Patient pathways for four major chronic respiratory diseases in England between 2008 and 2021.

Not all chronic diseases have clear pathways and time targets for diagnosis. We explored pathways and timings for four major chronic respiratory diseases in England. Using deidentified electronic healthcare records from Clinical Practice Research Datalink Aurum linked to Hospital Episode Statistics, we derived cohorts of patients diagnosed with asthma, chronic obstructive pulmonary disease (COPD), ILD or bronchiectasis at three time periods (2008/2009, 2018/2019 and 2020/2021). We followed people 2 years before and 2 years after diagnosis, calculating the proportion of people who presented with symptoms, underwent diagnostic tests, were treated and consulted healthcare (primary or secondary) and calculated time intervals between events. We repeated analyses by socioeconomic status and geographical region. We descriptively studied patient pathways for 429 619 individuals across all time frames and diseases. Most people (>87%) had first evidence of diagnosis in primary care. The proportion of people reporting symptoms prior to diagnosis was similar for asthma, COPD and ILD (41.0%-57.9%) and higher in bronchiectasis (67.9%-71.8%). The proportion undergoing diagnostic tests was high for COPD and bronchiectasis (77.6%-89.2%) and lower for asthma (14%-32.7%) and ILD (2.6%-3.3%). The proportion of people undergoing diagnostic tests decreased in 2020/2021 for all diseases, mostly COPD. Time (months) (median (IQR)) between symptoms and diagnosis, averaged over three time periods, was lowest in asthma (~7.5 (1.3-16.0)), followed by COPD (~8.6 (1.8-17.2)), ILD (~10.1 (3.6-18.0)) and bronchiectasis (~13.5 (5.9-19.8)). Time from symptoms to diagnosis increased by ~2 months in asthma and COPD over the three time periods. Although most patients were symptomatically treated prior to diagnosis, time between diagnosis and postdiagnostic treatment was around 4 months for ILD, 3 months for bronchiectasis and instantaneous for asthma and COPD. Socioeconomic status and regional trends showed little disparity. Current pathways demonstrate missed opportunities to diagnose and manage disease and to improve disease coding.

Ioannides AE ，Morgan AD ，Quint JK 《BMJ Open Respiratory Research》

Survey-identified experiences of prediagnosis and diagnosis process among patients with COPD, asthma, interstitial lung disease and bronchiectasis.

Diagnosis of asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis and interstitial lung disease (ILD) can be convoluted, and limited data exist on understanding the experience of diagnosis from a patient perspective. To investigate a patient's 'route to diagnosis', particularly focusing on the time prior to seeking healthcare, and perceived experiences of the diagnostic pathway. An online survey was distributed via the UK Taskforce for Lung Health and member mailing lists to patients as well as the website and social media accounts from 23 May 2022 to 5 July 2022. Analysis was descriptive; χ2 tests were performed to make comparisons across diseases. There were 398 valid responses (COPD=156, asthma=119, ILD=67 and bronchiectasis=56). While only 9.2% of respondents who were eventually diagnosed with asthma had not heard of their disease, the corresponding percentages for COPD, ILD and bronchiectasis were 34.0%, 74.6% and 69.6%, respectively. 33.9% of people with bronchiectasis believed their delayed diagnosis was due to the health professionals' lack of expertise or knowledge-24.4% for asthma, 19.2% for COPD and 17.9% for ILD.People with COPD were more likely (37.2%) and patients with asthma less likely (10.9%) to report they did not know the signs of potential lung disease (p<0.001). People with COPD were more likely to report that they did not appreciate the severity or urgency of the situation (58.3%) than people with asthma (32.8%), ILD (43.3%) or bronchiectasis (28.6%, p<0.001). The proportion of patients reporting that they were being initially treated for another lung condition was higher in people with bronchiectasis (44.6%) and lower in people with asthma (8.4%, p<0.001). Perceived reasons for diagnostic delay can help health professionals promote early diagnosis and management. Patients' limited knowledge of respiratory diseases also played a factor, indicating the necessity to promote patients' knowledge to encourage earlier help seeking.

Zhang X ，Ellis A ，Quint JK ，Bottle A ... -  《BMJ Open Respiratory Research》

Trends in Prevalence and Prognosis in Subjects With Acute Chronic Respiratory Failure Treated With Noninvasive and/or Invasive Ventilation.

The pattern and outcome of noninvasive ventilation (NIV) use in patients with acute or chronic respiratory disease other than COPD is not well known. The aims of this study were to investigate trends over time in underlying respiratory diseases, use of NIV, and outcomes in COPD and non-COPD patients with acute respiratory failure. We made a retrospective analysis of data recorded prospectively from 1,113 subjects admitted between 1998 and 2012. Subject diagnoses were distributed as follows: COPD, n=568 (51%); bilateral bronchiectasis, n=113 (10%); obesity, n=166 (15%); chronic diffuse interstitial lung disease, n=131 (12%); restrictive pulmonary disease, n=113 (10%); and asthma, n=22 (2%). The proportion of subjects with bilateral bronchiectasis significantly decreased (OR 0.91, 95% CI 0.865-0.951, P<.001), whereas the proportion of subjects with obesity increased (OR 1.03, 95% CI 1.001-1.063, P=.049) over time. The use of NIV (OR 1.05, 95% CI 1.010-1.090, P=.01) and the proportion of subjects initially treated with NIV (OR 1.05, 95% CI 1.013-1.094, P=.009) increased significantly in COPD subjects only. Time trend of mortality was not significant (OR 0.98, 95% CI 0.95-1.01, P=.23), whereas the severity of illness in subjects significantly increased. Transition from NIV to invasive mechanical ventilation (IMV) (OR 2.05, 95% CI 1.36-3.11, P=<.001), IMV (OR 10.49, 95% CI 4.88-10.56, P<.001) and diffuse interstitial lung disease (OR 10.63, 95% CI 5.43-20.83, P<.001) were independently associated with death in the ICU. Over time, respiratory diseases have changed in non-COPD subjects and trends in the use and efficacy of NIV differ between COPD and non-COPD subjects. Mortality remained stable while the severity of illness in subjects increased. In COPD and non-COPD subjects, transition from NIV to IMV was associated with a poorer prognosis.

Gacouin A ，Jouneau S ，Letheulle J ，Kerjouan M ，Bouju P ，Fillatre P ，Le Tulzo Y ，Tadié JM ... -  《-》

The 'ABC' of respiratory disorders among adult Indigenous people: asthma, bronchiectasis and COPD among Aboriginal Australians - a systematic review.

Aboriginal Australians are reported to have higher presence of chronic respiratory diseases. However, comprehensive evidence surrounding this is sparse. Hence, a systematic review was undertaken to appraise the current state of knowledge on respiratory health in the adult Aboriginal Australians, in particular among the three most common respiratory disorders: asthma, bronchiectasis and chronic obstructive pulmonary disease (COPD). A systematic review of primary literature published between January 2012 and October 2022, using the databases PubMed and Scopus, was conducted. Studies were included if they reported adult Aboriginal Australian prevalence's or outcomes related to asthma, bronchiectasis or COPD, and excluded if adult data were not reported separately, if Aboriginal Australian data were not reported separately or if respiratory disorders were combined into a single group. Risk of bias was assessed by both Joanne Briggs Institute checklists and Hoys' bias assessment. Summary data pertaining to prevalence, lung function, symptoms, sputum cultures and mortality for each of asthma, bronchiectasis and COPD were extracted from the included studies. Thirty-seven studies were included, involving approximately 33 364 participants (71% female). Eighteen studies reported on asthma, 21 on bronchiectasis and 30 on COPD. The majority of studies (94%) involved patients from hospitals or respiratory clinics and were retrospective in nature. Across studies, the estimated prevalence of asthma was 15.4%, bronchiectasis was 9.4% and COPD was 13.7%, although there was significant geographical variation. Only a minority of studies reported on clinical manifestations (n=7) or symptoms (n=4), and studies reporting on lung function parameters (n=17) showed significant impairment, in particular among those with concurrent bronchiectasis and COPD. Airway exacerbation frequency and hospital admission rates including mortality are high. Although risk of bias globally was assessed as low, and study quality as high, there was limited diversity of studies with most reporting on referred populations, and the majority originating from two centres in the Northern Territory. The states with the greatest Aboriginal Australian population (Victoria and New South Wales) reported the lowest number of studies and patients. This limits the generalisability of results to the wider Aboriginal Australian population due to significant environmental, cultural and socioeconomic variation across the population. Regardless, Aboriginal Australians appear to display a high prevalence, alongside quite advanced and complex chronic respiratory diseases. There is however significant heterogeneity of prevalence, risk factors and outcomes geographically and by patient population. Further collaborative efforts are required to address specific diagnostic and management pathways in order to close the health gap secondary to respiratory disorders in this population.

Howarth TP ，Jersmann HPA ，Majoni SW ，Mo L ，Ben Saad H ，Ford LP ，Heraganahally SS ... -  《BMJ Open Respiratory Research》

Cough of more than two weeks - Time to think beyond pulmonary TB.

Cough of more than two weeks has become sine quo non with pulmonary tuberculosis (PTB) in a developing country like India. The causes may be different in patients reporting to respiratory OPD vis a vis general OPD. To study the prevalence of PTB and causes of cough other than PTB among respiratory OPD attendees with cough of more than two weeks duration. A cross sectional study was carried out over two years in respiratory OPD of a tertiary care chest center of Indian armed forces. Of the 13,004 patients, 505 non HIV PTB suspects were included. Patients with definitive diagnosis of chronic cough were excluded. Efforts were made to establish diagnosis of pulmonary TB using clinical, microbiological and radiological features. However, patients were also subjected to further evaluation (spirometry, bronchoscopy, CECT) based on clinical features, radiological and lab profile to establish definitive diagnosis. Out of the 505 patients, 10.5% patients had smear positive pulmonary TB, 13.5% smear negative PTB, bronchial asthma (24%), COPD (9.3%), diffuse parenchymal lung diseases (DPLD's) (12.5%), bronchiectasis (6.3%), lung cancer (5.3%) and congestive cardiac failure (4.2%). Though prevalence of PTB in the study correlated well with the national statistics, but a significant number of patients had other causes of chronic cough, especially, obstructive airway diseases and DPLDs. Thus, there is a need to spread awareness regarding other causes of chronic cough and all efforts should be made to establish alternate diagnosis especially in patients who do not conclusively have PTB.

Chopra M ，Bhattacharyya D ，Barthwal MS ，Madan GDS ，Chakrabarthy B ，Pandey IM ，Chopra M ... -  《-》