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One of the characteristics of severe emphysema is hyperinflation of regions of the lungs. In this trial, valves that prevented air entry but allowed air to escape were placed in lobar airways. Patients receiving endobronchial valves had modest improvements in lung function and exercise performance. Emphysema is a leading cause of disability and death. Lung-volume–reduction surgery, in which selected areas of hyperinflated lungs are resected, improves exercise tolerance and prolongs life in selected patients. However, concern regarding the risk of perioperative death and complications contributes to underutilization. 1 – 4 Less invasive bronchoscopic techniques that are based on the presumed physiological effects of lung-volume–reduction surgery have been developed. 5 – 10 Early uncontrolled trials using unidirectional valves placed in selected lung airways to block regional inflation while allowing exhalation have reported improvements in lung function and symptoms with modest risk, including distal pneumonia or pneumothorax. 5 , 6 , 9 , 11 – . . .

There is limited knowledge of the prognostic value of quantitative computed tomography (CT) measures of emphysema and airway wall thickness (AWT) on mortality. To examine 8-year mortality in relation to CT-measured emphysema and AWT, and assess if potential impact of these predictors remained after adjustment for lung function. In the Norwegian GenKOLS study of 2003-2005, 947 ever-smokers (49% with COPD) aged 40-85 years performed spirometry and CT examination. Mortality data from 2003-2011 were gathered from the Norwegian Cause of Death Registry. CT emphysema % low-attenuation areas (%LAA) and standardized measure for AWT (AWT-Pi10) were main predictors. We performed Laplace regression for survival data, estimating survival time for specified population percentiles within each emphysema category. Models were adjusted for sex, FEV1, COPD status, age, body mass index, smoking, and inflation level. During 8-year follow-up all-cause mortality rate was 15%. Although 4% of the subjects with %LAA less than 3 died, 18% with %LAA 3-10 and 44% with %LAA greater than or equal to 10 died. After adjustment, the comparable percentile subjects with medium and high emphysema had 19 months shorter survival than subjects who died in the lowest emphysema category. Subjects with %LAA greater than or equal to 10 had 33 and 37 months shorter survival than the lowest emphysema category with regard to respiratory and cardiovascular mortality, respectively. No significant associations were found between %LAA and cancer and lung cancer mortality. AWT did not predict mortality independently, but a positive interaction with emphysema was observed. AWT affected mortality with increasing degree of emphysema, whereas CT measure of emphysema was a strong independent mortality predictor.

Background Whether the long-term survival of patients with idiopathic pulmonary fibrosis (IPF) is worse than that of patients with IPF combined with emphysema after anti-fibrotic therapy is unclear. This study aimed to compare treatment outcomes between the two groups and identify potential predictors of mortality. Methods This retrospective cohort study was conducted in seven hospitals across Taiwan between August 2015 and August 2022 and included patients with IPF who received anti-fibrotic agents covered by national insurance. Based on the extent of emphysema observed on high-resolution chest tomography, patients with IPF were categorized into two groups: IPF only; and IPF with emphysema. Baseline characteristics and survival outcomes were compared between the groups. Cox proportional hazards models were used for multivariable analysis to identify factors associated with overall mortality during the follow-up period. Results Of the 275 patients included, 126 (45.8%) had IPF with emphysema and 149 (54.2%) had IPF only. The emphysema group had a higher proportion of males and patients with a smoking history, finger clubbing, comorbidities, or a definite usual interstitial pneumonia (UIP) pattern compared to the IPF-only group. Additionally, this group had a higher forced vital capacity (FVC, %) and forced expiratory volume in 1 s (FEV₁, L), while FEV₁ (%) was similar and FEV₁/FVC (%) was lower. During a median follow-up of 3.7 years, the overall survival rates were comparable (IPF only: 45.6%; IPF with emphysema: 48.4%). The overall survival of patients with probable UIP was significantly better than that of patients with definite UIP (53.5% vs. 34.6%). Likewise, the survival rate of the group with a diffusing capacity of the lung for carbon monoxide (DLCO) > 49% was higher than that of the group with DLCO ≤ 49% (53.9% vs. 31.4%). After adjusting for confounders, lower body mass index (BMI) (adjusted hazard ratio [aHR] = 0.95) and comorbid pulmonary hypertension (aHR = 2.27) were independently associated with increased overall mortality. Neither the presence of emphysema nor the type of anti-fibrotic agent was associated with mortality. Conclusions The survival outcomes of patients with IPF and emphysema and those of patients with IPF only are comparable after treatment with anti-fibrotic agents. Lower BMI and comorbid pulmonary hypertension are significant predictors of increased mortality.

Background Interstitial lung disease (ILD) is a common and potentially life-threatening complication for rheumatoid arthritis (RA) patients. However, there is a lack of clear prognostic factors in rheumatoid arthritis-associated interstitial lung disease (RA-ILD) patients. The purpose of this study was to complete a systematic review and meta-analysis of the factors associated with mortality in RA-ILD patients. Methods Medline, EMBASE and the Cochrane Library were searched up to September 1, 2020. The Newcastle–Ottawa Scale (NOS) was applied to assess the methodological quality of the eligible studies. Study characteristics and magnitude of effect sizes were extracted. Then, pooled hazard ratios (HRs) with the corresponding 95% confidence intervals (CIs) and pooled risk ratios (RRs) with 95% CIs were calculated to assess the factors associated with mortality in RA-ILD. Results Twenty-three of 3463 articles were eligible, and ten factors associated with mortality for RA-ILD were evaluated in the meta-analysis. Older age (HRs = 1.04, 95% CI 1.03–1.05), male sex (HRs = 1.44, 95% CI 1.21–1.73), having a smoking history (HRs = 1.42, 95% CI 1.03–1.96), lower diffusing capacity of the lung for carbon monoxide (DLCO)% predicted (HRs = 0.98, 95% CI 0.97–1.00), forced vital capacity (FVC)% predicted (HRs = 0.99, 95% CI 0.98–1.00), composite physiological index (CPI) (HRs = 1.04, 95% CI 1.02–1.06), usual interstitial pneumonia (UIP) pattern on HRCT (HRs = 1.88, 95% CI 1.14–3.10 and RRs = 1.90, 95% CI 1.50–2.39), emphysema presence (HRs = 2.31, 95% CI 1.58–3.39), and acute exacerbation of ILD (HRs = 2.70, 95% CI 1.67–4.36) were associated with increased mortality in RA-ILD, whereas rheumatoid factor (RF) positive status was not associated. Conclusions Through this systematic review and meta-analysis, we found that older age, male sex, smoking history, higher CPI, lower DLCO% predicted, lower FVC% predicted, UIP pattern on HRCT, emphysema presence and acute exacerbation of ILD were associated with an increased risk of mortality in RA-ILD.

BackgroundEmphysema on CT is a risk factor for all-cause mortality in persons with and without airflow obstruction; however, causes of death associated with emphysema remain uncertain, particularly in the general population.AimsTo test associations between quantitatively assessed emphysema on CT and cause of death in persons with and without a substantial smoking history.MethodsThe Multi-Ethnic Study of Atherosclerosis recruited 6814 participants, aged 45–84 years and without clinical cardiovascular disease, in 2000–2002. Per cent emphysema was defined on cardiac CT as per cent of lung voxels less than −950 Hounsfield units; emphysema on CT was defined as per cent emphysema above the upper limit of normal. Cause of death was classified by administrative codes. Proportional-hazards models were adjusted for age, race/ethnicity, gender, body mass index, smoking status, pack-years, coronary artery calcium, site and education. Additional adjustment for lung function was made in a subset with spirometry from 2004 to 2006.ResultsThere were 1091 deaths over 12 years median follow-up. Emphysema on CT was strongly associated with increased mortality due to respiratory diseases (adjusted HR 2.94, 95% CI 1.68 to 5.15), particularly chronic lower respiratory diseases (adjusted HR 9.54, 95% CI 4.70 to 19.35), and lung cancer (adjusted HR 1.84, 95% CI 1.09 to 3.12), but not cardiovascular disease. Associations persisted among participants with fewer than 10 pack-years and those without physician-diagnosed respiratory disease, and were similar after adjustment for airflow measures and in persons without airflow limitation.ConclusionsQuantitatively assessed emphysema on CT is associated with greater respiratory disease and lung cancer mortality, even among persons without traditional risk factors.

Pulmonary emphysema results from the destruction of air spaces, with a loss of elastic recoil of the lungs and alveolar capillary surface for gas exchange. In this study, lung-volume–reduction surgery was compared with medical management of emphysema. Surgery had no overall effect on mortality from emphysema. There were identifiable subgroups of patients for whom surgery had either a beneficial or an adverse effect on outcomes. Surgery had no overall effect on mortality. Lung-volume–reduction surgery has been proposed as a palliative treatment for patients with severe emphysema. 1 – 8 Uncertainty about morbidity and mortality; the occurrence, magnitude, and duration of benefit; and preoperative predictors of benefit led us to conduct a federally sponsored, multicenter, randomized clinical trial, the National Emphysema Treatment Trial (NETT). 9 The primary outcomes for the trial were mortality and maximal exercise capacity two years after randomization. Secondary outcomes included the distance walked in six minutes, pulmonary function, quality of life, and degree of dyspnea. An important goal of the trial was to identify patient-selection criteria for lung-volume–reduction surgery. Criteria for inclusion . . .

BackgroundThis study aimed to evaluate whether incidental CT findings of emphysema, airway thickening and bronchiectasis, as seen on CT scans performed for other non-pulmonary clinical indications, are associated with future acute exacerbations of COPD resulting in hospitalisation or death.MethodsThis multicentre prospective case–cohort study comprised 6406 subjects who underwent routine diagnostic chest CT for non-pulmonary indications. Using a case–cohort approach, we visually graded CT scans from cases and a random sample of ∼10% of the baseline cohort (n=704) for emphysema severity (range 0–20), airway thickening (range 0–5) and bronchiectasis (range 0–5). We used weighted Cox proportional hazards analysis to assess the independent association between CT findings and hospitalisation or death due to COPD exacerbation.ResultsDuring a median follow-up of 4.4 years (maximum 5.2 years), 338 COPD events were identified. The risk of experiencing a future acute exacerbation of COPD resulting in hospitalisation or death was significantly increased in subjects with severe emphysema (score ≥7) and severe airway thickening (score ≥3). The respective HRs were 4.6 (95% CI 3.0 to 7.1) and 5.9 (95% CI 3.4 to 10.5). Severe bronchiectasis (score ≥3) was not significantly associated with increased risk of adverse events (HR 1.5; 95% CI 0.9 to 2.5).ConclusionsMorphological correlates of COPD such as emphysema and airway thickening detected on CT scans obtained for other non-pulmonary indications are strong independent predictors of subsequent development of acute exacerbations of COPD resulting in hospitalisation or death.

Substantial information regarding the role of lung volume reduction surgery (LVRS) in severe emphysema emanates from the National Emphysema Treatment Trial (NETT). The NETT was not a crossover trial and therefore was able to examine the effects of optimal medical management and LVRS on short- and long-term survival,as well as lung function, exercise performance, and quality of life.The NETT generated multiple insights into the preoperative, perioperative,and postoperative management of patients undergoing thoracotomy; described pain control techniques that were safe and effective; and emphasized the need to address nonpulmonary issues to optimize surgical outcomes. After the NETT, newer investigation has focused on bronchoscopic endobronchial interventions and other techniques less invasive than LVRS to achieve lung reduction.In this review, we summarize what we currently know about the role of LVRS in the treatment of severe emphysema as a result of insights gained from the NETT and provide a brief review of the newer techniques of lung volume reduction.

Background Interstitial pneumonia and emphysema may complicate patients with lung cancer. However, clinical significance of trivial and mild pulmonary abnormalities remains unclear. In this study, we aimed to investigate whether trivial and mild interstitial pneumonia and emphysema, in addition to their advanced forms, impact the prognosis and lead to acute exacerbation of interstitial pneumonia (AEIP) in patients with lung cancer. Methods This retrospective cohort study was conducted at a tertiary hospital and included patients with lung cancer. Computed tomography images were evaluated using the interstitial lung abnormality (ILA) score for interstitial pneumonia, which included no ILA, equivocal ILA, ILA, interstitial lung disease (ILD), and the Goddard score for emphysema. Cox analyses were performed using the ILA and Goddard scores as the main explanatory variables, adjusting for multiple covariates. Results Among 1,507 patients with lung cancer, 1,033 had no ILA, 160 had equivocal ILA, 174 had ILA, and 140 had ILD. In total, 474 patients (31.5%) exhibited interstitial pneumonia and 638 (42.3%) showed emphysema. The log-rank trend test showed that survival probability was significantly better in patients with no ILA, followed by those with equivocal ILA, ILA, and ILD ( P  < 0.001). After adjustment, the ILA and Goddard scores remained significant variables for increased hazard ratios (HR) for mortality: no ILA (HR, 1.00: reference), equivocal ILA (HR, 1.31; 95% confidence interval [CI], 1.18–1.46; P  < 0.001), ILA (HR, 1.71; 95% CI, 1.39–2.12; P  < 0.001), ILD (HR, 2.24; 95% CI, 1.63–3.09; P  < 0.001), and Goddard score (HR, 1.03; 95% CI, 1.01–1.06; P  < 0.010). Moreover, both scores were associated with increased cause-specific HRs for AEIP. Conclusion Our results revealed that approximately one-third of patients with lung cancer had interstitial pneumonia when incorporating trivial and mild cases. Because interstitial pneumonia and emphysema, ranging from trivial to severe, significantly impact mortality and AEIP in patients with lung cancer, we should identify even trivial and mild cases of these pulmonary abnormalities among patients with lung cancer in addition to the advanced ones.

The objective was to evaluate the association between serum carotenoid levels and respiratory morbidity and mortality in a nationally representative sample of US adults. We assessed the association of serum carotenoid levels with respiratory morbidity and mortality using logistic regression and proportional hazards regression models. Meanwhile, a series of confounders were controlled in regression models and restricted cubic spline, which included age, sex, race, marriage, education, income, drinking, smoking, regular exercise, BMI, daily energy intake, vitamin E, vitamin C, fruit intake, vegetable intake, diabetes, hypertension, asthma, emphysema and chronic bronchitis. Compared with participants in the lowest tertiles, participants in the highest tertiles of serum total carotenoids, β-cryptoxanthin and lutein/zeaxanthin levels had a significantly lower prevalence of emphysema (ORtotal carotenoids = 0·61, 95% CI: 0·41–0·89, OR β-cryptoxanthin = 0·67, 95% CI: 0·49–0·92), chronic bronchitis (OR β-cryptoxanthin = 0·66, 95% CI: 0·50–0·87) and asthma (Q2: ORlutein/zeaxanthin = 0·78, 95% CI: 0·62–0·97); participants in the highest tertiles of total carotenoids, α-carotene, lutein/zeaxanthin and lycopene had a lower risk of respiratory mortality (hazard ratio (HR)total carotenoids = 0·62, 95% CI: 0·42–0·90, HR α-carotene = 0·54, 95% CI: 0·36–0·82, HRlutein/zeaxanthin = 0·48, 95% CI: 0·33–0·71, HRlycopene = 0·66, 95% CI: 0·45–0·96) than those in the lowest tertiles. Higher serum total carotenoids and β-cryptoxanthin levels is associated with decreased prevalence of emphysema and chronic bronchitis, and higher serum total carotenoids, α-carotene, lutein/zeaxanthin and lycopene levels had a lower mortality of respiratory disease.