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Özsezen B, Yalçın E, Emiralioğlu N, Konşuk Ünlü H, Ademhan Tural D, Caka C, Sunman B, Doğru D, Özçelik U, Kiper N. The predictive role of lung clearance index on FEV 1 decline in cystic fibrosis. Turk J Pediatr 2024; 66:297-308. [PMID: 39024602 DOI: 10.24953/turkjpediatr.2024.4516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/10/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The lung clearance index (LCI) is a sensitive lung function index that is used to detect early lung disease changes in children with cystic fibrosis (CF). This study aimed to define the predictive role of baseline LCI, along with other potential factors on the change in forced expiratory volume in one second (FEV1) during one-year follow-up in CF patients who had a percent predicted (pp) FEV1≥80. METHODS LCI was concurrently performed on 57 CF patients who had ppFEV1 ≥80 at month zero. The ppFEV1 decline was evaluated prospectively during the one year follow up. The primary outcome of ppFEV1 decline in the study group in one year was dichotomized according to the median value for the decline in ppFEV1, which was 3.7. The LCI value predicting ppFEV1 decline at the end of one year was calculated with receiver operating characteristic curve analysis. Regression analysis was performed. Furthermore, a decision tree was constructed using classification and regression tree methods to better define the potential effect of confounders on the ppFEV1 decline. RESULTS The LCI value for predicting ppFEV1 decline >3.7% at the end of one year was 8.2 (area under the curve: 0.80) Multivariable regression analysis showed that the absence of the F508del mutation in at least one allele, LCI >8.2 and initial FEV1 z-score were predictors of a ppFEV1 decline >3.7 (p<0.001). Factors altering ppFEV1 decline>3.7% at the end of one-year evaluated by decision trees were as follows: initial FEV1 z-score, type of CFTR mutation, LCI value and initial weight-for-age z-score. CONCLUSIONS LCI is sensitive for predicting ppFEV1 decline in patients with ppFEV1 ≥80 along with the initial FEV1-z-score and type of CFTR mutation.
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Affiliation(s)
- Beste Özsezen
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Ebru Yalçın
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Nagehan Emiralioğlu
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | | | - Dilber Ademhan Tural
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Canan Caka
- Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Birce Sunman
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Deniz Doğru
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Ugur Özçelik
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
| | - Nural Kiper
- Department of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Türkiye
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Fevola C, Dolce D, Tosco A, Padoan R, Daccò V, Claut L, Schgor T, Sepe A, Timpano S, Fabrizzi B, Piccinini P, Taccetti G, Bonomi P, Terlizzi V. Risk of CFTR-related disorders and cystic fibrosis in an Italian cohort of CRMS/CFSPID subjects in preschool and school age. Eur J Pediatr 2024; 183:929-938. [PMID: 38054992 DOI: 10.1007/s00431-023-05359-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023]
Abstract
The identification of cystic fibrosis screening-positive, inconclusive diagnosis (CFSPID) in infants is a controversial outcome of newborn screening for cystic fibrosis (CF). Today, despite improvements in the knowledge of CFSPID and the description of several cohorts, little data are available on cohorts with a follow-up period of more than 6 years. In this study, we report the outcomes of an Italian cohort of CFSPID individuals with CFSPID or formerly CFTR-related disorders (CFTR-RD) (CFSPID > CFTR-RD) or diagnosed with CF (CFSPID > CF). This was an observational and multicentre Italian study collecting clinical data on CFSPID born between the period January 1, 2011, and December 13, 2019. A total of 268 participants were included: 243 with persistent CFSPID, 7 with CFSPID > CFTR-RD, and 18 with CFSPID > CF. The trend of sweat chloride (SC) values, percentage of definitive diagnoses, lung function in school-aged children, and development of CF-related complications were evaluated. At the end of the observation period, almost 80% of the individuals with CFSPID did not have a conclusive diagnosis. A total of 29 children (10.8%) transitioned to a diagnosis of CF for pathological SC values (≥ 60 mmol/L) or multi-organ involvement, and 18 (6.7%) to CFTR-RD. Children who were followed up for > 6 years (median age, 7.5 years; range, 6.04-10.5) had normal lung function and were pancreatic sufficient, and the evolution in CF was only present in two cases. CONCLUSION Most Italian preschool and school-aged children with CFSPID did not have a conclusive diagnosis, and progression to CF was unlikely in children > 6 years of age. An annual follow-up could be indicated to identify early evolution in clinical features consistent with a CFTR-RD. WHAT IS KNOWN • Cystic Fibrosis newborn screening identifies also subjects with an inconclusive diagnosis (CFSPID). • Over time a variable percentage of CFSPIDs will be diagnosed as CF. • Little data is available on CFSPIDs with a follow-up period of more than six years. WHAT IS NEW • 80% of Italian preschool and school-age CFSPIDs not have a conclusive diagnosis. • Italian preschool and school-age CFSPIDs have normal lung function and are pancreatic sufficient. • Annual follow-up after 6 years is recommended in CFSPID with abnormal LCI2.5 or with a CF-causing variant in trans with a VVCC.
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Affiliation(s)
- C Fevola
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 2, Florence, 50139, Italy
| | - D Dolce
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 2, Florence, 50139, Italy
| | - A Tosco
- Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - R Padoan
- Scientific Board Italian CF Registry, Rome, Italy
| | - V Daccò
- Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - L Claut
- Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - T Schgor
- Cystic Fibrosis Regional Reference Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - A Sepe
- Paediatric Unit, Department of Translational Medical Sciences, Cystic Fibrosis Regional Reference Center, University of Naples Federico II, Naples, Italy
| | - S Timpano
- Cystic Fibrosis Regional Support Center, Department of Pediatrics, University of Brescia, ASST Spedali Civili Brescia, Brescia, Italy
| | - B Fabrizzi
- Cystic Fibrosis Regional Reference Center, Mother‑Child Department, United Hospitals, Ancona, Italy
| | | | - G Taccetti
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 2, Florence, 50139, Italy
| | | | - V Terlizzi
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 2, Florence, 50139, Italy.
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Taylor-Cousar JL, Robinson PD, Shteinberg M, Downey DG. CFTR modulator therapy: transforming the landscape of clinical care in cystic fibrosis. Lancet 2023; 402:1171-1184. [PMID: 37699418 DOI: 10.1016/s0140-6736(23)01609-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 09/14/2023]
Abstract
Following discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene in 1989 and subsequent elucidation of the varied CFTR protein abnormalities that result, a new era of cystic fibrosis management has emerged-one in which scientific principles translated from the bench to the bedside have enabled us to potentially treat the basic defect in the majority of children and adults with cystic fibrosis, with a resultant burgeoning adult cystic fibrosis population. However, the long-term effects of these therapies on the multiple manifestations of cystic fibrosis are still under investigation. Understanding the effects of modulators in populations excluded from clinical trials is also crucial. Furthermore, establishing appropriate disease measures to assess efficacy in the youngest potential trial participants and in those whose post-modulator lung function is in the typical range for people without chronic lung disease is essential for continued drug development. Finally, recognising that a health outcome gap has been created for some people and widened for others who are not eligible for, cannot tolerate, or do not have access to modulators is important.
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Affiliation(s)
- Jennifer L Taylor-Cousar
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA; Division of Pediatric Pulmonary Medicine, National Jewish Health, Denver, CO, USA; Division of Pulmonary Sciences and Critical Care Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA.
| | - Paul D Robinson
- Department of Respiratory Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia; Children's Health and Environment Program, Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | - Michal Shteinberg
- Pulmonology Institute and CF Center, Carmel Medical Center, Haifa, Israel; B Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Sandvik RM, Schmidt MN, Voldby CM, Buchvald FF, Olesen HV, Olsen J, Kragh MV, Rubak SL, Pressler T, Robinson PD, Gustafsson PM, Skov M, Nielsen KG. Nationwide lung function monitoring from infancy in newborn-screened children with cystic fibrosis. ERJ Open Res 2023; 9:00317-2023. [PMID: 37908398 PMCID: PMC10613974 DOI: 10.1183/23120541.00317-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/01/2023] [Indexed: 11/02/2023] Open
Abstract
Background Cystic fibrosis (CF) lung disease starts in infancy and can be assessed for structural lung abnormalities using computed tomography or magnetic resonance scans, or for lung function impairment using multiple breath washout (MBW). However, in infancy these two methods are not well correlated. Trajectories of CF lung disease assessed by MBW in infants and toddlers remain poorly described, which is why we aimed to 1) describe the trajectory of lung function, 2) explore risk factors for progression and 3) explore the real-life effect of lumacaftor/ivacaftor. Methods This was a nationwide observational cohort study (2018-2021) using data collected as part of the routine clinical surveillance programme (including MBW and monthly endo-laryngeal suction sampling for bacterial pathogens) in children born after implementation of newborn screening for CF (May 2016). Lumacaftor/ivacaftor commenced from age 2 years in children homozygous for F508del. Ventilation distribution efficiency (VDE), recently described to have advantages over lung clearance index (LCI), was reported as the primary MBW outcome after z-score calculations based on published reference data. Mixed effect linear regression models were the main statistical analyses performed in this study. Results 59 children, aged 2-45 months, contributed with 211 MBW occasions (median (interquartile range (IQR)) 3 (2-5) MBW occasions per child) with a median (IQR) follow-up time of 10.8 (5.2-22.3) months. An overall mean annual deterioration rate of -0.50 (95% CI -0.78- -0.22) z-VDE was observed, starting from an estimated mean z-VDE of -1.68 (95% CI -2.15- -1.22) at age 0.0 years (intercept). Pseudomonas aeruginosa "ever" (n=14, MBWs 50) had a significantly worse z-VDE trajectory versus P. aeruginosa "never" (mean difference 0.53 (95% CI 0.16-0.89) per year; p=0.0047) and lumacaftor/ivacaftor treatment (n=22, MBWs 46) significantly improved the trajectory of z-VDE (mean difference 1.72 (95% CI 0.79-2.66) per year; p=0.0004), leading to a stable mean z-VDE trajectory after start of treatment. Conclusions Infants and toddlers with CF demonstrated progressive deterioration in z-VDE over the first years of life. P. aeruginosa isolation "ever" was associated with an accelerated deterioration in lung function, while lumacaftor/ivacaftor therapy significantly improved and stabilised the trajectory.
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Affiliation(s)
- Rikke M. Sandvik
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
| | - Marika N. Schmidt
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
| | - Christian M. Voldby
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
| | - Frederik F. Buchvald
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
| | - Hanne V. Olesen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, CF Centre Aarhus, Danish Centre of Paediatric Pulmonology and Allergology, Aarhus, Denmark
| | - Jørgen Olsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, CF Centre Aarhus, Danish Centre of Paediatric Pulmonology and Allergology, Aarhus, Denmark
| | - Maja V. Kragh
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
| | - Sune L.M. Rubak
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, CF Centre Aarhus, Danish Centre of Paediatric Pulmonology and Allergology, Aarhus, Denmark
| | - Tacjana Pressler
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
| | - Paul D. Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
- Airway Physiology and Imaging Group, The Woolcock Medical Research Institute, Sydney, Australia
| | - Per M. Gustafsson
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Children and Young Persons – Medical Clinic, Skaraborg Hospital, Skövde, Sweden
| | - Marianne Skov
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
| | - Kim G. Nielsen
- Department of Paediatric and Adolescent Medicine, Copenhagen University Hospital, Danish PCD and chILD Centre, CF Centre Copenhagen, Paediatric Pulmonary Service, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Terlizzi V, Fevola C, Ferrari B, Castellani C, Santini G, Innocenti D, Masi E, Bonomi P, Lombardi E, Taccetti G. Lung clearance index in children with cystic fibrosis previously diagnosed with CRMS/CFSPID: A monocentric prospective experience. Pediatr Pulmonol 2023. [PMID: 37133232 DOI: 10.1002/ppul.26442] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/16/2023] [Accepted: 04/20/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION No data are available on the values and role of lung clearance index (LCI) in cystic fibrosis (CF) Screen Positive Inconclusive Diagnosis (CFSPID) progressed to CF diagnosis (CFSPID > CF). This study aimed to assess the value of the LCI in correctly predicting the progression of CFSPID to CF. METHODS This is a prospective study carried out at the CF Regional Center of Florence, Italy from September 1, 2019. We compared LCI values in children with CF diagnosed for positive newborn screening (NBS), CFSPID or CFSPID > CF for pathological sweat chloride (SC). The Exhalyzer-D (EcoMedics AG, Duernten, Switzerland, software version 3.3.1) was used to conduct the LCI tests, every 6 months on stable children. RESULTS Forty-two cooperating children were enrolled (mean age at LCI tests: 5.4 years, range: 2.7-8.7): 26 (62%) had CF, 8 (19%) were CFSPID > CF for positive SC, while 8 (19%) kept the CFSPID label at last LCI test. The mean LCI value for patients with CF (7.39; 5.98-10.24) was statistically higher compared to both the mean LCI in the CFSPID > CF (6.62; 5.69-7.58) and in CFSPID (6.56; 5.64-7.21). CONCLUSIONS Most of asymptomatic CFSPID or progressed to CF have normal LCI. Further data on the longitudinal course of LCI during follow up of CFSPID and on larger cohorts is needed.
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Affiliation(s)
- Vito Terlizzi
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
| | - Cristina Fevola
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
| | - Beatrice Ferrari
- Meyer Children's Hospital IRCCS, Rehabilitation Unit, Florence, Italy
| | - Chiara Castellani
- Meyer Children's Hospital IRCCS, Rehabilitation Unit, Florence, Italy
| | - Giulia Santini
- Meyer Children's Hospital IRCCS, Rehabilitation Unit, Florence, Italy
| | - Diletta Innocenti
- Meyer Children's Hospital IRCCS, Rehabilitation Unit, Florence, Italy
| | - Eleonora Masi
- Meyer Children's Hospital IRCCS, Rehabilitation Unit, Florence, Italy
| | | | - Enrico Lombardi
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Pediatric Pulmonary Unit, Florence, Italy
| | - Giovanni Taccetti
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Florence, Italy
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Salinas DB, Ginsburg DK, Wee CP, Saeed MM, Brewington JJ. Gradual increase in sweat chloride concentration is associated with a higher risk of CRMS/CFSPID to CF reclassification. Pediatr Pulmonol 2023; 58:1074-1084. [PMID: 36582049 DOI: 10.1002/ppul.26296] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 12/10/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Universal implementation of cystic fibrosis (CF) newborn screening (NBS) has led to the diagnostic dilemma of infants with CF screen-positive, inconclusive diagnosis (CFSPID), with limited guidance regarding prognosis and standardized care. Rates of reclassification from CFSPID to CF vary and risk factors for reclassification are not well established. We investigated whether clinical characteristics are associated with the risk of reclassification from CFSPID to a CF diagnosis. METHODS Children with a positive CF NBS were recruited from two sites in California. Retrospective, longitudinal, and cross-sectional data were collected. A subset of subjects had nasal epithelial cells collected for CF transmembrane conductance regulator (CFTR) functional assessment. Multivariate logistic regression was used to assess the risk of reclassification. RESULTS A total of 112 children completed the study (CF = 53, CFSPID = 59). Phenotypic characteristics between groups showed differences in pancreatic insufficiency prevalence, immunoreactive trypsinogen (IRT) levels, and Pseudomonas aeruginosa (PSA) colonization. Spirometry measures were not different between groups. Nasal epithelial cells from 10 subjects showed 7%-30% of wild-type (WT)-CFTR (wtCFTR) function in those who reclassified and 27%-67% of wtCFTR function in those who retained the CFSPID designation. Modeling revealed that increasing sweat chloride concentration (sw[Cl- ]) and PSA colonization were independent risk factors for reclassification to CF. CONCLUSION Increasing sw[Cl- ] and a history of PSA colonization are associated with the risk of reclassification from CFSPID to CF in a population with high IRT and two CFTR variants. A close follow-up to monitor phenotypic changes remains critical in this population. The role of CFTR functional assays in this population requires further exploration.
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Affiliation(s)
- Danieli B Salinas
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Daniella K Ginsburg
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Choo Phei Wee
- Department of Population and Public Health Sciences, Keck School of Medicine, Southern California Clinical and Translational Science Institute (SC-CTSI), University of Southern California, Los Angeles, California, USA
| | - Muhammed M Saeed
- Division of Pediatric Pulmonology, Kaiser Permanente Los Angles Medical Center, Los Angeles, California, USA
| | - John J Brewington
- Department of Pediatrics, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Milinic T, McElvaney OJ, Goss CH. Diagnosis and Management of Cystic Fibrosis Exacerbations. Semin Respir Crit Care Med 2023; 44:225-241. [PMID: 36746183 PMCID: PMC10131792 DOI: 10.1055/s-0042-1760250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator (CFTR) therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is acute pulmonary exacerbation (PEx). Clinical and microbial epidemiology studies of CF PEx continue to provide important insight into the disease course, prognosis, and complications. This work has now led to several large-scale clinical trials designed to clarify the treatment paradigm for CF PEx. The primary goal of this review is to provide a summary and update of the pathophysiology, clinical and microbial epidemiology, outcome and treatment of CF PEx, biomarkers for exacerbation, and the impact of highly effective modulator therapy on these events moving forward.
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Affiliation(s)
- Tijana Milinic
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Oliver J McElvaney
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Christopher H Goss
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Cysic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Allen L, Allen L, Carr SB, Davies G, Downey D, Egan M, Forton JT, Gray R, Haworth C, Horsley A, Smyth AR, Southern KW, Davies JC. Future therapies for cystic fibrosis. Nat Commun 2023; 14:693. [PMID: 36755044 PMCID: PMC9907205 DOI: 10.1038/s41467-023-36244-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 01/20/2023] [Indexed: 02/10/2023] Open
Abstract
We are currently witnessing transformative change for people with cystic fibrosis with the introduction of small molecule, mutation-specific drugs capable of restoring function of the defective protein, cystic fibrosis transmembrane conductance regulator (CFTR). However, despite being a single gene disorder, there are multiple cystic fibrosis-causing genetic variants; mutation-specific drugs are not suitable for all genetic variants and also do not correct all the multisystem clinical manifestations of the disease. For many, there will remain a need for improved treatments. Those patients with gene variants responsive to CFTR modulators may have found these therapies to be transformational; research is now focusing on safely reducing the burden of symptom-directed treatment. However, modulators are not available in all parts of the globe, an issue which is further widening existing health inequalities. For patients who are not suitable for- or do not have access to- modulator drugs, alternative approaches are progressing through the trials pipeline. There will be challenges encountered in design and implementation of these trials, for which the established global CF infrastructure is a major advantage. Here, the Cystic Fibrosis National Research Strategy Group of the UK NIHR Respiratory Translational Research Collaboration looks to the future of cystic fibrosis therapies and consider priorities for future research and development.
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Affiliation(s)
| | | | - Siobhan B Carr
- Royal Brompton & Harefield Hospital, Guy's & St Thomas' Trust, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Gwyneth Davies
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children, London, UK
| | - Damian Downey
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | - Julian T Forton
- Noah's Ark Children's Hospital for Wales, Cardiff, UK
- School of Medicine, Cardiff University, Cardiff, UK
| | - Robert Gray
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Charles Haworth
- Royal Papworth Hospital and Department of Medicine, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Alexander Horsley
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
- Manchester Adult CF Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alan R Smyth
- School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Institute in the Park, Alder Hey Children's Hospital, Liverpool, UK
| | - Jane C Davies
- Royal Brompton & Harefield Hospital, Guy's & St Thomas' Trust, London, UK.
- National Heart & Lung Institute, Imperial College London, London, UK.
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9
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Svedberg M, Imberg H, Gustafsson PM, Tiddens H, Davies G, Lindblad A. Longitudinal lung clearance index and association with structural lung damage in children with cystic fibrosis. Thorax 2023; 78:176-182. [PMID: 35277449 PMCID: PMC9872247 DOI: 10.1136/thoraxjnl-2021-218178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/11/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Marcus Svedberg
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Henrik Imberg
- Departmemt of Mathematical Science, Chalmers University of Technology, Gothenburg, Sweden
| | - Per Magnus Gustafsson
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Pediatrics, Central Hospital, Skoevde, Sweden
| | - Harm Tiddens
- Department of Pediatric Pulmonology and Allergology, ErasmusMC-Sophia Children's hospital, Rotterdam, Netherlands
| | - Gwyneth Davies
- UCL Great Ormond Street Institute of Child Health, UCL, London, UK.,Department of Respiratory Medicine, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Anders Lindblad
- Department of Pediatrics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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10
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Hatziagorou E, Avramidou V, Gioulvanidou M, Talimtzi P, Kouroukli E, Mantsiou C, Lialias I, Nousia L, Tsanakas J. Pulmonary exacerbations, airway pathogens, and long-term course of lung clearance index in children and young adults with cystic fibrosis. Pediatr Pulmonol 2022; 57:3069-3076. [PMID: 36059241 DOI: 10.1002/ppul.26136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 07/29/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pulmonary exacerbations (PEx), pathogens colonizing the respiratory tract, and patients' age are associated with progressive worsening of lung function among patients with cystic fibrosis (CF). However, the effect of these factors on longitudinal changes of Lung Clearance Index (LCI) remains unclear. AIM To assess the role of age, different types of bronchial infection, and PEx on LCI deterioration. METHODS We conducted a retrospective study assessing multiple-breath washout (MBW) and spirometry changes among CF patients evaluated at quarterly outpatient clinic visits over 8 years. MBW and spirometry were performed at each visit, sputum samples and/or cough swabs were obtained for culture, whereas respiratory symptoms and clinical examination findings were recorded. Patients who had ≥5 serial MBW measurements, one of which coincided with a pulmonary exacerbation, were reviewed. RESULTS Seventy-six patients were included in the study: mean age of 10.61 years (range 1.75-23.75). A total of 1152 MBW tests and 1047 spirometry tests were performed. LCI was significantly higher among CF patients aged 11-15, 16-20, and over 20 years than those under 5 years of age; ΔLCI: 1.16 (confidence interval [CI] 0.43-1.90) and 3.25 (CI 2.33-4.17), respectively. Furthermore, LCI was significantly elevated in CF patients with positive cultures for Pseudomonas aeruginosa (0.52 LCI [CI -0.12 to 0.71]) and Stenotrophomonas Maltophilia (1.41 LCI [CI 0.61-2.21]). Moreover, increased values of LCI in CF patients were significantly associated with increased risk of PEx (odds ratio [OR] 1.19, CI [1.14-1.25], p < 0.001). CONCLUSION LCI demonstrates a progression of lung disease and corresponds to changes in bacterial infections and PEx among patients with CF. LCI may be a valuable marker for tracking disease deterioration and may have a role in the routine clinical care of patients with CF.
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Affiliation(s)
- Elpis Hatziagorou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Avramidou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Gioulvanidou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Persefoni Talimtzi
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleana Kouroukli
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysanthi Mantsiou
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Lialias
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lemonia Nousia
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Tsanakas
- Pediatric Pulmonology and CF Unit, 3rd Pediatric Department, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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11
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Britto CJ, Ratjen F, Clancy JP. Emerging Approaches to Monitor and Modify Care in the Era of Cystic Fibrosis Transmembrane Conductance Regulators. Clin Chest Med 2022; 43:631-646. [PMID: 36344071 DOI: 10.1016/j.ccm.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As we characterize the clinical benefits of highly effective modulator therapy (HEMT) in the cystic fibrosis (CF) population, our paradigm for treating and monitoring disease continues to evolve. More sensitive approaches are necessary to detect early disease and clinical progression. This article reviews evolving strategies to assess disease control and progression in the HEMT era. This article also explores developments in pulmonary function monitoring, advanced respiratory imaging, tools for the collection of patient-reported outcomes, and their application to profile individual responses, guide therapeutic decisions, and improve the quality of life of people with CF.
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Affiliation(s)
- Clemente J Britto
- Yale Adult Cystic Fibrosis Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine.
| | - Felix Ratjen
- Division of Respiratory Medicine, Translational Medicine, University of Toronto Hospital for Sick Children, 555 University Avenue, Toronto Ontario M5G 1X8, Canada
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12
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Bowerman C, Ratjen F, Stanojevic S. Estimating the minimum sample size for interventional and observational studies using the lung clearance index as an endpoint✰. J Cyst Fibros 2022; 22:356-362. [PMID: 36402729 DOI: 10.1016/j.jcf.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/16/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND With the increasing availability of highly effective modulators for people living with cystic fibrosis (CF), there is a need to re-design research studies to reflect the changing epidemiology of the CF population. The lung clearance index (LCI), a sensitive physiological measure of lung function, may be ideally suited as an endpoint in the era of CF modulator therapies. In this study we describe study design considerations for implementing LCI into interventional and observational research. METHODS Simulations were used to estimate the required sample size to detect a range of treatment effects for interventional studies (including cross-over trials) and to track lung disease progression in observational studies. RESULTS Using published treatment effects to inform the design of prospective studies can lead to inefficient study designs. Large improvements in LCI for a few individuals can skew results and can influence interpretations of treatment effects. Adjusting for baseline LCI can help to improve the efficiency of a study. Compared to the forced expiratory volume in 1 second (FEV1), analysis using LCI as an endpoint requires as little as one third of the total sample size. CONCLUSIONS Planning of prospective studies that include LCI as an endpoint need to consider baseline LCI and disease severity of the study population; whereas interpretation of results needs to consider whether a few individuals skew the overall treatment effect.
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13
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Davies G. Does newborn screening improve early lung function in cystic fibrosis? Paediatr Respir Rev 2022; 42:17-22. [PMID: 32952050 DOI: 10.1016/j.prrv.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/23/2022]
Abstract
Despite evidence showing an improvement in nutritional outcomes following diagnosis by newborn screening (NBS) for cystic fibrosis (CF), the impact on pulmonary outcomes has been less clear. In this review the approaches to measurement of early lung function and knowledge gained from NBS CF cohorts will be described. Studies which have compared outcomes in those diagnosed by NBS to those diagnosed following symptomatic presentation will be presented. Compiling the evidence base used to evaluate the impact of NBS on pulmonary outcomes has been complicated by improvements in clinical management, infection control practices, as well as public health interventions (such as tobacco smoking bans in public places) that have evolved substantially over recent decades. Forced expiratory volumes have been used as the main outcome but it is important not to draw conclusions for 'early lung function' from tests such as spirometry alone, which lack sensitivity in early lung disease. There is, at present, insufficient evidence to draw firm conclusions about the effect of NBS on early lung function. In an era of highly effective treatments targeting the underlying molecular defect responsible for CF, future opportunities for early initiation of treatment may mean that the impact of NBS on early lung function may yet to be realised.
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Affiliation(s)
- Gwyneth Davies
- UCL Great Ormond Street Institute of Child Health, London, UK; Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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14
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Aurora P, Duncan JA, Lum S, Davies G, Wade A, Stocks J, Viviani L, Raywood E, Pao C, Ruiz G, Bush A. Early Pseudomonas aeruginosa predicts poorer pulmonary function in preschool children with cystic fibrosis. J Cyst Fibros 2022; 21:988-995. [DOI: 10.1016/j.jcf.2022.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/08/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022]
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15
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Lahiri T, Sullivan JS. Recent advances in the early treatment of cystic fibrosis: Bridging the gap to highly effective modulator therapy. Pediatr Pulmonol 2022; 57 Suppl 1:S60-S74. [PMID: 34473419 DOI: 10.1002/ppul.25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022]
Abstract
Highly effective modulator therapy (HEMT) for cystic fibrosis (CF) has been touted as one of the greatest advances to date in CF care. As these therapies are now available for many older children and adults with CF, marked improvement of their nutritional status, pulmonary and gastrointestinal symptoms has been observed. However, most infants and younger children are not current candidates for HEMT due to age and/or cystic fibrosis transmembrane conductance regulator (CFTR) mutation. For these young children, it is essential to provide rigorous monitoring and care to avoid potential disease sequelae while awaiting HEMT availability. The following article highlights recent advances in the care of infants and young children with CF with regard to surveillance and treatment of nutritional, pulmonary, and gastrointestinal disorders. Recent clinical trials in this population are also reviewed.
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Affiliation(s)
- Thomas Lahiri
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jillian S Sullivan
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
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16
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Stanojevic S, Bowerman C, Robinson P. Multiple breath washout: measuring early manifestations of lung pathology. Breathe (Sheff) 2022; 17:210016. [PMID: 35035543 PMCID: PMC8753656 DOI: 10.1183/20734735.0016-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/13/2021] [Indexed: 11/05/2022] Open
Abstract
The multiple breath washout (MBW) test measures the efficiency of gas mixing in the lungs and has gained significant interest over the past 20 years. MBW outcomes detect early lung function impairment and peripheral airway pathology, through its main outcome measure lung clearance index (LCI). LCI measures the number of lung turnovers required to washout an inert tracer gas. MBW is performed during normal (tidal) breathing, making it particularly suitable for young children or those who have trouble performing forced manoeuvres. Additionally, research in chronic respiratory disease populations has shown that MBW can detect acute clinically relevant changes before conventional lung function tests, such as spirometry, thus enabling early intervention. The development of technical standards for MBW and commercial devices have allowed MBW to be implemented in clinical research and potentially routine clinical practice. Although studies have summarised clinimetric properties of MBW indices, additional research is required to establish the clinical utility of MBW and, if possible, shorten testing time. Sensitive, feasible measures of early lung function decline will play an important role in early intervention for people living with respiratory diseases. Educational aim To describe the multiple breath washout test, its applications to lung pathology and respiratory disease, as well as directions for future research.
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Affiliation(s)
- Sanja Stanojevic
- Dept of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Cole Bowerman
- Dept of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Paul Robinson
- Dept of Respiratory Medicine, Children's Hospital at Westmead, Sydney, Australia.,The Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, Australia
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17
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Pulmonary Dysfunction after Treatment for Childhood Cancer. Comparing Multiple-Breath Washout with Spirometry. Ann Am Thorac Soc 2021; 18:281-289. [PMID: 32877212 DOI: 10.1513/annalsats.202003-211oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Rationale: Childhood cancer survivors are at risk of long-term pulmonary dysfunction, but we lack sensitive outcome measures to detect early pulmonary damage.Objectives: To assess the ability of nitrogen multiple-breath washout (N2MBW) for detecting pulmonary dysfunction compared with spirometry in long-term survivors of childhood cancer.Methods: We analyzed cross-sectional data from long-term (≥5-yr) survivors of childhood cancer, aged ≤16 years at cancer diagnosis, ≥16 years at study (assessment period 2015-2019). We categorized survivors by risk: high risk for those having had pulmotoxic chemotherapy, chest radiation, thoracic surgery, and/or hematopoietic stem cell transplantation, and standard risk for other cancer therapies. Primary outcomes were the global lung clearance index (LCI) and acinar ventilation inhomogeneity index (SACIN) from N2MBW, and forced expiratory volume in 1 second (FEV1) and functional vital capacity (FVC) from spirometry. We calculated z-scores for N2MBW and spirometry parameters and compared pulmonary dysfunction between risk groups. Pulmonary dysfunction was defined as z-score +1.64 for N2MBW and -1.64 for spirometry.Results: We studied 46 survivors, median age at diagnosis 10 years (interquartile range, 4-14), median age at study 30 years (interquartile range, 25-40). Thirty-seven percent were at high risk and 63% at standard risk for pulmonary dysfunction. LCI and SACIN were higher in the high-risk group compared with the standard-risk group (mean LCI z-scores 2.09, standard deviation [SD] 2.39 vs. 0.95, SD 2.81; mean SACIN z-scores 2.45, SD 3.29 vs. 0.65, SD 2.79). FEV1 and FVC were lower in the high-risk compared with the standard-risk group (mean FEV1 z-scores -0.94, SD 1.39 vs. -0.10, SD 1.07; mean FVC z-scores -1.14, SD 1.23 vs. 0.15, SD 1.61). Overall, LCI, SACIN, FEV1, and FVC were abnormal in 60%, 53%, 33%, and 33% of high-risk patients compared with 23%, 21%, 0%, and 4% of standard-risk patients.Conclusions: N2MBW identified more cases of pulmonary dysfunction in long-term survivors of childhood cancer than spirometry, even in patients who had cancer therapy not specifically known as being pulmotoxic. N2MBW could be a complementary screening tool for early pulmonary damage after treatment for childhood cancer.Clinical trial registered with www.clinicaltrials.gov (NCT02730767).
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18
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Early surveillance of infants and preschool children with cystic fibrosis. CURRENT OPINION IN PHYSIOLOGY 2021. [DOI: 10.1016/j.cophys.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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19
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Martins Costa Gomes G, de Gouveia Belinelo P, Starkey MR, Murphy VE, Hansbro PM, Sly PD, Robinson PD, Karmaus W, Gibson PG, Mattes J, Collison AM. Cord blood group 2 innate lymphoid cells are associated with lung function at 6 weeks of age. Clin Transl Immunology 2021; 10:e1296. [PMID: 34306680 PMCID: PMC8292948 DOI: 10.1002/cti2.1296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/27/2021] [Accepted: 05/21/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Offspring born to mothers with asthma in pregnancy are known to have lower lung function which tracks with age. Human group 2 innate lymphoid cells (ILC2) accumulate in foetal lungs, at 10‐fold higher levels compared to adult lungs. However, there are no data on foetal ILC2 numbers and the association with respiratory health outcomes such as lung function in early life. We aimed to investigate cord blood immune cell populations from babies born to mothers with asthma in pregnancy. Methods Cord blood from babies born to asthmatic mothers was collected, and cells were stained in whole cord blood. Analyses were done using traditional gating approaches and computational methodologies (t‐distributed stochastic neighbour embedding and PhenoGraph algorithms). At 6 weeks of age, the time to peak tidal expiratory flow as a percentage of total expiratory flow time (tPTEF/tE%) was determined as well as Lung Clearance Index (LCI), during quiet natural sleep. Results Of 110 eligible infants (March 2017 to November 2019), 91 were successfully immunophenotyped (82.7%). Lung function was attempted in 61 infants (67.0%), and 43 of those infants (70.5% of attempted) had technically acceptable tPTEF/tE% measurements. Thirty‐four infants (55.7% of attempted) had acceptable LCI measurements. Foetal ILC2 numbers with increased expression of chemoattractant receptor‐homologous molecule (CRTh2), characterised by two distinct analysis methodologies, were associated with poorer infant lung function at 6 weeks of age.” Conclusion Foetal immune responses may be a surrogate variable for or directly influence lung function outcomes in early life.
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Affiliation(s)
- Gabriela Martins Costa Gomes
- Priority Research Centre GrowUpWell® - Hunter Medical Research Institute The University of Newcastle Newcastle NSW Australia
| | - Patricia de Gouveia Belinelo
- Priority Research Centre GrowUpWell® - Hunter Medical Research Institute The University of Newcastle Newcastle NSW Australia
| | - Malcolm R Starkey
- Priority Research Centre GrowUpWell® - Hunter Medical Research Institute The University of Newcastle Newcastle NSW Australia.,Priority Research Centre for Healthy Lungs - Hunter Medical Research Institute University of Newcastle Newcastle NSW Australia.,Department of Immunology and Pathology Central Clinical School Monash University Melbourne VIC Australia
| | - Vanessa E Murphy
- Priority Research Centre GrowUpWell® - Hunter Medical Research Institute The University of Newcastle Newcastle NSW Australia
| | - Philip M Hansbro
- Priority Research Centre for Healthy Lungs - Hunter Medical Research Institute University of Newcastle Newcastle NSW Australia.,Centenary UTS Centre for Inflammation Centenary Institute Sydney NSW Australia
| | - Peter D Sly
- Child Health Research Centre University of Queensland Brisbane QLD Australia
| | - Paul D Robinson
- Department of Respiratory Medicine The Children's Hospital at Westmead Sydney NSW Australia
| | | | - Peter G Gibson
- Priority Research Centre for Healthy Lungs - Hunter Medical Research Institute University of Newcastle Newcastle NSW Australia.,Sleep Medicine Department John Hunter Hospital Newcastle NSW Australia
| | - Joerg Mattes
- Priority Research Centre GrowUpWell® - Hunter Medical Research Institute The University of Newcastle Newcastle NSW Australia.,Paediatric Respiratory & Sleep Medicine Department John Hunter Children's Hospital Newcastle NSW Australia
| | - Adam M Collison
- Priority Research Centre GrowUpWell® - Hunter Medical Research Institute The University of Newcastle Newcastle NSW Australia
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20
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Stahl M, Steinke E, Graeber SY, Joachim C, Seitz C, Kauczor HU, Eichinger M, Hämmerling S, Sommerburg O, Wielpütz MO, Mall MA. Magnetic Resonance Imaging Detects Progression of Lung Disease and Impact of Newborn Screening in Preschool Children with Cystic Fibrosis. Am J Respir Crit Care Med 2021; 204:943-953. [PMID: 34283704 DOI: 10.1164/rccm.202102-0278oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Previous cross-sectional studies demonstrated that chest magnetic resonance imaging (MRI) is sensitive to detect early lung disease in infants and preschool children with cystic fibrosis (CF) without radiation exposure. However, the ability of MRI to detect progression of lung disease and the impact of early diagnosis in preschool children with CF remains unknown. OBJECTIVES To investigate the potential of MRI to detect progression of early lung disease and impact of early diagnosis by CF newborn screening (NBS) in preschool children with CF. METHODS Annual MRI was performed from diagnosis over four years in a cohort of 96 preschool children with CF (age 0-4 yr) that were concurrently diagnosed based on NBS (n=28) or clinical symptoms (n=68). MRI scans were evaluated using a dedicated morphofunctional score and the relationship between longitudinal MRI scores and respiratory symptoms, pulmonary exacerbations, upper airway microbiology and mode of diagnosis were determined. MEASUREMENTS AND MAIN RESULTS The MRI global score increased in the total cohort of children with CF during preschool years (P<0.001) which was associated with cough, pulmonary exacerbations (P<0.0001), and detection of Staphylococcus aureus and Haemophilus influenzae (P<0.05). MRI-defined abnormalities in lung morphology, especially airway wall thickening/bronchiectasis, were lower in NBS compared to clinically diagnosed children with CF throughout the observation period (P<0.01). CONCLUSIONS MRI detected progression of early lung disease and benefits of early diagnosis by NBS in preschool children with CF. These findings support MRI as sensitive outcome measure for diagnostic monitoring and early intervention trials in preschool children with CF.
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Affiliation(s)
- Mirjam Stahl
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Berlin, Germany.,German Center for Lung Research (DZL), associated partner site, Berlin, Germany.,University of Heidelberg, Department of Translational Pulmonology, Heidelberg, Germany.,German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Eva Steinke
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Berlin, Germany.,University of Heidelberg, Department of Translational Pulmonology, Heidelberg, Germany.,University of Heidelberg, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Simon Y Graeber
- Charite Universitatsmedizin Berlin, 14903, Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Berlin, Germany.,German Center for Lung Research (DZL), associated partner site, Berlin, Germany.,University of Heidelberg, Department of Translational Pulmonology, Heidelberg, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Cornelia Joachim
- University of Heidelberg, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Christoph Seitz
- University of Heidelberg, 9144, Department of Pediatrics, Division of Neonatology, Heidelberg, Germany.,Pediatric Practice , Medical Biometrics Advisor, Bad Saulgau, Germany
| | - Hans-Ulrich Kauczor
- University of Heidelberg, 9144, Department of Translational Pulmonology, Heidelberg, Germany.,German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany.,University of Heidelberg, 9144, Department of Diagnostic and Interventional Radiology, Heidelberg, Germany
| | - Monika Eichinger
- German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany.,University of Heidelberg, Department of Diagnostic and Interventional Radiology, Heidelberg, Germany.,Thoraxklinik at University Hospital Heidelberg, Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Heidelberg, Germany
| | - Susanne Hämmerling
- University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany
| | - Olaf Sommerburg
- University of Heidelberg, 9144, Department of Translational Pulmonology, Heidelberg, Germany.,University of Heidelberg, 9144, Department of Pediatrics, Division of Pediatric Pulmonology and Allergy and Cystic Fibrosis Center, Heidelberg, Germany.,German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany
| | - Mark O Wielpütz
- German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), Heidelberg, Germany.,University of Heidelberg, 9144, Department of Diagnostic and Interventional Radiology, Heidelberg, Germany.,German Cancer Research Center (DKFZ), Department of Radiology, Heidelberg, Germany
| | - Marcus A Mall
- Charité Universitätsmedizin Berlin, 14903, Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Berlin, Germany.,German Center for Lung Research (DZL), associated partner site, Berlin, Germany.,University of Heidelberg, Department of Translational Pulmonology, Heidelberg, Germany.,Berlin Institute of Health (BIH), Berlin, Germany;
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21
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Stanojevic S, Davis SD, Perrem L, Shaw M, Retsch-Bogart G, Davis M, Jensen R, Clem CC, Isaac SM, Guido J, Jara S, France L, McDonald N, Solomon M, Sweezey N, Grasemann H, Waters V, Sanders DB, Ratjen FA. Determinants of lung disease progression measured by lung clearance index in children with cystic fibrosis. Eur Respir J 2021; 58:13993003.03380-2020. [PMID: 33542049 DOI: 10.1183/13993003.03380-2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/11/2020] [Indexed: 02/06/2023]
Abstract
The lung clearance index (LCI) measured by the multiple breath washout (MBW) test is sensitive to early lung disease in children with cystic fibrosis. While LCI worsens during the preschool years in cystic fibrosis, there is limited evidence to clarify whether this continues during the early school age years, and whether the trajectory of disease progression as measured by LCI is modifiable.A cohort of children (healthy and cystic fibrosis) previously studied for 12 months as preschoolers were followed during school age (5-10 years). LCI was measured every 3 months for a period of 24 months using the Exhalyzer D MBW nitrogen washout device. Linear mixed effects regression was used to model changes in LCI over time.A total of 582 MBW measurements in 48 healthy subjects and 845 measurements in 64 cystic fibrosis subjects were available. The majority of children with cystic fibrosis had elevated LCI at the first preschool and first school age visits (57.8% (37 out of 64)), whereas all but six had normal forced expiratory volume in 1 s (FEV1) values at the first school age visit. During school age years, the course of disease was stable (-0.02 units·year-1 (95% CI -0.14-0.10). LCI measured during preschool years, as well as the rate of LCI change during this time period, were important determinants of LCI and FEV1, at school age.Preschool LCI was a major determinant of school age LCI; these findings further support that the preschool years are critical for early intervention strategies.
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Affiliation(s)
- Sanja Stanojevic
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Dept of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Stephanie D Davis
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Lucy Perrem
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Michelle Shaw
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - George Retsch-Bogart
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Miriam Davis
- Dept of Pediatrics; Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, UNC Children's, Chapel Hill, NC, USA
| | - Renee Jensen
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Charles C Clem
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah M Isaac
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Julia Guido
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Jara
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lisa France
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nancy McDonald
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Valerie Waters
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada
| | - D B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Dept of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Felix A Ratjen
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada.,Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
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22
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Stahl M. Sensitive markers to detect progression of lung disease in children with cystic fibrosis. Eur Respir J 2021; 58:58/1/2100236. [PMID: 34244301 DOI: 10.1183/13993003.00236-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Mirjam Stahl
- Dept of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany .,German Center for Lung Research (DZL), Associated Partner Site, Berlin, Germany
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23
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Quantification of Phenotypic Variability of Lung Disease in Children with Cystic Fibrosis. Genes (Basel) 2021; 12:genes12060803. [PMID: 34070354 PMCID: PMC8229033 DOI: 10.3390/genes12060803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 12/28/2022] Open
Abstract
Cystic fibrosis (CF) lung disease has the greatest impact on the morbidity and mortality of patients suffering from this autosomal-recessive multiorgan disorder. Although CF is a monogenic disorder, considerable phenotypic variability of lung disease is observed in patients with CF, even in those carrying the same mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene or CFTR mutations with comparable functional consequences. In most patients with CF, lung disease progresses from childhood to adulthood, but is already present in infants soon after birth. In addition to the CFTR genotype, the variability of early CF lung disease can be influenced by several factors, including modifier genes, age at diagnosis (following newborn screening vs. clinical symptoms) and environmental factors. The early onset of CF lung disease requires sensitive, noninvasive measures to detect and monitor changes in lung structure and function. In this context, we review recent progress with using multiple-breath washout (MBW) and lung magnetic resonance imaging (MRI) to detect and quantify CF lung disease from infancy to adulthood. Further, we discuss emerging data on the impact of variability of lung disease severity in the first years of life on long-term outcomes and the potential use of this information to improve personalized medicine for patients with CF.
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24
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Bayfield KJ, Douglas TA, Rosenow T, Davies JC, Elborn SJ, Mall M, Paproki A, Ratjen F, Sly PD, Smyth AR, Stick S, Wainwright CE, Robinson PD. Time to get serious about the detection and monitoring of early lung disease in cystic fibrosis. Thorax 2021; 76:1255-1265. [PMID: 33927017 DOI: 10.1136/thoraxjnl-2020-216085] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 02/24/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022]
Abstract
Structural and functional defects within the lungs of children with cystic fibrosis (CF) are detectable soon after birth and progress throughout preschool years often without overt clinical signs or symptoms. By school age, most children have structural changes such as bronchiectasis or gas trapping/hypoperfusion and lung function abnormalities that persist into later life. Despite improved survival, gains in forced expiratory volume in one second (FEV1) achieved across successive birth cohorts during childhood have plateaued, and rates of FEV1 decline in adolescence and adulthood have not slowed. This suggests that interventions aimed at preventing lung disease should be targeted to mild disease and commence in early life. Spirometry-based classifications of 'normal' (FEV1≥90% predicted) and 'mild lung disease' (FEV1 70%-89% predicted) are inappropriate, given the failure of spirometry to detect significant structural or functional abnormalities shown by more sensitive imaging and lung function techniques. The state and readiness of two imaging (CT and MRI) and two functional (multiple breath washout and oscillometry) tools for the detection and monitoring of early lung disease in children and adults with CF are discussed in this article.Prospective research programmes and technological advances in these techniques mean that well-designed interventional trials in early lung disease, particularly in young children and infants, are possible. Age appropriate, randomised controlled trials are critical to determine the safety, efficacy and best use of new therapies in young children. Regulatory bodies continue to approve medications in young children based on safety data alone and extrapolation of efficacy results from older age groups. Harnessing the complementary information from structural and functional tools, with measures of inflammation and infection, will significantly advance our understanding of early CF lung disease pathophysiology and responses to therapy. Defining clinical utility for these novel techniques will require effective collaboration across multiple disciplines to address important remaining research questions. Future impact on existing management burden for patients with CF and their family must be considered, assessed and minimised.To address the possible role of these techniques in early lung disease, a meeting of international leaders and experts in the field was convened in August 2019 at the Australiasian Cystic Fibrosis Conference. The meeting entitiled 'Shaping imaging and functional testing for early disease detection of lung disease in Cystic Fibrosis', was attended by representatives across the range of disciplines involved in modern CF care. This document summarises the proceedings, key priorities and important research questions highlighted.
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Affiliation(s)
- Katie J Bayfield
- Department of Respiratory Medicine, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Tonia A Douglas
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Tim Rosenow
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Perth, Western Australia, Australia
| | - Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Stuart J Elborn
- Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Marcus Mall
- Department of Pediatric Pulmonology, Immunology, and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Department of Translational Pulmonology, German Center for Lung Research, Berlin, Germany
| | - Anthony Paproki
- The Australian e-Health Research Centre, CSIRO, Brisbane, Queensland, Australia
| | - Felix Ratjen
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Peter D Sly
- Children's Health and Environment Program, Child Health Research Centre, The University of Queenland, Herston, Queensland, Australia
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology. School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Stephen Stick
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Child Health Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Claire E Wainwright
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Paul D Robinson
- Department of Respiratory Medicine, Children's Hospital at Westmead, Westmead, New South Wales, Australia .,Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.,The Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
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25
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Mondéjar-López P, Horsley A, Ratjen F, Bertolo S, de Vicente H, Asensio de la Cruz Ò. A multimodal approach to detect and monitor early lung disease in cystic fibrosis. Expert Rev Respir Med 2021; 15:761-772. [PMID: 33843417 DOI: 10.1080/17476348.2021.1908131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: In the early stages, lung involvement in cystic fibrosis (CF) can be silent, with disease progression occurring in the absence of clinical symptoms. Irreversible airway damage is present in the early stages of disease; however, reliable biomarkers of early damage due to inflammation and infection that are universally applicable in day-to-day patient management have yet to be identified.Areas covered: At present, the main methods of detecting and monitoring early lung disease in CF are the lung clearance index (LCI), computed tomography (CT), and magnetic resonance imaging (MRI). LCI can be used to detect patients who may require more intense monitoring, identify exacerbations, and monitor responses to new interventions. High-resolution CT detects structural alterations in the lungs of CF patients with the best resolution of current imaging techniques. MRI is a radiation-free imaging alternative that provides both morphological and functional information. The role of MRI for short-term follow-up and pulmonary exacerbations is currently being investigated.Expert opinion: The roles of LCI and MRI are expected to expand considerably over the next few years. Meanwhile, closer collaboration between pulmonology and radiology specialties is an important goal toward improving care and optimizing outcomes in young patients with CF.
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Affiliation(s)
- Pedro Mondéjar-López
- Pediatric Pulmonologist, Pediatric Pulmonology and Cystic Fibrosis Unit, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Alexander Horsley
- Honorary Consultant, Respiratory Research Group, Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, UK
| | - Felix Ratjen
- Head, Division of Respiratory Medicine, Department of Pediatrics, Translational Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Silvia Bertolo
- Radiologist, Department of Radiology, Ca'Foncello Regional Hospital, Treviso, Italy
| | | | - Òscar Asensio de la Cruz
- Pediatric Pulmonologist, Pediatric Unit, University Hospital Parc Taulí de Sabadell, Sabadell, Spain
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26
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Hildebrandt J, Rahn A, Kessler A, Speth F, Fischer DC, Ballmann M. Lung clearance index and diffusion capacity for CO to detect early functional pulmonary impairment in children with rheumatic diseases. Pediatr Rheumatol Online J 2021; 19:23. [PMID: 33676536 PMCID: PMC7937245 DOI: 10.1186/s12969-021-00509-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/19/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In adults with rheumatic diseases pulmonary complications are relevant contributors to morbidity and mortality. In these patients diffusion capacity for CO (DLCO) is an established method to detect early pulmonary impairment. Pilot studies using DLCO indicate that early functional pulmonary impairment is present even in children with rheumatic disease albeit not detectable by spirometry and without clinical signs of pulmonary disease. Since the lung clearance index (LCI) is also a non-invasive, feasible and established method to detect early functional pulmonary impairment especially in children and because it requires less cooperation (tidal breathing), we compared LCI versus DLCO (forced breathing and breath-holding manoeuvre) in children with rheumatic diseases. FINDINGS Nineteen patients (age 9-17 years) with rheumatic disease and no clinical signs of pulmonary disease successfully completed LCI and DLCO during annual check-up. In 2 patients LCI and DLCO were within physiological limits. By contrast, elevated LCI combined with physiological results for DLCO were seen in 8 patients and in 9 patients both, the LCI and DLCO indicate early functional pulmonary changes. Overall, LCI was more sensitive than DLCO to detect early functional pulmonary impairment (p = 0.0128). CONCLUSIONS Our findings suggest that early functional pulmonary impairment is already present in children with rheumatic diseases. LCI is a very feasible and non-invasive alternative for detection of early functional pulmonary impairment in children. It is more sensitive and less cooperation dependent than DLCO. Therefore, we suggest to integrate LCI in routine follow-up of rheumatic diseases in children.
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Affiliation(s)
- Julia Hildebrandt
- grid.10493.3f0000000121858338Department of Pediatrics, Rostock University Medical Centre, Ernst-Heydemann Strasse 8, DE 18057 Rostock, Germany
| | - Anja Rahn
- grid.10493.3f0000000121858338Department of Pediatrics, Rostock University Medical Centre, Ernst-Heydemann Strasse 8, DE 18057 Rostock, Germany
| | - Anja Kessler
- grid.10493.3f0000000121858338Department of Pediatrics, Rostock University Medical Centre, Ernst-Heydemann Strasse 8, DE 18057 Rostock, Germany
| | - Fabian Speth
- grid.10493.3f0000000121858338Department of Pediatrics, Rostock University Medical Centre, Ernst-Heydemann Strasse 8, DE 18057 Rostock, Germany
| | - Dagmar-Christiane Fischer
- grid.10493.3f0000000121858338Department of Pediatrics, Rostock University Medical Centre, Ernst-Heydemann Strasse 8, DE 18057 Rostock, Germany
| | - Manfred Ballmann
- Department of Pediatrics, Rostock University Medical Centre, Ernst-Heydemann Strasse 8, DE 18057, Rostock, Germany.
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27
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Muston HN, Perrem L, Davis MD, Ratjen F, Ren CL. The remaining barriers to normalcy in CF: Advances in assessment of CF lung disease. Pediatr Pulmonol 2021; 56 Suppl 1:S90-S96. [PMID: 32589821 DOI: 10.1002/ppul.24929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/20/2020] [Accepted: 06/23/2020] [Indexed: 11/12/2022]
Abstract
Despite early diagnosis of cystic fibrosis (CF) through newborn screening, a substantial proportion of infants and young children with CF still demonstrate physiologic and structural evidence of lung disease progression, such as obstructive airway disease and bronchiectasis. The growing availability of highly effective CF transmembrane conductance regulatory modulator therapy to the vast majority of people with CF has led to the potential to alter the natural history of CF lung disease, but to assess the full impact of these therapies on CF lung disease and to help guide treatment, sensitive measures of early and mild disease are needed. Chest imaging using computed tomography or magnetic resonance imaging is one approach, but technologic barriers and/or concern about exposure to ionizing radiation may limit its use. However, advances in physiologic measurement techniques and exhaled breath analysis offer another option for assessment of CF lung disease.
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Affiliation(s)
- Heather N Muston
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Michael D Davis
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Riley Hospital for Children, Indianapolis, Indiana
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28
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Singer F, Schlegtendal A, Nyilas S, Vermeulen F, Boon M, Koerner-Rettberg C. Lung clearance index predicts pulmonary exacerbations in individuals with primary ciliary dyskinesia: a multicentre cohort study. Thorax 2021; 76:681-688. [PMID: 33504569 DOI: 10.1136/thoraxjnl-2020-215504] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lung clearance index (LCI) is a promising lung function outcome in individuals with primary ciliary dyskinesia (PCD). The impact of events clinically important for individuals with PCD, such as pulmonary exacerbations, on LCI is unknown. METHODS We conducted an international, multicentre, observational cohort study to assess the association of LCI and risk of pulmonary exacerbation, specific changes in LCI during pulmonary exacerbation and global variability of LCI across four visits every 4 months. Ninety individuals with PCD, aged 3-41 years, underwent nitrogen multiple-breath washout (MBW) and spirometry measurements. The association of LCI and pulmonary exacerbations was assessed by Cox proportional hazards and random-effects regression models. RESULTS We obtained 430 MBW and 427 spirometry measurements. In total, 379 person-years at risk contributed to the analysis. Per one unit increase (deterioration) in LCI, the risk of future pulmonary exacerbation increased by 13%: HR (95% CI), 1.13 (1.04 to 1.23). If LCI changed from a range of values considered normal to abnormal, the risk of future pulmonary exacerbations increased by 87%: 1.87 (1.08 to 3.23). During pulmonary exacerbations, LCI increased by 1.22 units (14.5%). After pulmonary exacerbations, LCI tended to decline. Estimates of variability in LCI suggested lower variation within individuals compared with variation between individuals. Findings were comparable for forced expiratory volume in 1 s. CONCLUSION On a visit-to-visit basis, LCI measurement may add to the prediction of pulmonary exacerbations, the assessment of lung function decline and the potential lung function response to treatment of pulmonary exacerbations.
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Affiliation(s)
- Florian Singer
- Division of Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Schlegtendal
- Department of Paediatric Pulmonology, University Children's Hospital of Ruhr University Bochum at St. Josef-Hospital, Bochum, Germany
| | - Sylvia Nyilas
- Department of Diagnostic, Interventional, and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - François Vermeulen
- Paediatric Pulmonology, Department of Paediatrics, University Hospital Gasthuisberg, Leuven, Belgium
| | - Mieke Boon
- Paediatric Pulmonology, Department of Paediatrics, University Hospital Gasthuisberg, Leuven, Belgium
| | - Cordula Koerner-Rettberg
- Department of Paediatric Pulmonology, University Children's Hospital of Ruhr University Bochum at St. Josef-Hospital, Bochum, Germany .,Children's Hospital, Research Institute, Marien Hospital Wesel, Wesel, Germany
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29
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Hatziagorou E, Kampouras A, Avramidou V, Toulia I, Chrysochoou EA, Galogavrou M, Kirvassilis F, Tsanakas J. Toward the Establishment of New Clinical Endpoints for Cystic Fibrosis: The Role of Lung Clearance Index and Cardiopulmonary Exercise Testing. Front Pediatr 2021; 9:635719. [PMID: 33718306 PMCID: PMC7946844 DOI: 10.3389/fped.2021.635719] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/03/2021] [Indexed: 01/25/2023] Open
Abstract
As Cystic Fibrosis (CF) treatment advances, research evidence has highlighted the value and applicability of Lung Clearance Index and Cardiopulmonary Exercise Testing as endpoints for clinical trials. In the context of these new endpoints for CF trials, we have explored the use of these two test outcomes for routine CF care. In this review we have presented the use of these methods in assessing disease severity, disease progression, and the efficacy of new interventions with considerations for future research.
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Affiliation(s)
- Elpis Hatziagorou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Asterios Kampouras
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Avramidou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ilektra Toulia
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elisavet-Anna Chrysochoou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Galogavrou
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Kirvassilis
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Tsanakas
- Pediatric Pulmonology and Cystic Fibrosis Unit, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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30
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Frauchiger BS, Carlens J, Herger A, Moeller A, Latzin P, Ramsey KA. Multiple breath washout quality control in the clinical setting. Pediatr Pulmonol 2021; 56:105-112. [PMID: 33058570 DOI: 10.1002/ppul.25119] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Multiple breath washout (MBW) is increasingly used in the clinical assessment of patients with cystic fibrosis (CF). Guidelines for MBW quality control (QC) were developed primarily for retrospective assessment and central overreading. We assessed whether real-time QC of MBW data during the measurement improves test acceptability in the clinical setting. METHODS We implemented standardized real-time QC and reporting of MBW data at the time of the measurement in the clinical pediatric lung function laboratory in Bern, Switzerland, in children with CF aged 4-18 years. We assessed MBW test acceptability before (31 tests; 89 trials) and after (32 tests; 96 trials) implementation of real-time QC and compared agreement between reviewers. Further, we assessed the implementation of real-time QC at a secondary center in Zurich, Switzerland. RESULTS Before the implementation of real-time QC in Bern, only 58% of clinical MBW tests were deemed acceptable following retrospective QC by an experienced reviewer. After the implementation of real-time QC, MBW test acceptability improved to 75% in Bern. In Zurich, after the implementation of real-time QC, test acceptability improved from 38% to 70%. Further, the agreement between MBW operators and an experienced reviewer for test acceptability was 84% in Bern and 93% in Zurich. CONCLUSION Real-time QC of MBW data at the time of measurement is feasible in the clinical setting and results in improved test acceptability.
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Affiliation(s)
- Bettina S Frauchiger
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Julia Carlens
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Clinic for Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Andreas Herger
- Division of Respiratory Medicine and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Alexander Moeller
- Division of Respiratory Medicine and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Philipp Latzin
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kathryn A Ramsey
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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31
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Pennati F, Borzani I, Moroni L, Russo MC, Faelli N, Aliverti A, Colombo C. Longitudinal Assessment of Patients With Cystic Fibrosis Lung Disease With Multivolume Noncontrast
MRI
and Spirometry. J Magn Reson Imaging 2020; 53:1570-1580. [DOI: 10.1002/jmri.27461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria Politecnico di Milano Milan Italy
| | - Irene Borzani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Pediatric Radiology Milan Italy
| | - Laura Moroni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Università degli Studi di Milano, Centro Fibrosi Cistica Milan Italy
| | - Maria Chiara Russo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Università degli Studi di Milano, Centro Fibrosi Cistica Milan Italy
| | - Nadia Faelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Università degli Studi di Milano, Centro Fibrosi Cistica Milan Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria Politecnico di Milano Milan Italy
| | - Carla Colombo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Università degli Studi di Milano, Centro Fibrosi Cistica Milan Italy
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32
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Multiple breath washout: A noninvasive tool for identifying lung disease in symptomatic military deployers. Respir Med 2020; 176:106281. [PMID: 33340829 DOI: 10.1016/j.rmed.2020.106281] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023]
Abstract
RATIONALE Military deployments to austere environments since November 9, 2001 may put "deployers" at risk for respiratory disease. Sensitive, noninvasive tools for detecting large and small airways injury are needed to identify early disease and help inform management for this at-risk population. OBJECTIVES We examined multiple breath washout (MBW) as a tool for identifying deployment-related airways disease and assessed host and exposure risk factors compared to healthy controls. METHODS Between March 2015 and March 2020, 103 healthy controls and 71 symptomatic deployers with asthma and/or distal lung disease completed a questionnaire, spirometry and MBW testing. SAS v. 9.4 was used to compare MBW parameters between deployers and controls via univariate analyses and adjusted for demographic factors using multiple linear regression. MEASUREMENTS AND MAIN RESULTS Deployers were significantly more likely than controls to have an abnormal lung clearance index (LCI) score indicating global ventilation inhomogeneity. Adjusting for sex, smoking status, smoking pack-years and body mass index, LCI scores were significantly more abnormal among those with deployment-related asthma and distal lung disease compared to controls. The unadjusted variable Sacin (a marker of ventilation inhomogeneity in the acinar airways) was higher and thus more abnormal in those with both proximal and distal airways disease. Deployers who reported more frequent exposure to explosive blasts had significantly higher LCI scores. CONCLUSIONS This study demonstrates the utility of MBW in evaluating exposure-related airways disease in symptomatic military personnel following deployment to austere environments, and is the first to link exposure to explosive blasts to measurable small airways injury.
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33
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Davies G, Stanojevic S, Raywood E, Duncan JA, Stocks J, Lum S, Bush A, Viviani L, Wade A, Calder A, Owens CM, Goubau C, Carr SB, Bossley CJ, Pao C, Aurora P. An observational study of the lung clearance index throughout childhood in cystic fibrosis: early years matter. Eur Respir J 2020; 56:13993003.00006-2020. [PMID: 32444409 PMCID: PMC7527650 DOI: 10.1183/13993003.00006-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 04/23/2020] [Indexed: 01/15/2023]
Abstract
The London Cystic Fibrosis Collaboration (LCFC) has prospectively followed a clinically diagnosed cohort of infants with cystic fibrosis (CF) born in South East England since 1999 [1–4]. Over the past 20 years, the LCFC has obtained comprehensive measures of lung function and structure, including measures of ventilation inhomogeneity (lung clearance index (LCI)) and high-resolution computed tomography (HRCT) scans. By pre-school age, 73% of this cohort had LCI above the limits of normal, compared with 7% with abnormal forced expiratory volume in 0.5 seconds (FEV0.5) [1]. Children with elevated LCI during pre-school years also had worse lung function at early school age [2]. The aim of this study was to investigate how LCI changes across childhood to better understand to what extent LCI results at pre-school age are an indicator of lung disease severity in adolescence. Lung clearance index (LCI) in the early years was associated with LCI during adolescence in children with cystic fibrosis. Pre-school LCI may help to identify children in whom treatment could be intensified.https://bit.ly/2yKyMbM
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Affiliation(s)
- Gwyneth Davies
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK .,Dept of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Joint first authors
| | - Sanja Stanojevic
- Translational Medicine, SickKids Research Institute, Toronto, ON, Canada.,Joint first authors
| | - Emma Raywood
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK
| | - Julie A Duncan
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK
| | - Janet Stocks
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK
| | - Sooky Lum
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK
| | - Andrew Bush
- Dept of Paediatric Respiratory Medicine, Imperial College and Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Laura Viviani
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK
| | - Angie Wade
- Clinical Epidemiology, Nutrition and Biostatistics Section, UCL GOS ICH, London, UK
| | - Alistair Calder
- Dept of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Catherine M Owens
- Dept of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Christophe Goubau
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK
| | - Siobhán B Carr
- Dept of Paediatric Respiratory Medicine, Imperial College and Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Cara J Bossley
- Dept of Paediatric Respiratory Medicine, Kings College Hospital, London, UK
| | - Caroline Pao
- Dept of Paediatric Respiratory Medicine, Royal London Hospital, London, UK
| | - Paul Aurora
- Infection, Immunity and Inflammation Research and Teaching Dept, UCL Great Ormond Street Institute of Child Health (UCL GOS ICH), London, UK.,Dept of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Davies JC, Sermet-Gaudelus I, Naehrlich L, Harris RS, Campbell D, Ahluwalia N, Short C, Haseltine E, Panorchan P, Saunders C, Owen CA, Wainwright CE. A phase 3, double-blind, parallel-group study to evaluate the efficacy and safety of tezacaftor in combination with ivacaftor in participants 6 through 11 years of age with cystic fibrosis homozygous for F508del or heterozygous for the F508del-CFTR mutation and a residual function mutation. J Cyst Fibros 2020; 20:68-77. [PMID: 32967799 DOI: 10.1016/j.jcf.2020.07.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The CFTR modulator tezacaftor/ivacaftor was efficacious and generally safe and well tolerated in Phase 3 studies in participants ≥12 years of age with cystic fibrosis (CF) homozygous for the F508del-CFTR mutation or heterozygous with a residual function-CFTR mutation (F/F or F/RF respectively). We evaluated tezacaftor/ivacaftor's efficacy and safety over 8 weeks in participants 6 through 11 years of age with these mutations. METHODS Participants were randomized 4:1 to tezacaftor/ivacaftor or a blinding group (placebo for F/F, ivacaftor for F/RF). The primary endpoint was within-group change from baseline in the lung clearance index 2·5 (LCI2·5) through Week 8. Secondary endpoints were change from baseline in sweat chloride (SwCl), cystic fibrosis questionnaire-revised (CFQ-R) respiratory domain score, and safety. RESULTS Sixty-seven participants received at least one study drug dose. Of those, 54 received tezacaftor/ivacaftor (F/F, 42; F/RF, 12), 10 placebo, and 3 ivacaftor; 66 completed the study. The within-group change in LCI2·5 was significantly reduced (improved) by -0·51 (95% CI: -0·74, -0·29). SwCl concentration decreased (improved) by -12·3 mmol/L and CFQ-R respiratory domain score increased (improved, nonsignificantly) by 2·3 points. There were no serious adverse events (AEs) or AEs leading to tezacaftor/ivacaftor discontinuation or interruption. The most common AEs (≥10%) in participants receiving tezacaftor/ivacaftor were cough, headache, and productive cough. CONCLUSIONS Tezacaftor/ivacaftor improved lung function (assessed using LCI) and CFTR function (measured by SwCl concentration) in participants 6 through 11 years of age with F/F or F/RF genotypes. Tezacaftor/ivacaftor was safe and well tolerated; no new safety concerns were identified.
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Affiliation(s)
- Jane C Davies
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
| | - Isabelle Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Université Paris Sorbonne, Paris, France, Hôpital Necker-Enfants malades, Paris, France
| | - Lutz Naehrlich
- Department of Pediatrics, Justus Liebig University Giessen, Giessen, Germany; Universities of Giessen and Marburg Lung Center, The German Center for Lung Research, Giessen, Germany
| | - R Scott Harris
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Daniel Campbell
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Neil Ahluwalia
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Christopher Short
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Eric Haseltine
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Paul Panorchan
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
| | - Clare Saunders
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Caroline A Owen
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States
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Skov L, Green K, Stanojevic S, Jensen R, Buchvald F, Ratjen F, Nielsen KG. Lung compartment analysis assessed from N 2 multiple-breath washout in children with cystic fibrosis. Pediatr Pulmonol 2020; 55:1671-1680. [PMID: 32297698 DOI: 10.1002/ppul.24773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 03/31/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Compartment analysis (CA) based on nitrogen multiple-breath washout (N2 MBW) has been shown to allow the assessment of specific volume and ventilation of faster- and slower-ventilating lung compartments of the lung in adults with cystic fibrosis (CF). The aim of this study was to extend previous findings into the pediatric age range. METHODS Cross-sectional multicenter observational study in children with CF and healthy controls (HC) was done with the assessment of N2 MBW and spirometry. A two-lung compartment model-based analysis (CA) was used to estimate size and function of faster- and slower-ventilating lung compartments from N2 MBW. RESULTS A total of 125 children with CF and 177 HC, median age 10.8 (range, 2.8-18.9) years, were included in the analysis. CA could be calculated in 66 (53%) children with CF compared with 48 (27%) HC (P < .0001). The proportion of the slower-ventilating lung compartment was significantly smaller in children with CF (53.5%; 95% confidence interval [CI]: 51.9%-55.7%) compared with HC (62.2%; 95% CI: 59.0%-65.0%) The regional specific ventilation of the slower compartment (rVT ,slow/rFRC,slow, %) was significantly lower in children with CF (4.9%; 95% CI: 4.5-5.9) compared with HC (9.7%, 95% CI: 9.2-10.9), and showed inverse correlation to lung clearance index (r2 = -.65; P < .0001), Sacin × VT (r2 = -.36; P = .003) and Scond × VT (r2 = -.51; P < .0001). There was no significant difference in pulmonary parameters between children with CF with and without feasible CA. CONCLUSION CA is less feasible in children than in adults and correlated to other MBW parameters. The clinical value of CA is still unclear and is yet to be established.
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Affiliation(s)
- Linnea Skov
- Pediatric Pulmonary Service, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kent Green
- Pediatric Pulmonary Service, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanja Stanojevic
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Renee Jensen
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Frederik Buchvald
- Pediatric Pulmonary Service, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Felix Ratjen
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kim G Nielsen
- Pediatric Pulmonary Service, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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36
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Robinson TE, Goris ML, Moss RB, Tian L, Kan P, Yilma M, McCoy KS, Newman B, de Jong PA, Long FR, Brody AS, Behrje R, Yates DP, Cornfield DN. Mucus plugging, air trapping, and bronchiectasis are important outcome measures in assessing progressive childhood cystic fibrosis lung disease. Pediatr Pulmonol 2020; 55:929-938. [PMID: 31962004 DOI: 10.1002/ppul.24646] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/30/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine which outcome measures could detect early progression of disease in school-age children with mild cystic fibrosis (CF) lung disease over a two-year time interval utilizing chest computed tomography (CT) scores, quantitative CT air trapping (QAT), and spirometric measurements. METHODS Thirty-six school-age children with mild CF lung disease (median [interquartile range] age 12 [3.7] years; percent predicted forced expiratory volume in 1 second (ppFEV1 ) 99 [12.5]) were evaluated by serial spirometer-controlled chest CT scans and spirometry at baseline, 3-month, 1- and 2-years. RESULTS No significant changes were noted at 3-month for any variable except for decreased ppFEV1 . Mucus plugging score (MPS) and QATA1andA2 increased at 1- and 2-years. The bronchiectasis score (BS), and total score (TS) were increased at 2-year. All variables tested with the exception of bronchial wall thickness score, parenchymal score (PS), and ppFEV1 , were consistent with longitudinal worsening of lung disease. Multivariate analysis revealed baseline PS, baseline TS, and 1-year changes in BS and air trapping score were predictive of 2-year changes in BS. CONCLUSIONS MPS and QATA1-A2 were the most sensitive indicators of progressive childhood CF lung disease. The 1-year change in the bronchiectasis score had the most positive predictive power for 2-year change in bronchiectasis.
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Affiliation(s)
- Terry E Robinson
- Department of Pediatrics, Center of Excellence in Pulmonary Biology, Stanford University School of Medicine, Stanford, California
| | - Michael L Goris
- Division of Nuclear Medicine/Radiology, Stanford University School of Medicine, Stanford, California
| | - Richard B Moss
- Department of Pediatrics, Center of Excellence in Pulmonary Biology, Stanford University School of Medicine, Stanford, California
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
| | - Peiyi Kan
- Department of Pediatrics Research and Statistical Unit, Stanford University School of Medicine, Stanford, California
| | - Mignote Yilma
- Department of Pediatrics, Center of Excellence in Pulmonary Biology, Stanford University School of Medicine, Stanford, California
| | - Karen S McCoy
- Division of Pulmonary Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Beverley Newman
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Frederick R Long
- Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Alan S Brody
- Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Rhett Behrje
- Department of Global Development, Takeda Pharmaceuticals, Cambridge, Massachusetts
| | - Denise P Yates
- Department of Biomarker Development, Novartis Institutes for BioMedical Research, Cambridge, Massachusetts
| | - David N Cornfield
- Department of Pediatrics, Center of Excellence in Pulmonary Biology, Stanford University School of Medicine, Stanford, California
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Lung clearance index evaluation in detecting nocturnal hypoxemia in cystic fibrosis patients: Toward a new diagnostic tool. Respir Med 2020; 164:105906. [PMID: 32217291 DOI: 10.1016/j.rmed.2020.105906] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/15/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Nocturnal hypoxemia adversely affects outcomes in patients with cystic fibrosis (CF). Although an early detection of this abnormality may be desirable, still its predictability remains uncertain. The Lung Clearance Index (LCI) is a measure of lung ventilation distribution obtained from a multiple-breath washout technique (MBW), recently implemented in patients with CF. This study aimed to establish whether the LCI predicts nocturnal hypoxemia in patients with stable CF, with mild to moderate disease, and normal diurnal gas exchange. METHODS 31 stable patients (15 males, mean age 17.4 ± 5.2 years) with mild to moderate CF, normoxic when awake, were enrolled. In all patients we performed nocturnal cardio-respiratory polygraphy, lung function measurement, and MBW test to derive LCI values. RESULTS LCI was abnormal in most of the patients and inversely correlated with mean nocturnal SpO2 (r = -0.880 p < 0.01). A receiver operating characteristic (ROC) analysis, performed to assess whether LCI predicted nocturnal hypoxemia, revealed a high predictive accuracy of LCI for nocturnal desaturation (AUC = 0.96; Youden index = 0.79). Forced expiratory volume in 1 s (FEV1) was predictive only in patients with more severe airway obstruction, with a moderate degree of accuracy (AUC 0.71). CONCLUSIONS The LCI showed a high effectiveness in predicting nocturnal hypoxemia in stable patients with CF, particularly when compared with a traditional parameter of lung function such as FEV1.
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Davies G, Thia LP, Stocks J, Bush A, Hoo AF, Wade A, Nguyen TTD, Brody AS, Calder A, Klein NJ, Carr SB, Wallis C, Suri R, Pao CS, Ruiz G, Balfour-Lynn IM. Minimal change in structural, functional and inflammatory markers of lung disease in newborn screened infants with cystic fibrosis at one year. J Cyst Fibros 2020; 19:896-901. [PMID: 32044244 DOI: 10.1016/j.jcf.2020.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND With the widespread introduction of newborn screening for cystic fibrosis (CF), there has been considerable emphasis on the need to develop objective markers of lung health that can be used during infancy. We hypothesised that in a newborn screened (NBS) UK cohort, evidence of airway inflammation and infection at one year would be associated with adverse structural and functional outcomes at the same age. METHODS Infants underwent lung function testing, chest CT scan and bronchoscopy with bronchoalveolar lavage (BAL) at 1 year of age when clinically well. Microbiology cultures were also available from routine cough swabs. RESULTS 65 infants had lung function, CT and BAL. Mean (SD) lung clearance index and forced expiratory volume in 0.5 s z-scores were 0.9(1.2) and -0.6(1.1) respectively; median Brody II CF-CT air trapping score on chest CT =0 (interquartile range 0-1, maximum possible score 27). Infants isolating any significant pathogen by 1 yr of age had higher LCI z-score (mean difference 0.9; 95%CI:0.4-1.4; p = 0.001) and a trend towards higher air trapping scores on CT (p = 0.06). BAL neutrophil elastase was detectable in 23% (10/43) infants in whom BAL supernatant was available. This did not relate to air trapping score on CT. CONCLUSIONS In this UK NBS cohort at one year of age, lung and airway damage is much milder and associations between inflammation, abnormal physiology and structural changes were at best weak, contrary to our hypothesis and previously published reports. Continued follow-up will clarify longer term implications of these very mild structural, functional and inflammatory changes.
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Affiliation(s)
- Gwyneth Davies
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.
| | - Lena P Thia
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Paediatric Respiratory Medicine, Cardiff University and Children's Hospital for Wales, Cardiff, United Kingdom
| | - Janet Stocks
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Imperial College & Royal Brompton & Harefield Hospital NHS Foundation Trust, London, United Kingdom
| | - Ah-Fong Hoo
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Angie Wade
- Clinical Epidemiology, Nutrition and Biostatistics Section, UCL GOS ICH, London, United Kingdom
| | - The Thanh Diem Nguyen
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Alan S Brody
- University of Cincinnati College of Medicine and Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Alistair Calder
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Nigel J Klein
- Infection, Inflammation and Rheumatology Section, UCL GOS ICH, London, United Kingdom
| | - Siobhán B Carr
- Department of Paediatric Respiratory Medicine, Imperial College & Royal Brompton & Harefield Hospital NHS Foundation Trust, London, United Kingdom
| | - Colin Wallis
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Ranjan Suri
- Respiratory, Critical Care and Anaesthesia section, UCL Great Ormond Street Institute of Child Health (GOS ICH), London, United Kingdom; Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Caroline S Pao
- Department of Paediatric Respiratory Medicine, Royal London Hospital, London, United Kingdom
| | - Gary Ruiz
- Department of Paediatric Respiratory Medicine, Kings College Hospital, London, United Kingdom
| | - Ian M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Imperial College & Royal Brompton & Harefield Hospital NHS Foundation Trust, London, United Kingdom
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Postinfectious Bronchiolitis Obliterans in Children: Diagnostic Workup and Therapeutic Options: A Workshop Report. Can Respir J 2020; 2020:5852827. [PMID: 32076469 PMCID: PMC7013295 DOI: 10.1155/2020/5852827] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/29/2019] [Accepted: 12/27/2019] [Indexed: 12/23/2022] Open
Abstract
Bronchiolitis obliterans (BO) is a rare, chronic form of obstructive lung disease, often initiated with injury of the bronchiolar epithelium followed by an inflammatory response and progressive fibrosis of small airways resulting in nonuniform luminal obliteration or narrowing. The term BO comprises a group of diseases with different underlying etiologies, courses, and characteristics. Among the better recognized inciting stimuli leading to BO are airway pathogens such as adenovirus and mycoplasma, which, in a small percentage of infected children, will result in progressive fixed airflow obstruction, an entity referred to as postinfectious bronchiolitis obliterans (PIBO). The present knowledge on BO in general is reasonably well developed, in part because of the relatively high incidence in patients who have undergone lung transplantation or bone marrow transplant recipients who have had graft-versus-host disease in the posttransplant period. The cellular and molecular pathways involved in PIBO, while assumed to be similar, have not been adequately elucidated. Since 2016, an international consortium of experts with an interest in PIBO assembles on a regular basis in Geisenheim, Germany, to discuss key areas in PIBO which include diagnostic workup, treatment strategies, and research fields.
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40
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Kasi AS, Wee CP, Keens TG, Salinas DB. Abnormal Lung Clearance Index in Cystic Fibrosis Screen Positive, Inconclusive Diagnosis (CFSPID) Children with Otherwise Normal FEV1. Lung 2019; 198:163-167. [DOI: 10.1007/s00408-019-00307-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
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Abstract
With the improving survival of cystic fibrosis (CF) patients and the advent of highly effective cystic fibrosis transmembrane conductance regulator therapy, the clinical spectrum of this complex multisystem disease continues to evolve. One of the most important clinical events for patients with CF in the course of this disease is an acute pulmonary exacerbation. Clinical and microbial epidemiology studies of CF pulmonary exacerbations continue to provide important insight into the disease course, prognosis, and complications. This work has now led to a number of large scale clinical trials with the goal of improving the treatment paradigm for CF pulmonary exacerbation. The primary goal of this review is to provide a summary of the pathophysiology, the clinical epidemiology, microbial epidemiology, outcome and the treatment of CF pulmonary exacerbation.
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Affiliation(s)
- Christopher H Goss
- CFF Therapeutics Development Network Coordinating Center, Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington.,Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine and Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Abstract
Electronic cigarettes (e-cigarettes) are alternative, non-combustible tobacco products that generate an inhalable aerosol containing nicotine, flavors, propylene glycol, and vegetable glycerin. Vaping is now a multibillion dollar industry that appeals to current smokers, former smokers, and young people who have never smoked. E-cigarettes reached the market without either extensive preclinical toxicology testing or long term safety trials that would be required of conventional therapeutics or medical devices. Their effectiveness as a smoking cessation intervention, their impact at a population level, and whether they are less harmful than combustible tobacco products are highly controversial. Here, we review the evidence on the effects of e-cigarettes on respiratory health. Studies show measurable adverse biologic effects on organ and cellular health in humans, in animals, and in vitro. The effects of e-cigarettes have similarities to and important differences from those of cigarettes. Decades of chronic smoking are needed for development of lung diseases such as lung cancer or chronic obstructive pulmonary disease, so the population effects of e-cigarette use may not be apparent until the middle of this century. We conclude that current knowledge of these effects is insufficient to determine whether the respiratory health effects of e-cigarette are less than those of combustible tobacco products.
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Affiliation(s)
- Jeffrey E Gotts
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sven-Eric Jordt
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Yale Center for the Study of Tobacco Products and Addiction, Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Rob McConnell
- Department of Preventive Medicine, University of Southern California, CA, USA
| | - Robert Tarran
- Marsico Lung Institute, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
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43
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Hardaker K, Panda H, Hulme K, Wong A, Coward E, Cooper P, Fitzgerald D, Pandit C, Towns S, Selvadurai H, Robinson P. Abnormal preschool Lung Clearance Index (LCI) reflects clinical status and predicts lower spirometry later in childhood in cystic fibrosis. J Cyst Fibros 2019; 18:721-727. [DOI: 10.1016/j.jcf.2019.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/26/2022]
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Ratjen F, Davis SD, Stanojevic S, Kronmal RA, Hinckley Stukovsky KD, Jorgensen N, Rosenfeld M, Kerby G, Kopecky C, Anthony M, Mogayzel P, Walker D, Zeglin B, Hoover W, Hathorne H, Slaten K, Dorkin H(H, Fowler R, Fenton C(N, Ulles M, Goetz D, Caci N, Cahill B, Roach C, Retsch-Bogart G, Johnson R, Cunnion R, McColley S, Ward S, Bell E, McPhail G, Keller K, Thornton K, Parsons A, Chmiel J, Schaefer C, Tribout M, Consiglio B, Tribout H, McCoy K, Johnson T, Olson P, Raterman L, Hiatt P, Walker B, Schaap N, Davis M, Davis S, Clem C, Bendy L, Starner T, Lux C, Carver T, Thompson R, Williams A, Schmoll C, Hastings PM, Noe J, Roth L, Kump T, McNamara J, Franck Thompson E, Yousef S, Wezel G(G, Oquendo O, Darling A, Valencia W, Milla C, Zirbes J, Rubenstein R, Donnelly E, Malpass J, Weiner D, Agostini B, Hartigan E, Cornell A, Klein B, Bucher J, Nusbaum P, Rosenfeld M, McNamara S, Genatossio A, Pittman J, Hicks T, Bauer I, Siegel M, Isaac S, Jensen R, Au J, Stanojevic S, Ratjen F, McDonald N, Prentice C, Chilvers M, Richmond M. Inhaled hypertonic saline in preschool children with cystic fibrosis (SHIP): a multicentre, randomised, double-blind, placebo-controlled trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:802-809. [DOI: 10.1016/s2213-2600(19)30187-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023]
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Southern KW, Sinha IP. Inhaled hypertonic saline for 3-6-year-olds with cystic fibrosis. THE LANCET. RESPIRATORY MEDICINE 2019; 7:730-732. [PMID: 31178424 DOI: 10.1016/s2213-2600(19)30183-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Institute in the Park, Alder Hey Children's Hospital, Eaton Road, Liverpool L12 2AP, UK.
| | - Ian P Sinha
- Department of Women's and Children's Health, University of Liverpool, Institute in the Park, Alder Hey Children's Hospital, Eaton Road, Liverpool L12 2AP, UK
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Detecting respiratory infection in children with cystic fibrosis: Cough swab, sputum induction or bronchoalveolar lavage. Paediatr Respir Rev 2019; 31:28-31. [PMID: 31153794 DOI: 10.1016/j.prrv.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/05/2019] [Indexed: 11/21/2022]
Abstract
Young children with cystic fibrosis (CF) are generally very well, cough free and non-productive, and are often incapable of spontaneously expectorating sputum even if actively coughing during an exacerbation. Obtaining a meaningful airway sample for microbiological analysis is therefore problematic, yet essential if lower airway infection is to be detected and adequately treated. Recently there has been increasing interest in the use of sputum-induction in young children with CF, as a simple, cost effective, well tolerated and frequently repeatable approach to sampling the lower airway, and the relative merits of this approach to bacterial sampling are discussed. Culture-independent microbiology has increased our understanding of the respiratory microbiota and has challenged the current paradigm of "single pathogen causes disease". Understanding how to diagnose infection using these new, highly sensitive technologies will be important. How we should best intervene to optimise, manipulate and prevent disruption of the respiratory microbiota is likely to greatly influence how we manage infection in the future.
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Robinson PD, Latzin P, Ramsey KA, Stanojevic S, Aurora P, Davis SD, Gappa M, Hall GL, Horsley A, Jensen R, Lum S, Milla C, Nielsen KG, Pittman JE, Rosenfeld M, Singer F, Subbarao P, Gustafsson PM, Ratjen F. Preschool Multiple-Breath Washout Testing. An Official American Thoracic Society Technical Statement. Am J Respir Crit Care Med 2019; 197:e1-e19. [PMID: 29493315 DOI: 10.1164/rccm.201801-0074st] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Obstructive airway disease is nonuniformly distributed throughout the bronchial tree, although the extent to which this occurs can vary among conditions. The multiple-breath washout (MBW) test offers important insights into pediatric lung disease, not available through spirometry or resistance measurements. The European Respiratory Society/American Thoracic Society inert gas washout consensus statement led to the emergence of validated commercial equipment for the age group 6 years and above; specific recommendations for preschool children were beyond the scope of the document. Subsequently, the focus has shifted to MBW applications within preschool subjects (aged 2-6 yr), where a "window of opportunity" exists for early diagnosis of obstructive lung disease and intervention. METHODS This preschool-specific technical standards document was developed by an international group of experts, with expertise in both custom-built and commercial MBW equipment. A comprehensive review of published evidence was performed. RESULTS Recommendations were devised across areas that place specific age-related demands on MBW systems. Citing evidence where available in the literature, recommendations are made regarding procedures that should be used to achieve robust MBW results in the preschool age range. The present work also highlights the important unanswered questions that need to be addressed in future work. CONCLUSIONS Consensus recommendations are outlined to direct interested groups of manufacturers, researchers, and clinicians in preschool device design, test performance, and data analysis for the MBW technique.
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Ratjen F, Jensen R, Klingel M, McDonald R, Moore C, Benseler N, Wilson D, Stanojevic S. Effect of changes in tidal volume on multiple breath washout outcomes. PLoS One 2019; 14:e0219309. [PMID: 31269068 PMCID: PMC6608950 DOI: 10.1371/journal.pone.0219309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/20/2019] [Indexed: 01/03/2023] Open
Abstract
The lung clearance index (LCI), measured by multiple breath washout (MBW), reflects global ventilation inhomogeneity and is a sensitive marker of early obstructive airway disease. For the MBW test to accurately reflect a subject's gas mixing within the lungs, the breathing pattern should represent physiologically appropriate tidal volumes (VT) and respiratory rate (RR). We aimed to assess whether changes in VT impact MBW outcome measures with a series of prospective and retrospective studies. MBW testing was performed using the Exhalyzer ® D (EcoMedics AG, Switzerland). Healthy adult subjects performed MBW with uninstructed tidal breathing and a series of instructed tidal breathing tests, designed to isolate specific features of the breathing pattern. In addition, we retrospectively analyzed MBW data from two pediatric multi-centre interventional studies of cystic fibrosis (CF) subjects to determine the range of VT observed during uninstructed breathing, and whether breathing outside this range impacted results. The LCI was lower, but not significantly different between deep breathing at 20 ml/kg body weight and uninstructed tidal breathing; whereas LCI was significantly higher during shallow breathing compared with normal tidal breathing. For the majority of subjects with CF (80%), VT ranged from 9-15mL/kg. Within the observed VT range, LCI was similar in trials with mean VT /kg below this range compared to trials with VT /kg within the range. If subjects breathe naturally and are not instructed to use specific targets, the range of VT is within physiologically appropriate limits and normal variations observed do not impact MBW outcomes.
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Affiliation(s)
- Felix Ratjen
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Renee Jensen
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Michelle Klingel
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Reginald McDonald
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Courtney Moore
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - Nick Benseler
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
| | - David Wilson
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Sanja Stanojevic
- Translational Medicine Research Program, The Hospital for Sick Children, Toronto, Canada
- University of Toronto, Toronto, Canada
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Uhlving HH, Skov L, Buchvald F, Heilmann C, Grell K, Ifversen M, Green K, Müller K, Nielsen KG. Lung clearance index for early detection of pulmonary complications after allo-HSCT in children. Pediatr Pulmonol 2019; 54:1029-1038. [PMID: 31004401 DOI: 10.1002/ppul.24340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/13/2019] [Accepted: 03/31/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pulmonary chronic graft-vs-host disease (cGvHD) after hematopoietic stem cell transplantation (HSCT) is characterized by impairment of the small airways. Assessment of lung clearance index (LCI) gained from multiple breath washout (MBW) is more sensitive than spirometry in detection of small airways disease. The aim of this study was to describe the development of LCI during the first year after pediatric HSCT and how LCI relates to other pulmonary function parameters and cGvHD. METHODS This prospective, longitudinal study included 28 pediatric HSCT-recipients. Spirometry, Sulfur hexafluoride MBW and diffusion capacity of the lungs were performed before and at 3, 6, 9, and 12 months after HSCT. Respiratory symptoms and signs of cGvHD were recorded at each visit. RESULTS Before HSCT, 47.8% had abnormal LCI and 12.5% had abnormal forced expiratory volume in 1 second (FEV1 ). Patients with persisting respiratory symptoms 12 months post-HSCT had higher median LCI (factor 5.7, P = 0.0018) and lower FEV1 z-scores (-1.5, P = 0.033) post-HSCT compared to patients free of respiratory symptoms. Overall, post-HSCT LCI values were 3.49 times higher and FEV1 was 2.31 z-scores lower in eight patients with cGvHD in any organ system compared with patients without cGvHD (P = 0.0089 and P < 0.0001). LCI values during the first 3 months were not predictive of pulmonary cGvHD. CONCLUSION LCI is a sensitive marker for cGvHD and high LCI values were associated with persisting respiratory symptoms after 1 year. Further evaluation of MBW in early detection of HSCT-related pulmonary complications require larger patient cohorts and closer follow-up during the first months after HSCT.
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Affiliation(s)
- Hilde H Uhlving
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Linnea Skov
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Pediatric Pulmonary Service, Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederik Buchvald
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Pediatric Pulmonary Service, Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carsten Heilmann
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kathrine Grell
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kent Green
- Pediatric Pulmonary Service, Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Klaus Müller
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Institute for Inflammation Research, Department of Infectious Diseases and Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kim G Nielsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Pediatric Pulmonary Service, Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Anagnostopoulou P, Vomsattel S, Kentgens AC, Guidi M, Binggeli S, Kohler L, Singer F, Latzin P, Obrist D. An innovative lung model for multiple breath washout testing in health and disease. Clin Biomech (Bristol, Avon) 2019; 66:74-80. [PMID: 29157654 DOI: 10.1016/j.clinbiomech.2017.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple breath washout (MBW) is a lung function test that identifies the degree of ventilation inhomogeneity (VI) in the lungs. In vitro validation of MBW devices is recommended. So far, plastic lung models for MBW validation ignored variable degrees of VI. Our primary aim was to create a plastic lung model applicable for physiological lung volumes and variable VI. METHODS A plastic box divided in two chambers was filled with water and ventilated in various lung volumes and respiratory rates. A ventilator was used for efficient gas distribution (model with low VI). An additional divider was inserted to create a model with high VI. The model was connected to commercial MBW devices and measurements were performed using different tracer gases and conditions. Primary outcome was the precision of generated functional residual capacity (FRC) and the ability to generate variable VI. The latter was estimated by lung clearance index (LCI) and expiratory phase III slopes (SIII). LCI was also compared to a mathematical model. FINDINGS The intra-test variability for FRC was minimal, mean(SD) coefficient of variation 0.96(0.63)%, using different tracer gases under different conditions. Compared to the model with low VI, in the model with high VI LCI and washout SIII were significantly increased. LCI compared well to the mathematical model. INTERPRETATION This novel lung model shows excellent precision in lung volumes and VI estimates independent of tracer gases and conditions. The model can mimic the lungs of patients with uneven gas distribution.
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Affiliation(s)
- Pinelopi Anagnostopoulou
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Sarah Vomsattel
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Anne-Christiane Kentgens
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Respiratory Medicine and Allergy, Radboud University Medical Centre, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Marisa Guidi
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Severin Binggeli
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lena Kohler
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Florian Singer
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Philipp Latzin
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
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