Annals of the American Thoracic Society最新文献

{"title":"Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease: Medicine's Best-kept Secret That Could Save Medicare a Billion Dollars a Year.","authors":"Christopher L Mosher, Michael Belman, Chris Garvey, Richard Casaburi","doi":"10.1513/AnnalsATS.202304-366VP","DOIUrl":"10.1513/AnnalsATS.202304-366VP","url":null,"abstract":"Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease Medicine’s Best-kept Secret That Could Save Medicare a Billion Dollars a Year Christopher L. Mosher, Michael Belman, Chris Garvey, and Richard Casaburi Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; American Thoracic Society Pulmonary Rehabilitation ReimbursementWorking Group (virtual), United States; and Rehabilitation Clinical Trials Center, Lundquist Institute for Biomedical Innovation at HarborUniversity of California, Los Angeles (UCLA)Medical Center, Torrance, California","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1397-1399"},"PeriodicalIF":8.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/33/db/AnnalsATS.202304-366VP.PMC10559142.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9687112","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Personalizing Selection of Inhaled Delivery Systems in Chronic Obstructive Pulmonary Disease.","authors":"Donald A Mahler,&nbsp;David M G Halpin","doi":"10.1513/AnnalsATS.202304-384CME","DOIUrl":"10.1513/AnnalsATS.202304-384CME","url":null,"abstract":"<p><p>It can be challenging for healthcare professionals (HCPs) to prescribe inhaled therapy for patients with chronic obstructive pulmonary disease (COPD) because of the multiple individual and combinations of inhaled medications available in numerous delivery systems. Guidance on the selection of an inhaled delivery system has received limited attention compared with the emphasis on prescribing the class of the inhaled molecule(s). Although numerous recommendations and algorithms have been proposed to guide the selection of an inhaled delivery system for patients with COPD, no specific approach has been endorsed in COPD guidelines/strategies or by professional organizations. To provide recommendations for an inhaler selection strategy at initial and follow-up appointments, we examined the impact of patient errors using handheld inhalers on clinical outcomes and performed a focused narrative review to consider patient factors (continuity of the inhaled delivery system, cognitive function, manual function/dexterity, and peak inspiratory flow) when selecting an inhaled delivery system. On the basis of these findings, five questions are proposed for HCPs to consider in the initial selection of an inhaler delivery system and three questions to consider at follow-up. We propose that HCPs consider the inhaled medication delivery system as a unit and to match appropriate medication(s) with the unique features of the delivery system to individual patient factors. Assessment of inhaler technique and adherence together with patient outcomes/satisfaction at each visit is essential to determine whether the inhaled medication delivery system is providing benefits. Continued and repeated education on device features and correct technique is warranted to optimize efficacy.</p>","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1389-1396"},"PeriodicalIF":8.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/12/24/AnnalsATS.202304-384CME.PMC10559134.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9877419","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Obstructive Sleep Apnea Is a Distinct Physiological Endotype in Individuals with Comorbid Insomnia and Sleep Apnea.","authors":"Elliot J Brooker,&nbsp;Shane A Landry,&nbsp;Luke D J Thomson,&nbsp;Garun S Hamilton,&nbsp;Pedro Genta,&nbsp;Sean P A Drummond,&nbsp;Bradley A Edwards","doi":"10.1513/AnnalsATS.202304-350OC","DOIUrl":"10.1513/AnnalsATS.202304-350OC","url":null,"abstract":"<p><p><b>Rationale:</b> With up to 40% of individuals with either insomnia or obstructive sleep apnea (OSA) demonstrating clinically significant symptoms of the other disorder, the high degree of comorbidity among the two most common sleep disorders suggests a bidirectional relationship and/or shared underpinnings. Although the presence of insomnia disorder is believed to influence the underlying pathophysiology of OSA, this influence is yet to be examined directly. <b>Objectives:</b> To investigate whether the four OSA endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) are different in patients with OSA with and without comorbid insomnia disorder. <b>Methods:</b> Using the ventilatory flow pattern captured from routine polysomnography, the four OSA endotypes were measured in 34 patients with OSA who met the diagnostic criteria for insomnia disorder (COMISA) and 34 patients with OSA without insomnia (OSA only). Patients demonstrated mild-to-severe OSA (apnea-hypopnea index, 25.8 ± 2.0 events/h) and were individually matched according to age (50.2 ± 1.5 yr), sex (42 male: 26 female), and body mass index (29.3 ± 0.6 kg/m²). <b>Results:</b> Compared with patients with OSA without comorbid insomnia, patients with COMISA demonstrated significantly lower respiratory arousal thresholds (128.9 [118.1 to 137.1] vs. 147.7 [132.3 to 165.0] % eupneic ventilation ([Formula: see text]); <i>U</i> = 261; 95% confidence interval [CI], -38.3 to -13.9; <i>d</i> = 1.1; <i>P</i> < 0.001), less collapsible upper airways (88.2 [85.5 to 94.6] vs. 72.9 [64.7 to 79.2] %[Formula: see text]; <i>U</i> = 1081; 95% CI, 14.0 to 26.7; <i>d</i> = 2.3; <i>P</i> < 0.001), and more stable ventilatory control (i.e., lower loop gain: 0.51 [0.44 to 0.56] vs. 0.58 [0.49 to 0.70]; <i>U</i> = 402; 95% CI, -0.2 to -0.01; <i>d</i> = 0.05; <i>P</i> = 0.03). Muscle compensation was similar between groups. Moderated linear regression revealed that the arousal threshold moderated the relationship between collapsibility and OSA severity in patients with COMISA but not in patients with OSA only. <b>Conclusions:</b> A low arousal threshold is an overrepresented endotypic trait in individuals with COMISA and may exhibit a greater relative contribution to OSA pathogenesis in these patients. Contrastingly, the prevalence of a highly collapsible upper airway in COMISA was low, suggesting that anatomical predisposition may contribute less to OSA development in COMISA. Based on our findings, we theorize that conditioned hyperarousal perpetuating insomnia may translate to a reduced arousal threshold to respiratory events, thereby increasing the risk or severity of OSA. Therapies that target increased nocturnal hyperarousal (e.g., through cognitive behavior therapy for insomnia) may be effective in individuals with COMISA. Clinical trial registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12616000586415).</p>","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1508-1515"},"PeriodicalIF":8.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10086609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cardiopulmonary Exercise Testing in Patients with Persistent Dyspnea after Pulmonary Embolism.","authors":"Louisa A Mounsey,&nbsp;Alison S Witkin,&nbsp;C Corey Hardin,&nbsp;Josanna Rodriguez-Lopez","doi":"10.1513/AnnalsATS.202302-108RL","DOIUrl":"10.1513/AnnalsATS.202302-108RL","url":null,"abstract":"","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1528-1530"},"PeriodicalIF":8.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9982930","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation.","authors":"Griffin H Olsen, Perry M Gee, Doug Wolfe, Carrie Winberg, Lori Carpenter, Chris Jones, Jason R Jacobs, Lindsay Leither, Ithan D Peltan, Sara J Singer, Steven M Asch, Colin K Grissom, Rajendu Srivastava, Andrew J Knighton","doi":"10.1513/AnnalsATS.202212-1048OC","DOIUrl":"10.1513/AnnalsATS.202212-1048OC","url":null,"abstract":"<p><p><b>Rationale:</b> Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. <b>Objectives:</b> We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. <b>Methods:</b> We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (<i>n</i> = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. <b>Results:</b> The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5-11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. <b>Conclusions:</b> Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.</p>","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1483-1490"},"PeriodicalIF":6.8,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10559139/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10231938","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cardiovascular Autonomic Function and Incident Chronic Obstructive Pulmonary Disease Hospitalizations in Atherosclerosis Risk in Communities.","authors":"David M MacDonald, Yuekai Ji, Selcuk Adabag, Alvaro Alonso, Lin Yee Chen, Benjamin E Henkle, Stephen P Juraschek, Faye L Norby, Pamela L Lutsey, Ken M Kunisaki","doi":"10.1513/AnnalsATS.202211-964OC","DOIUrl":"10.1513/AnnalsATS.202211-964OC","url":null,"abstract":"<p><p><b>Rationale:</b> The autonomic nervous system extensively innervates the lungs, but its role in chronic obstructive pulmonary disease (COPD) outcomes has not been well studied. <b>Objective:</b> We assessed relationships between cardiovascular autonomic nervous system measures (heart rate variability [HRV] and orthostatic hypotension [OH]) and incident COPD hospitalization in the multicenter ARIC (Atherosclerosis Risk In Communities) study. <b>Methods:</b> We used Cox proportional hazards regression models to estimate hazard ratios and 95% confidence intervals between baseline (1987-1989) autonomic function measures (HRV measures from 2-minute electrocardiograms and OH variables) and incident COPD hospitalizations through 2019. Adjusted analyses included demographic data, smoking status, lung function, comorbidities, and physical activity. We also performed analyses stratified by baseline airflow obstruction. <b>Results:</b> Of the 11,625 participants, (mean age, 53.8 yr), 56.5% were female and 26.3% identified as Black. Baseline mean percentage predicted forced expiratory volume in 1 second was 94 ± 17% (standard deviation), and 2,599 participants (22.4%) had airflow obstruction. During a median follow-up time of 26.9 years, there were 2,406 incident COPD hospitalizations. Higher HRV (i.e., better autonomic function) was associated with a lower risk of incident COPD hospitalization. Markers of worse autonomic function (OH and greater orthostatic changes in systolic and diastolic blood pressure) were associated with a higher risk of incident COPD hospitalization (hazard ratio for the presence of OH, 1.5; 95% confidence interval, 1.25-1.92). In stratified analyses, results were more robust in participants without airflow obstruction at baseline. <b>Conclusions:</b> In this large multicenter prospective community cohort, better cardiovascular autonomic function at baseline was associated with a lower risk of subsequent hospitalization for COPD, particularly among participants without evidence of lung disease at baseline.</p>","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1435-1444"},"PeriodicalIF":6.8,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10559138/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9687110","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Neighborhood Socioeconomic Disadvantage, Healthcare Access, and Outcomes of Hospitalizations for Common Pulmonary Conditions: A National Study of Medicare Beneficiaries.","authors":"Jay B Lusk,&nbsp;Molly N Hoffman,&nbsp;Amy G Clark,&nbsp;Hannah Mahoney,&nbsp;Beau Blass,&nbsp;Jonathan Bae,&nbsp;Deepshikha C Ashana,&nbsp;Christopher E Cox,&nbsp;Bradley G Hammill","doi":"10.1513/AnnalsATS.202304-310OC","DOIUrl":"10.1513/AnnalsATS.202304-310OC","url":null,"abstract":"<p><p><b>Rationale:</b> Understanding how systemic forces and environmental exposures impact patient outcomes is critical to advancing health equity and improving population health for patients with pulmonary disease. This relationship has not yet been assessed at the population level nationally. <b>Objectives:</b> To determine whether neighborhood socioeconomic deprivation is independently associated with 30-day mortality and readmission for hospitalized patients with pulmonary conditions, after controlling for demographics, access to healthcare resources, and characteristics of admitting healthcare facilities. <b>Methods:</b> This was a retrospective, population-level cohort study of 100% of United States nationwide Medicare inpatient and outpatient claims from 2016-2019. Patients were admitted for one of four pulmonary conditions (pulmonary infections, chronic lower respiratory disease, pulmonary embolism, and pleural and interstitial lung diseases), defined by diagnosis-related group. The primary exposure was neighborhood socioeconomic deprivation, measured by the area deprivation index. The main outcomes were 30-day mortality and 30-day unplanned readmission, defined by Centers for Medicare and Medicaid Services methodologies. Generalized estimating equations were used to estimate logistic regression models for the primary outcomes, addressing clustering by hospital. A sequential adjustment strategy was first adjusted for age, legal sex, Medicare-Medicaid dual eligibility, and comorbidity burden, then adjusted for metrics of access to healthcare resources, and finally adjusted for characteristics of the admitting healthcare facility. <b>Results:</b> After full adjustment, patients from low socioeconomic status neighborhoods had greater 30-day mortality after admission for pulmonary embolism (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13-1.40), respiratory infections (OR, 1.20; 95% CI, 1.16-1.25), chronic lower respiratory disease (OR, 1.31; 95% CI, 1.22-1.41), and interstitial lung disease (OR, 1.15; 95% CI, 1.04-1.27) when compared to patients from the highest SES neighborhoods. Low neighborhood socioeconomic status was also associated with 30-day readmission for all groups except the interstitial lung disease group. <b>Conclusions:</b> Neighborhood socioeconomic deprivation may be a key factor driving poor health outcomes for patients with pulmonary diseases.</p>","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1416-1424"},"PeriodicalIF":8.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10029782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Novel Approach to Clinical Change Endpoints: A Win Ratio Analysis of the INCREASE Trial.","authors":"Steven D Nathan, Boris Medarov, Lawrence Ho, John Kingrey, Taekwon Hong, Youlan Rao, Eric Shen, Peter Smith, Chunqin Deng, Aaron Waxman","doi":"10.1513/AnnalsATS.202303-229RL","DOIUrl":"10.1513/AnnalsATS.202303-229RL","url":null,"abstract":"","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1537-1540"},"PeriodicalIF":8.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/ce/a6/AnnalsATS.202303-229RL.PMC10559141.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9749465","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Fungi in Early-Life House Dust Samples and the Development of Asthma: A Birth Cohort Study.","authors":"Martin Täubel,&nbsp;Jonna Jalanka,&nbsp;Pirkka V Kirjavainen,&nbsp;Pauli Tuoresmäki,&nbsp;Anne Hyvärinen,&nbsp;Chrysanthi Skevaki,&nbsp;Eija Piippo-Savolainen,&nbsp;Juha Pekkanen,&nbsp;Anne M Karvonen","doi":"10.1513/AnnalsATS.202303-187OC","DOIUrl":"10.1513/AnnalsATS.202303-187OC","url":null,"abstract":"<p><p><b>Rationale:</b> Fungal exposure has been associated with predisposing and protective effects on the development of childhood asthma. <b>Objectives:</b> To study whether early-life house dust mycobiota composition is associated with the development of asthma. <b>Methods:</b> Mycobiota were determined by amplicon sequencing from 382 dust samples collected from living room floors 2 months after birth in homes of the LUKAS cohort. Asthma status by 10.5 years of age was defined from questionnaires and assigned as ever asthma (<i>n</i> = 68) or current asthma (<i>n</i> = 27). Inhalant atopy was clinically determined at the same age. β-composition was analyzed using PERMANOVA-S, and asthma and atopy analyses were performed using discrete time hazard models and logistic regression, respectively. <b>Results:</b> The house dust mycobiota composition based on Bray-Curtis distance was different in the homes of children who later did or did not develop asthma. The first and the fourth axes scores of principal coordinates analysis based on Bray-Curtis were associated with ever asthma. Of the genera with the strongest correlation with these axes, the relative abundance of <i>Boeremia</i>, <i>Cladosporium</i>, <i>Microdochium</i>, <i>Mycosphaerella</i>, and <i>Pyrenochaetopsis</i> showed protective associations with asthma. None of these associations remained significant after mutual adjustment among the five genera or when mutually adjusted for other microbial cell wall markers and previously identified asthma-protective bacterial indices. Neither fungal α-diversity nor load was associated with asthma in the whole population, but higher fungal richness was a risk factor among children on farms. Higher fungal loads (measured via quantitative polymerase chain reaction) in house dust were associated with the risk of inhalant atopy. <b>Conclusions:</b> The results of our analyses from this well-characterized birth cohort suggest that the early-life house dust mycobiota in Finnish homes, characterized via DNA amplicon sequencing, do not have strong predisposing or protective effects on asthma development.</p>","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1456-1464"},"PeriodicalIF":8.3,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/f0/04/AnnalsATS.202303-187OC.PMC10559140.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10066922","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Higher, but Not Too High, Dose Is Only One Determinant of Corticosteroid Treatment Success in Severe COVID-19.","authors":"Francesco Salton,&nbsp;Paola Confalonieri,&nbsp;Chiara Torregiani,&nbsp;Barbara Ruaro,&nbsp;Marco Confalonieri","doi":"10.1513/AnnalsATS.202304-329LE","DOIUrl":"https://doi.org/10.1513/AnnalsATS.202304-329LE","url":null,"abstract":"We read with interest the study from Pitre and colleagues, who systematically reviewed 20 randomized controlled trials published through August 2022, concluding that higher doses of corticosteroids (CSs) probably reduce mortality (relative risk, 0.92; 95% confidence interval [CI], 0.85–0.98) and the need for mechanical ventilation (relative risk, 0.91; 95% CI, 0.87–1.03) compared with lower doses in severe-to-critical coronavirus disease (COVID-19), without significantly impacting either the duration of hospitalization or the incidence of nosocomial infections (1). These results are mostly aligned with those of our recent randomized controlled trial investigating methylprednisolone 80mg as a continuous daily infusion for 8days followed by slow tapering, versus dexamethasone 6mg daily for 10 days in a similar population (2). However, their results need to be interpreted comprehensively before being transferred into clinical practice, as possible misinterpretations may lead to hazardous conclusions. First, the authors defined “higher” and “lower” doses in a comparative fashion, referring to 12mg of dexamethasone equivalent daily for 10 days as the former and to 6mg of dexamethasone equivalent daily for 10 days as the latter. However, both these dosages and administration schedules fall within the prolonged, paraphysiological, low-to-intermediate dose (i.e.,&lt;1mg of prednisone equivalent/kg/d for at least 8–10 d) CS treatment conception that has shown the greatest efficacy in acute respiratory distress syndrome (ARDS) (3). On the contrary, short courses (&lt;3 d) of truly high doses (10–30mg of prednisone equivalent/kg/d) of CSs have proven detrimental in both septic shock and ARDS—including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)related ARDS—because of inflammatory rebound after discontinuation (4). Second, there is now substantial evidence of a proportional benefit of CSs for patients requiring higher-intensity respiratory support modalities (i.e., mechanical ventilation and high-flow nasal cannula) rather than lower-intensity ones (i.e., low-flow oxygen therapy), as opposed to the increased mortality observed among patients not requiring any respiratory support (5). Therefore, we highlight that the findings of this study can only be generalized to patients affected by moderate-to-severe COVID-19 and not by COVID-19 of any severity. Third, different patients receiving the same CS protocol may experience different disease progression and outcomes. This provides a rationale for dose and duration adjustments based on clinical and laboratory responses, as a higher dose may overcome a decreased sensitivity to CSs in the most critically ill patients (3). Indeed, both traditional and Bayesian analyses conducted within the COVID STEROID 2 trial suggest that 12mg of dexamethasone/d might benefit patients who require high levels of respiratory support more than 6mg of dexamethasone/d (6). Therefore, some clinicians might choose to titrate C","PeriodicalId":8018,"journal":{"name":"Annals of the American Thoracic Society","volume":"20 9","pages":"1371"},"PeriodicalIF":8.3,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d7/48/AnnalsATS.202304-329LE.PMC10502891.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10319888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}