Risk Of Adverse Respiratory Outcomes Research Articles

Bronchiolitis recovery and the use of High Efficiency Particulate Air (HEPA) Filters (The BREATHE Study): study protocol for a multi-center, parallel, double-blind, randomized controlled clinical trial

BackgroundAcute viral bronchiolitis is the most common reason for hospitalization of infants in the USA. Infants hospitalized for bronchiolitis are at high risk for recurrent respiratory symptoms and wheeze in the subsequent year, and longer-term adverse respiratory outcomes such as persistent childhood asthma. There are no effective secondary prevention strategies. Multiple factors, including air pollutant exposure, contribute to risk of adverse respiratory outcomes in these infants. Improvement in indoor air quality following hospitalization for bronchiolitis may be a prevention opportunity to reduce symptom burden. Use of stand-alone high efficiency particulate air (HEPA) filtration units is a simple method to reduce particulate matter ≤ 2.5 µm in diameter (PM2.5), a common component of household air pollution that is strongly linked to health effects.MethodsBREATHE is a multi-center, parallel, double-blind, randomized controlled clinical trial. Two hundred twenty-eight children < 12 months of age hospitalized for the first time with bronchiolitis will participate. Children will be randomized 1:1 to receive a 24-week home intervention with filtration units containing HEPA and carbon filters (in the child’s sleep space and a common room) or to a control group with units that do not contain HEPA and carbon filters. The primary objective is to determine if use of HEPA filtration units reduces respiratory symptom burden for 24 weeks compared to use of control units. Secondary objectives are to assess the efficacy of the HEPA intervention relative to control on (1) number of unscheduled healthcare visits for respiratory complaints, (2) child quality of life, and (3) average PM2.5 levels in the home.DiscussionWe propose to test the use of HEPA filtration to improve indoor air quality as a strategy to reduce post-bronchiolitis respiratory symptom burden in at-risk infants with severe bronchiolitis. If the intervention proves successful, this trial will support use of HEPA filtration for children with bronchiolitis to reduce respiratory symptom burden following hospitalization.Trial registrationNCT05615870. Registered on November 14, 2022.

Adverse respiratory outcomes among patients with resolved asthma: matched retrospective cohort study.

Patients with asthma may have symptom remission leading to a primary care code of resolved asthma. Little is known about subsequent rates of exacerbations and respiratory tract infections (RTIs). To assess the risk of adverse respiratory outcomes for people with resolved asthma compared with those with active asthma and without asthma. This was a retrospective cohort study of patients aged >5 years, registered with a general practice in England contributing data to the Clinical Practice Research Datalink between January 2010 and December 2019. Patients with resolved asthma were matched to non-asthma controls and active asthma controls for age, sex, and practice. Negative binomial regression was used to estimate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for asthma exacerbations, RTIs, flu/pneumonia, and antibiotic prescriptions. Cohorts included 16 023 patients (8720 (54.4%) females, mean age 37 years). Compared with the active asthma cohort, the resolved cohort had fewer hospital admissions (adjusted IRR 0.29, 95% CI = 0.27 to 0.32) and general practice consultations (adjusted IRR 0.05, 95% CI = 0.04 to 0.07) for asthma exacerbations. The resolved and non-asthma cohorts had similar rates of hospital admissions for RTIs or flu/pneumonia. However, the resolved cohort had significantly greater incidence of general practice consultations for lower RTIs (adjusted IRR 2.34, 95% CI = 2.08 to 2.64) and antibiotic prescriptions (adjusted IRR 1.37, 95% CI = 1.30 to 1.44). Patients with resolved asthma had greater risk of general practice RTI and antibiotic prescription than the general population and may benefit from defined strategies for reassessing symptoms and reinitiating asthma therapy.

Feasibility, Safety, and Short-Term Outcomes of Transcatheter Patent Ductus Arteriosus Closure in Premature Infants on High-Frequency Jet Ventilation.

BackgroundProlonged exposure to a hemodynamically significant patent ductus arteriosus (PDA) is associated with major morbidity, particularly in infants born at <27 weeks’ gestation. High‐frequency jet ventilation (HFJV) is a standard of care at our center. There are no data about transcatheter PDA closure while on HFJV. The aim of this study was to assess the feasibility, safety, and outcomes of HFJV during transcatheter PDA closure.Methods and ResultsThis is a retrospective cohort study of premature infants undergoing transcatheter device closure on HFJV. The primary outcome was successful device placement. Secondary outcomes included procedure time, fluoroscopy time and dose, time off unit, device complications, need for escalation in respiratory support, and 7‐day survival. Subgroup comparative evaluation of patients managed with HFJV versus a small cohort of patients managed with conventional mechanical ventilation was performed. Thirty‐eight patients were included in the study. Median age and median weight at PDA device closure for the HFJV cohort were 32 days (interquartile range, 25.25–42.0 days) and 1115 g (interquartile range, 885–1310 g), respectively. There was successful device placement in 100% of patients. There were no device complications noted. The time off unit and the procedure time were not significantly different between the HFJV group and the conventional ventilation group. Infants managed by HFJV had shorter median fluoroscopy times (4.5 versus 6.1 minutes; P<0.05) and no increased risk of adverse respiratory outcomes.ConclusionsTranscatheter PDA closure in premature infants on HFJV is a safe and effective approach that does not compromise device placement success rate and does not lead to secondary complications.

Saharan Dust and Childhood Respiratory Symptoms in Benin.

Mineral dust is one of the largest natural constituents of coarse particulate matter (PM10). Most of these dust emissions originate from northern Africa, and several hundred tera-grams of dust are emitted annually from this region. Previous evidence has linked dust PM10 to adverse respiratory outcomes in children. However, most of these studies have been from high-income countries (HICs) or examined dust from other regions of the world, mainly Asia. Evidence from low-to-middle-income countries (LMICs) in Africa is scarce. Respiratory infections are one of the leading causes of under-five mortality across the globe. However, there is a poignant disparity in studies examining these outcomes in children in the region where most dust is emitted. This study linked remotely sensed satellite data to a nationally representative survey to examine acute exposure to dust in children living in Benin using a time-stratified case-crossover analysis. We identified acute effects of exposure to dust and increased risk of cough in children under five. The effect of increased risk is strongest within two weeks of exposure and dissipates by four weeks. Children living in rural areas and households with lower income had a greater risk of adverse respiratory outcomes when exposed to dust. We could elucidate the specific period and conditions of increased risk for respiratory problems in children living in Benin.

Silica Exposure Estimates in Artificial Stone Benchtop Fabrication and Adverse Respiratory Outcomes.

Silicosis is being increasingly reported among young stonemasons in the artificial stone (AS) benchtop fabrication and installation industry. Respiratory health screening, which included a job and exposure history, a chest X-ray (CXR), a respiratory health questionnaire, and gas transfer testing, were offered to stonemasons in Victoria, Australia. Workers typically reported a variety of tasks, including cleaning and labouring, which made exposure assessment complex. We estimated the relative respirable crystalline silica exposure intensity of each job from the proportion of time using AS and the proportion of time doing dry work (work without water suppression). The relative average intensity of exposure for up to five jobs was calculated. Cumulative exposure was calculated as the sum of the duration multiplied by intensity for each job. Installers and factory machinists (other than computer numeric control operators) were the most likely to report dry work with AS, and so had a greater average intensity of exposure. Exposure intensity and cumulative exposure were associated with increased odds of an ILO (International Labour Organisation) CXR profusion major category of ≥1 and with dyspnoea. Exposure duration was also associated with ILO profusion category. In multivariate analyses of health outcomes, only job type was associated with the ILO profusion category. For both most recent and longest-duration job types, when compared to the lowest exposure group, factory machinists were more likely to have an ILO category ≥1. This suggests that intensity of exposure estimated from the proportion of time dry cutting and proportion of time working on AS can predict the risk of adverse respiratory outcomes for workers in this industry.

Timing of term elective cesarean section and adverse neonatal outcomes: A multi-center retrospective cohort study.

BackgroundRate of cesarean section (CS), including elective CS has globally increased. Studies have found that term elective CS before 39 weeks of gestation is associated with increased risk of adverse respiratory outcomes.ObjectiveTo determine the rate of elective CS and examine the association between timing of elective term CS and adverse neonatal outcomes in a large population of Lebanese women.MethodsA Multi-Center Study was conducted using data from the National Collaborative Perinatal Neonatal Network database. Simple and multivariable logistic regression models were used to examine the association between timing of term elective CS and adverse neonatal outcomes. Some of the neonatal adverse outcomes we examined included respiratory distress syndrome, admission to the NICU, and a composite of respiratory outcomes.ResultsA total of 28,997 low risk mothers who delivered through primary and repeat elective CS were included in the study. Uncomplicated elective planned term CS constituted 25% of all CS deliveries in Lebanon. Primary and repeat CS at 37 weeks of gestation increased the odds of most of the studied adverse neonatal outcomes. There were few associations between CS and adverse neonatal outcomes at 38 weeks of gestation.ConclusionsTerm primary and repeat cesarean delivery prior to 39 weeks of gestation is associated with respiratory and other adverse neonatal outcomes. Delaying birth 1–2 weeks till 39 weeks of gestation can prevent 64–77% of adverse respiratory outcomes.

Respiratory health effect of exposure to Indoor Microbiome on children under-five: a meta-analysis

Background/AimThe association between specific microbial agents such as mold within the indoor environment and adverse respiratory outcome among children under-five years of age has been widely reported but none have investigated the risk of exposure to the microbiome within the indoor environment. The aim of this review is to summarize published association between exposure to the microbiome within the indoor environment and respiratory endpoints among under-five children (U5-C).MethodsElectronic scientific repositories; PUBMED, WEB OF SCIENCE, GREENFILE, EMBASE and Cochrane library were searched and screened through January 2020 for published reports for inclusion in the meta-analysis. Studies were eligible for inclusion if it reported an adjusted measure of risk for any of the respiratory outcomes associated with exposure to indoor microbiome, including the relative risk (RR) or odds ratio (OR) and CI. The pooled effective estimates was computed using inverse of variance method for weighting. Sensitivity analysis was used to evaluate the potential effect of individual studies on the overall estimates, while heterogeneity was evaluated by I2 statistics using RevMan 5.3.ResultsFifteen studies were eligible for inclusion in our meta-analysis. Exposure to a higher concentration of indoor microbiome was associated with an increased risk of wheeze [1.20 (1.03, 1.41), P &lt; 0.02,I2 = 76%], allergic rhinitis [1.25 (1.02, 1.54), P = 0.03,I2 = 65%] and acute respiratory infections [1.35 (1.12, 1.62), P = 0.002,I2 = 59%] among under-five children. The risk was stronger with exposure to fungi/molds [1.42 (1.27, 1.59), P &lt; 0.00001;I2 = 31%] than endotoxins [1.09 (0.93, 1.29), P = 0.29;I2 = 72%].ConclusionsThe pooled effect estimate indicates an increased risk of adverse respiratory outcomes among U-5C. Therefore, interventions addressing exposure to microbiome within the indoor environment should be considered in the management of respiratory outcomes among under-five children.

Respiratory health, occupation and the healthy worker effect.

Workers are exposed to physical, chemical and other hazards in the workplace, which may impact their respiratory health. To examine the healthy worker effect in the Canadian working population and to identify the association between occupation and respiratory health. Data from four cycles of the Canadian Health Measures Survey were utilized. The current occupation of employed participants was classified into 10 broad categories based on National Occupation Category 2011 codes. Data relating to 15 400 subjects were analysed. A significantly lower proportion of those in current employment than those not in current employment reported respiratory symptoms or diseases or had airway obstruction. Similarly, those currently employed reported better general health and had greater mean values for percent-predicted forced vital capacity (FVC), forced expiratory volume in one second (FEV1), forced expiratory flow between 25% and 75% of FVC (FEF25-75%) and FEV1/FVC ratio. Among males, females and older age groups, significant differences were observed for almost all the respiratory outcomes for those in current employment. Those in 'Occupations unique to primary industry' had a significantly greater likelihood of regular cough with sputum and ever asthma and had lower mean values of percent-predicted FEV1/FVC and FEF25-75% than those in 'Management occupations'. Those in 'Health occupations' had the highest proportion of current asthma. Participants in current employment were healthier than those not in current employment providing further support for the healthy worker effect. Those in 'Occupations unique to primary industry' had an increased risk of adverse respiratory outcomes and reducing workplace exposures in these occupations has the potential to improve their respiratory health.

Exposure Determinants of Wood Dust, Microbial Components, Resin Acids and Terpenes in the Saw- and Planer Mill Industry.

ObjectivesSawmill workers have an increased risk of adverse respiratory outcomes, but knowledge about exposure–response relationships is incomplete. The objective of this study was to assess exposure determinants of dust, microbial components, resin acids, and terpenes in sawmills processing pine and spruce, to guide the development of department and task-based exposure prediction models.Methods2474 full-shift repeated personal airborne measurements of dust, resin acids, fungal spores and fragments, endotoxins, mono-, and sesquiterpenes were conducted in 10 departments of 11 saw- and planer mills in Norway in 2013–2016. Department and task-based exposure determinants were identified and geometric mean ratios (GMRs) estimated using mixed model regression. The effects of season and wood type were also studied.ResultsThe exposure ratio of individual components was similar in many of the departments. Nonetheless, the highest microbial and monoterpene exposure (expressed per hour) were estimated in the green part of the sawmills: endotoxins [GMR (95% confidence interval) 1.2 (1.0–1.3)], fungal spores [1.1 (1.0–1.2)], and monoterpenes [1.3 (1.1–1.4)]. The highest resin acid GMR was estimated in the dry part of the sawmills [1.4 (1.2–1.5)]. Season and wood type had a large effect on the estimated exposure. In particular, summer and spruce were strong determinants of increased exposure to endotoxin (GMRs [4.6 (3.5–6.2)] and [2.0 (1.4–3.0)], respectively) and fungal spores (GMRs [2.2 (1.7–2.8)] and [1.5 (1.0–2.1)], respectively). Pine was a strong determinant for increased exposure to both resin acid and monoterpenes. Work as a boilerman was associated with moderate to relatively high exposure to all components [1.0–1.4 (0.8–2.0)], although the estimates were based on 13–15 samples only. Cleaning in the saw, planer, and sorting of dry timber departments was associated with high exposure estimates for several components, whereas work with transportation and stock/finished goods were associated with low exposure estimates for all components. The department-based models explained 21–61% of the total exposure variances, 0–90% of the between worker (BW) variance, and 1–36% of the within worker (WW) variances. The task-based models explained 22–62% of the total variance, 0–91% of the BW variance, and 0–33% of the WW variance.ConclusionsExposure determinants in sawmills including department, task, season, and wood type differed for individual components, and explained a relatively large proportion of the total variances. Application of department/task-based exposure prediction models for specific exposures will therefore likely improve the assessment of exposure–response associations.

Adverse respiratory outcomes among head and neck cancer survivors in the Utah Cancer Survivors Study.

The number of head and neck cancer (HNC) survivors has been increasing because of improving survival in the United States. The aim of this study was to evaluate the incidence of respiratory disease diagnoses in HNC survivors in comparison with cancer-free individuals. A second aim was to investigate risk factors for respiratory disease among HNC survivors. Patients with HNC diagnosed from 1996 to 2012 were identified in the Utah Cancer Registry (n=1901). Up to 5 cancer-free individuals from the general population (n=7796) were matched to each HNC survivor by birth year, sex, birth state, and follow-up time. Electronic medical records and statewide health care facility data were used to identify a disease diagnosis after the cancer diagnosis. Cox proportional hazards models were used to estimate the risks of respiratory diseases. The median follow-up times were 4.5years for HNC survivors and 7.8years for the general population cohort. The risks of respiratory infection (hazard ratio [HR], 1.63; 95% confidence interval [CI], 1.40-1.90), chronic obstructive pulmonary diseases and bronchiectasis (HR, 2.65; 95% CI, 2.13-3.29), and aspiration pneumonitis (HR, 6.21; 95% CI, 3.98-9.68) were higher among HNC survivors than the general population cohort more than 5years after the cancer diagnosis. Age at diagnosis, baseline body mass index, sex, baseline smoking status, treatment modality, primary site, and stage were associated with the risk of adverse respiratory outcomes among HNC survivors. The risk of adverse respiratory outcomes was much higher among HNC survivors than the general population cohort. Multidisciplinary care is needed to prevent the occurrence of adverse respiratory outcomes among HNC survivors.

531 Patients Undergoing Outpatient Upper Endoscopy and Colonoscopy on the Same Day (Double Procedures) Are at Increased Risk for Adverse Respiratory Outcomes

INTRODUCTION: Between 11-15 million colonoscopies and 6-7 million upper endoscopies are performed in the United States annually, with over half the cases occurring in an ambulatory setting (1,2). Recent claims-based data has suggested that infectious complications may be increased when upper endoscopy and colonoscopy are performed together compared to when they are performed separately (3). The purpose of this study is to determine endoscopic and anesthesia variables that increase the risk of periprocedural respiratory complications. METHODS: Medical records from 2000 consecutive upper endoscopies and colonoscopies performed at five high volume ambulatory surgery centers were reviewed. Patient characteristics were recorded, along with endoscopic and anesthesia variables. End points chosen to serve as surrogates of aspiration risk were intra-procedure cough, desaturation, placement of a nasal or oral airway, and use of oral suction. RESULTS: In 2000 cases, desaturation occurred in 3.25%, cough in 3.5% cases, need for suction in 2.45%, and need for oral airway / nasal trumpet in 0.4%. Multiple logistic regression analysis demonstrated supine position, double procedure, bowel prep taken as a single dose, NPO time of less than 3 hours, BMI &gt;35 kg/m2 and Propofol dose &gt;300 mg, and supine position to be independent risk factors for adverse respiratory events. CONCLUSION: Supine position during procedures, double procedures, bowel prep taken as a single dose, NPO duration of less than 3 hours, high BMI and high propofol dose are risk factors for adverse respiratory outcomes during endoscopic procedures.

Occupational and work-related respiratory disease attributed to cleaning products

ObjectivesExposure to cleaning products has been associated with adverse respiratory outcomes. This study aimed to investigate the medically reported incidence, trends in incidence and occupational determinants of work-related respiratory disorders...

Established and Emerging Environmental Contributors to Disparities in Asthma and Chronic Obstructive Pulmonary Disease.

Multiple respiratory diseases, including asthma and chronic obstructive pulmonary disease (COPD), display significant socioeconomic and racial/ethnic disparities. The objective of this review is to evaluate the evidence supporting a link between disproportionate environmental exposures and these health disparities. Studies suggest that various co-occurring factors related to the home environment, neighborhood environment, non-modifiable individual factors, and individual behaviors and attributes can increase or modify the risk of adverse respiratory outcomes among socioeconomically-disadvantaged and racially/ethnically diverse populations. Pollutants in the home environment, including particulate matter, nitrogen dioxide, and pesticides, are elevated among lower socioeconomic status populations and have been implicated in the development or exacerbation of respiratory-related conditions. Neighborhood crime and green space are socioeconomically patterned and linked with asthma outcomes through psychosocial pathways. Non-modifiable individual factors such as genetic predisposition cannot explain environmental health disparities but can increase susceptibility to air pollution and other stressors. Individual behaviors and attributes, including obesity and physical activity, contribute to worse outcomes among those with asthma or COPD. The root causes of these multifactorial exposures are complex, but many likely stem from economic forces and racial/ethnic and economic segregation that influence the home environment, neighborhood environment, and access to healthy foods and consumer products. Critical research needs include investigations that characterize exposure to and health implications of numerous stressors simultaneously, both to guard against potential confounding in epidemiological investigations and to consider the cumulative impact of multiple elevated environmental exposures and sociodemographic stressors on health disparities.

Vitamin D status in pregnant women with asthma and its association with adverse respiratory outcomes during infancy

Background Vitamin D may influence pregnancy and infant outcomes, especially infant respiratory health. This study aimed to examine vitamin D status in pregnant women with asthma, and whether higher vitamin D levels are associated with fewer adverse respiratory outcomes in their infants. Methods Pregnant women with asthma, recruited from John Hunter Hospital Newcastle Australia (latitude 33°S), had serum total 25-hydroxyvitamin-D (25(OH)D) measured at 16 and 35 weeks gestation. Infant respiratory outcomes were collected at 12 months by parent-report questionnaire. Mother–infant dyads were grouped by serum 25(OH)D during pregnancy: 25(OH)D < 75 nmol/L (at both time-points) versus 25(OH)D ≥ 75 nmol/L (at one or both time-points). Results In 52 pregnant women with asthma, mean serum 25(OH)D levels were 61 (range 26–110) nmol/L at 16 weeks, and 65 (range 32–116) nmol/L at 35 weeks, gestation. Thirty-one (60%) women had 25(OH)D < 75 nmol/L at both time-points; 21 (40%) had 25(OH)D ≥ 75 nmol/L at one or both time-points. Maternal 25(OH)D < 75 nmol/L during pregnancy was associated with a higher proportion of infants with “wheeze ever” at 12 months, compared with 25(OH)D ≥ 75 nmol/L (71 versus 43%, p = .04). Infant acute-care presentations (45 versus 13%, p = .02) and oral corticosteroid use (26 versus 4%, p = .03) due to “asthma/wheezing” were higher in the maternal group with 25(OH)D < 75 nmol/L, versus ≥75 nmol/L. Conclusions Most pregnant women with asthma had low vitamin D status, which persisted across gestation. Low maternal vitamin D status was associated with greater risk of adverse respiratory outcomes in their infants, a group at high risk of developing childhood asthma.

Potential Toxicity and Underlying Mechanisms Associated with Pulmonary Exposure to Iron Oxide Nanoparticles: Conflicting Literature and Unclear Risk.

Fine/micron-sized iron oxide particulates are incidentally released from a number of industrial processes, including iron ore mining, steel processing, welding, and pyrite production. Some research suggests that occupational exposure to these particulates is linked to an increased risk of adverse respiratory outcomes, whereas other studies suggest that iron oxide is biologically benign. Iron oxide nanoparticles (IONPs), which are less than 100 nm in diameter, have recently surged in use as components of novel drug delivery systems, unique imaging protocols, as environmental catalysts, and for incorporation into thermoplastics. However, the adverse outcomes associated with occupational exposure to IONPs remain relatively unknown. Relevant in vivo studies suggest that pulmonary exposure to IONPs may induce inflammation, pulmonary fibrosis, genotoxicity, and extra-pulmonary effects. This correlates well with in vitro studies that utilize relevant dose, cell type(s), and meaningful end points. A majority of these adverse outcomes are attributed to increased oxidative stress, most likely caused by particle internalization, dissolution, release of free iron ions, and disruption of iron homeostasis. However, because the overall toxicity profile of IONPs is not well understood, it is difficult to set safe exposure limit recommendations that would be adequate for the protection of at-risk workers. This review article will focus on known risks following IONPs exposure supported by human, animal, and cell culture-based studies, the potential challenges intrinsic to IONPs toxicity assessment, and how these may contribute to the poorly characterized IONPs toxicity profile.

Particulate matter from re-suspended mineral dust and emergency cause-specific respiratory hospitalizations in Hong Kong

While contribution from non-exhaust particulate matter (PM) emissions towards traffic-related emissions is increasing, few epidemiologic evidence of their health impact is available. We examined the association of short-term exposure to PM10 apportioned to re-suspended mineral dust with emergency hospitalizations for three major respiratory causes in Hong Kong between 2001 and 2008. Time-series regression model was constructed to examine association of PM10 from re-suspended mineral dust with emergency hospitalizations for upper respiratory infection (URI), chronic obstructive pulmonary disease (COPD) and asthma at exposure lag 0–5 days, adjusting for time trends, seasonality, temperature and relative humidity. An interquartile range (6.8 μg/m3) increment in re-suspended mineral dust on previous day was associated with 0.66% (95% CI: 0.12, 0.98) increase in total respiratory hospitalizations, and 1.01% (95% CI: 0.14, 1.88) increase in URI hospitalizations. A significant 0.66%–0.80% increases in risk of COPD hospitalizations were found after exposure to re-suspended mineral dust at lag 3 or later. Exposure to mineral dust at lag 4 was linked to 1.71% increase (95% CI: 0.14, 2.22) in asthma hospitalizations. Associations from single-pollutant models remained significant in multi-pollutant models, which additionally adjusted for PM10 contributing from vehicle exhaust, regional combustion, residual oil, fresh sea salt, aged sea salt, secondary nitrate and secondary sulfate, or gaseous pollutants (i.e., nitrogen dioxide, sulfur dioxide, or ozone), respectively. Our findings provide insight into the biological mechanism by which non-exhaust pollution may be associated with risk of adverse respiratory outcomes, and also stress the needs for strategies to reduce emission and re-suspension of mineral dust. More research is warranted to assess the health effects of different non-exhaust PM emissions under various roadway conditions and vehicle fleets.

Incident opioid drug use and adverse respiratory outcomes among older adults with COPD.

We evaluated risk of adverse respiratory outcomes associated with incident opioid use among older adults with chronic obstructive pulmonary diseases (COPD).This was a retrospective population-based cohort study using a validated algorithm applied to health administrative data to identify adults aged 66 years and older with COPD. Inverse probability of treatment weighting using the propensity score was used to estimate hazard ratios comparing adverse respiratory outcomes within 30 days of incident opioid use compared to controls.Incident opioid use was associated with significantly increased emergency room visits for COPD or pneumonia (HR 1.14, 95% CI 1.00-1.29; p=0.04), COPD or pneumonia-related mortality (HR 2.16, 95% CI 1.61-2.88; p<0.0001) and all-cause mortality (HR 1.76, 95% CI 1.57-1.98; p<0.0001), but significantly decreased outpatient exacerbations (HR 0.88, 95% CI 0.83-0.94; p=0.0002). Use of more potent opioid-only agents was associated with significantly increased outpatient exacerbations, emergency room visits and hospitalisations for COPD or pneumonia, and COPD or pneumonia-related and all-cause mortality.Incident opioid use, and in particular use of the generally more potent opioid-only agents, was associated with increased risk for adverse respiratory outcomes, including respiratory-related mortality, among older adults with COPD. Potential adverse respiratory outcomes should be considered when prescribing new opioids in this population.

Respiratory morbidity in late preterm infants.

Late preterm delivery (74% of all preterm births) increases the incidence of respiratory pathology, namely respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN) and the need of ventilator support when compared to term delivery. The aim is to evaluate the respiratory morbimortality in late preterm infants and the risk factors associated with RDS and TTN. Descriptive retrospective study of all newborns of 34+0 to 36+6 weeks of gestational age, born at our center between September 1, 2012 and August 31, 2015. Those with major malformations, chromosomopathies, hydrops fetalis and congenital TORCH infection were excluded. A total of 498 newborns were studied, 44 (8.83%) of them with either RDS or TTN. Respiratory morbidity was significantly associated with lower gestational age, male gender, caesarean section, exposure to peripartum antibiotics, overweighed and nulliparous mothers. RDS newborns had a significantly higher need for resuscitation, endotracheal intubation, oxygen therapy, early invasive ventilation, parenteral nutrition and a longer NICU stay when compared to newborns with TTN. 55% of the patients with RDS had 35+0 to 36+6 weeks of gestational age, moderate or severe RDS and required mechanical ventilation; six needed surfactant. Caesarean section and resuscitation with ETT were independent risk factors for respiratory morbidity. Late preterm remain at risk for adverse respiratory outcomes, particularly newborns delivered after 35 weeks, whose mothers are not given ACS and still have considerable morbidity. Growing evidence supports the possibility of extending the management window further into the LPT period. Caesarean section was an independent risk factor for respiratory morbidity and efforts should be undertaken to reduce the procedure rate.

Ventilation-induced lung injury is not exacerbated by growth restriction in preterm lambs.

Intrauterine growth restriction (IUGR) and preterm birth are frequent comorbidities and, combined, increase the risk of adverse respiratory outcomes compared with that in appropriately grown (AG) infants. Potential underlying reasons for this increased respiratory morbidity in IUGR infants compared with AG infants include altered fetal lung development, fetal lung inflammation, increased respiratory requirements, and/or increased ventilation-induced lung injury. IUGR was surgically induced in preterm fetal sheep (0.7 gestation) by ligation of a single umbilical artery. Four weeks later, preterm lambs were euthanized at delivery or delivered and ventilated for 2 h before euthanasia. Ventilator requirements, lung inflammation, early markers of lung injury, and morphological changes in lung parenchymal and vascular structure and surfactant composition were analyzed. IUGR preterm lambs weighed 30% less than AG preterm lambs, with increased brain-to-body weight ratio, indicating brain sparing. IUGR did not induce lung inflammation or injury or alter lung parenchymal and vascular structure compared with AG fetuses. IUGR and AG lambs had similar oxygenation and respiratory requirements after birth and had significant, but similar, increases in proinflammatory cytokine expression, lung injury markers, gene expression, and surfactant phosphatidylcholine species compared with unventilated controls. IUGR does not induce pulmonary structural changes in our model. Furthermore, IUGR and AG preterm lambs have similar ventilator requirements in the immediate postnatal period. This study suggests that increased morbidity and mortality in IUGR infants is not due to altered lung tissue or vascular structure, or to an altered response to early ventilation.

Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants

Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population. To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation. We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database. The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses. The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy. We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54-2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88-5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04-2.01). The number of ventilation courses was not associated with increased risk of supplemental oxygen use at discharge after adjustment for the length of ventilation. A greater number of ventilation courses did not increase the risk of tracheostomy. Among ELBW infants, a longer cumulative duration of mechanical ventilation largely accounts for the increased risk of chronic respiratory morbidity associated with reinitiation of mechanical ventilation. These results support attempts of extubation in ELBW infants receiving mechanical ventilation on low ventilator settings, even when success is not guaranteed.