Airway Involvement Research Articles

Small airway involvement in severe asthma: how common is it and what are its implications?

Asthma is a prevalent chronic respiratory disease affecting all age groups globally, causing significant morbidity and mortality. Small airway involvement, often undetected by traditional spirometry, has emerged as a critical aspect of asthma pathophysiology, especially in severe cases. This retrospective observational study aimed to assess small airway dysfunction using impulse oscillometry (IOS) in 94 severe asthma patients. Results indicated that 27.3% of patients had small airway obstruction. While spirometry showed no statistical differences between groups, IOS parameters were significantly different, highlighting its sensitivity in detecting small airway disease. Patients with small airway involvement exhibited poorer asthma control, emphasizing the clinical relevance of identifying and addressing small airway dysfunction. The study underscores the need for comprehensive evaluation tools like IOS alongside spirometry, especially in severe asthma management. Further large-scale studies are warranted to validate IOS's utility in optimizing therapeutic strategies and improving asthma control, particularly in resource-limited settings. Recognizing and addressing small airway involvement could lead to individualized management approaches and better outcomes in severe asthma patients.

Clinical characteristics of 6 cases of relapsing polychondritis in children with airway involvement

Objective: To investigate the pathogenesis, clinical signs and diagnosing procedures of relapsing polychondritis(RP) in children with airway involvement. Methods: The medical history, clinical symptoms, physical examination, electronic laryngoscopy and imaging findings of six patients were retrospectively analyzed. The patients diagnosed as relapsing polychondritis with involving the airway from January 2018 to December 2021 were in our hospital. The clinical features of the 6 cases were summarized. Results: All 6 patients were male, ranging in age from 8 years 1 month to 14 years 1 month, with a median age of 12.04 years. Stridor and dyspnea were observed in all patients, with hoarseness in 2 patients and frequently nocturnal dyspnea during sleep in 2 patients. Initially, all children were diagnosed as laryngitis or laryngotracheitis, and were treated symptomatically with glucocorticoids and aerosol inhalation. Immunosuppressants and targeted therapy with biologics were given after patients diagnosed as RP. All patients were ultimately required tracheostomy. The time from the onset of airway symptoms to tracheostomy ranged from 1 month to 27 months. Two children had a history of endotracheal intubation prior to tracheostomy. All 6 patients underwent electronic laryngoscopy, revealing involvement of the laryngeal and subglottic mucosa and cartilage structures, which showed gradual improvement with medical therapy. Computed tomography (CT) of the trachea with three-dimensional reconstruction was performed in all patients, demonstrating moderate to severe subglottic stenosis. Two patients exhibited complete airway obstruction at the C4-C6 cervical level. Three children underwent suspension laryngoscopy under general anesthesia and endotracheal mucosal biopsy.Of the 6 children, 3 presented with nasal tip collapse or saddle nose, 2 had auricular cartilage changed, and 1 had scleralinvolvement. One patient underwent PET-CT scanning, which revealed tracheal collapse, diffuse increase in FDG(Flurodeoxyglucose)metabolism with increased FDG uptake in the nasal alar regions. All children were followed up for 2-3 years, 1 child died, while the remaining five continued to receive medical treatment. Conclusions: Relapsing polychondritis with airway involvement has an insidious onset and is difficult to diagnose. The airway stenosisresulting from RP is always severe and necessitating tracheotomy to maintain airway patency in the majority of cases.The treatment coursef or RP is prolonged, requiring long-term tracheostomy tube placement.

Management of adult bronchiectasis - Consensus-based Guidelines for the German Respiratory Society (DGP) e. V. (AWMF registration number 020-030)

Bronchiectasis is an etiologically heterogeneous, chronic, and often progressive respiratory disease characterized by irreversible bronchial dilation. It is frequently associated with significant symptom burden, multiple complications, and reduced quality of life. For several years, there has been a marked global increase in the prevalence of bronchiectasis, which is linked to a substantial economic burden on healthcare systems. This consensus-based guideline is the first German-language guideline addressing the management of bronchiectasis in adults. The guideline emphasizes the importance of thoracic imaging using CT for diagnosis and differentiation of bronchiectasis and highlights the significance of etiology in determining treatment approaches. Both non-drug and drug treatments are comprehensively covered. Non-pharmacological measures include smoking cessation, physiotherapy, physical training, rehabilitation, non-invasive ventilation, thoracic surgery, and lung transplantation. Pharmacological treatments focus on the long-term use of mucolytics, bronchodilators, anti-inflammatory medications, and antibiotics. Additionally, the guideline covers the challenges and strategies for managing upper airway involvement, comorbidities, and exacerbations, as well as socio-medical aspects and disability rights. The importance of patient education and self-management is also emphasized. Finally, the guideline addresses special life stages such as transition, family planning, pregnancy and parenthood, and palliative care. The aim is to ensure comprehensive, consensus-based, and patient-centered care, taking into account individual risks and needs.

The Impact of Lung Function on Sleep Monitoring in Obstructive Sleep Apnea Associated with Obstructive Lung Diseases: Insights from a Clinical Study.

Background/Objectives: Obstructive sleep apnea (OSA) and obstructive lung diseases (OLD) are common and interdependent respiratory disorders, where one condition may contribute to the development and worsening of the other (OLDOSA syndrome). The term OLDOSA syndrome includes two different conditions: Overlap syndrome (OVS: OSA + chronic obstructive pulmonary disease, COPD) and Alternative Overlap syndrome (aOVS: OSA + Asthma). Data on the interactions between lung function and respiratory monitoring during sleep in OLDOSA patients are few and controversial. Our study aims to evaluate the impact of lung function impairment on sleep breathing disorders, paying attention to the lack of literature about comparisons between OVS, aOVS, and the impact of small airways disease (SAD) in these patients. Methods: In total, 101 patients with a diagnosis of OSA and asthma or COPD underwent pulmonary function tests (PFTs) and nocturnal home sleep cardiorespiratory monitoring (HSCM). Exclusion criteria: Obesity hypoventilation syndrome (OHS) and other non-respiratory sleep disorders. Results: Sleep time with oxygen saturation below 90% (T90) was negatively correlated with forced expiratory volume in the first second, % of predicted (%FEV1), forced vital capacity, % of predicted (%FVC), forced expiratory flow at 25-75% of the pulmonary volume, % of predicted (%FEF25-75), and, after multivariable linear regression analysis, %FEF25-75 remained an independent factor for T90 with a negative correlation in mild and moderate OSA. Obstructive apnea index (oAI) and FEV1/FVC were negatively correlated in mild and moderate OSA. OVS presented with more severe OSA (higher AHI, oAI, and T90) and SAD (lower FEF25-75) compared to aOVS. Conclusions: This study highlights a possible interdependence between OLD and OSA; obstruction of the large and small airways at PFTs contributes to the worsening of these patients' nocturnal hypoxemia and obstructive events of the upper airway during sleep. Furthermore, this study shows that patients with OVS should be carefully monitored, as they present worse data at HSCM and have greater small airways involvement compared to aOVS.

A Comparative Observational Study of the Diagnostic Utility of Impulse Oscillometry Versus Spirometry in Obstructive Airway Diseases.

Background Obstructive airway diseases, including asthma and chronic obstructive pulmonary disease (COPD), significantly impact respiratory function, making accurate diagnosis and differentiation essential for proper management. While spirometry is the gold standard for assessing lung function, impulse oscillometry (IOS) has emerged as a complementary tool, especially when spirometry results are inconclusive. This study aimed to compare the diagnostic utility of IOS with spirometry in patients with obstructive airway diseases and evaluate the correlation between these two methods. Methods A comparative observational study was conducted over 18 months at a tertiary care hospital in central India, including 130 patients (65 with asthma and 65 with COPD). Diagnostic evaluations using spirometry and IOS were performed before and after bronchodilator administration. Spirometry parameters assessed were forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio, while IOS parameters evaluated included resistance at 5 Hz (R5), resistance at20Hz (R20), resonant frequency(Fres), reactance at 5 Hz (X5), and the area under the reactance curve (AX). Statistical analysis was conducted using IBM SPSS version 27.0 (IBM Corp., Armonk, USA) and GraphPad Prism version 7.0 (Dotmatics, Boston, USA). Results Significant differences were observed in spirometry parameters between asthma and COPD groups, with asthma patients showing better lung function (FEV1, FVC, and FEV1/FVC; p<0.05). No significant differences were found in IOS parameters between the groupsexcept for a correlation between FEV1 (%) and IOS measurements in the asthma group. Spirometry demonstrated superior sensitivity in identifying airway obstruction compared to IOS. However, IOS was more effective in detecting peripheral airway obstruction in asthma patients, with 22 out of 65 (33.85%) asthma patients showing peripheral airway obstruction compared to six out of 65 (9.23%) COPD patients (p=0.001). Conclusion While spirometry remains the primary diagnostic tool for assessing obstructive airway diseases, IOS is a valuable adjunct, particularly for detecting peripheral airway involvement in asthma patients. Combining spirometry and IOS enhances diagnostic accuracy and provides a more comprehensive assessment of lung function in patients with asthma and COPD.

Characteristics of Severe Asthma Clinic Patients With Eosinophilic Granulomatosis With Polyangiitis

BackgroundEosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis associated with varying clinical presentations and overlapping multiorgan involvement. Asthma is a predominant feature of EGPA, typically in its prodromal phase, often severe and precedes vasculitic complications. However, there is paucity of studies describing the prevalence and characteristics of EGPA in the asthma population. ObjectiveWe aim to describe the clinical and serological characteristics and longitudinal therapeutic outcomes of patients with EGPA in the severe asthma (SA) cohort. MethodsRetrospective study of patients with EGPA attending the multidisciplinary SA clinic in a tertiary hospital from 2011 to 2023 was conducted. Baseline demographics, organ manifestations, biological markers, lung function and therapeutic outcomes were assessed. Results23 out of 596 patients in the SA registry were identified to have EGPA. Median time interval between asthma and EGPA diagnosis was 10 years (range 2.5 to 32 years). Almost all patients (95.7%) had peak blood eosinophil count of >1.0 x 109/L (range 0.47 – 14.08 x 109/L). Upper airway involvement was the most detected manifestation in addition to asthma, followed by neuropathy and renal involvement. Patients who were treated with biologic therapy were significantly younger, had more upper airway, renal, pulmonary involvement and lower five factor score (FFS). ConclusionThe prevalence of EGPA in the SA population was 3.9% in our cohort. Its diagnosis requires high clinical suspicion in patients with SA and blood eosinophilia, prompting stringent evaluation for extrapulmonary manifestations and multidisciplinary involvement.

TNF-α inhibitors in the management of refractory granulomatosis with polyangiitis: A report of two cases

Granulomatosis with polyangiitis (GPA) is a type of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) that causes granulomatous necrotizing inflammation of small blood vessels. The goal of AAV treatment is to create a long-term remission. For inducing remission, the European League Against Rheumatism recommends using glucocorticoids (GCs) in combination with either cyclophosphamide (CYC) or rituximab (RTX). Despite this, in 10-40% the disease is resistant to initial treatment. In this report, we present two cases of refractory GPA that successfully achieved long-term remission using tumor necrosis factor-α inhibitors. The first case is a 27-year-old woman with GPA with involvement of upper airway, breast and central nervous system with active disease despite treatment with high dose GCs, CYC and RTX, successfully treated with infliximab and the disease was in complete remission for 54 months. The second case is a 35-year-old man with GPA with arthritis, lung cavitary lesions and nephritis resistant to treatment with high dose GCs, CYC and RTX, treated with adalimumab and the disease was in complete remission for 40 months.

Nasal epithelial gene expression identifies relevant asthma endotypes in the ATLANTIS study

IntroductionAsthma is an inflammatory airways disease encompassing multiple phenotypes and endotypes. Several studies suggested gene expression in nasal epithelium to serve as a proxy for bronchial epithelium, being a non-invasive...

777. COMBINED OESOPHAGEAL AND AIRWAY STENTING FOR MALIGNANT OESOPHAGEAL STRICTURES: THE UK’S LARGEST TERTIARY CENTRE EXPERIENCE AND DEVELOPMENT OF A NOVEL ALGORITHM

Abstract Background Malignant oesophageal strictures can cause airway compromise and fistula formation. Combined oesophageal and airway stenting is a potential treatment yet no guidelines exist. This study aims to describe the outcomes of same-session oesophageal and airway endoscopic stenting for malignant strictures and propose an algorithm for intervention. Methods A retrospective study on patients undergoing same-session gastroenterology (GI) and respiratory endoscopy at University College London Hospital, 2019-2023. All procedures were with anaesthetic-led propofol sedation. Endoscopic decision making was based on pre-procedure multidisciplinary team meeting (MDM) and intra-procedure clinical assessment. Data collected included malignancy type, luminal narrowing, complications, and mortality. Results 26 patients were identified. Mean age was 63 years. Cancer type was oesophageal (81%) or lung (19%). The most common referral indication was dysphagia (42%); airway compromise was often seen on imaging (65%). Stent insertion was oesophageal only (35%), airway only (19%) and dual (27%). Airway stenting was common (80%) if airway stenosis was &amp;gt;50%. No airway stenting occurred if stenosis was &amp;lt;50%. After oesophageal stenting, repeat bronchoscopy showed increased airway stenosis in 4 patients (25%). The only intraoperative complication was one oesophageal perforation. New tracheooesophageal fistula was the most common post-intervention complication (15%). Median time from malignancy diagnosis to death was 7.9 weeks. Conclusion We present the first algorithm (Figure 1) for endoscopic stenting in patients with malignant oesophageal stricture and airway involvement. We suggest upper GI and respiratory MDM to plan same-session endoscopy with decision-making framed by patient-centred goals given their poor prognosis.

Differentiating lung neuroendocrine neoplasms from tumor-like infection using CT in patients with ectopic ACTH syndrome

ObjectivesPulmonary neuroendocrine neoplasms (NENs) are the most frequent cause of ectopic adrenocorticotropic hormone syndrome (EAS); lung infection is common in EAS. An imaging finding of infection in EAS patients can mimic NENs. This retrospective study investigated EAS-associated pulmonary imaging indicators.MethodsForty-five pulmonary NENs and 27 tumor-like infections from 59 EAS patients (45 NEN and 14 infection patients) were included. Clinical manifestations, CT features, 18F-FDG, or 68Ga-DOTATATE-PET/CT images and pathological results were collected.ResultsHigh-sensitivity C-reactive protein (p < 0.001) and expectoration occurrence (p = 0.04) were higher, and finger oxygen saturation (p = 0.01) was lower in the infection group than the NENs group. Higher-grade NENs were underrepresented in our cohort. Pulmonary NENs were solitary primary tumors, 80% of which were peripheral tumors. Overlying vessel sign and airway involvement were more frequent in the NENs group (p < 0.001). Multifocal (p = 0.001) and peripheral (p = 0.02) lesions, cavity (p < 0.001), spiculation (p = 0.01), pleural retraction (p < 0.001), connection to pulmonary veins (p = 0.02), and distal atelectasis or inflammatory exudation (p = 0.001) were more frequent in the infection group. The median CT value increment between the non-contrast and arterial phases was significantly higher in NENs lesions (p < 0.001). Receiver operating characteristic curve analysis indicated a moderate predictive ability at 48.3 HU of delta CT value (sensitivity, 95.0%; specificity, 54.1%).ConclusionChest CT scans are valuable for localizing and characterizing pulmonary lesions in rare EAS, thereby enabling prompt differential diagnosis and treatment.Critical relevance statementThin-slice CT images are valuable for the localization and identification of pulmonary ectopic adrenocorticotropic hormone syndrome lesions, leading to prompt differential diagnosis and effective treatment.Key PointsLung tumor-like infections can mimic neuroendocrine neoplasms (NENs) in ectopic adrenocorticotropic hormone syndrome (EAS) patients.NENs are solitary lesions, whereas infections are multiple peripheral pseudotumors each with identifying imaging findings.Typical CT signs aid in localization and creating an appropriate differential diagnosis.Graphical

Surviving laryngotracheal mucormycosis: conquering central airway challenges

Laryngotracheal mucormycosis presents a rare but critical challenge, particularly in immunocompromised individuals. This report details the case of a 31-year-old diabetic male who experienced central airway obstruction due to mucormycosis. Despite the complexity of managing airway involvement, a multidisciplinary approach involving airway debridement surgery, liposomal amphotericin B, and posaconazole resulted in successful airway mucor treatment and resolution. This case underscores the importance of early recognition, aggressive intervention, and collaborative care in managing life-threatening conditions.

Submandibular Sialolithiasis Mimicking Ludwig’s Angina: A Case Report and Brief Clinical Review

The “double tongue sign” is a characteristic finding in patients with Ludwig's angina, a potentially life-threatening infection due to airway compromise. Management primarily focuses on early airway protection and antibiotic administration. Submandibular sialolithiasis, on the other hand, could present with the double tongue sign without symptoms suggestive of airway involvement. Unlike Ludwig’s angina, conservative treatment is usually the first-line approach for sialolithiasis. The importance of rapidly recognizing and distinguishing between the 2 conditions is emphasized through effective triage and risk stratification, particularly in rural areas where physicians are not readily available.

Sex differences in asthma control, lung function and exacerbations: the ATLANTIS study

BackgroundAsthma is a heterogeneous disease with a prevalence and severity that differs between male and female patients.QuestionWhat are differences between male and female patients with asthma with regard to asthma...

FOT Technique Applied for Monitoring of COVID-19 Pneumonia Reveals Small Airways Involvement.

The fact that some SARS-CoV-2 pneumonia patients benefit from changing body position, and some from continuous positive airways pressure (CPAP), indicates the functional character of hypoxia. We hypothesize that such effects could be explained by the closure of small airways. To prove the hypothesis, we evaluated the patency of small airways in 30 oxygen-dependent, spontaneously breathing patients with SARS-CoV-2 pneumonia during their hospital stay using the FOT method and then compared the results with data obtained three months later. During the acute period, total resistance (R5) and peripheral resistance (R5-20) rose above the upper limit of normal (ULN) in 28% and 50% of all patients, respectively. Reactance indices X5, AX and Fres exceeded ULN in 55%, 68% and 66% of cases. Significant correlations were observed between PaO2/FiO2, the time spent in the hospital and R5, X5, AX and Fres. After 3 months, 18 patients were re-examined. During the hospital stay, 11 of them had risen above the upper limit of normal (ULN), for both resistance (R5-20) and reactance (X5, AX) values. Three months later, ULN for R5-20 was exceeded in only four individuals, but ULN for X5 and AX was exceeded in five individuals. Lung function examination revealed a combined restrictive/obstructive ventilatory failure and reduced CO transfer factor. We interpret these changes as lung tissue remodeling due to the process of fibrosis. We conclude that during acute period of SARS-CoV-2 pneumonia, dilated pulmonary blood vessels and parenchymal oedema induce functional closure of small airways, which in turn induce atelectasis with pulmonary right-to-left shunting, followed by the resulting hypoxemia.

Neonatal Endotracheal Intubation: Comparison of Existing Formulae for Accuracy

Background There are several formulae proposed to calculate the ideal depth of insertion of the endotracheal tube (ETT) in neonates, none of which are universally accurate. Our objective is to identify the most accurate of these formulae and to determine the most suitable formula for babies weighing less than 1 kg. Methods This is a retro-prospective observational study conducted in a tertiary neonatal intensive care unit. All intubated babies, irrespective of their gestational age, were included in this study. Those with congenital airway anomalies or syndromes with involvement of the upper airway and those who required short-term ventilation restricted to the theatre complex were excluded. The ideal insertion depth was determined via a chest X-ray (CXR) with the ETT projecting between thoracic vertebrae 2 and 3. Predictions from eight formulae investigated in the Indian population were analysed using paired Wilcoxon tests and Bland–Altman plots. Results The sample size was 83, of which 16 weighed less than 1 kg. Neither weight-based nor naso-tragal length (NTL)-based formulae were universally accurate in the prediction of the ideal depth of insertion, and using either of the formulae resulted in a high rate of malpositioning. Amongst the NTL-based formulae, Tatwavedi and Singh’s adjustments worked better than the original. Conclusion The currently available formulae remain inaccurate in the prediction of the ideal length of insertion of ETT, more so in babies less than 1 kg in our study population.

Microscopic Small Airway Abnormalities Identified in Early Idiopathic Pulmonary Fibrosis InVivo Using Endobronchial Optical Coherence Tomography.

Rationale: Idiopathic pulmonary fibrosis (IPF) affects the subpleural lung but is considered to spare small airways. Micro-computed tomography (micro-CT) studies demonstrated small airway reduction in end-stage IPF explanted lungs, raising questions about small airway involvement in early-stage disease. Endobronchial optical coherence tomography (EB-OCT) is a volumetric imaging modality that detects microscopic features from subpleural to proximal airways. Objectives: In this study, EB-OCT was used to evaluate small airways in early IPF and control subjects invivo. Methods: EB-OCT was performed in 12 subjects with IPF and 5 control subjects (matched by age, sex, smoking history, height, and body mass index). Subjects with IPF had early disease with mild restriction (FVC: 83.5% predicted), which was diagnosed per current guidelines and confirmed by surgical biopsy. EB-OCT volumetric imaging was acquired bronchoscopically in multiple, distinct, bilateral lung locations (total: 97 sites). IPF imaging sites were classified by severity into affected (all criteria for usual interstitial pneumonia present) and less affected (some but not all criteria for usual interstitial pneumonia present). Bronchiole count and small airway stereology metrics were measured for each EB-OCT imaging site. Measurements and Main Results: Compared with the number of bronchioles in control subjects (mean = 11.2/cm3; SD = 6.2), there was significant bronchiole reduction in subjects with IPF (42% loss; mean = 6.5/cm3; SD = 3.4; P = 0.0039), including in IPF affected (48% loss; mean: 5.8/cm3; SD: 2.8; P < 0.00001) and IPF less affected (33% loss; mean: 7.5/cm3; SD: 4.1; P = 0.024) sites. Stereology metrics showed that IPF-affected small airways were significantly larger, more distorted, and more irregular than in IPF-less affected sites and control subjects. IPF less affected and control airways were statistically indistinguishable for all stereology parameters (P = 0.36-1.0). Conclusions: EB-OCT demonstrated marked bronchiolar loss in early IPF (between 30% and 50%), even in areas minimally affected by disease, compared with matched control subjects. These findings support small airway disease as a feature of early IPF, providing novel insight into pathogenesis and potential therapeutic targets.

Dysfunctional Breathing in Children: A Literature Review.

Dysfunctional breathing (DB) describes a respiratory condition that is mainly characterized by abnormal breathing patterns, affecting both children and adults, often leading to intermittent or chronic complaints and influencing physiological, psychological, and social aspects. Some symptoms include breathlessness; dizziness; palpitations; and anxiety, while its classification lies in breathing pattern disorders and upper airway involvement. Its prevalence among the pediatric population varies with a female overrepresentation, while the existence of comorbidities in DB, such as asthma, gastro-esophageal reflux, nasal diseases, and anxiety/depression, frequently leads to misdiagnosis or underdiagnosis and complicates therapeutic approaches. The basic diagnostic tools involve a detailed history, physical examination, and procedures such as structured light plethysmography, cardiopulmonary exercise testing, and laryngoscopy when a laryngeal obstruction is present. The management of DB presumes a multidimensional approach encompassing breathing retraining, disease-specific advice through speech and language therapy in the presence of laryngeal obstruction, psychotherapy for fostering self-efficacy, and surgical therapy in a structural abnormality. The current review was developed to provide a summary of classifications of DB and epidemiological data concerning the pediatric population, comorbidities, diagnostic tools, and therapeutic approaches to enhance the comprehension and management of DB in children.

An unusual case of Juvenile-onset Recurrent Respiratory Papillomatosis with lower airway involvement in a 15-month-old boy

An unusual case of Juvenile-onset Recurrent Respiratory Papillomatosis with lower airway involvement in a 15-month-old boy

Diagnostic Approach to Interstitial Lung Diseases Associated with Connective Tissue Diseases.

Interstitial lung disorders are a group of respiratory diseases characterized by interstitial compartment infiltration, varying degrees of infiltration, and fibrosis, with or without small airway involvement. Although some are idiopathic (e.g., idiopathic pulmonary fibrosis, idiopathic interstitial pneumonias, and sarcoidosis), the great majority have an underlying etiology, such as systemic autoimmune rheumatic disease (SARD, also called Connective Tissue Diseases or CTD), inhalational exposure to organic matter, medications, and rarely, genetic disorders. This review focuses on diagnostic approaches in interstitial lung diseases associated with SARDs. To make an accurate diagnosis, a multidisciplinary, personalized approach is required, with input from various specialties, including pulmonary, rheumatology, radiology, and pathology, to reach a consensus. In a minority of patients, a definitive diagnosis cannot be established. Their clinical presentations and prognosis can be variable even within subsets of SARDs.

Post-COVID-19 respiratory sequelae two years after hospitalization: an ambidirectional study

COVID-19 lung sequelae can impact the course of patient lives. We investigated the evolution of pulmonary abnormalities in post-COVID-19 patients 18-24 months after hospital discharge. A cohort of COVID-19 patients admitted to the Hospital das Clínicas da Faculdade de Medicina da USP in São Paulo, Brazil, between March and August of 2020, were followed-up 6-12 months after hospital discharge. A subset of patients with pulmonary involvement and chest computed tomography (CT) scans were eligible to participate in this second follow-up (18-24 months). Data was analyzed in an ambidirectional manner, including retrospective data from the hospitalization, and from the first follow-up (6-12 months after discharge), and compared with the prospective data collected in this new follow-up. From 348 patients eligible, 237 (68%) participated in this follow-up. Among participants, 139 (58%) patients presented ground-glass opacities and reticulations, and 80 (33%) presented fibrotic-like lesions (traction bronchiectasis and architectural distortion). Five (2%) patients improved compared to the 6-12-month assessment, but 20 (25%) of 80 presented worsening of lung abnormalities. For those with relevant assessments on both occasions, comparing the CT findings between this follow-up with the previous assessment, there was an increase in patients with architectural distortion (43 [21%] of 204 vs 57 [28%] of 204, p=0.0093), as well as in traction bronchiectasis (55 [27%] of 204 vs 69 [34%] of 204, p=0.0043). Patients presented a persistent functional impairment with demonstrated restrictive pattern in both follow-ups (87 [42%] of 207 vs 91 [44%] of 207, p=0.76), as well as for the reduced diffusion capacity (88 [42%] of 208 vs 87 [42%] of 208, p=1.0). Length of hospitalization (OR 1.04 [1.01-1.07], p=0.0040), invasive mechanical ventilation (OR 3.11 [1.3-7.5] p=0.011), patient's age (OR 1.03 [1.01-1.06] p=0.0074 were consistent predictors for development of fibrotic-like lung lesions in post-COVID-19 patients. Post-COVID-19 lung sequelae can persist and progress after hospital discharge, suggesting airways involvement and formation of new fibrotic-like lesions, mainly in patients who were in intensive care unit (ICU). São Paulo Research Foundation (22/01769-5) and Instituto Todos pela Saúde (C1721).