Pneumonia intersticial associada à esclerose sistêmica: avaliação da função pulmonar no período de cinco anos

Heterogeneity of determining disease severity, clinical course and outcomes in systemic sclerosis-associated interstitial lung disease: a systematic literature review

Objective The course of systemic sclerosis-associated interstitial lung disease (SSc-ILD) is highly variable and different from continuously progressive idiopathic pulmonary fibrosis (IPF). Most proposed definitions of progressive pulmonary fibrosis or SSc-ILD severity are based on the research data from patients with IPF and are not validated for patients with SSc-ILD. Our study aimed to gather the current evidence for severity, progression and outcomes of SSc-ILD.Methods A systematic literature review to search for definitions of severity, progression and outcomes recorded for SSc-ILD was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in Medline, Embase, Web of Science and Cochrane Library up to 1 August 2023.Results A total of 9054 papers were reviewed and 342 were finally included. The most frequent tools used for the definition of SSc-ILD progression and severity were combined changes of carbon monoxide diffusing capacity (DLCO) and forced vital capacity (FVC), isolated FVC or DLCO changes, high-resolution CT (HRCT) extension and composite algorithms including pulmonary function test, clinical signs and HRCT data. Mortality was the most frequently reported long-term event, both from all causes or ILD related.Conclusions The studies presenting definitions of SSc-ILD 'progression', 'severity' and 'outcome' show a large heterogeneity. These results emphasise the need for developing a standardised, consensus definition of severe SSc-ILD, to link a disease specific definition of progression as a surrogate outcome for clinical trials and clinical practice.PROSPERO registration number CRD42022379254.Cite Now.

Evaluation of cardiac autonomic control during the 6-min walk test in women with systemic sclerosis

OBJECTIVE

To evaluate the association between sympathovagal balance and exercise performance, as measured by the 6-min walk test (6MWT), in women with systemic sclerosis (SSc) without cardiac involvement.

RESULTS

This was a cross-sectional study in which 69 women with SSc [median age 51 (40-63 years)] without cardiac involvement underwent the 6MWT. Throughout the 6MWT, heart rate variability (HRV) was assessed using dedicated software.

METHODS

The median 6-min walking distance (6MWD) was 451 (392-498) meters, and 29 (42%) participants did not achieve 80% of the predicted value for healthy adults. Desaturation during the 6MWT (SpO2 ≤ 4%) was observed in 10.1% of participants. Significant correlations were observed between the 6MWD and the following HRV parameters: number of successive normal-to-normal RR interval differences > 50 ms (rs=-0.397, P = 0.013), low-frequency range (rs=0.374, P = 0.023), high-frequency range (rs=-0.372, P = 0.023), and parasympathetic nervous system index (rs=-0.342, P = 0.045).

CONCLUSION

In women with SSc, there is an interrelationship of the 6MWD with both vagal withdrawal and sympathetic hyperactivation. This relationship between autonomic imbalance and worse exercise performance might increase cardiovascular risk, even in patients without apparent cardiac involvement. Control of the heart by the autonomic nervous system may be a potential target for treating patients with SSc.

Bronchoalveolar Lavage in Systemic Sclerosis Patients: A Systematic Review

INTRODUCTION

We performed a systematic review of the literature to determine the value of bronchoalveolar lavage (BAL) in evaluating the pulmonary involvement of systemic sclerosis (SSc).

METHODS

Articles published between 1980 and 2019 were retrieved from the databases: PubMed and Scielo. The search was restricted to clinical trials published in English, utilizing the keywords "scleroderma, systemic sclerosis, interstitial lung disease, and bronchoalveolar lavage".

RESULTS

Twenty-two papers were analyzed. A positive correlation was observed between increased BAL cellularity (alveolitis) and worsening clinical symptoms, pulmonary function, and radiological pattern in 2, 11, and 15 studies, respectively. The majority of BAL studies that evaluated interleukin levels, including TNF-α, IL-6, IL-7, and IL-8, observed higher levels in patients with impaired pulmonary function and increased lung involvement.

CONCLUSIONS

Alveolitis and the increase of some cytokines/chemokines in BAL were related to more severe pulmonary disease in SSc in the majority of the studies and seemed to be markers of worse prognosis, but it is unknown whether BAL adds clinical value to the use of the other non-invasive diagnostic procedures.

Mycophenolate mofetil for scleroderma-related interstitial lung disease: A real world experience

Background and objective

Interstitial lung disease (ILD) remains the number one cause of mortality in scleroderma (SSc). Our goal was to determine the effectiveness of mycophenolate mofetil (MMF) in treating SSc-ILD in a retrospective study.

Methods

A retrospective, computer-assisted search was performed to identify patients with SSc-ILD treated with MMF from 1997 through 2014. We used a novel software tool, Computer-Aided Lung Informatics for Pathology Evaluation and Rating (CALIPER), to quantify parenchymal lung abnormalities on high-resolution computed tomography. Lung function was evaluated at baseline, 6, 12, and 24 months of MMF therapy.

Results

We identified 46 patients (28 females) with SSc-ILD (mean age at diagnosis 55 y) treated with MMF for at least 1 year (majority on 2 gm/day). Twenty-one patients (45.7%) stopped using MMF during the follow up period after the first 12 months, and they took MMF for a median of 2.12 years (range, 0.91–8.93 years). Only 4 discontinued MMF because of disease progression. Compared to baseline, the mean percentage change in forced vital capacity (95% CI) at 6, 12, and 24 months, respectively, was 1.01% (−2.38%-4.39%) (n = 26), 2.06% (−1.09%-5.22%) (n = 31), and −0.07% (−3.31%-3.17%) (n = 30), and the mean percentage change in ILD as measured by CALIPER (95% CI) was −5.40% (−18.62%-7.83%) (n = 18), −1.51% (−14.69%-11.68%) (n = 17), and −8.35% (−20.71%-4.02%) (n = 22).The mean right ventricular systolic pressure (RVSP) remained stable over the study period.

Conclusions

MMF is well tolerated and slows the rate of decline in lung function in SSc-ILD patients, even at doses lower at 3 g/day.

Systemic sclerosis: Association between physical function, handgrip strength and pulmonary function

BACKGROUND

Systemic sclerosis (SSc) is a multisystem disease affecting the skin, respiratory system and skeletal muscles. In SSc patients, hand function disability is the major factor limiting daily activities.

AIM

To evaluate the association of physical function with handgrip strength and pulmonary function in SSc patients. A further aim was to assess the relationship between handgrip strength and pulmonary function in patients with SSc.

METHOD

A cross-sectional study in which 28 patients with SSc underwent isometric handgrip strength (IHGS) measurement and pulmonary function tests and completed the Health Assessment Questionnaire Disability Index (HAQ-DI) to measure physical function.

RESULTS

The HAQ-DI scores were associated with the IHGS (r_s = -0.599, P = 0.001) and pulmonary function parameters, particularly the diffusion capacity for carbon monoxide (DLco; r_s = -0.642, P = 0.0004).

CONCLUSION

In patients with SSc, the degree of physical disability is associated with both hand grip strength and pulmonary function. However, there is no relationship between handgrip strength and pulmonary function in these patients.

Ventilation distribution and small airway function in patients with systemic sclerosis

BACKGROUND

Despite the importance of traditional pulmonary function tests (PFTs) in managing systemic sclerosis (SSc), many patients with pulmonary disease diagnosed by computed tomography (CT) present with normal PFTs.

OBJECTIVE

To evaluate the efficacy of the nitrogen single-breath washout (N₂SBW) test in diagnosing SSc and to correlate N₂SBW parameters with the PFT indexes used in the follow-up of these patients, clinical data, and CT findings.

METHODS

Cross-sectional study in which 52 consecutive SSc patients were subjected to spirometry, body plethysmography, analysis of the diffusing capacity for carbon monoxide (DLCO), analysis of respiratory muscle strength, N₂SBW testing, and CT analysis.

RESULTS

Twenty-eight patients had a forced vital capacity (FVC) that was <70% of the predicted value. In the N₂SBW test, 44 patients had a phase III slope (Phase III slope_N2SBW) that was >120% of the predicted value, while 15 patients had a closing volume/vital capacity (CV/VC) that was >120% of the predicted value. A significant difference in Phase III slope_N2SBW was observed when the patients with predominant traction bronchiectasis and honeycombing were compared to the patients with other CT patterns (p<0.0001). The Phase III slope_N2SBW was correlated with FVC (r_s=-0.845, p<0.0001) and DLCO (r_s=-0.600, p<0.0001), and the CV/VC was correlated with FVC (r_s=-0.460, p=0.0006) and residual volume/total lung capacity (r_s=0.328, p=0.017).

CONCLUSION

Ventilation heterogeneity is a frequent finding in SSc patients that is associated with restrictive damage, changes in pulmonary diffusion, and CT patterns. In addition, approximately one-third of the patients presented with findings that were compatible with small airway disease.

Causes and prevalence of inadequate pulmonary function testing among patients with systemic sclerosis

INTRODUCTION

Spirometry is a screening tool for evaluating the degree of restrictive lung disease in systemic sclerosis (SSc). Observations indicated that some patients could not complete the test. The aim of the study was to identify the prevalence, causes and clinical predictors of an inadequate pulmonary function test (PFT) in SSc.

MATERIAL AND METHODS

A cross-sectional study was performed among SSc patients over 18 years old followed up at Srinagarind Hospital, Khon Kaen, Thailand, during January 2006-December 2012. The adequacy of the PFT was based on the acceptable blow criteria as set out by the American Thoracic Society and the European Respiratory Society 2005 Standardizations of Spirometry.

RESULTS

Two hundred and forty-nine patients were included (female to male ratio was 2 : 1). The mean age at performing PFT was 51.4 ±11.1 years (range: 19.6-79.5). Median duration of disease at performing PFT was 2 years (IQR: 0.6-4.4). Inadequate PFT occurred in 73 cases (prevalence 29.3%: 95% CI: 23.6-35.0); the majority (60 cases; 82.2%) had an expiration time < 6 s and the others were due to plateau < 1 s (11 cases; 15%), air leak around mouth piece (1 case; 1.4%) and hesitation (1 case; 1.4%). Thirteen of 73 (17.8%) had an unusable graph with the overall prevalence of 5.2% (95% CI: 2.4-8.0). The factor associated with inadequate PFT was docy mass index (BMI) < 18.5 kg/m(2) (OR = 2.17: 95% CI: 1.49-3.17); the same factor was associated with an unusable graph, which was confirmed by the multivariate analysis (OR = 5.21; 95% CI: 1.60-16.95).

CONCLUSIONS

One-third of Thai SSc patients had an inadequate pulmonary function test - the majority because of inadequate time for expiring. Low BMI influenced the effectiveness of the test, leading to an incomplete graph for evaluating lung disease in SSc.

Predictors of mortality and progression in scleroderma-associated interstitial lung disease: a systematic review

BACKGROUND

Interstitial lung disease (ILD) is the leading cause of morbidity and mortality in patients with systemic sclerosis (SSc); however, prognostication of SSc-associated ILD (SSc-ILD) remains challenging. We conducted a systematic review to identify variables that predict mortality and ILD progression in SSc-ILD.

METHODS

Three databases were searched to identify all studies relating to predictors of mortality or ILD progression in SSc-ILD. Studies were eligible if they were published in English and included ≥ 10 adults with SSc-ILD. Two authors independently reviewed and extracted data from acceptable studies.

RESULTS

The initial search identified 3,145 unique citations. Twenty-seven studies, including six abstracts, met the inclusion criteria. A total of 1,616 patients with SSc-ILD were included. Patient-specific, ILD-specific, and SSc-specific variables predicted mortality and progression; however, most predictors were identified in only one study. Most studies did not fully account for potential confounders, and none of the studies included a validation cohort. Older age, lower FVC, and lower diffusing capacity of carbon monoxide predicted mortality in more than one study. Male sex, extent of disease on high-resolution CT (HRCT) scan, presence of honeycombing, elevated KL-6 values, and increased alveolar epithelial permeability were identified as predictors of both mortality and ILD progression on unadjusted analysis. The extent of disease on HRCT scan was the only variable that independently predicted both mortality and ILD progression.

CONCLUSIONS

Mortality and ILD progression were predicted by several patient-specific, ILD-specific, and SSc-specific factors. Additional prospective studies are required to validate these preliminary findings and to identify combinations of variables that accurately predict the prognosis of SSc-ILD.