: This clinically applicable risk prediction tool predicted new-onset exertional and resting hypoxemia at 6 months in the derivation cohort and a diverse validation cohort. Suboptimal GoF in the validation cohort likely reflected overestimation of hypoxemia risk and indicated that the model is not flawed because of underestimation of hypoxemia.

Oscillometry in Lung Function Assessment: A Comprehensive Review of Current Insights and Challenges

Oscillometry, a non-invasive technique for assessing lung function, has gained significant recognition and importance in modern pulmonary medicine. This comprehensive review thoroughly explores its principles, applications, advantages, limitations, recent innovations, and future directions. Oscillometry's primary strength lies in its ability to offer a holistic assessment of lung mechanics. Unlike traditional spirometry, oscillometry captures the natural airflow during quiet breathing, making it suitable for patients of all ages and those with severe respiratory conditions. It provides a comprehensive evaluation of airway resistance, reactance, and compliance, offering insights into lung function that were previously challenging to obtain. In clinical practice, oscillometry finds extensive application in diagnosing and managing respiratory diseases. It plays a pivotal role in asthma, chronic obstructive pulmonary disease (COPD), and interstitial lung diseases. By detecting subtle changes in lung function before symptoms manifest, oscillometry facilitates early interventions, improving disease management and patient outcomes. Oscillometry's non-invasive and patient-friendly nature is precious in pediatric care, where traditional spirometry may be challenging for young patients. It aids in diagnosing and monitoring pediatric respiratory disorders, ensuring that children receive the care they need from an early age. Despite its many advantages, oscillometry faces challenges, such as the need for standardized protocols and the complexity of data interpretation. However, ongoing efforts to establish global standards and provide education and training for healthcare professionals aim to address these issues. Looking ahead, oscillometry holds great promise in the field of personalized medicine. With its ability to tailor treatment plans based on individualized lung function data, healthcare providers can optimize therapy selection and dosing, ultimately improving patient care and quality of life. In conclusion, oscillometry is poised to play an increasingly pivotal role in modern pulmonary medicine. As standardization efforts continue and technology evolves, it is an indispensable tool in the clinician's arsenal for diagnosing, managing, and personalizing respiratory care, ultimately leading to improved patient outcomes and better respiratory health.

Trastuzumab-Induced Interstitial Pneumonitis

Trastuzumab is a recombinant immunoglobulin G1 monoclonal antibody used to treat human epidermal growth factor receptor 2 (HER2) cancers. Trastuzumab-induced interstitial pneumonitis is a rare adverse effect reported in a few patients. Interstitial pneumonitis presents as symptoms of dyspnea, hypoxia, cough, and fever. If the patient is treated early, corticosteroids can slow or reverse the disease progression. A 41-year-old woman presented with dyspnea and a dry cough three weeks after her third cycle of trastuzumab therapy for breast cancer. A diagnosis of trastuzumab-induced interstitial pneumonitis was made after multiple other disease processes were ruled out. The patient was started on methylprednisolone while inpatient and transitioned to prednisone for outpatient therapy. The patient was maintained on 2-3L of oxygen throughout her hospital stay and was discharged on 3L of oxygen through nasal cannula. Trastuzumab was never restarted after discharge. There have been many trials evaluating the safety, efficacy, and optimal treatment regimen of trastuzumab, but there are only a few reports of interstitial pneumonitis adverse reaction. The lack of correlation and limited cases make this adverse effect very difficult to diagnose and monitor. New trials and case reports can bring an insight into contributing factors, symptoms at onset, and treatment for future patients. With the increase in use of trastuzumab therapy, physicians should be aware of how to diagnose and treat the rare adverse reaction of trastuzumab-induced interstitial pneumonitis.

Impact of physical functional capacity on quality of life in patients with interstitial lung diseases

This study aimed to investigate the physical functioning predictors for health-related quality of life (HRQL) decline in patients with idiopathic interstitial fibrosis (IPF), sarcoidosis and other interstitial lung disease (ILD). The study enrolled 52 patients with ILD and 16 healthy individuals. Participants' HRQL was assessed using the 36-item Short-Form Health Survey questionnaire. Spirometry, physical performance, and daily physical activity (PA) were monitored. Patients with IPF showed significantly lower PA compared to patients with other ILD (p =0.002)and sarcoidosis (p =0.01). The type of disease aetiology had no significant effect on aerobic capacity, HRQL and fatigue. Patients with ILD showed significant greater fatigue, lower physical functioning and greater physical aspects scores compared to the control group (F=6.0; p=0.018; F=12.64; p=0.001, respectively). A significant positive correlation was observed between 6-minute walking distance (6MWD) and the physical domain of HRQL (r=0.35, p=0.012) and PA and the physical aspects of HRQL (r=0.37, p=0.007). This study revealed that the key predictors for HRQL decline were lower lung function, lower PA and physical performance.

Röntgenbefunde bei diffusen parenchymatösen Lungenerkrankungen

Klinisches Problem

Empfehlungen für die Praxis

Asthma can Promote Cardiomyocyte Mitophagy in a Rat Model

Clinical observations have shown the risk of cardiovascular disease during asthmatic changes. Whether and how asthma causes heart failure is the subject of debate. Here, we aimed to investigate the possibility of cardiomyocyte mitophagy in a rat model of asthma. Twelve mature Wistar rats were randomly allocated into the Control and Asthmatic rats (n = 6). To induce asthma, ovalbumin was injected intraperitoneally on days 1 and 8 and procedure followed by nebulization from days 14 to 32. After 2 weeks, we performed the pathological examination of both lungs and heart using Hematoxylin-Eosin staining. Real-time PCR analysis was used to measure the expression of mitophagic factors, such as Optineurin, Pink1, and mitofusin 1 and 2. Typical changes like increased inter-alveolar septa thickness and interstitial pneumonia were evident in asthmatic lungs. In cardiac tissue, slight inflammatory response, and hydropic degeneration with an eosinophilic appearance were detected in the cytoplasm of cardiomyocytes. Real-time PCR analysis showed mitophagic response in pulmonary and cardiac tissues via upregulation of mitophagy-related genes like Optineurin and Pink-1 in asthmatic lungs and hearts compared to the control group (p < 0.05). Likewise, asthmatic changes increased the expression of genes associated with mitochondrial fusion in the lungs and heart. The expression of mitofusin1 and 2 was significantly increased following inflammatory response in pulmonary and cardiac tissues (p < 0.05). Our findings showed the expression of certain factors related to mitophagy during chronic asthmatic conditions. The findings open a new avenue in the understanding of cardiomyocyte injury during asthma.

FVC-NET: An Automated Diagnosis of Pulmonary Fibrosis Progression Prediction Using Honeycombing and Deep Learning

Pulmonary fibrosis is a severe chronic lung disease that causes irreversible scarring in the tissues of the lungs, which results in the loss of lung capacity. The Forced Vital Capacity (FVC) of the patient is an interesting measure to investigate this disease to have the prognosis of the disease. This paper proposes a deep learning-based FVC-Net architecture to predict the progression of the disease from the patient's computed tomography (CT) scan and the patient's metadata. The input to the model combines the image score generated based on the degree of honeycombing for a patient identified based on segmented lung images and the metadata. This input is then fed to a 3-layer net to obtain the final output. The performance of the proposed FVC-Net model is compared with various contemporary state-of-the-art deep learning-based models, which are available on a cohort from the pulmonary fibrosis progression dataset. The model showcased significant improvement in the performance over other models for modified Laplace Log-Likelihood (-6.64). Finally, the paper concludes with some prospects to be explored in the proposed study.

Gut Microbiome and Organ Fibrosis

Fibrosis is a pathological process associated with most chronic inflammatory diseases. It is defined by an excessive deposition of extracellular matrix proteins and can affect nearly every tissue and organ system in the body. Fibroproliferative diseases, such as intestinal fibrosis, liver cirrhosis, progressive kidney disease and cardiovascular disease, often lead to severe organ damage and are a leading cause of morbidity and mortality worldwide, for which there are currently no effective therapies available. In the past decade, a growing body of evidence has highlighted the gut microbiome as a major player in the regulation of the innate and adaptive immune system, with severe implications in the pathogenesis of multiple immune-mediated disorders. Gut microbiota dysbiosis has been associated with the development and progression of fibrotic processes in various organs and is predicted to be a potential therapeutic target for fibrosis management. In this review we summarize the state of the art concerning the crosstalk between intestinal microbiota and organ fibrosis, address the relevance of diet in different fibrotic diseases and discuss gut microbiome-targeted therapeutic approaches that are current being explored.

[Chest radiography findings in diffuse parenchymal lung diseases]

CLINICAL ISSUE

Diffuse parenchymal lung diseases include a heterogeneous group of diseases of the lung parenchyma, the alveolar spaces, the vessels and the airways, which can be triggered by various pathomechanisms, such as inflammation and fibrotic changes. Since the therapeutic approaches and prognoses differ significantly between the diseases, the correct diagnosis is of fundamental importance. In routine clinical practice, next to the patients' history, the clinical presentation, the laboratory findings and the bronchoscopy, imaging plays a central role in establishing a diagnosis.

PRACTICAL RECOMMENDATIONS

The diagnosis of diffuse parenchymal lung diseases is an enormous challenge for clinicians, radiologists as well as pathologists and should therefore preferably be carried out in a multidisciplinary setting. Since patients often present with unspecific, respiratory symptoms, chest radiographs are the first imaging method used. Many patterns of diffuse parenchymal lung diseases (e.g., ground-glass opacities and consolidations), their distribution (e.g., cranial-caudal) and the presence of additional findings (e.g., mediastinal lymphadenopathy) are often already detectable on chest X‑rays. However, the imaging reference standard and thus, an integral part of the assessment of diffuse parenchymal lung disease, is the chest HR-CT. In some cases, the pattern of the HR-CT is pathognomonic, in others it is unspecific for a disease, so that further diagnostic steps are necessary.

Pain is a common problem in patients with ILD

BACKGROUND

As it is less known about the prevalence and characteristics of pain in the patients with interstitial lung disease (ILD), this paper aims at determining the characteristics of the pain in the patients with ILD.

METHODS

Subjects with ILD and health controls with the matched ages and genders completed Short Form McGill Pain Questionnaire (SF-MPQ) and part of the Brief Pain Inventory (BPI) Short Form to elicit the characteristics of the pain. The patients with ILD were also assessed through Pulmonary Function Test, Six Minutes Walking Test (6MWT), modified Medical Research Council Dyspnea Scale (mMRC) for state of the illness and measured health-related quality of life (HRQoL) by Short Form-36 (SF-36) and psychological associations by Hospital Anxiety and Depression Scale (HADS).

RESULTS

A total of 63 subjects with ILD and 63 healthy controls (HC) were recruited in our study. The prevalence of the pain was 61.9% in ILD versus 25.3% in HC (P = 0.005) and the median score of the pain rank index (PRI) in ILD was higher than that in HC (P = 0.014). Chest (46.1%) accounted for the highest of overall pain locations in subjects with ILD. Associated clinical factors for pain intensity in the patients with ILD included exposure history of risk factors of ILD, with a longer distance of 6MWD (≥ 250 m), and a higher mMRC score (2-4). The patients with ILD and pain are more likely to suffer impaired HRQoL (P = 0.0014) and psychological problems (P = 0.0017, P = 0.044).

CONCLUSION

The pain is common in those with ILD and the pain intensity is associated with exposure history, 6MWD, and mMRC score. The patients with ILD and pain were possibly to suffer depression, anxiety, and impaired HRQoL.