Addressing Reduced Laboratory-Based Pulmonary Function Testing During a Pandemic

Lung volume measurement using chest CT in COVID-19 patients: a cohort study in Japan

OBJECTIVE

This study aimed to investigate the utility of CT quantification of lung volume for predicting critical outcomes in COVID-19 patients.

METHODS

This retrospective cohort study included 1200 hospitalised patients with COVID-19 from 4 hospitals. Lung fields were extracted using artificial intelligence-based segmentation, and the percentage of the predicted (%pred) total lung volume (TLC (%pred)) was calculated. The incidence of critical outcomes and posthospitalisation complications was compared between patients with low and high CT lung volumes classified based on the median percentage of predicted TLCct (n=600 for each). Prognostic factors for residual lung volume loss were investigated in 208 patients with COVID-19 via a follow-up CT after 3 months.

RESULTS

The incidence of critical outcomes was higher in the low TLCct (%pred) group than in the high TLCct (%pred) group (14.2% vs 3.3%, p<0.0001). Multivariable analysis of previously reported factors (age, sex, body mass index and comorbidities) demonstrated that CT-derived lung volume was significantly associated with critical outcomes. The low TLCct (%pred) group exhibited a higher incidence of bacterial infection, heart failure, thromboembolism, liver dysfunction and renal dysfunction than the high TLCct (%pred) group. TLCct (%pred) at 3 months was similarly divided into two groups at the median (71.8%). Among patients with follow-up CT scans, lung volumes showed a recovery trend from the time of admission to 3 months but remained lower in critical cases at 3 months.

CONCLUSION

Lower CT lung volume was associated with critical outcomes, posthospitalisation complications and slower improvement of clinical conditions in COVID-19 patients.

[National Survey on the Activity of Lung Function Laboratories. Effects During the SARS-COV-2 Pandemic]

Introduction

Following the SARS-CoV-2 pandemic in March 2020, pulmonary function testing (PFT) laboratories underwent a transformation, with a reduction in the number of tests or closure in some cases. The aim of this work was to know the activity of PFT in Spain and the modification of this activity due to the pandemic.

Material and methods

A protocolised survey was carried out to members of the PFT laboratories through the Spanish Society of Pneumology and Thoracic Surgery (SEPAR).

Results

Thirty-nine hospitals in Spain responded. The pulmonary function tests most frequently performed in the PFT laboratories were forced spirometry with bronchodilator test (100%), body plethysmography (97.4%), CO transfer capacity (97.4%), respiratory muscle strength measured in the mouth (97.4%), 6-minute walking test (94.7%), measurement of exhaled fraction of nitric oxide (92.3%) and incremental exercise test (71.8%).The pandemic led to a significant decrease in the number of tests (35.4%) during 2020 with subsequent recovery in 2021, without reaching pre-pandemic values.The most important changes were increased examination times, working with personal protective equipment and ventilation of the rooms. The performance of the nasopharyngeal swab for SARS-CoV2 testing prior to the tests was not homogeneous in the PFT laboratories.

Conclusions

Most hospitals are sufficiently equipped to perform the most common pulmonary function tests. The pandemic resulted in a loss of activity in all hospitals.

What is the Best Way to Diagnose Possible Asthma Patients with Negative Bronchodilator Reversibility Tests?

Objective

The best method and strategy for the diagnosis of asthma remains unclear, especially in patients with negative bronchodilator reversibility test (BDRT). In our study, we aimed to investigate the diagnostic yield of peak expiratory flow (PEF) variability for this patient group.

Methods

A total of 50 patients with suspected asthma, all with negative BDR test, were included in the study. Demographic information and symptoms were recorded and PEF variability was monitored for 2 weeks. Metacolinbronchial provocation test (mBPT) was performed. Asthma was diagnosed when PEF variability ≥20% and/or positive mBPT was observed.

Results

30 of 50 patients were diagnosed with asthma. After 1 month, 17 patients were evaluated for treatment outcomes. The sensitivity and specificity of PEF variability for different cut-off values (≥20%, >15% and >10%) were 61.5-83.3, 88.5-62.5 and 100-16.7, respectively. One of the most important findings of our study was the absence of variable airflow limitation or airway hyper reactivity in 39% patients with a previous diagnosis of asthma. Multiple logistic regression analysis revealed that a low baseline FEF25-75 value was an independent predictive factor for the diagnosis of asthma (p= 0.05).

Conclusion

The most efficient diagnostic test for asthma is still unclear due to many factors. Our study is one of the few studies on this subject. Although current diagnostic recommendations generally recommend a PEF variability of 10% for the diagnosis of asthma, this threshold may not be appropriate for the BDR-negative patient group. Our results suggest using a threshold value of <15% for PEF variability when excluding asthma and ≥20% when confirming the diagnosis of asthma in patients with clinically suspected but unproven reversibility. Furthermore, FEF25-75 is considered to be an important diagnostic parameter that should be included in diagnostic recommendations for asthma.

Factors disrupting the continuity of care for patients with chronic disease during the pandemics: A systematic review

Background and Aims

Continuous routine care is necessary to prevent long-term complications of chronic diseases and improve patients' health conditions. This review study was conducted to determine the factors disrupting continuity of care for patients with chronic diseases during the pandemic.

Methods

All original articles published on factors disrupting continuity of care for patients with chronic disease during a pandemic between December 2019 and June 28, 2023, in PubMed, Web of Science, Scopus, and ProQuest databases were searched. Selection of articles, data extraction, and qualitative evaluation of articles (through STROBE and COREQ checklist) were done by two researchers separately. Data graphing form was used to extract the data of each study and then the data were classified by thematic analysis method.

Results

Out of 1708 articles reviewed from the databases, 22 were included. The factors disrupting the continuity of care for patients with chronic diseases during the epidemics were classified into two main categories: patient-side factors and health system-side factors. Patient-side factors including psychological, individual and social, disease-related, and health system-side factors including provider access, health system institutional, and infrastructural and financial problems were among the subcategories disrupting the continuity of care for patients with chronic diseases during the pandemic. Based on the studies, psychological factors and access to the provider were among the most frequent factors affecting the continuity of care for patients with chronic diseases in the pandemic.

Conclusion

Considering the factors disrupting the continuity of care and applying appropriate interventions based on them, can guarantee the continuity of providing services to chronic patients in health crises.

Spirometry services in England post-pandemic and the potential role of AI support software: a qualitative study of challenges and opportunities

BACKGROUND

Spirometry services to diagnose and monitor lung disease in primary care were identified as a priority in the NHS Long Term Plan, and are restarting post-COVID-19 pandemic in England; however, evidence regarding best practice is limited.

AIM

To explore perspectives on spirometry provision in primary care, and the potential for artificial intelligence (AI) decision support software to aid quality and interpretation.

DESIGN AND SETTING

Semi-structured interviews with stakeholders in spirometry services across England.

METHOD

Participants were recruited by snowball sampling. Interviews explored the pre- pandemic delivery of spirometry, restarting of services, and perceptions of the role of AI. Transcripts were analysed thematically.

RESULTS

In total, 28 participants (mean years' clinical experience = 21.6 [standard deviation 9.4, range 3-40]) were interviewed between April and June 2022. Participants included clinicians (n = 25) and commissioners (n = 3); eight held regional and/or national respiratory network advisory roles. Four themes were identified: 1) historical challenges in provision of spirometry services; 2) inequity in post- pandemic spirometry provision and challenges to restarting spirometry in primary care; 3) future delivery closer to patients' homes by appropriately trained staff; and 4) the potential for AI to have supportive roles in spirometry.

CONCLUSION

Stakeholders highlighted historic challenges and the damaging effects of the pandemic contributing to inequity in provision of spirometry, which must be addressed. Overall, stakeholders were positive about the potential of AI to support clinicians in quality assessment and interpretation of spirometry. However, it was evident that validation of the software must be sufficiently robust for clinicians and healthcare commissioners to have trust in the process.

The incidence and factors of inappropriate rapid antigen test usage for group A streptococcus

INTRODUCTION

Although rapid antigen tests (RADTs) for group A streptococcus (GAS) can help diagnose group A streptococcal pharyngitis, little is known about the inappropriate use of these RADTs.

METHODS

This retrospective observational study compared the appropriate vs. inappropriate use of RADTs in patients who had a RADT between January 2019 and August 2022. RADTs for patients with a low Centor score of 0-1 point were deemed inappropriate.

RESULTS

Of the 1015 patients, 380 (37.4%) had inappropriate RADTs. Patients with asthma were associated with an increased risk of inappropriate testing. In contrast, during the coronavirus 2019 pandemic, outpatients and residents were associated with a reduced risk of inappropriate testing. Consequent to the inappropriate use of RADTs, 162 (16.0%) patients received potentially inappropriate antibiotics.

CONCLUSIONS

Our results suggest that diagnostic stewardship for pharyngitis, including education for healthcare workers, is needed to reduce inappropriate test ordering and prevent unnecessary care.

Clinical Guidance on the Monitoring and Management of Trastuzumab Deruxtecan (T-DXd)-Related Adverse Events: Insights from an Asia-Pacific Multidisciplinary Panel

Trastuzumab deruxtecan (T-DXd)-an antibody-drug conjugate targeting the human epidermal growth factor receptor 2 (HER2)-improved outcomes of patients with HER2-positive and HER2-low metastatic breast cancer. Guidance on monitoring and managing T-DXd-related adverse events (AEs) is an emerging unmet need as translating clinical trial experience into real-world practice may be difficult due to practical and cultural considerations and differences in health care infrastructure. Thus, 13 experts including oncologists, pulmonologists and a radiologist from the Asia-Pacific region gathered to provide recommendations for T-DXd-related AE monitoring and management by using the latest evidence from the DESTINY-Breast trials, our own clinical trial experience and loco-regional health care considerations. While subgroup analysis of Asian (excluding Japanese) versus overall population in the DESTINY-Breast03 uncovered no major differences in the AE profile, we concluded that proactive monitoring and management are essential in maximising the benefits with T-DXd. As interstitial lung disease (ILD)/pneumonitis is a serious AE, patients should undergo regular computed tomography scans, but the frequency may have to account for the median time of ILD/pneumonitis onset and access. Trastuzumab deruxtecan appears to be a highly emetic regimen, and prophylaxis with serotonin receptor antagonists and dexamethasone (with or without neurokinin-1 receptor antagonist) should be considered. Health care professionals should be vigilant for treatable causes of fatigue, and patients should be encouraged to use support groups and practice low-intensity exercises. To increase treatment acceptance, patients should be made aware of alopecia risk prior to starting T-DXd. Detailed monitoring and management recommendations for T-DXd-related AEs are discussed further.

Exploring the Perspectives and Experiences of Older Adults With Asthma and Chronic Obstructive Pulmonary Disease Toward Mobile Health: Qualitative Study

BACKGROUND

The use of mobile health (mHealth) in asthma and chronic obstructive pulmonary disease (COPD) is growing, and as the population ages, a greater number of older adults stand to benefit from mHealth-enhanced airway disease care. Though older adults are a heterogeneous population of health technology users, older age represents a potential barrier to health technology adoption, and there is currently a lack of knowledge on how older age influences mHealth use in asthma and COPD.

OBJECTIVE

In this qualitative study, we sought to explore the experiences and perspectives of adults who were aged 65 years and older with asthma and COPD toward mHealth use.

METHODS

Semistructured individual interviews were conducted with adults who were aged 65 years and older with asthma or COPD and owned a smartphone. Applying phenomenological methodology, we analyzed interview transcripts in order to develop themes and propose an essential experience of mHealth use among older adults with airway disease. We then summarized our qualitative findings and proposed strategies to leverage our results in order to guide future research and implementation efforts targeting older adults' use of airway mHealth.

RESULTS

Twenty participants (mean age 79.8, SD 4.4 years) were interviewed. Participants described a central tension between (1) the perception that mHealth could help maintain independence throughout aging and (2) an apprehension toward the ways in which mHealth could negatively affect established health care experiences. Several elements of these 2 themes are absent from previous research focusing on younger adults with asthma and COPD. The individual elements of these 2 themes informed potential strategies to optimize future older adults' use of asthma and COPD mHealth tools.

CONCLUSIONS

Focusing on the perspectives and experiences of older adults with asthma and COPD in their use of mHealth identified novel understandings of health technology use in this important demographic in need of greater care. These lessons were translated into potential strategies that will need to be objectively evaluated in future airway mHealth research, development, and implementation efforts.

Feasibility and acceptability of home monitoring with portable spirometry in young adults with asthma

OBJECTIVE

Self-monitoring asthma control is a key component of asthma management. Few studies have reported usability and acceptability of portable spirometry among young adults with asthma. Portable spirometry offers a practical solution to monitoring airway narrowing at home. The purpose of this paper was to determine if self-administered spirometry is feasible and acceptable in young adults with asthma and whether regular monitoring resulted in improved airway function as measured by forced expiratory volume in one second (FEV1).

METHODS

Sixty-seven young adults (18-26 years) with self-reported asthma participated in a clinical trial during wildfire season which measured FEV1 as an outcome measure. Data was collected at baseline, week 4, and week 8 using a portable spirometer linked to a smartphone application. A subset of intervention participants completed spirometry twice daily. Acceptability of self-administered spirometry was evaluated after the trial among participants that volunteered to submit a survey and be interviewed.

RESULTS

At baseline, all 67 participants (100.0%) completed their scheduled spirometry readings which declined to 94.0% (n = 63) at week 4 and 86.6% (n = 58) at week 8. Daily readings were completed 83.2% of the time in the mornings and 84.3% of the time in the evenings. Mean FEV1 values were lower than predicted values, but above the lower limit of expected. FEV1 remained steady throughout the study period. Over two-thirds of participants used the notes feature in the application and described symptoms, asthma triggers, mitigating actions and test-taking issues.

CONCLUSIONS

Young adults in our sample were highly compliant with regular, self-administered spirometry.

Digital health in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) can be prevented and treated through effective care, reducing exacerbations and hospitalizations. Early identification of individuals at high risk of COPD exacerbation is an opportunity for preventive measures. However, many patients struggle to follow their treatment plans because of a lack of knowledge about the disease, limited access to resources, and insufficient clinical support. The growth of digital health-which encompasses advancements in health information technology, artificial intelligence, telehealth, the Internet of Things, mobile health, wearable technology, and digital therapeutics-offers opportunities for improving the early diagnosis and management of COPD. This study reviewed the field of digital health in terms of COPD. The findings showed that despite significant advances in digital health, there are still obstacles impeding its effectiveness. Finally, we highlighted some of the major challenges and possibilities for developing and integrating digital health in COPD management.

Impact of accumulative smoking exposure and chronic obstructive pulmonary disease on COVID-19 outcomes: report based on findings from the Japan COVID-19 task force

OBJECTIVES

Smoking and chronic obstructive pulmonary disease (COPD) are risk factors for severe COVID-19. However, limited literature exists on the effect of COPD and smoking on COVID-19 outcomes. This study examined the impact of smoking exposure in pack-years (PY) and COPD on COVID-19 outcomes among smokers in Japan.

METHODS

The study included 1266 smokers enrolled by the Japan COVID-19 task force between February 2020 and December 2021. PY and COPD status was self-reported by patients. Patients were classified into the non-COPD (n = 1151) and COPD (n = 115) groups; the non-COPD group was further classified into <10 PY (n = 293), 10-30 PY (n = 497), and >30 PY (n = 361). The study outcome was the need for invasive mechanical ventilation (IMV).

RESULTS

The incidence of IMV increased with increasing PY and was highest in the COPD group (<10 PY = 7.8%, 10-30 PY = 12.3%, >30 PY = 15.2%, COPD = 26.1%; P <0.001). A significant association was found for IMV requirement in the >30 PY and COPD groups through univariate (odds ratio [OR]: >30 PY = 2.11, COPD = 4.14) and multivariate (OR: >30 PY = 2.38; COPD = 7.94) analyses. Increasing PY number was also associated with increased IMV requirement in patients aged <65 years.

CONCLUSION

Cumulative smoking exposure was positively associated with COVID-19 outcomes in smokers.

Integrating User Preferences for Asthma Tools and Clinical Guidelines Into Primary Care Electronic Medical Records: Mixed Methods Study

BACKGROUND

Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices.

OBJECTIVE

The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance.

METHODS

In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis.

RESULTS

Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care.

CONCLUSIONS

Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

Novel diagnostic techniques in interstitial lung disease

Research into novel diagnostic techniques and targeted therapeutics in interstitial lung disease (ILD) is moving the field toward increased precision and improved patient outcomes. An array of molecular techniques, machine learning approaches and other innovative methods including electronic nose technology and endobronchial optical coherence tomography are promising tools with potential to increase diagnostic accuracy. This review provides a comprehensive overview of the current evidence regarding evolving diagnostic methods in ILD and to consider their future role in routine clinical care.

Comparison of Lung, Lobe, and Airway Volumes between Supine and Upright Computed Tomography and Their Correlation with Pulmonary Function Test in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Correlations between upright CT and pulmonary function test (PFT) measurements, and differences in lung/lobe/airway volumes between supine and standing positions in patients with chronic obstructive pulmonary disease (COPD) remain unknown.

OBJECTIVES

The study aimed to evaluate correlations between lung/airway volumes on both supine and upright CT and PFT measurements in patients with COPD, and compare CT-based inspiratory/expiratory lung/lobe/airway volumes between the two positions.

METHODS

Forty-eight patients with COPD underwent both conventional supine and upright CT in a randomized order during inspiration and expiration breath-holds, and PFTs within 2 h. We measured the lung/lobe/airway volumes on both CT.

RESULTS

The correlation coefficients between total lung volumes on inspiratory CT in supine/standing position and PFT total lung capacity and vital capacity were 0.887/0.920 and 0.711/0.781, respectively; between total lung volumes on expiratory CT in supine/standing position and PFT functional residual capacity and residual volume, 0.676/0.744 and 0.713/0.739, respectively; and between airway volume on inspiratory CT in supine/standing position and PFT forced expiratory volume in 1 s, 0.471/0.524, respectively. Inspiratory/expiratory bilateral upper and right lower lobe, bilateral lung, and airway volumes were significantly higher in the standing than supine position (3.6-21.2% increases, all p < 0.05); however, inspiratory/expiratory right middle lobe volumes were significantly lower in the standing position (4.6%/15.9% decreases, respectively, both p < 0.001).

CONCLUSIONS

Upright CT-based volumes were more correlated with PFT measurements than supine CT-based volumes in patients with COPD. Unlike other lobes and airway, inspiratory/expiratory right middle lobe volumes were significantly lower in the standing than supine position.

Differences in lung and lobe volumes between supine and upright computed tomography in patients with idiopathic lung fibrosis

No clinical study has compared lung or lobe volumes on computed tomography (CT) between the supine and standing positions in patients with idiopathic lung fibrosis (IPF). This study aimed to compare lung and lobe volumes between the supine and standing positions and evaluate the correlations between the supine/standing lung volumes on CT and pulmonary function in patients with IPF. Twenty-three patients with IPF underwent a pulmonary function test and both low-dose conventional (supine position) and upright CT (standing position) during inspiration breath-holds. The volumes of the total lungs and lobes were larger in the standing than in the supine position in patients with IPF (all p < 0.05). Spearman's correlation coefficients between total lung volumes on chest CT in supine/standing positions and vital capacity (VC) or forced VC (FVC) were 0.61/0.79 or 0.64/0.80, respectively. CT-based volumes on upright CT were better correlated with VC and FVC than those on supine CT. Lung and lobe volumes in the standing position may be useful biomarkers to assess disease severity or therapeutic effect in patients with IPF.

Airwave oscillometry and spirometry in children with asthma or wheeze

OBJECTIVE

Lung function testing is used in diagnosing asthma and assessing asthma control. Spirometry is most commonly used, but younger children can find performing this test challenging. Non-volitional tests such as airwave oscillometry (AOS) may be helpful in that population. We compared the success of spirometry and AOS in assessing bronchodilator responsiveness in children.

METHODS

AOS was conducted alongside routine lung function testing. Resistance at 5 Hz (R5), the difference between the resistance at 5 and 20 Hz (R5-20) and the area under the reactance curve (AX) were assessed. Patients between 5 and 16 years old attending clinic with wheeze or asthma were assessed. Patients performed AOS, followed by spirometry and were then given 400 µg salbutamol; the tests were repeated 15 minutes later.

RESULTS

Lung function testing was performed in 47 children of whom 46 (98%) and 32 (68%) performed acceptable baseline oscillometry and spirometry, respectively (p < 0.001). Children unable to perform acceptable spirometry were younger (7.35, range: 5.4-10.3 years) than those who could (10.4, range: 5.5-16.9 years), p < 0.001. The baseline z-scores of AOS R5 correlated with FEV₁ (r = 0.499, p = 0.004), FEF₇₅ (r = 0.617, p < 0.001), and FEV₁/FVC (r = 0.618, p < 0.001). There was a positive bronchodilator response assessed by spirometry (change in FEV₁ ≥ 12%) in eight children which corresponded to a change in R5 of 36% (range: 30%-50%) and a change in X5 of 39% (range: 15%-54%).

CONCLUSIONS

Oscillometry is a useful adjunct to spirometry in assessing young asthmatic children's lung function. The degree of airway obstruction, however, might affect the comparability of the results of the two techniques.

Transcutaneous electrical nerve stimulation over acupoint for chronic obstructive pulmonary disease: A systematic review and meta-analysis

Background

Transcutaneous electrical nerve stimulation over an acupoint (acu-TENS), a new technique applied in pulmonary rehabilitation programs, has been gradually used in the management of chronic obstructive pulmonary disease (COPD). However, the effects of acu-TENS have not been fully evaluated. Therefore, this review was conducted to assess the effects of acu-TENS on COPD.

Methods

A total of seven electronic databases were searched from their inception to September 2021 for randomized controlled trials of acu-TENS for COPD. Two investigators independently performed data extraction and methodological quality assessment. Heterogeneity was examined by Cochrane χ2 and I 2 tests. The source of heterogeneity was investigated by subgroup analysis or sensitivity analysis.

Results

In our review, ten studies between 2008 and 2021 were included. The aggregated results indicated that acu-TENS showed positive effects in forced expiratory volume in 1 s (FEV1) [MD = 0.13 L, 95% CI (0.11-0.16), P < 0.00001], FEV1% predicted [MD = 5.92%, 95% CI (3.43-8.41), P < 0.00001], 6-min walk distance (6MWD) [MD = 14.68m, 95% CI (6.92-22.44), P = 0.0002], dyspnea visual analog scale (DVAS) [MD = -7.58, 95%CI (-14.33 to -0.84), P = 0.03], modified Borg scale (MBS) [MD = -0.46, 95% CI (-0.86 to -0.06), P = 0.03], and COPD assessment test (CAT) [MD = -4.25, 95% CI (-5.24 to -3.27), P < 0.00001]. Although six studies reported adverse effects, only one patient had shoulder pain after acu-TENS.

Conclusion

Acu-TENS seems to be effective in improving pulmonary function and health status in patients with COPD, with little effect on exercise capacity and dyspnea. However, this result should be interpreted with caution, and high-quality RCTs were needed for further verification.

mHealth and telemedicine utility in the monitoring of allergic diseases

This literature review discusses the use of mHealth technologies and telemedicine for monitoring various allergic diseases both in everyday life and in the context of COVID-19. Telemedicine, whose popularity, and demand has skyrocketed during the pandemic, rely on mHealth technologies, video calls and websites as a resource-saving and safe way of consulting patients. The incorporation of new mHealth technologies into telemedicine practice may not only be relevant in the context of pandemic restrictions but can also be applied in everyday medical practice as an effective method of patient counseling. The mobile healthcare applications include a wide range of mobile apps for patients' education, monitoring, and disease management. However, applications for the people with food allergies lack relevant information about allergies and, like most other applications, are developed without the contribution of healthcare specialists. During the COVID-19 pandemic, low-risk food-allergic patients were able to rely on telemedicine services where they could get the help, they needed without increasing risk of contracting COVID-19 while saving time. Meanwhile, some applications for allergic rhinitis and asthma patients are showing practical benefits in clinical trials by allowing an efficient assessment of treatment regimens and efficacy. The use of digital symptom diaries further facilitates the implementation of real-life studies. However, for respiratory allergic diseases, the often insufficient quality of pollen prediction needs to be taken into account. Even though studies have shown that asthma is better controlled with mHealth technologies, the quality of mobile apps for asthma patients varies widely, as many products provide information that has not been scientifically proven. Inhaler sensors - have been shown to improve the course of asthma and its monitoring, while push notifications prompting people to take their medication double the likelihood of treatment adherence. Teledermatology has a high level of patient satisfaction - as it is perceived as a more time-saving method of consultation. However, the diagnostic accuracy of contact consultations remains higher. mHealth technologies provide a patient's health data from his/her daily life, which enables insights into behavioral patterns. This closer look at the daily routine can have a significant impact on developing individualized treatment and care guidelines.

The Role of Access and Cost-Effectiveness in Managing Asthma: A Systematic Review

Background

Inconsistent and unequal access to medical care is an issue that predates the COVID19 pandemic, which only worsened the problem. Limited access to care from asthma specialists and other specialists treating comorbid diseases may adversely affect asthma.

Objective

The purpose of this review is to identify health disparities associated with access to care for asthma, and cost-effectiveness of therapies and interventions addressing this health disparity.

Methods

A narrative systematic review was undertaken using MeSH searches of English language articles published in CINAHL, Scopus, or PubMed.

Results

A total of 725 articles were identified. Barriers recognized from the literature included access to diagnostic spirometry, access to specialists, medication formulary restrictions, and issues leading to medical nonadherence. Telemedicine, school-based health care interventions, digital applications, and non–office-based digital spirometry could be used to address these gaps in access to asthma care while potentially being cost-effective.

Conclusion

With the widespread adoption of telemedicine because of the pandemic, and adoption of other mobile services, we now have potential tools that can increase access to asthma care, which can help address this health care inequity. Evidence is limited, but favorable, that some of these tools may be cost-effective.

Telehealth in chronic obstructive pulmonary disease: before, during, and after the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

Many healthcare systems rapidly implemented telehealth as a substitute for in-person care during the coronavirus disease 2019 (COVID-19) pandemic. The purpose of this review is to describe the evidence base supporting the use of telehealth for chronic obstructive pulmonary disease (COPD) prior to the COVID-19 pandemic, discuss the barriers to implementing telehealth during the pandemic, and share our opinion about the future of telehealth in COPD.

RECENT FINDINGS

The evidence from randomized clinical trials in COPD completed prior to the COVID-19 pandemic indicate that the effectiveness of telehealth interventions compared to in-person usual care on clinical outcomes is inconclusive. Recent experience during the COVID-19 pandemic indicates that telehealth may increase access to healthcare and satisfaction with care when delivered in addition to usual in-person care. While some reimbursement-related barriers to telehealth have been alleviated during the COVID-19 pandemic, several patient, provider, and health-system barriers to implementation remain.

SUMMARY

There is a need to further evaluate the delivery of telehealth services as an adjunct to traditional in-person models of COPD care. Standardization and reporting of core clinical, satisfaction, accessibility, and quality of care outcomes are needed to promote cross-study learning and more rapid translation of research evidence into practice.

Prediction of Postoperative Respiratory Complications after Lobectomy in Lung Cancer Patients with COPD by Quantitative Image Analysis: A Historical Cohort Study

PURPOSE

We examined whether preoperative assessment of percentage of low attenuation area (LAA%) on the non-resected side can predict postoperative respiratory complications (PRC) after lobectomy.

MATERIALS AND METHODS

We conducted a historical cohort study of 217 smokers (175 males and 42 females) who underwent lobectomy for primary lung cancer at our hospital between January 2014 and March 2021. First, the relationship between LAA% and respiratory function parameters (RFPs) calculated for both the bilateral and non-resected sides was used to estimate the most effective patient group. Next, multivariate analyses of the relationship between LAA% of the non-resected side and PRC were performed using logistic regression analysis after adjusting for basic patient attributes and respiratory function.

RESULTS

A correlation was found between LAA% and RFP in smoking males. Multivariate analysis showed a strong relationship between model 3, adjusted for basic patient attributes and lung function factors, and PRC (odds ratio, 2.43; 95% confidence interval, 1.05-5.63).

CONCLUSION

LAA% of the non-resected side suggested that it may be able to predict the occurrence of PRC after lung cancer lobectomy.

Exploring the 175-year history of spirometry and the vital lessons it can teach us today

175 years have elapsed since John Hutchinson introduced the world to his version of an apparatus that had been in development for nearly two centuries, the spirometer. Though he was not the first to build a device that sought to measure breathing and quantify the impact of disease and occupation on lung function, Hutchison coined the terms spirometer and vital capacity that are still in use today, securing his place in medical history. As Hutchinson envisioned, spirometry would become crucial to our growing knowledge of respiratory pathophysiology, from Tiffeneau and Pinelli's work on forced expiratory volumes, to Fry and Hyatt's description of the flow-volume curve. In the 20th century, standardization of spirometry further broadened its reach and prognostic potential. Today, spirometry is recognized as essential to respiratory disease diagnosis, management and research. However, controversy exists in some of its applications, uptake in primary care remains sub-optimal and there are concerns related to the way in which race is factored into interpretation. Moving forward, these failings must be addressed, and innovations like Internet-enabled portable spirometers may present novel opportunities. We must also consider the physiologic and practical limitations inherent to spirometry and further investigate complementary technologies such as respiratory oscillometry and other emerging technologies that assess lung function. Through an exploration of the storied history of spirometry, we can better contextualize its current landscape and appreciate the trends that have repeatedly arisen over time. This may help to improve our current use of spirometry and may allow us to anticipate the obstacles confronting emerging pulmonary function technologies.

Single-Breath Counting Test Predicts Non-Invasive Respiratory Support Requirements in Patients with COVID-19 Pneumonia

The use of non-invasive respiratory strategies (NIRS) is crucial to improve oxygenation in COVID-19 patients with hypoxemia refractory to conventional oxygen therapy. However, the absence of respiratory symptoms may delay the start of NIRS. The aim of this study was to determine whether a simple bedside test such as single-breath counting test (SBCT) can predict the need for NIRS in the 24 h following the access to Emergency Department (ED). We performed a prospective observational study on 120 patients with COVID-19 pneumonia. ROC curves were used to analyze factors which might predict NIRS requirement. We found that 36% of patients had normal respiratory rate and did not experience dyspnea at rest. 65% of study population required NIRS in the 24 h following the access to ED. NIRS-requiring group presented lower PaO₂/FiO₂ (235.09 vs. 299.02), SpO₂/FiO₂ ratio (357.83 vs. 431.07), PaCO₂ (35.12 vs. 40.08), and SBCT (24.46 vs. 30.36) and showed higher incidence of dyspnea at rest (57.7% vs. 28.6%). Furthermore, SBCT predicted NIRS requirement even in the subgroup of patients without respiratory symptoms (AUC = 0.882, cut-off = 30). SBCT might be a valuable tool for bedside assessment of respiratory function in patients with COVID-19 pneumonia and might be considered as an early clinical sign of impending respiratory deterioration.

Small airway dysfunction on impulse oscillometry and pathological signs on lung ultrasound are frequent in post-COVID-19 patients with persistent respiratory symptoms

Background

Thousands of people worldwide are suffering the consequences of coronavirus disease-2019 (COVID-19), and impulse oscillometry (IOS) and lung ultrasound (LUS) might be important tools for the follow-up of this population. Our objective was to prospectively evaluate abnormalities detected using these two methods in a cohort of COVID-19 survivors with respiratory symptoms.

Methods

In this follow-up study, 59 patients underwent clinical evaluations, spirometry, IOS and LUS in the 2nd (M1) and 5th (M2) months after diagnostic confirmation of COVID-19 by real-time reverse transcriptase–polymerase chain reaction. Aeration scores were obtained from the LUS exams based on the following findings: B-lines >2, coalescent B-lines, and subpleural consolidations.

Results

Fifty-nine (100%) participants had cough and/or dyspnea at M1, which decreased to 38 (64.4%) at M2 (p = 0.0001). Spirometry was abnormal in 26 (44.1%) and 20 (33.9%) participants at M1 and M2, respectively, although without statistical significance (p = 0.10). Normal examination, restrictive patterns, and obstructive patterns were observed in 33 (55.9%), 18 (30.5%), and 8 (13.6%) participants, respectively, at M1 and in 39 (66.1%), 13 (22%), and 7 (11.9%) participants at M2 (p = 0.14). Regarding IOS, considering changes in resistive and reactive parameters, abnormal exams were detected in 52 (88.1%) and 42 (71.2%) participants at M1 and M2, respectively (p = 0.002). Heterogeneity of resistance between 4 and 20 Hz >20% was observed in 38 (64.4%) and 33 (55.9%) participants at M1 and M2, respectively (p = 0.30). Abnormal LUS was observed in 46 (78%) and 36 (61%) participants at M1 and M2, respectively (p = 0.002), with a reduction in aeration scores between M1 and M2 [5 (2–8) vs. 3 (0–6) points, p<0.0001].

Conclusions

IOS and LUS abnormalities are frequent in the first 5 months post-COVID-19 infection; however, when prospectively evaluated, significant improvement is evident in the parameters measured by these two methods.

Clinical Utility of the Electrocardiographic P-Wave Axis in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

The vertical P-wave axis on electrocardiography (ECG) is a useful criterion for screening patients with chronic obstructive pulmonary disease (COPD). This study aimed to investigate the clinical characteristics of patients with COPD with a vertical P-wave axis as they have not yet been elucidated.

METHODS

Keio University and its affiliated hospitals conducted an observational COPD cohort study over 3 years. We analyzed 201 patients using ECG and chest computed tomography.

RESULTS

The severity of airflow limitation was higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. Patients with a P-wave axis >75° exhibited significantly higher total COPD assessment test scores and increased St. George's Respiratory Questionnaire total, activity, and impact scores than those with a P-wave axis ≤75°. The incidence of exacerbations over 1 and 3 years was significantly higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. The optimal cutoff for the P-wave axis for a percentage of the predicted forced expiratory volume in 1 s <50% and future exacerbations over 3 years was 70° (the areas under the curve [AUC]: 0.788; sensitivity: 65.3%; specificity: 78.3%) and 79° (AUC: 0.642; sensitivity: 36.7%; specificity: 92.6%). The ratio of the low attenuation area was also significantly higher in patients with a P-wave axis >75° than in those with a P-wave axis ≤75°. However, the ratio of the airway wall area did not differ between the 2 groups.

CONCLUSIONS

Patients with COPD with a vertical P-wave axis exhibited severe airflow limitation and emphysema, a worse health status, and more frequent exacerbation than patients without a vertical P-wave. Detection of the vertical P-wave axis by ECG is beneficial for the management of patients with COPD.

Impulse Oscillometry Findings and Their Associations With Lung Ultrasound Signs in COVID-19 Survivors

BACKGROUND

Because impulse oscillometry (IOS) can detect changes in the small airways and is safer to perform during the COVID-19 pandemic than other pulmonary function tests, it may have value in investigating pulmonary sequelae in COVID-19 survivors. This study evaluated the performance of IOS in detecting lung abnormalities in COVID-19 survivors and investigated the associations of the findings with those of lung ultrasound (LUS) and spirometry.

METHODS

In this cross-sectional study, 117 subjects underwent IOS at a frequency range of 4-20 Hz 2 months after COVID-19 diagnosis. They also underwent spirometry and LUS, and their aeration scores were calculated.

RESULTS

On IOS, the resonance frequency was > 12 Hz, and the area under the reactance curve was > 3.60 cm H₂O/L/s in 70 (59.8%) and 55 (47.0%) subjects, respectively. A heterogeneity of resistance between R4 and R20 (R4-R20) > 20% was observed in 60 (51.3%) participants. Based on their abnormalities in resistive and reactive parameters, 76 (65.0%) participants had abnormal IOS. Spirometry abnormalities were detected in 40 (34.2%) cases. LUS was abnormal in 51 (43.6%) participants, and the median aeration score was 0 (0-8) points. Abnormal IOS was associated with abnormal LUS (P < .001) and abnormal spirometry (P = .002). Abnormal spirometry had a significant but weaker association with abnormal LUS (P = .031). In participants who reported hospitalization, abnormal IOS was associated with both abnormal LUS (P = .001) and abnormal spirometry (P = .006). In participants who did not report hospitalization, abnormal IOS was associated with abnormal LUS (P < .001) but not abnormal spirometry (P = .063).

CONCLUSIONS

In COVID-19 survivors, IOS detected changes even when spirometry was normal. In these individuals, IOS parameters were more strongly associated with abnormalities on LUS than with abnormalities on spirometry.

Correlations between measures of ALS respiratory function: is there an alternative to FVC?

Background: An ongoing longitudinal study in six European sites includes a 3-monthly assessment of forced vital capacity (FVC), slow vital capacity (SVC), peak cough flow (PCF), and Sniff nasal inspiratory pressure (SNIP). The aim of this interim analysis was to assess the potential for SNIP to be a surrogate for aerosol generating procedures given COVID-19 related restrictions. Methods: This was a prospective observational study. Patients attending six study sites with King's Stage 2 or 3 ALS completed baseline FVC/SVC/SNIP/PCF and repeated assessments 3 monthly. Data were collected from March 2018 to March 2020, after which a COVID-19 related study suspension was imposed. Correlations between the measures were calculated. A Bayesian multiple outcomes random-effects model was constructed to investigate rates of decline across measures. Results: In total, 270 cases and 828 assessments were included (Mean age 65.2 ± 15.4 years; 32.6% Female; 60% Kings stage 2; 81.1% spinal onset). FVC and SVC were the most closely correlated outcomes (0.95). SNIP showed the least correlation with other metrics 0.53 (FVC), 0.54 (SVC), 0.60 (PCF). All four measures significantly declined over time. SNIP in the bulbar onset group showed the fastest rate of decline. Discussion: SNIP was not well correlated with FVC and SVC, probably because it examines a different aspect of respiratory function. Respiratory measures declined over time, but differentially according to the site of onset. SNIP is not a surrogate for FVC and SVC, but is a complementary measure, declining linearly and differentiating spinal and bulbar onset patients.

A portable triboelectric spirometer for wireless pulmonary function monitoring

Coronavirus disease 2019 (COVID-19) as a severe acute respiratory syndrome infection has spread rapidly across the world since its emergence in 2019 and drastically altered our way of life. Patients who have recovered from COVID-19 may still face persisting respiratory damage from the virus, necessitating long-term supervision after discharge to closely assess pulmonary function during rehabilitation. Therefore, developing portable spirometers for pulmonary function tests is of great significance for convenient home-based monitoring during recovery. Here, we propose a wireless, portable pulmonary function monitor for rehabilitation care after COVID-19. It is composed of a breath-to-electrical (BTE) sensor, a signal processing circuit, and a Bluetooth communication unit. The BTE sensor, with a compact size and light weight of 2.5 cm3 and 1.8 g respectively, is capable of converting respiratory biomechanical motions into considerable electrical signals. The output signal stability is greater than 93% under 35%-81% humidity, which allows for ideal expiration airflow sensing. Through a wireless communication circuit system, the signals can be received by a mobile terminal and processed into important physiological parameters, such as forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). The FEV1/FVC ratio is then calculated to further evaluate pulmonary function of testers. Through these measurement methods, the acquired pulmonary function parameters are shown to exhibit high accuracy (>97%) in comparison to a commercial spirometer. The practical design of the self-powered flow spirometer presents a low-cost and convenient method for pulmonary function monitoring during rehabilitation from COVID-19.

Impact of COVID-19 on pediatric pulmonology healthcare practice

INTRODUCTION

Coronavirus 2019 (COVID-19) is typically spread by droplets and has had a remarkable effect on pediatric pulmonology healthcare practice. Here, we aimed to evaluate the effect of the COVID-19 pandemic on the clinical follow-up and hospital visits of patients followed up at a pediatric pulmonology unit at a tertiary care center.

METHODS

This study was an observational descriptive study performed at a tertiary care center pediatric pulmonology unit between January 2019 and December 2020. We analyzed the outpatient visits, laboratory procedures which including pulmonary function tests (PFTs), diffusion capacity assessment, plethysmography, and lung clearance index (LCI), high-speed video microscopy, gastric aspirate sampling, and Flexible fiberoptic bronchoscopy (FFB) during clinical follow-up, and hospitalization numbers of patients with chronic lung diseases during the COVID-19 pandemic and compared them with the previous year before the pandemic started.

RESULTS

In 2020, compared with 2019, outpatient visits decreased by 42.2%; from 8324 patients to 4804 patients and other laboratory procedures decreased after the pandemic started; PFTs including spirometry by 87.2%; from 2990 to 380 tests, diffusion capacity assessment from 172 to 55 tests, plethysmography from 172 to 53 and LCI from 70 to 9 tests, also high-speed video microscopy analyses by 64.3% from 300 to 107 patients, and gastric aspirate sampling by 75.5% from 42 to 9 patients. FFB procedures also decreased by 59.1%, from 142 to 58 patients, and only 15 were after the first reported case of COVID-19 in our country, and they were all for urgent indications. None of these patients was positive pretesting for COVID-19 who underwent the FFB. There was no significant decrease in patients' hospitalization due to pulmonary exacerbation in cystic fibrosis, interstitial lung disease, and primary ciliary dyskinesia.

Diffusion capacity abnormalities for carbon monoxide in patients with COVID-19 at 3-month follow-up

Objective

To evaluate pulmonary function and clinical symptoms in coronavirus disease 2019 (COVID-19) survivors within 3 months after hospital discharge, and to identify risk factors associated with impaired lung function.

Methods and material

COVID-19 patients were prospectively followed-up with pulmonary function tests and clinical characteristics for 3 months following discharge from a hospital in Wuhan, China between January and February 2020.

Results

647 patients were included. 87 (13%) patients presented with weakness, 63 (10%) with palpitations and 56 (9%) with dyspnoea. The prevalence of each of the three symptoms were markedly higher in severe patients than nonsevere patients (19% versus 10% for weakness, p=0.003; 14% versus 7% for palpitations, p=0.007; 12% versus 7% for dyspnoea, p=0.014). Results of multivariable regression showed increased odds of ongoing symptoms among severe patients (OR 1.7, 95% CI 1.1–2.6; p=0.026) or patients with longer hospital stays (OR 1.03, 95% CI 1.00–1.05; p=0.041). Pulmonary function test results were available for 81 patients, including 41 nonsevere and 40 severe patients. In this subgroup, 44 (54%) patients manifested abnormal diffusing capacity of the lung for carbon monoxide (D_LCO) (68% severe versus 42% nonsevere patients, p=0.019). Chest computed tomography (CT) total severity score >10.5 (OR 10.4, 95% CI 2.5–44.1; p=0.001) on admission and acute respiratory distress syndrome (ARDS) (OR 4.6, 95% CI 1.4–15.5; p=0.014) were significantly associated with impaired D_LCO. Pulmonary interstitial damage may be associated with abnormal D_LCO.

Conclusion

Pulmonary function, particularly D_LCO, declined in COVID-19 survivors. This decrease was associated with total severity score of chest CT >10.5 and ARDS occurrence. Pulmonary interstitial damage might contribute to the imparied D_LCO.

COVID-19 patients present with impaired D_LCO at 90 days after discharge, particularly severe patients. Chest CT TSS >10.5 and ARDS occurrence are associated with impaired D_LCO. Pulmonary interstitial damage may contribute to the impaired D_LCO.https://bit.ly/2JevUtm

COVID-19 infection in patients with sarcoidosis: susceptibility and clinical outcomes

PURPOSE OF REVIEW

Patients with sarcoidosis may be at higher risk of coronavirus disease-19 (COVID-19) as over 90% of the patients have pulmonary involvement and many are treated with immunosuppressive agents. This review will summarize the current literature regarding sarcoidosis and COVID-19, with a particular focus on susceptibility, clinical outcomes, management, and approach to vaccination.

RECENT FINDINGS

Data about COVID-19 and sarcoidosis include a number of case series and reports, cohort studies, and registries. Literature is not conclusive whether patients with sarcoidosis have increased susceptibility to COVID-19. Patients with moderate to severe impaired pulmonary function may be at increased risk of adverse outcomes and mortality. Whether immunosuppressive medication increases risk of COVID-19 severity or affects vaccination response is not yet clear. Novel approaches, such as telemedicine and home monitoring programs, are promising to ensure continuity of care for patients with sarcoidosis during the COVID-19 pandemic.

SUMMARY

Current evidence about the risk and clinical outcomes of COVID-19 infection in patient with sarcoidosis, is mainly extrapolated from other immune-mediated diseases. Hence, further research that focuses on the sarcoidosis population is warranted.

Difference in the airway luminal area between the standing and supine positions using upright and conventional computed tomography

No clinical studies to date have compared the airway luminal area between supine and standing positions. Our aim was therefore to compare the airway luminal area between these two positions on computed tomography (CT) and to determine its correlation with forced expiratory volume in 1 s (FEV1). Thirty-two asymptomatic volunteers underwent both conventional (supine position) and upright (standing position) CT during deep inspiration breath-holding. Pulmonary function tests were conducted on the same day. We measured the airway luminal area on CT in each position. Paired t-tests and Pearson's correlation coefficients were used for statistical analysis. The average luminal areas of the trachea, right and left main bronchi, and average third-generation airway were greater in the standing than the supine position by 3.4%, 6.1%, 5.5%, and 5.2%, respectively. The correlation coefficients between airway luminal areas and FEV1 tended to be higher in the standing than the supine position; this correlation was highest for the average third-generation airway (r = 0.70, P < 0.0001). The airway luminal areas of the trachea, bilateral main bronchi, and average third-generation airway were greater in the standing than the supine position. The average third-generation airway area in the standing position had the highest correlation with FEV1.

Application of Machine Learning in Pulmonary Function Assessment Where Are We Now and Where Are We Going?

Analysis of pulmonary function tests (PFTs) is an area where machine learning (ML) may benefit clinicians, researchers, and the patients. PFT measures spirometry, lung volumes, and carbon monoxide diffusion capacity of the lung (DLCO). The results are usually interpreted by the clinicians using discrete numeric data according to published guidelines. PFT interpretations by clinicians, however, are known to have inter-rater variability and the inaccuracy can impact patient care. This variability may be caused by unfamiliarity of the guidelines, lack of training, inadequate understanding of lung physiology, or simply mental lapses. A rules-based automated interpretation system can recapitulate expert’s pattern recognition capability and decrease errors. ML can also be used to analyze continuous data or the graphics, including the flow-volume loop, the DLCO and the nitrogen washout curves. These analyses can discover novel physiological biomarkers. In the era of wearables and telehealth, particularly with the COVID-19 pandemic restricting PFTs to be done in the clinical laboratories, ML can also be used to combine mobile spirometry results with an individual’s clinical profile to deliver precision medicine. There are, however, hurdles in the development and commercialization of the ML-assisted PFT interpretation programs, including the need for high quality representative data, the existence of different formats for data acquisition and sharing in PFT software by different vendors, and the need for collaboration amongst clinicians, biomedical engineers, and information technologists. Hurdles notwithstanding, the new developments would represent significant advances that could be the future of PFT, the oldest test still in use in clinical medicine.

Impact of COVID-19 pandemic on chronic diseases care follow-up and current perspectives in low resource settings: a narrative review

Coronavirus is a respiratory disease that spreads globally. The severity and mortality risk of the disease is significant in the elderly, peoples having co-morbidities, and immunosuppressive patients. The outbreak of the pandemic created significant barriers to diagnosis, treatment and follow-up of chronic diseases. Delivering regular and routine comprehensive care for chronic patients was disrupted due to closures of healthcare facilities, lack of public transportation or reductions in services. The purpose of this narrative review was to update how patients with chronic care were affected during the pandemic, healthcare utilization services and available opportunities for better chronic disease management during the pandemic in resources limited settings. Moreover, this review may call to the attention of concerned bodies to make decisions and take measures in the spirit of improving the burden of chronic diseases by forwarding necessary recommendations for possible change and to scale up current intervention programs.

Management of COPD patients during COVID: difficulties and experiences

Introduction: The role of COPD in COVID-19 is not yet well understood. However, there is increasing evidence showing that COPD patients with COVID-19 have a higher risk of presenting a serious infection, a greater likelihood of requiring ICU support, and a higher mortality than other groups.Areas covered: In this article, we address some critical questions on COVID-19 as they pertain to COPD. In particular, we discuss whether the usual algorithms of pharmacological and non-pharmacological management in COPD still apply.Expert opinion: Patients with COPD must continue their regular therapy, regardless of whether they are affected by COVID-19. Corticosteroids reduce mortality in COVID-19 patients in need of supportive oxygen therapy or invasive mechanical ventilation. It is essential that a COPD patient who has tested positive for SARS-CoV-2 is closely followed over time because any delay in diagnosis and initiation of appropriate therapy could negatively affect his/her prognosis. However, we still do not know if COVID-19 infection occurs and evolves differently in each of the recognized COPD phenotypes and, therefore, whether it needs a different management. There are other open questions concerning COVID-19 and COPD that need to be considered. Future studies are absolutely necessary to answer these questions.

Breathless and awaiting diagnosis in UK lockdown for COVID-19…We're stuck

During the COVID-19 pandemic, semi-structured interviews were undertaken with 20 adults awaiting a diagnosis for their chronic breathlessness. Three key themes were identified using thematic analysis: (1) de-prioritisation of diagnosis, (2) following UK 'lockdown' guidance for the general population but patients fearful they were more at risk, and (3) the impact of lockdown on coping strategies for managing breathlessness. The existing unpredictable pathway to diagnosis for those with chronic breathlessness has been further interrupted during the COVID-19 pandemic.

Oscillometry of the respiratory system: a translational opportunity not to be missed

Airway oscillometry has become the de facto standard for quality assessment of lung physiology in laboratory animals and has demonstrated its usefulness in understanding diseases of small airways. Nowadays, it is seeing extensive use in daily clinical practice and research; however, a question that remains unanswered is how well physiological findings in animals and humans correlate? Methodological and device differences are obvious between animal and human studies. However, all devices deliver an oscillated airflow test signal and output respiratory impedance. In addition, despite analysis differences, there are ways to interpret animal and human oscillometry data to allow suitable comparisons. The potential with oscillometry is its ability to reveal universal features of the respiratory system across species, making translational extrapolation likely to be predictive. This means that oscillometry can thus help determine if an animal model displays the same physiological characteristics as the human disease. Perhaps more importantly, it can also be useful to determine whether an intervention is effective as well as to understand if it affects the desired region of the respiratory system, e.g., the periphery of the lung. Finally, findings in humans can also inform preclinical scientists and give indications as to what type of physiological changes should be observed in animal models to make them relevant as models of human disease. The present article will attempt to demonstrate the potential of oscillometry in respiratory research, an area where the development of novel therapies is plagued with a failure rate higher than in other disease areas.

Longitudinal monitoring of asthma in the clinic using respiratory oscillometry

BACKGROUND AND OBJECTIVE

Asthma guidelines emphasize the importance of assessing lung function and symptoms. The forced oscillation technique (FOT) and its longitudinal relationship with spirometry and symptoms are unresolved. We examined concordance between longitudinal spirometry, FOT and symptom control, and determined FOT limits of agreement in stable asthma.

METHODS

Over a 3-year period, adults with asthma attending a tertiary clinic completed the asthma control test (ACT), fraction of exhaled nitric oxide (FeNO), FOT and spirometry. Analysis included between-visit concordance for significant change using Cohen's kappa (κ) and stable asthma FOT limits of agreement.

RESULTS

Data (n = 186) from 855 visits (mean ± SD 4.6 ± 3.0 visits), 114 ± 95 days apart, were analysed. Between-visit concordance was moderate between reactance at 5 Hz (X5) and forced expiratory volume in 1 s (FEV₁ ) (κ = 0.34, p = 0.001), and weak between ACT and FEV₁ (κ = 0.18, p = 0.001). Change in FeNO did not correlate with lung function or ACT (κ < 0.05, p > 0.1). Stable asthma between visits (n = 75; 132 visits) had reduced lung function variability, but comparable concordance to the entire cohort. Limits of agreement for FEV₁ (0.42 L), resistance at 5 Hz (2.06 cm H₂ O s L^-1 ) and X5 (2.75 cm H₂ O s L^-1 ) in stable asthma were at least twofold greater than published values in health.

CONCLUSION

In adults with asthma, there is moderate concordance between longitudinal change in FOT and spirometry. Both tests relate poorly to changes in asthma control, highlighting the need for multi-modal assessment in asthma rather than symptoms alone. The derivation of longitudinal FOT limits of agreement will assist in its clinical interpretation.

Differences in airway lumen area between supine and upright computed tomography in patients with chronic obstructive pulmonary disease

BACKGROUND

No clinical studies to date have compared the inspiratory and expiratory airway lumen area between supine and standing positions. Thus, the aims of this study were twofold: (1) to compare inspiratory and expiratory airway lumen area (IAA and EAA, respectively) on computed tomography (CT) among supine and standing positions; and (2) to investigate if IAA and EAA are associated with lung function abnormality in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Forty-eight patients with COPD underwent both low-dose conventional (supine position) and upright CT (standing position) during inspiration and expiration breath-holds and a pulmonary function test (PFT) on the same day. We measured the IAA and EAA in each position.

RESULTS

For the trachea to the third-generation bronchi, the IAA was significantly larger in the standing position than in the supine position (4.1-4.9% increase, all p < 0.05). The EAA of all bronchi was significantly larger in the standing position than in the supine position (9.7-62.5% increases, all p < 0.001). The correlation coefficients of IAA in the standing position and forced expiratory volume in 1 s were slightly higher than those in the supine position. The correlation coefficients of EAA or EAA/IAA in the standing position and residual volume, and the inspiratory capacity/total lung capacity ratio were higher than those in the supine position.

CONCLUSIONS

Airway lumen areas were larger in the standing position than in the supine position. IAAs reflect airway obstruction, and EAAs reflect lung hyperinflation. Upright CT might reveal these abnormalities more precisely. Trial registration University Hospital Medical Information Network (UMIN 000026587), Registered 17 March 2017. URL: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000030456 .

The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review

BACKGROUND

Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions.

METHODS

A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021.

FINDINGS

During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed.

INTERPRETATION

Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.

ERS International Congress 2020: highlights from the General Pneumology Assembly

The European Respiratory Society (ERS) accepted 4062 abstracts for presentation at the ERS International Congress in 2020. Although the conference was held virtually, making it possible to replay presentations, it remains a challenge to keep abreast of all the clinical and scientific advances. Therefore, this article provides highlights from the General Pneumology Assembly. Selected presentations from rehabilitation and chronic care, general practice and primary care, and electronic/mobile health (e-health/m-health) are summarised. The highlights incorporate novel findings from laboratory-based science, randomised controlled trials and qualitative research together with insights from newly available clinical guidelines.

Pediatric Pulmonary Function Testing in COVID-19 Pandemic and Beyond. A Position Statement From the Hellenic Pediatric Respiratory Society

As the COVID-19 pandemic is still evolving, guidelines on pulmonary function testing that may dynamically adapt to sudden epidemiologic changes are required. This paper presents the recommendations of the Hellenic Pediatric Respiratory Society (HPRS) on pulmonary function testing in children and adolescents during the COVID-19 era. Following an extensive review of the relevant literature, we recommend that pulmonary function tests should be carried out after careful evaluation of the epidemiologic load, structured clinical screening of all candidates, and application of special protective measures to minimize the risk of viral cross infection. These principles have been integrated into a dynamic action plan that may readily adapt to the phase of the pandemic.