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Introduction: Deployed military personnel may be at risk for developing acute and chronic lung disease. Prior studies of this patient population have revealed that unexplained exertional dyspnea is the most common diagnosis despite an extensive evaluation. There is a concern that an occult disorder may be affecting this population. This study evaluated the role for bronchoalveolar lavage (BAL) fluid analysis in the evaluation of chronic deployment-associated dyspnea., Materials and Methods: Military personnel who reported chronic respiratory symptoms were evaluated as part of the Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures III study. Participants underwent bronchoscopy with BAL as part of a standardized evaluation., Results: A total of 308 patients with a mean age of 38 ± 8.6 years underwent bronchoscopy with BAL. BAL cell-count percentages of macrophages, lymphocytes, neutrophils, and eosinophils were: 76.2 ± 17.0%, 16.3 ± 13.4%, 6.6 ± 8.9%, and 0.9 ± 3.2%, respectively. There was no clear differentiation between groups based on increases in lymphocyte counts (P = .640), although lymphocyte values were more elevated (21.4 ± 12.1%) in the interstitial lung disease category. Neutrophil counts (6.6 ± 8.9%) were elevated compared to the reported normal reference values and were increased in the isolated pulmonary function test abnormality (9.4 ± 11.6%), large airway disorder (10.0 ± 7.5%), miscellaneous (10.9 ± 20.2%), and obstructive lung disease (11.0 ± 15.6%) groups. Eosinophil counts were within normal limits (0.9 ± 3.2%) and showed no differences between groups (P = .545); asthma patients trended higher (1.6 ± 5.7%). BAL counts for the exertional dyspnea group were within normal reference values and showed no differences from the entire cohort., Conclusions: The addition of BAL cytology did not help differentiate those patients with unexplained dyspnea from other etiologies., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Dyspnea is a common symptom in neuromuscular disorders and, although multifactorial, it is usually due to respiratory muscle involvement, associated musculoskeletal changes such as scoliosis or, in certain neuromuscular conditions, cardiomyopathy. Clinical history can elicit symptoms such as orthopnea, trepopnea, sleep disruption, dysphagia, weak cough, and difficulty with secretion clearance. The examination is essential to assist with the diagnosis of an underlying neurologic disorder and determine whether dyspnea is from a cardiac or pulmonary origin. Specific attention should be given to possible muscle loss, use of accessory muscles of breathing, difficulty with neck flexion/extension, presence of thoraco-abdominal paradox, conversational dyspnea, cardiac examination, and should include a detailed neurological examination directed at the suspected differential diagnosis. Pulmonary function testing including sitting and supine spirometry, measures of inspiratory and expiratory muscle strength, cough peak flow, sniff nasal inspiratory pressure, pulse oximetry, transcutaneous CO 2 , and arterial blood gases will help determine the extent of the respiratory muscle involvement, assess for hypercapnic or hypoxemic respiratory failure, and qualify the patient for noninvasive ventilation when appropriate. Additional testing includes dynamic imaging with sniff fluoroscopy or diaphragm ultrasound, and diaphragm electromyography. Polysomnography is indicated for sleep related symptoms that are not otherwise explained. Noninvasive ventilation alleviates dyspnea and nocturnal symptoms, improves quality of life, and prolongs survival. Therapy targeted at neuromuscular disorders may help control the disease or favorably modify its course. For patients who have difficulty with secretion clearance, support of expiratory function with mechanical insufflation-exsufflation, oscillatory devices can reduce the aspiration risk., (© 2024 by the American Association of Neuromuscular & Electrodiagnostic Medicine, Inc. All rights reserved.)

Background: Therapies are needed to address worsening congestion, without hospitalization, in patients with chronic heart failure (HF)., Objectives: This pilot study assessed outcomes of a novel subcutaneous (SC) furosemide formulation compared to usual care in outpatients with worsening congestion., Methods: Participants with chronic HF and worsening congestion were randomized open-label 2:1 to SC furosemide compared to usual care (UC). Decongestion was estimated by tracking body weight. The primary endpoint was a win ratio of a 30-day hierarchical composite of cardiovascular death, HF events, and change in N-terminal pro-B-type natriuretic peptide. Secondary endpoints included dyspnea severity, functional capacity, and quality of life., Results: Thirty-four participants were randomized to SC furosemide and 17 to UC. SC furosemide caused greater reduction in body weight: between-group difference in least square mean change was -2.02 kg at day 3 (95% CI: -3.9 to -0.14; P = 0.035). SC furosemide-to-UC win ratio was 1.11 (95% CI: 0.48-2.50; P = 0.806). Significant between-group least square mean differences favoring SC furosemide occurred in 7-point dyspnea score (P = 0.017) and 6-minute walk test (P = 0.032), with trend in Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 Overall Summary Score of 9.15 (95% CI: 1.95-20.3; P = 0.106). The most common related adverse event with SC furosemide was mild infusion site pain (11.8%)., Conclusions: SC furosemide augmented weight loss in patients with HF and worsening congestion. The composite primary endpoint was not statistically significant in this pilot investigation. However, findings of improved dyspnea scores and functional capacity, with favorable trend in KCCQ-12 score, warrant additional investigation to further document the clinical value of SC furosemide as an alternative to hospitalization (AT HOME-HF [Avoiding Treatment in the Hospital With Furoscix for the Management of Congestion in Heart Failure-A Pilot Study]; NCT04593823)., Competing Interests: Funding Support and Author Disclosures This study was funded by scPharmaceuticals, Inc. Dr M.A. Konstam has received personal fees from Alnylam, Boehringer-Ingelheim, Cardurian, LivaNova, scPharmaceuticals, Fire 1, Vicardia, and Alleviant. Dr Dhingra has received personal fees from scPharmaceuticals, Bristol Myers Squibb, and CareDx. Dr Walsh has received personal fees from scPharmaceuticals. Ms Ordway has received personal fees from scPharmaceuticals. Dr Pursley has received personal fees from scPharmaceuticals. Dr McLean has received personal fees from scPharmaceuticals. Mr Saha is a full-time employee of Cardiovascular Clinical Science Foundation. Dr Close is a full-time employee of EmpiriStat, Inc. Mr J.M. Konstam is a full-time employee of iQVIA. Dr Luepke is a full-time employee of scPharmaceuticals. Dr Mohr is a full-time employee of scPharmaceuticals. Dr Udelson has received personal fees from scPharmaceuticals, Merck, Alleviant, Reprieve CV, and Cardurion., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Individuals with chronic obstructive pulmonary disease (COPD) constitute a significant portion of patients who present to the emergency department with dyspnea. However, there is no ideal method for predicting mortality or making hospitalization decisions in the emergency department (ED). In this regard, objective findings are needed for these patients. Since there are no objective findings regarding the hospitalization decision, there may be an increase in the re-admission rate of patients who needed hospitalization but were decided to be discharged. Side-stream end-tidal carbon dioxide (EtCO 2 ) measurements offer a non-invasive, easy-to-interpret, quickly accessible, and reproducible method that can be applied at the bedside., Objectives: The aim of this study was to evaluate the relationship between the alpha angle values obtained by capnography and readmission rates within 30 days for patients experiencing COPD exacerbations who presented to the ED with dyspnea and were discharged after treatment., Methods: In this study, we studied with 130 participants presented to the emergency department of a tertiary care university hospital with dyspnea, who are >18 y. Forty patients were excluded after evaluation for eligibility for the study. Thus, the data of 90 patients included were analyzed. We obtained alpha angle and EtCO 2 values for all patients at the time of admission and also after treatment. The primary outcome measure of the study was the relationship between the patients' readmission situations within 30 days of the alpha angle measurements. The secondary outcome measure was the association between patients' EtCO 2 values ​​and readmission within 30 days., Results: It was observed that both the pretreatment alpha angle values and the posttreatment alpha angle variables were statistically significant in predicting the readmission of the patients within 30 days (p = 0.001, p = 0.003) CONCLUSION: The results of this study show that alpha angle values measured for patients with COPD who present to the ED with the complaint of dyspnea may be used to predict readmission., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Considering the limitations in activities of daily living (ADL) and the impact of improvements in patients with heart failure (HF), appropriate assessment of upper extremity functional capacity and ADL is important., Objectives: To evaluate upper extremity functional capacity and ADL in patients with HF and compare them with healthy controls., Methods: This study included 30 HF patients and healthy controls. Upper extremity functional capacity was assessed with the 6-Minute Pegboard Ring Test (6PBRT), ADL by the Londrina protocol, exercise capacity by 6-Minute Walk Test (6MWT), peripheral muscle strength by hand dynamometer, and dyspnea by Modified Medical Research Council Scale (MMRC). For performance tests, pre-test (resting) and post-test (after performance) values ​​were also measured., Results: Patients with HF with ejection fraction ≤50 % and controls were similar in terms of age (52.63±6.2 and 50.03±6.5 years, respectively) and gender (25 females for each group) (p > 0.05). Patients showed a statistically significant increase in total test time in the Londrina protocol and fewer rings moved in 6PBRT (p < 0.0001). The post-test dyspnea (p = 0.03) and pre-test arm fatigue (p < 0.0001) were observed to be higher in patients in the Londrina protocol. There was a statistically significant group by time interaction in the patients' pre- and post-test lower heart rate (F= 4.80, p = 0.03), post-test dyspnea (p < 0.0001), and post-test arm fatigue (p = 0.005) were observed to be higher in patients in 6PBRT., Conclusions: The evidence showed a decrease in upper extremity functional capacity in patients with HF. Patients required more time to perform their ADLs compared with healthy controls., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

Dyspnea, the subjective sensation of breathlessness, is a distressing and potentially traumatic symptom. Dyspnea associated with mechanical ventilation may contribute to intensive care unit (ICU) associated post-traumatic stress disorder and impaired quality of life. Dyspnea is both difficult to alleviate and a cause of significant distress to patients, their loved ones, and care providers People living with neuromuscular disease, such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MG), often rely on a ventilator at late stages of illness due to complications of progressive respiratory muscle weakness and paralysis. When unable to wean from the ventilator, conversations turn towards goals of care and release from the ventilator for comfort and end of life (EOL). Patients with and without neuromuscular disease have high risk for dyspnea at EOL upon ventilator liberation. Although limited recommendations have been published specific to patients with ALS, no guidelines currently exist for the terminal liberation from mechanical ventilation in patients experiencing respiratory muscle insufficiency from a neuromuscular disease. Further research on this topic is needed, including creation of a protocol for ventilator release in patients with neuromuscular disease. The following case reports detail the dissimilar EOL experiences of two patients with different forms of neuromuscular disease., (Copyright © 2024 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Rationale: Regular, low-dose, sustained-release morphine is frequently prescribed for persistent breathlessness in chronic obstructive pulmonary disease (COPD). However, effects on daytime sleepiness, perceived sleep quality, and daytime function have not been rigorously investigated. Objectives: We sought to determine the effects of regular, low-dose, sustained-release morphine on sleep parameters in COPD. Methods: We conducted prespecified secondary analyses of validated sleep questionnaire data from a randomized trial of daily, low-dose, sustained-release morphine versus placebo over 4 weeks commencing at 8 or 16 mg/d with blinded up-titration over 2 weeks to a maximum of 32 mg/d. Primary outcomes for these analyses were Week-1 Epworth Sleepiness Scale (ESS) and Karolinska Sleepiness Scale (KSS) scores on morphine versus placebo. Secondary outcomes included Leeds Sleep Evaluation Questionnaire scores (end of Weeks 1 and 4), KSS and ESS scores beyond Week 1, and associations between breathlessness, morphine, and questionnaire scores. Measurements and Main Results: One hundred fifty-six people were randomized. Week-1 sleepiness scores were not different on morphine versus placebo (ΔESS [95% confidence interval] versus placebo: 8-mg group, -0.59 [-1.99, 0.81], P  = 0.41; 16-mg group, -0.72 [-2.33, 0.9], P  = 0.38; ΔKSS vs. placebo, 8-mg group: 0.11 [-0.7, 0.9], P  = 0.78; 16-mg group, -0.41 [-1.31, 0.49], P  = 0.37). This neutral effect persisted at later time points. In addition, participants who reported reduced breathlessness with morphine at 4 weeks also showed improvement in LSEQ domain scores including perceived sleep quality and daytime function. Conclusions: Regular, low-dose morphine does not worsen sleepiness when used for breathlessness in COPD. Individual improvements in breathlessness with morphine may be related to improvements in sleep. Clinical trial registered with www.clinicaltrials.gov (NCT02720822).

Objectives: Patients presenting with suspected ST segment elevation myocardial infarction frequently have symptoms in addition to chest pain, including dyspnea, nausea or vomiting, diaphoresis, and lightheadedness or syncope. These symptoms are often regarded as supporting the diagnosis of infarction. We sought to determine the prevalence of the non-chest pain symptoms among patients who were confirmed as having a critically diseased coronary vessel as opposed to those with no angiographic culprit lesion., Methods: Data from 1393 consecutive patients with ST segment elevation who underwent emergent coronary angiography were analyzed. Records were reviewed in detail for symptoms, ECG findings, prior history, angiographic findings, and in-hospital outcomes., Results: Dyspnea was present in 50.8% of patients, nausea or vomiting in 36.5%, diaphoresis in 51.2%, and lightheadedness/syncope in 16.8%. On angiography, 1239 (88.9%) patients had a culprit lesion and 154 (11.1%) were found not to have a culprit. Only diaphoresis had a higher prevalence among the patients with, as compared with those without a culprit, with an odds ratio of 2.64 ( P  < 0.001). The highest occurrence of diaphoresis was among patients with a totally occluded artery, with an intermediate frequency among patients with a subtotal stenosis, and the lowest prevalence among those with no culprit. These findings were consistent regardless of ECG infarct location, affected vessel, patient age, or sex. Among the subset of patients who presented without chest discomfort, none of the symptoms were associated with the presence of a culprit., Conclusion: The presence of diaphoresis, but not dyspnea, nausea, or lightheadedness is associated with an increased likelihood that patients presenting with ST elevation will prove to have a culprit lesion. In patients who present with ST elevation but without chest discomfort, these symptoms should not be regarded as 'chest pain equivalents'. Further objective data among patients with angiographic confirmation of culprit lesion status is warranted., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Many patients with chronic obstructive pulmonary disease and fibrotic interstitial lung disease suffer from severe dyspnea and reduced quality of life, despite receiving optimal disease-modifying treatment for their illness. Studies have suggested that these patients may benefit from treatment with low-dose opioids. However, many patients decline opioid treatment. This has led to patients not receiving proper palliative treatment of their lung disease., Aim: To identify potential barriers that prevent patients from receiving adequate palliative care with opioids and enable doctors to address patients' concerns., Design: A qualitative study based on semi-structured interviews. Interviews were transcribed and thematic analysis was done using NVivo., Setting/participants: Patients were recruited when scheduled for out-patient follow-up at Center for Rare Lung Diseases or at the COPD clinic, Aarhus University Hospital. Eligible patients were 18 years of age, did not currently receive opioids or had ever received opioids for dyspnea., Results: A total of 28 patients participated. One patient was excluded before final analysis of 27 patients. Four themes were identified: Fear of side-effects, Need for more information, Stigma of opioids association with severe illness and dying, and No discernible barriers. Furthermore, three sub-themes to Fear of side-effects were identified: Fear of addiction, concern for sedative effect, and fear for loss of mobility due to inability to drive a car. The most expressed concern was Fear of side-effects, especially addiction., Conclusions: Pre-conceived notions about opioids prevent some patients with chronic obstructive lung disease or interstitial lung disease from receiving palliative care for breathlessness., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Cricotracheostomy is a useful surgical procedure for opening the airway in cases where conventional tracheotomy is difficult. This is a safe and easy technique involving removal of the anterior portion of the cricoid cartilage. Herein, we report the case of a patient with difficulty in neck extension due to severe kyphosis, who underwent cricotracheostomy. A 65-year-old woman developed dyspnea and was transported to our hospital. SpO 2 was 60% (room air) and endotracheal intubation was performed. She was managed on ventilator. However, weaning off the ventilator was difficult, and endotracheal intubation was prolonged. Subsequently, the patient was referred to us for a tracheostomy. The patient was unable to maintain the supine position due to severe kyphosis, and computed tomography revealed that the brachiocephalic artery was running just below the thyroid gland. Therefore, conventional tracheostomy was difficult to perform, and we performed cricotracheostomy instead. After the cricotracheostomy, there were no tracheal problems, such as tracheal stenosis and stomal hemorrhage. Cricotracheostomy can be performed in cases where multiple anatomical difficulties may be faced in the tracheostomy site, as in this case. Furthermore, cricotracheostomy is beneficial for long-term airway management because it causes fewer complications compared to conventional tracheotomy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Aeorobic exercise is an essential component of the pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). Single-limb exercises are a type of aeorobic exercise that aims to increase patient tolerance by reducing the workload of the respiratory system., Objektives: The aim of our systematic review was to determine the effects of single-limb exercises on pulmonary function, dyspnea, fatigue, and muscle dysfunction in patients with COPD., Methods: Searches were performed using PubMed, Pedro, Google Scholar, MEDLINE, EMBASE, Scopus, Cochrane Library, Web of Science databases. Publications from the beginning to 2023 searched. Studies were selected by two authors by scanning the title, Mesh terms abstract in Rayyan QCRI software. Selected studies were subjected to full-text screening by applying selection criteria. Randomized controlled, case-control, cohort studies were included., Results: In the first screening according to mesh terms, 1011 articles were identified. After the screening criteria and duplicate articles were evaluated, 10 articles were included. This systematic review includes seven case-control, one randomized control trial (RCT), one cross-sectional, and one non-randomized study. A total of 157 patients with COPD received treatment in these studies. According to the Bakker scale, single-limb exercises have been shown to improve pulmonary function with strong evidence. There is strong evidence that single-limb exercises have no effect on dyspnea and fatigue in COPD patients. There is limited evidence that single-limb exercises have an effect on functional exercise capacity., Conclusion: Single-limb exercise can advised in terms of improving pulmonary function in patients with COPD. Current systematic review has found single limb exercise has no effect on dyspnea and fatigue perception. No side effects were reported in the studies and these exercises can be considered safe., Competing Interests: Declaration of competing interest There is no conflict of interest current study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Pulmonary hamartomas are abnormal growths of mature cell or tissue types, including cartilage, epithelium, fat or muscle. Although most cases are benign, asymptomatic and often incidentally discovered, these masses may provoke significant complications via predisposition to obstruction, ischaemia or infection. Pulmonary hamartomas located within the tracheal lumen are exceedingly rare clinical entities which produce symptoms of dyspnoea, cough, stridor, wheezing or angina. Significant clinical consequences include airway obstruction and cardiovascular collapse. Most cases of tracheal hamartoma are initially diagnosed as obstructive pulmonary disease. We present a structured case report of a tracheal hamartoma identified in a patient with recent coronary artery bypass grafting who was initially evaluated for persistent ischaemic pathology, resulting in delay of diagnosis. By review of limited literature of this disorder, we emphasise the need for clinicians to be aware of this indolent and rare entity., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In adults with serious respiratory illness, breathlessness is prevalent and associated with reduced health-related quality of life. The aim of this review was to assess the impact of breathing techniques on breathlessness in adults with serious respiratory illness., Methods: Electronic databases were searched to identify randomised controlled trials testing breathing techniques (techniques that aim to alter the respiratory pattern, excluding respiratory muscle training) in people with serious respiratory illness. The primary outcome was breathlessness and secondary outcomes were health-related quality of life and adverse events. Two authors independently screened for inclusion, evaluated risk of bias and extracted data., Results: 73 randomised controlled trials were included with 5479 participants, most with COPD or asthma. Breathing exercises (pursed lip and/or diaphragmatic breathing) reduced breathlessness measured by the modified Medical Research Council scale compared to usual care (mean difference (MD) -0.40 points, 95% CI -0.70- -0.11, eight studies, n=323), although the effect did not exceed the minimal important difference. Yoga breathing also improved modified Medical Research Council score compared to usual care (MD -1.05 points, 95% CI -2.45-0.35, three studies, n=175). Breathing techniques consistently improved health-related quality of life in people with COPD and asthma on multiple health-related quality of life measures in comparison to usual care, with effects that generally exceeded the minimal important difference. No adverse events related to breathing techniques were reported., Conclusion: Breathing techniques may improve breathlessness, and consistently improve health-related quality of life, in people with serious respiratory illness. These findings support the use of breathing exercises in the care of people with serious respiratory illness., Competing Interests: Conflicts of interest: L. Romero declares funding from the European Respiratory Society to design search strategies for this review. A.E. Holland declares authorship on one of the systematic reviews included in this study but no other conflicts of interest. All other authors declare no conflicts of interest., (Copyright ©The authors 2024.)

Objectives: This study aimed to identify the risk factors and construct the diagnostic model associated with pneumocystis pneumonia (PCP) in pediatric patients., Methods: This retrospective observational study analyzed 34 cases of PCP and 51 cases of other types of pneumonia treated at Children's Hospital Affiliated to Shandong University between January 2021 and August 2023. Multivariate binary logistic regression was used to identify the risk factors associated with PCP. Receiver operating characteristic curves and calibration plots were constructed to evaluate the diagnostic model., Results: Twenty clinical variables significantly differed between the PCP and non-PCP groups. Multivariate binary logistic regression analysis revealed that dyspnea, body temperature>36.5°C, and age<1.46 years old were risk factors for PCP. The area under the curve of the diagnostic model was 0.958, the P -value of Hosmer-Lemeshow calibration test was 0.346, the R 2 of the calibration plot for the actual and predicted probability of PCP was 0.9555 ( P <0.001), and the mean Brier score was 0.069. In addition, metagenomic next-generation sequencing revealed 79.41% (27/34) and 52.93% (28/53) mixed infections in the PCP and non-PCP groups, respectively. There was significantly more co-infection with cytomegalovirus and Streptococcus pneumoniae in the PCP group than that in the non-PCP group (p<0.05)., Conclusions: Dyspnea, body temperature>36.5°C, and age<1.46 years old were found to be independent risk factors for PCP in pediatric patients. The probability of co-infection with cytomegalovirus and S. pneumoniae in the PCP group was significantly higher than that in the non-PCP group., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhang, Li, Chen, Wang, Yang, Xu and Wang.)

Purpose: In patients with lung cancer, dyspnea is one of the most prevalent and disabling symptoms, for which effective treatments are lacking. We examined the efficacy of a nurse-led brief behavioral intervention to improve dyspnea in patients with advanced lung cancer., Methods: Patients with advanced lung cancer reporting at least moderate breathlessness (n = 247) were enrolled in a randomized trial of a nurse-led two-session intervention (focused on breathing techniques, postural positions, and fan therapy) versus usual care. At baseline and weeks 8 (primary end point), 16, and 24, participants completed measures of dyspnea (Modified Medical Research Council Dyspnea Scale [mMRCDS]; Cancer Dyspnoea Scale [CDS]), quality of life (Functional Assessment of Cancer Therapy-Lung [FACT-L]), psychological symptoms (Hospital Anxiety and Depression Scale), and activity level (Godin-Shephard Leisure Time Physical Activity Questionnaire). To examine intervention effects, we conducted analysis of covariance and longitudinal mixed effects models., Results: The sample (Age mean = 66.15 years; 55.9% female) primarily included patients with advanced non-small cell lung cancer (85.4%). Compared with usual care, the intervention improved the primary outcome of patient-reported dyspnea on the mMRCDS (difference = -0.33 [95% CI, -0.61 to -0.05]) but not the CDS total score at 8 weeks. Intervention patients also reported less dyspnea on the CDS sense of discomfort subscale (difference = -0.59 [95% CI, -1.16 to -0.01]) and better functional well-being per the FACT-L (difference = 1.39 [95% CI, 0.18 to 2.59]) versus the control group. Study groups did not differ in overall quality of life, psychological symptoms, or activity level at 8 weeks or longitudinally over 24 weeks., Conclusion: For patients with advanced lung cancer, a scalable behavioral intervention alleviated the intractable symptom of dyspnea. Further research is needed on ways to enhance intervention effects over the long-term and across additional outcomes.

Objective: Dyspnoea and sleep-disordered breathing (SDB) are common in children with life-limiting conditions but studies on treatment with non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) are scarce. The aim of the study was to describe children treated with long-term NIV/CPAP within a paediatric palliative care programme in France., Methods: Cross-sectional survey on children and young adults with complex medical conditions treated within the French paediatric NIV network with long-term NIV/CPAP. Characteristics of the patients were analysed and patient-related outcome measures of NIV/CPAP benefit were reported., Results: The data of 50 patients (68% boys), median age 12 (0.4-21) years were analysed. Twenty-three (46%) patients had a disorder of the central nervous system and 5 (10%) a chromosomal anomaly. Thirty-two (64%) patients were treated with NIV and 18 (36%) with CPAP. NIV/CPAP was initiated on an abnormal Apnoea-Hypopnoea Index in 18 (36%) of the patients, an abnormal nocturnal gas exchange alone in 28 (56%), and after an acute respiratory failure in 11 (22%) of the patients. Mean objective NIV/CPAP adherence was 9.3±3.7 hours/night. NIV/CPAP was associated with a decrease in dyspnoea in 60% of patients, an increase in sleep duration in 60% and in sleep quality in 74%, and an improvement in parents' sleep in 40%., Conclusions: In children with life-limiting conditions, long-term NIV/CPAP may be associated with relief of dyspnoea, an improvement of SDB and an improvement in parents' sleep., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Diffuse large B-cell lymphoma is the most common subtype of non-Hodgkin lymphomas that remains a major diagnostic challenge due to the variety of its clinical presentations. This case highlights the importance of early biopsy of oral lesions without tendency to heal to attain the diagnosis more quickly. To the best of our knowledge, this study is the first to focus on both oral and pulmonary involvements in a patient with diffuse large B-cell lymphoma., Case Presentation: The presented case describes an Iranian 18-year-old girl with chronic cough and dyspnea referred for evaluation of the upper jaw due to bone exposure, bone loss, and soft tissue ulceration. Her medical history revealed mediastinal mass, cavitary lesion, and mediastinal lymphadenopathy. However, cytologic and immunohistochemical analysis did not show any evidence of malignancy. In this case a lymphoproliferative disease was suspected but ultimately the oral biopsy diagnosed diffuse large B-cell lymphoma and chemotherapy could be started., Conclusions: Systemic conditions should be considered as a possible cause of oral lesions and a biopsy should also be performed immediately if there is any doubt concerning the nature of the lesion. Moreover, some conditions necessitate multiple biopsies to attain an accurate diagnosis., (© 2024. The Author(s).)

An early adolescent girl presented to the emergency department (ED) of her local hospital following a syncopal episode after a warm bath on a background of increasing breathlessness for 1-year duration. On examination, she was fully alert, no pain or injuries from her syncope, she was warm and well perfused, her respiratory rate at rest was normal and she showed no signs of respiratory distress, there were no signs of seizure activity such as incontinence or tongue biting, she had a raised Jugular Venous Pressure (JVP), a loud pansystolic murmur, there was no cyanosis and no oedema. She was referred for a chest radiograph due to her history of breathlessness and for an ECG based on the examination findings of a murmur. Her ECG showed marked right axis deviation with tall T waves in V1 and P waves in lead II. Therefore, she was referred for an outpatient echocardiogram which demonstrated severely dilated right ventricular (RV) with impaired RV function. She was diagnosed with primary pulmonary hypertension.Her history included red flag symptoms including worsening breathlessness and syncope. Syncopal episodes are common and mostly benign, that is, vasovagal, but attention to a detailed history including constitutional symptoms and examination is crucial to ensure appropriate investigations and management. While causes are commonly benign in paediatrics, it is important to ensure that there are no features of an underlying cause. This includes ruling out commonly seen paediatric presentations that could present as an unwitnessed syncopal episode and this should include seizures, anaemia, arrhythmias, hypotension, hypoglycaemia and pain. If other causes are not ruled out, it can lead to an incorrect diagnosis as found in this patient when she presented a further three times to ED while waiting for her tertiary appointment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Case Presentation: A 47-year-old Asian woman was admitted with worsening chest tightness and dyspnea for 10 days. Computed tomography (CT) showed changes in the trachea and segmental bronchi. Pulmonary function results suggestive of severe obstructive ventilatory dysfunction. Bronchoscopic findings showed the presence of multiple nodular lesions in the patient's trachea and left and right main bronchi. Bronchoscopic biopsy, lymph node biopsy and bone marrow aspiration flow cytometry test results led to a definitive diagnosis of chronic lymphocytic leukemia (CLL), staged as Binet stage B and Rai stage 2., (© 2024. The Author(s).)

Case Presentation: A 63-year-old woman without significant medical history presented to an urgent care center with a 3-day history of fatigue and dyspnea on exertion. She was found to have an oxygen saturation in the low 80s on room air and was transferred to the closest hospital for further evaluation. Initial chest radiographs showed extensive bilateral interstitial opacities favoring the mid to lower lungs. A general infectious workup was unrevealing. The cause of her symptoms was thought to be an atypical bacterial or viral infection. She was discharged home on supplemental oxygen, 2 L/min via nasal cannula; instructed to finish a 7-day course of antibiotics; and given strict return precautions. Six days later she returned to the ED with worsening dyspnea despite finishing the prescribed course of antibiotics; she was admitted for further evaluation. She had emigrated from Northern India in the early 2000s. While in India, cooking was performed over an open fire. Their home was situated on a poultry farm. She has never smoked. She was up to date on typical cancer screening. She had no pets and denied further exposure to birds since moving to the United States. Her occupational history included manufacturing, but she denied significant exposure to dusts or metal shavings., Competing Interests: Financial/Nonfinancial Disclosures None declared., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Case Presentation: A 78-year-old man with a history of GI stromal tumor (GIST) in the stomach with metastasis to the liver presented with progressive shortness of breath, dry cough, and subjective fever that started 1 week after radioembolization of liver metastatic lesions. His initial diagnosis of GIST was 10 years before, for which he underwent surgical resection; however, more recently he was noted to have hepatic lesions biopsy-proven to be metastatic GIST lesions. He stated that he did not have any respiratory symptoms before the radioembolization procedure and denied having a history of pulmonary disease. His medical history was otherwise notable for coronary artery disease post coronary artery bypass graft in 2002, heart failure with reduced ejection fraction, and atrioventricular block after pacemaker placement. After the diagnosis of liver metastasis, he began treatment with imatinib 6 months earlier and consequently received radioembolization with yttrium-90 (Y-90) microspheres., Competing Interests: Financial/Nonfinancial Disclosures None declared., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Acute dyspnoea is common in acute care settings. However, identifying the origin of dyspnoea in the emergency department (ED) is often challenging. We aimed to investigate whether our artificial intelligence (AI)-powered ECG analysis reliably distinguishes between the causes of dyspnoea and evaluate its potential as a clinical triage tool for comparing conventional heart failure diagnostic processes using natriuretic peptides., Methods: A retrospective analysis was conducted using an AI-based ECG algorithm on patients ≥18 years old presenting with dyspnoea at the ED from February 2006 to September 2023. Patients were categorised into cardiac or pulmonary origin groups based on initial admission. The performance of an AI-ECG using a transformer neural network algorithm was assessed to analyse standard 12-lead ECGs for accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Additionally, we compared the diagnostic efficacy of AI-ECG models with N-terminal probrain natriuretic peptide (NT-proBNP) levels to identify cardiac origins., Results: Among the 3105 patients included in the study, 1197 had cardiac-origin dyspnoea. The AI-ECG model demonstrated an AUC of 0.938 and 88.1% accuracy for cardiac-origin dyspnoea. The sensitivity, specificity and positive and negative predictive values were 93.0%, 79.5%, 89.0% and 86.4%, respectively. The F1 score was 0.828. AI-ECG demonstrated superior diagnostic performance in identifying cardiac-origin dyspnoea compared with NT-proBNP. True cardiac origin was confirmed in 96 patients in a sensitivity analysis of 129 patients with a high probability of cardiac origin initially misdiagnosed as pulmonary origin predicted by AI-ECG., Conclusions: AI-ECG demonstrated superior diagnostic accuracy over NT-proBNP and showed promise as a clinical triage tool. It is a potentially valuable tool for identifying the origin of dyspnoea in emergency settings and supporting decision-making., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: We declare no competing interests.

Background: Breathlessness frequently becomes severe among people with respiratory disease. Mirtazapine, a widely used antidepressant, has shown promise in the modulation of respiratory sensation and the response to it, as well as reducing feelings of panic, which often accompanies breathlessness. We aimed to determine the effectiveness of mirtazapine to alleviate severe persisting breathlessness., Methods: This international, multicentre, phase 3, parallel-group, double-blind, randomised, placebo-controlled trial across 16 centres in seven countries (Australia, Germany, Ireland, Italy, New Zealand, Poland, and the UK), recruited adults with chronic obstructive pulmonary disease (COPD), interstitial lung diseases, or both, and grade 3 or 4 of the modified Medical Research Council breathlessness scale. Consenting participants were randomly assigned (1:1) to receive oral mirtazapine or matching placebo for 56 days. Randomisation was by minimisation. The initial mirtazapine dose was 15 mg, escalating to a maximum of 45 mg per day, tapered at treatment end. Participants, caregivers, assessors, and investigators were masked to group assignment. The primary outcome was worst breathlessness in the preceding 24 h measured on a 0-10 numerical rating scale (NRS), at 56 days post-treatment start, with follow-up to 180 days. The primary analysis was performed in the modified intention-to-treat population using multivariable multi-level repeated measures model. This trial was registered with ISRCTN (ISRCTN10487976 and ISRCTN15751764 [Australia and New Zealand]) and EudraCT (2019-002001-21) and is complete., Findings: Between Feb 4, 2021 and March 28, 2023, we enrolled 225 eligible participants (148 men and 77 women, 113 to the mirtazapine group and 112 to the placebo group). The median age was 74 years (IQR 67-78). No evidence of a difference was found in worst breathlessness at day 56 between mirtazapine and placebo (difference in adjusted mean NRS score was 0·105 [95% CI -0·407 to 0·618]; p=0·69). Although the study was underpowered, the primary endpoint effect did not reach the pre-specified treatment effect of 0·55 for worst breathlessness score reduction that the study was powered to detect for the primary analysis. There were 215 adverse reactions in 72 (64%) of 113 participants in the mirtazapine group versus 116 in 44 (40%) of 110 participants in the placebo group; 11 serious adverse events in six (5%) participants in the mirtazapine group versus eight in seven (6%) participants in the placebo group; and one (1%) suspected unexpected serious adverse reaction in the mirtazapine group. At day 56, there were three deaths in the mirtazapine group and two deaths in the placebo group. At day 180, there were seven deaths in the mirtazapine group and 11 deaths in the placebo group., Interpretation: Our findings suggested that mirtazapine of doses 15 to 45 mg daily over 56 days does not improve severe breathlessness among patients with COPD or interstitial lung diseases and might cause adverse reactions. Based on these findings, we do not recommend mirtazapine as a treatment to alleviate severe breathlessness., Funding: EU Horizon 2020 (grant agreement No. 825319); Cicely Saunders International Breathlessness Programme; National Institute for Health and Care Research Applied Research Collaboration South London; Australian National Health and Medical Research Council-EU (application ID: APP1170731)., Competing Interests: Declaration of interests IJH reports grants from EU, Marie Curie Cancer Care, and National Institute for Health and Care Research (NIHR), and is Scientific Director of Cicely Saunders International, NIHR Emeritus Senior Investigator, and is an Honorary Clinical Consultant in Palliative Medicine for hospitals under Kings College Hospital National Health Service Foundation Trust outside of the submitted work. CEB reports grants from the EU, NIHR, AstraZeneca as well as an industry collaboration and a personal fee from Roche outside of the submitted work. JMBr reports grants from the EU and reports being an uncompensated NIHR Health Technology Assessment Funding Committee Chair outside of the submitted work. DCC reports personal fees from Helsinn Pharmaceuticals, Mayne Pharma International, Nous Group, iCare Dust Disease Board, and an unpaid consultant to Chris O'Brien Lighthouse outside of the submitted work. BF reports grants from the Wellcome Trust and is a member of the Ethics Advisory Board Our Future Health, Assurance Board member Cass Review, EU appointed Ethics Advisor to the River EU project, Advisory Board Member Italian MS ConCure project, Advisory Group for Monash University, and Advisory Panel Member for Economic and Social Research Council outside of the submitted work. SPH reports personal fees from Trevi Therapeutics, Boehringer Ingelheim, Chiesi, and is a Trustee for Action for Pulmonary Fibrosis outside of the submitted work. CB, MJJ, AOO, KR, and STS report grants from the EU. MM reports grants from the EU, UKRI, and NIHR. MK and PJ report grants from the EU and Poland Ministry of Science and Higher Education for participation in Horizon 2020. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Patients with prior COVID-19 infections often develop chronic post-COVID symptoms, such as fatigue and dyspnea. Some patients have residual pulmonary disorders with abnormal pulmonary function tests and/or chest radiographs to explain their dyspnea. However, other patients appear to have dyspnea that is out of proportion to any measurable change in lung function. Some of these patients have abnormal cardiopulmonary exercise testing with definite cardiac or respiratory limits. However, others have normal cardiopulmonary exercise testing based on VO 2 measurement but pronounced dyspnea during this testing. These patients often have abnormal respiratory patterns, referred to as dysfunctional breathing, with irregular and variable respiratory rates and/or tidal volumes. Consequently, their control of breathing is impaired, and this may represent residual effects from prior COVID-19 infection involving the central nervous system. Alternatively, patients may have acquired "a memory" of respiratory symptoms during their infection which persists post-infection. These patients should participate in pulmonary rehabilitation and breathing retraining., Competing Interests: Declaration of competing interest The authors have no conflict of interest related to this manuscript., (Copyright © 2024 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Introduction: Type 4 posterior glottic stenosis and bilateral vocal fold paralysis are clinically challenging causes of bilateral vocal fold immobility (BVFI) that result in glottic airway obstruction. Established procedures for BVFI typically worsen dysphonia. We hypothesize the use of thyroarytenoid myomectomy (TAM) in the setting of BVFI will improve dyspnea with decreased detriment to voice., Methods: Eleven unilateral TAM procedures were performed between April 2021 and June 2023 at a single institution. Pre- and postoperative patient reported outcomes were compared. Representative images of maximal glottic opening were analyzed in ImageJ to calculate ipsilateral bowing index (BI), total BI, maximum glottic surface area (MGSA), and maximum opening angle (MOA). Statistical comparisons were performed with paired t-tests when normality was confirmed with Shapiro-Wilk test and otherwise with Wilcoxon signed-rank tests, with threshold for significance of α = 0.05. Interrater reliability for objective glottal measures was compared with intraclass correlation coefficient (ICC)., Results: Dyspnea Index improved from mean (standard error) of 24.1 (3.8) to 9.1 (3.3), p = 0.004. Voice Handicap Index-10 improved from 20.0 (4) to 10.3 (3.8), p = 0.011. Glottal Function Index improved from 9.6 (1.4) to 6.3 (1.3), p = 0.017. There was no significant difference in ipsilateral BI, total BI, MOA, and median MGSA. There was good to excellent ICCs for all comparisons (0.83-0.95)., Conclusions: TAM demonstrated significant improvement in symptoms from BVFI while not significantly altering glottal structure. These data suggest TAM improves dyspnea in patients with BVFI without significantly impairing voice., Level of Evidence: 4 Laryngoscope, 134:4307-4312, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Dyspnea is one of the most common and distressing symptoms in patients with cancer and noncancer advanced diseases. The Japanese Society for Palliative Medicine revised previous guidelines for the management of respiratory symptoms in patients with cancer and newly developed clinical guidelines for managing dyspnea in patients with advanced disease, based on the result of systematic reviews for each clinical question and consensus among experts. We describe the recommendations of the guidelines as well as provide insights into the reasoning behind the recommendations and their development process. There has been a paucity of evidence regarding the interventions for dyspnea in patients with advanced disease. Thus, more clinical research that includes not only randomized controlled trials but also real-world observational studies is warranted.

Background: Physical inactivity, which is highly prevalent in patients with systemic lupus erythematosus (SLE), is an independent risk factor for cardiovascular events and causes many complications. This study aimed to investigate the effect of objective measurement and physical activity level on peripheral muscle strength, exercise capacity, pain, dyspnea, fatigue, anxiety, and depression in patients with SLE., Methods: The present cross-sectional study analyzed 41 patients with SLE. Clinical and demographic characteristics of patients were recorded. Functional exercise capacity, peripheral muscle strength, dyspnea, pain, fatigue, anxiety, and depression were assessed. The physical activity level was assessed by a wearable activity tracker (Mi Band four smart band)., Results: The number of steps measured by the activity tracker was 4384.43 ± 1558.21 steps per day in patients with SLE. Patients with physical activity levels below 5000 steps exhibited elevated levels of fatigue, along with diminished functional exercise capacity and knee muscle strength, in comparison to those who were above the 5000-step threshold. Physical activity levels correlated with functional exercise capacity (6MWT), physiological parameters (maximum heart rate, Δ heart rate, Δ dyspnea, QFM fatigue, Δ QFM fatigue), and knee extension muscle strength. The functional exercise capacity and knee extension were identified as significantly and dependently associated with physical activity levels in SLE patients., Conclusion: Physical activity level is associated with functional exercise capacity and knee muscle strength in patients with SLE., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Post-acute sequelae of COVID-19 (PASC) is incurring a huge health and economic burden worldwide. There is currently no effective treatment or recommended drug for PASC., Methods: This prospective randomized controlled study was conducted in a hospital in China. The effect of intermittent hypoxia exposure (IHE; 5-min hypoxia alternating with 5-min normal air, repeated five times) on dyspnea and fatigue was investigated in patients meeting the NICE definition of PASC. Patients were computationally randomized to receive normoxia exposure (NE) and routine therapy or IHE and routine therapy. Six-minute walk distance (6MWD) and spirometry were tested before and after the interventions; the Borg Dyspnea Scale (Borg) and the modified Medical Research Council Dyspnea Scale (mMRC) were used to assess dyspnea; and the Fatigue Assessment Scale (FAS) and the Chalder Fatigue Scale-11 (CFQ-11) were used to assess fatigue. The study was registered in the Chinese Clinical Trial Registry (ChiCTR2300070565)., Findings: Ninety-five participants (33 males and 62 females) were recruited between March 1, 2023 and December 30, 2023. Forty-seven patients in the IHE group received 10.0 (9.0, 15.0) days of IHE, and 48 patients in NE group received 10.0 (8.0, 12.0) days of NE. 6MWD, forced vital capacity (FVC), FVC %pred, forced expiratory volume in 1 s (FEV 1 ), FEV 1 %pred, tidal volume (V T ), and dyspnea and fatigue scales markedly improved after IHE (p < 0.05), and improvements were greater than in the NE group (all p < 0.05). Furthermore, participants in IHE group had better subjective improvements in dyspnea and fatigue than those in the NE group (p < 0.05). Compared with <10 days of IHE, ≥10 days of IHE had a greater impact on 6MWD, FVC, FEV 1 , FEV 1 %pred, V T , FAS, and CFQ-11. No severe adverse events were reported., Interpretation: IHE improved spirometry and 6MWD and relieved dyspnea and fatigue in PASC patients. Larger prospective studies are now needed to verify these findings., Competing Interests: Declaration of competing interest The authors have no relevant conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Limited data exist on post-severe COVID-19 functional trajectory, particularly considering premorbid status. We characterized 1-year functional recovery post-hospitalization for COVID-19, highlighting predictors of long-term recovery., Methods: We enrolled adult patients with lab-confirmed SARS-CoV-2 infection and hospitalized for COVID-19 sequelae, from five major Ontario, Canada hospitals in a prospective cohort study. Assessments included telephone interviews on admission followed by telephone and in-person assessments at 3-, 6-, 9-, and 12-months post-discharge. The Activity-Measure for Post-Acute Care (AM-PAC) Mobility and Cognition scales were administered at baseline and every 3 months for 1 year. Secondary outcomes included symptoms, spirometry, physical performance, dyspnea, fatigue, distress, anxiety and depression, and quality of life., Results: A total of 254 patients (57.1% male) with a mean age of 60.0 (±13.1) years and an average hospital stay of 14.3 (±19.7) days agreed to participate. At 12 months, 55.3% demonstrated clinically important deficits in mobility and 38.8% had cognitive deficits compared to premorbid levels. Fatigue was reported in 44.2%, followed by difficulty walking long distances in 35.8% and dyspnea in 33.0%. Almost 40% of patients had an FEV1(% Pred) < 80% at 12 months, 60.3% had impairments in physical performance, and 44.5% had problems with anxiety or depression. Predictors of better mobility at 12 months included higher premorbid mobility status, male sex, shorter hospital stay, fewer comorbidities, and higher FEV1 (% pred) at the 3-month follow-up., Conclusions: Our study provides compelling evidence of the long-term impact of COVID-19 on functional and cognitive status 1-year post-infection., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Intensive care unit (ICU) patients experience several symptoms, yet patterns of symptoms and their relationship with demographic and clinical characteristics have not previously been investigated., Objectives: To identify and compare subgroups (i.e. latent symptom classes) of intensive ICU patients based on prevalence of co-occurring symptoms over seven days., Research Methodology: Prospective cohort study of adult ICU patients' self-reports of five symptoms during seven days in ICU. Latent class analysis was applied to identify subgroups of ICU patients., Setting: Multicenter study with patients from six mixed ICUs in Norway., Main Outcome Measures: Patient Symptom Survey was used to assess five symptoms (i.e., thirst, pain, anxiousness, tiredness, shortness of breath)., Results: Among 353 included patients, median age was 63 years and 60.3 % were male. Subgroups of patients were identified in a Low class (n = 126, 35.7 %), Middle Class (n = 177, 50.1 %) and High Class (n = 50, 14.2 %) based on reporting of the prevalence of five symptoms. Patients in the Low class had a low prevalence of all symptoms. Middle Class patients had a high prevalence of thirst and tiredness and a low prevalence of pain, anxiousness and shortness of breath. The High class patients had a high prevalence of all symptoms. Symptom prevalence remained stable in the Low and Middle class over time and increased over time in the High class. There were significant differences among symptom classes in use of mechanical ventilation (p = 0.012), analgesics (p < 0.001), alpha-2 agonists (p = 0.004) and fluid restriction (p = 0.006). Patients in the High class received more of these ICU-treatments., Conclusions: Findings suggest that subgroups of ICU patients with distinct symptom experiences can be identified. The High prevalence class patients had consistently high levels of all symptoms across seven ICU days and received more ICU-related interventions., Implication for Clinical Practice: Some ICU patients experience a consistently high prevalence of co-occurring symptoms. Clinicians should be aware of treatment factors that could be linked to a high burden of symptoms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Pulmonary alveolar proteinosis is a rare diffuse lung disease; diagnosis and treatment of which is often delayed. We present the case study of a 43-year-old male with a six-month history of worsening breathlessness and non-productive cough referred for specialist respiratory input. Rapid investigations, including high-resolution computed tomography (HRCT) and bronchoalveolar lavage, confirmed the diagnosis of pulmonary alveolar proteinosis. Treatment with whole lung lavage significantly improved pulmonary function and quality of life. We discuss the diagnosis and management of this condition and highlight the importance of early recognition and multidisciplinary teamwork in managing pulmonary alveolar proteinosis.

Cricoid chondronecrosis is a rare entity and is scarcely reported in the literature. Its prevalence is increasing in the form of chondroradionecrosis among the survivorship of head and neck carcinoma patients treated with radiotherapy. We have reported a case of cricoid chondronecroisis caused by trauma from repeated tracheostomy. The patient presented with hoarseness and dyspnoea. Radiological findings in multidetector computed tomography showed disintegration of the cricoid and confirmed the diagnosis. Conservative treatment was given in the form of antibiotics, steroids and nebulised anticholinergics and bronchodilators. However, the patient did not improve and his condition worsened throughout two months of hospitalisation. He was referred for hyperbaric oxygen treatment, which was given over 30 sessions. This was associated with improvement in his condition and he was able to be decannulated from tracheostomy. Six monthly follow up of the patient showed a well-healed tracheostomy scar., Competing Interests: The authors report no conflicts of interest in this work., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)

Coronary arteries normally originate from two separate cusps from the aorta, and various anomalies can occur. One such anomaly is the single coronary artery (SCA), where the coronary arteries originate from a single ostium due to the absence of the contralateral ostia. In a rare case we encountered while evaluating a patient with atypical chest pain, computed tomography angiography revealed that the right ostia was absent, and the right coronary artery originated from the left circumflex artery. This subtype of SCA has been exceedingly rare, with only a few cases reported in the literature., Competing Interests: The authors have no competing interests to declare. The patient provided informed consent for documenting this case., (Copyright: © 2024 The Author(s).)

The respiratory muscles in chronic obstructive pulmonary disease (COPD) patients have reduced strength and resistance, leading to loss of the functional ability of these muscles. Lung hyperinflation is one of the main alterations, and air trapping is the main factor limiting diaphragmatic mobility (DM) in these patients; however, its correlation with functional parameters, exercise capacity, and indicators of disease severity remains underexplored. This study aimed to assess DM in stable COPD patients and relate the findings with parameters such as the 6-minute walk test distance, forced expiratory volume in 1 second (FEV1) %predicted, residual volume (RV) %predicted, and dyspnea. An observational cohort study was conducted to measure DM using ultrasound both at rest (DMrest) and during deep inspiration (DMmax). Forty-nine patients with stable COPD were included in this study. There was a correlation between DMmax and FEV1 %predicted (R = 0.36; P = .012), RV %predicted (r = -0.42; P = .01), RV/total lung capacity (r = -0.61; P < .001), and distance reached in the 6MWT (R = 0.46; P = .001). Patients with a modified Medical Research Council score <2 exhibited greater DM than those with a score ≥2 (mean difference = 13.20 ± 4.6 mm; P = .0059). Similarly, patients with a Body Mass Index, Airflow Obstruction, Dyspnea and Exercise Capacity index ≤4 showed greater DM (61.95 mm) than those with a Body Mass Index, Airflow Obstruction, Dyspnea and Exercise Capacity index >4 (47.89 mm; mean difference = 14.05 ± 5.3 mm; 95% confidence interval = 25.09-3.01 mm). DM is correlated with bronchial obstruction (FEV1), lung hyperinflation (RV and RV/total lung capacity), exercise capacity, and dyspnea in patients with COPD, suggesting its utility as an evaluative tool in this population., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

A male patient in his 50s presented to the emergency department with a three-day history of shortness of breath, New York Heart Association class IV, and oxygen desaturation. His physical examination revealed a large volume radial pulse with bibasal crepitation in the lungs and a soft diastolic murmur in the aortic area on auscultation of his heart. He was managed on the line of decompensated heart failure. Transthoracic echocardiography showed a dissection flap in the ascending aorta with acute severe aortic regurgitation. A subsequent urgent CT angiography of the whole aorta confirmed a complex type A aortic dissection with an aneurysmal ascending aorta. An emergency type A aortic dissection repair (modified Bentall's procedure) was done. The patient made a good recovery, was discharged successfully 2 weeks after the procedure and was doing well on postoperative follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A female of reproductive age presents to the emergency department with progressive dyspnoea due to pneumothorax. She has a history of lymphangioleiomyomatosis (LAM) diagnosed by lung biopsy 15 years ago following incidental finding of pneumothorax. Despite various procedural and medicinal treatments, she continued to have recurrent pneumothorax, with three hospital admissions over the preceding 3 months. LAM is a rare cystic lung disease affecting the lymphatic system, which most commonly affects women of childbearing age. It can be diagnosed via imaging or tissue biopsy (gold standard). Treatment can be difficult, and it often requires highly specialised care by pulmonologists and often confers significant limitations to patients' independence and quality of life. Family physicians are often part of multidisciplinary team to provide care to patients with rare chronic conditions., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives : PoCUS ultrasound applications are widely used in everyday work, especially in the field of emergency medicine. The main goal of this research was to create a diagnostic and therapeutic protocol that will integrate ultrasound examination of the lungs, ultrasound measurements of the inferior vena cava (assessment of central venous pressure) and BREST scores (risk stratification for heart failure), with the aim of establishing a more effective differential diagnostic approach for dyspneic patients. Materials and Methods: A cross-sectional study was conducted in the emergency medicine department with the educational center of the community health center of Banja Luka. Eighty patients of both sexes were included and divided into experimental and control groups based on the presence or absence of dyspnea as a dominant subjective complaint. Based on the abovementioned variables, the LUSBI protocol (lung ultrasound/BREST score/inferior vena cava) was created, including profiles to determine the nature of the origin of complaints. The biochemical marker of heart failure NT pro-BNP served as a laboratory confirmation of the cardiac origin of the complaints. Results : The distribution of NT pro BNP values in the experimental group showed statistically significant differences between individual profiles of the LUSBI protocol ( p < 0.001). Patients assigned to group B PLAPS 2 had significantly higher average values of NT pro-BNP (20159.00 ± 3114.02 pg/mL) compared to other LUSBI profiles. Patients from the experimental group who had a high risk of heart failure according to their BREST scores also had a significantly higher average maximum expiratory diameter compared to those without heart failure ( p = 0.004). A statistically significant difference ( p = 0.001) in LUSBI profiles was observed between the groups of patients divided according to CVP categories. Conclusion : The integration of the LUSBI protocol into the differential diagnosis of dyspnea has been shown to be very effective in confirming or excluding a cardiac cause of the disease in patients.

Objective: Hypertrophic cardiomyopathy (HCM), including obstructive HCM (oHCM), is the most common inherited cardiomyopathy causing lifestyle-limiting symptoms. Data are lacking about patients' perspectives on the daily impact of their symptoms. This qualitative interview study was conducted to better understand patients' experiences with oHCM., Methods: In October 2019, telephone interviews were conducted with 20 US adults with oHCM identified by the Hypertrophic Cardiomyopathy Association. Using a semi-structured interview guide, key symptoms, impacts of oHCM and oHCM treatment goals were discussed., Results: Median age was 54 years (range 29-78), 55% were women, 85% were white and 15% were Hispanic or Latino. Median time since diagnosis was 3 years. Symptoms included shortness of breath, dizziness/light-headedness, heart palpitations/fluttering (all 95%), fatigue (90%) and chest pain/pressure (80%). All participants reported limitations in physical functioning/activities; most reported additional impacts (emotional stress (80%), fear of dying (55%)). Shortness of breath and fatigue were among their most bothersome symptoms; an effective oHCM treatment would need to improve ≥1 of these symptoms (allowing increased physical/social activity)., Conclusions: Patients with oHCM experience a high symptom burden and psychosocial impacts, affecting health status. Improved shortness of breath, fatigue and physical functioning are highly valued by patients and represent important treatment goals., Competing Interests: Competing interests: SSh has received a grant from the American Heart Association (grant ID 855105). CE, KK and SF are employees of RTI Health Solutions. LS has no conflicts of interest to declare. MB, SBH and DJ are employees of Cytokinetics, Incorporated, and hold stock in Cytokinetics, Incorporated. SSa has received consultant/adviser fees from Bristol Myers Squibb and research grants from Bristol Myers Squibb, Cytokinetics, Novartis and Actelion Pharmaceuticals., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The aim of the study was investigate the effect of corticosteroid use on the need for invasive procedure like tube thoracostomy with underwater seal drainage (TT-UWSD) and Video Assisted Thoracoscopic Surgery (VATS) in adult patients diagnosed with parapneumonic effussion in the exudative phase. A retrospective cohort study was performed in a chest diseases hospital. A total of 65 patients were included in the study. While 30 patients received only medical treatment, 35 patients underwent invasive procedures. Data on characteristics, vital signs, and laboratory parameters were recorded from electronic medical records. Univariate and multivariate logistic regression analyses were performed to identify corticosteroid and other predictors of the need for invasive procedures. The outcomes of the multivariate regression analysis revealed that an longer duration of symptoms (OR = 1.10, 95% CI: 1.01-1.21, P < .033) and the presence of dyspnea (OR = 5.44, 95% CI: 1.26-23.50, P < .023) independently associated with an increased need for invasive procedures, while corticosteroid treatment (OR = 0.15, 95% CI: 0.02-0.81, P < .028) was observed to be associated with a reduced necessity for invasive procedures. Treatment with metilprednisolone, together with the absence of dyspnea and shorter symptom duration may independently decrease the need for invasive procedure in patients with parapneumonic pleural effusion in the exudative phase., Competing Interests: All authors have no conflicts of interest to declare., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Dabbing is recently getting popular among young adults. It is a new method of using the most active form of marijuana where large amounts of concentrated tetrahydrocannabinol are inhaled. Tetrahydrocannabinol is associated with a feeling of 'High' which makes the user feel joyous and relaxed. With increasing use of such techniques, dabbing becomes an important differential for evaluation of acute respiratory failure with pneumonitis especially in the adult population., Case Presentation: A Fifty-one years old Caucasian man presented to the hospital with chest pressure and shortness of breath. The patient was noted to be hypoxic, desaturating down to 82-83% on nasal cannula oxygen. Imaging revealed bilateral lung infiltrates. Patient was started on high flow oxygen, broad spectrum antibiotics and intravenous corticosteroids. The patient gradually improved and was able to come off oxygen completely. He was discharged home on prednisone taper., Conclusions: Dabbing is a newer technique which has been gaining popularity for marijuana usage. With the legalization of marijuana, newer techniques are getting popular. Our case report emphasizes the importance of keeping dabbing as a differential when a patient presents with respiratory failure and has concerns for pneumonitis. Patients might not reveal until specifically asked about their practices., (© 2024. The Author(s).)

A man in his early 50s with previously treated pulmonary tuberculosis (TB) presented with a 3-month history of cough, expectoration and progressive breathlessness, accompanied by significant weight loss. Examination revealed tachycardia, tachypnoea, hypoxaemia and unilateral diminished breath sounds. Investigations showed anaemia, leucocytosis and a homogeneous opacity on the left side of the CXR. ECG and echocardiography suggested pulmonary thromboembolism (PTE). A CT pulmonary angiogram confirmed a chronic embolus and a severely fibrosed left lung. A comprehensive thrombophilia workup yielded normal results and the PTE was attributed to his history of TB. Sputum analysis confirmed reactivated TB, leading to the initiation of antitubercular therapy. The patient improved clinically with plans for a repeat CT pulmonary angiography to assess the need for pulmonary thromboendarterectomy after completing TB treatment. This case highlights the possible association of TB and PTE, its management and why it should be considered as a differential diagnosis in patients with a history of TB presenting with exacerbated breathlessness., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The differential diagnosis of dysphagia and dyspnoea with cervicofacial oedema is wide and includes diseases with variable prognosis that may require an urgent approach. This article presents the case of a middle-aged man who came to the emergency room referring to the symptoms described, with a history of central venous access established approximately 4 years ago. The patient was diagnosed with superior vena cava syndrome and treated with anticoagulants and removal of the catheter. After a week of admission with anticoagulation, the patient clinically improved with a considerable decrease in thrombus and pharyngolaryngeal and subcutaneous mucosal oedema. In the differential diagnosis of dysphagia and dyspnoea, we must also consider systemic diseases, and more specifically, these symptoms such as those described, and think about this entity because of its severity., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In recent years, there has been a significant increase in the survival rates of cancer patients. However, this has also led to an increase in side effects, such as dyspnoea, which can negatively impact of patients. We propose a programme for re-educating effort. The main objective is to test the effectiveness of this programme in improving respiratory symptoms and functionality in cancer patients., Methodology: Experimental, prospective, longitudinal, randomised study with a parallel fixed-assignment scheme (CG-IG). The patients were selected from the Medical Oncology Service of the University Hospital Complex of Salamanca (CAUSA), Spain. Two parallel intervention programmes were designed for the two study groups (Conventional Clinical Practice-Effort Re-education Programme). Primary variables: dyspnoea (MRC), functionality (Barthel); secondary variables: physical performance (SPPB) and functional capacity (ECOG) and the socio-demographic variables (age, sex, anatomopathological diagnosis, and number of treatment lines)., Results: The study sample consisted of 182 patients, with 12 excluded, resulting in a final sample size of n = 170. Sex distribution (CG: 52.9% male and 47.1% female; IG: 49.4% male and 50.6% female). The primary oncological diagnosis was lung cancer, and the most frequent tumour stages were III and IV. Statistically significant differences were found between the IG and CG scores (p < 0.001, d = 0.887, 95% CI) and between the IG and CG scores (p = 0.004, d = 0.358, 95% CI), indicating that the IG performed better., Conclusion: The results of this study support the beneficial effects of an exercise re-education programme, carried out by an interdisciplinary team in improving the autonomy of oncology patients with dyspnoea., Trial Registration: The clinical trial was registered in ClinicalTrials.gov (NCT04186754). (03 September 2019)., (© 2024. The Author(s).)

Background: In the postacute phase of coronavirus disease-2019 (COVID-19), survivors may have persistent symptoms, lung function abnormalities, and sequelae lesions on thoracic computed tomography (CT). This new entity has been defined as post-COVID interstitial lung disease (ILD) or residual disease., Aims: To evaluate the characteristics, risk factors and clinical significance of post-COVID ILD., Study Design: Multicenter cross-sectional analysis of data from a randomized clinical study., Methods: In this study, patients with persistent respiratory symptoms 3 months after recovery from COVID-19 were evaluated by two pulmonologists and a radiologist. post-COVID ILD was defined as the presence of respiratory symptoms, hypoxemia, restrictive defect on lung function tests, and interstitial changes on follow-up high-resolution computed tomography (HRCT)., Results: At the three-month follow-up, 375 patients with post-COVID-19 syndrome were evaluated, and 262 patients were found to have post-COVID ILD. The most prevalent complaints were dyspnea (n = 238, 90.8%), exercise intolerance (n = 166, 63.4%), fatigue (n = 142, 54.2%), and cough (n = 136, 52%). The mean Medical Research Council dyspnea score was 2.1 ± 0.9, oxygen saturation was 92.2 ± 5.9%, and 6-minute walking distance was 360 ± 140 meters. The mean diffusing capacity of the lung for carbon monoxide was 58 ± 21, and the forced vital capacity was 70% ± 19%. Ground glass opacities and fibrotic bands were the most common findings on thoracic HRCT. Fibrosis-like lesions such as interlobular septal thickening and traction bronchiectasis were observed in 38.3% and 27.9% of the patients, respectively. No honeycomb cysts were observed. Active smoking [odds ratio (OR), 1.96; 95% confidence interval (CI), 1.44-2.67), intensive care unit admission during the acute phase (OR, 1.46; 95% CI, 1.1-1.95), need for high-flow nasal oxygen (OR, 1.55; 95% CI, 1.42-1.9) or non-invasive ventilation (OR, 1.31; 95% CI, 0.8-2.07), and elevated serum lactate dehydrogenase levels (OR, 1.23; 95% CI 1.18-1.28) were associated with the development of post-COVID ILD. At the 6-month follow-up, the respiratory symptoms and pulmonary functions had improved spontaneously without any specific treatment in 35 patients (13.4%). The radiological interstitial lesions had spontaneously regressed in 54 patients (20.6%)., Conclusion: The co-existence of respiratory symptoms, radiological parenchymal lesions, and pulmonary functional abnormalities which suggest a restrictive ventilatory defect should be defined as post-COVID-19 ILD. However, the term “fibrosis” should be used carefully. Active smoking, severe COVID-19, and elevated lactate dehydrogenase level are the main risk factors of this condition. These post-COVID functional and radiological changes could disappear over time in 20% of the patients., Competing Interests: Conflict of Interest: The authors declare that they have no conflict of interest.