Prognostic Factors of Mortality in Nonchronic Obstructive Pulmonary Disease Chronic Lung Disease: A Scoping Review.

Introduction: Patients with chronic lung disease (CLD) experience a heavy symptom burden at the end of life, but their uptake of palliative care is notably low. Having an understanding of a patient's prognosis would facilitate shared decision making on treatment options and care planning between patients, families, and their clinicians, and complement clinicians' assessments of patients' unmet palliative needs. While literature on prognostication in patients with chronic obstructive pulmonary disease (COPD) has been established and summarized, information for other CLDs remains less consolidated. Summarizing the mortality risk factors for non-COPD CLDs would be a novel contribution to literature. Hence, we aimed to identify and summarize the prognostic factors associated with non-COPD CLDs from the literature. Methods: We conducted a scoping review following published guidelines. We searched MEDLINE, Embase, PubMed, CINAHL, Cochrane Library, and Web of Science for studies published between 2000 and 2020 that described non-COPD CLD populations with an all-cause mortality risk period of up to three years. Only primary studies which reported associations with mortality adjusted through multivariable analysis were included. Results: Fifty-five studies were reviewed, with 53 based on interstitial lung disease (ILD) or connective tissue disease-associated ILD populations and two in bronchiectasis populations. Prognostic factors were classified into 10 domains, with pulmonary function and disease being the largest. Older age, lower forced vital capacity, and lower carbon monoxide diffusing capacity were most commonly investigated and associated with statistically significant increases in mortality risks. Conclusions: This comprehensive overview of prognostic factors for patients with non-COPD CLDs would facilitate the identification and prioritization of candidate factors to predict short-term mortality, supporting tool development for decision making and to identify high-risk patients for palliative needs assessments. Literature focused on patients with ILDs, and more studies should be conducted on other CLDs to bridge the knowledge gap.

Impact of Palliative Care in End-of-Life of Fibrotic Interstitial Lung Disease Patients.

Background: Interstitial lung disease (ILD) is associated with poor quality of life (QoL) and high symptom burden. Studies evaluating the benefits of palliative care examined mainly idiopathic pulmonary fibrosis (IPF) patients. We aim to examine the impact of palliative care on a broader group of fibrotic ILD patients. Methods: Single center retrospective cohort study comparing deceased ILD patients who received outpatient palliative care services (palliative-intervention group) against a usual care group. Results: Of 63 subjects, 26 (41%) were in the palliative-intervention group and 37 (59%) in the usual care group. Median time to palliative care referral was 8.6 (IQR .3-21.2) months. Dyspnea-related disability was greater in the palliative-intervention group [mMRC dyspnea score 3.5(IQR 2-4) vs 2(IQR 2-4), P = .039], with more patients requiring long term oxygen therapy (70% vs 30%, P < .001). There was no difference in the median number of hospitalizations or length of stay in the last 6 months of life. Patients in the palliative-intervention group had a higher uptake of advance care planning (ACP) (39% vs 11%, P = .014), lower frequency of intensive care unit (ICU) admissions (5% vs 19%, P = .102) and were prescribed more opioids (96% vs 27%, P < .001) and benzodiazepines (39% vs 14%, P = .022). The palliative-intervention group experienced a longer median survival of 23.9 months (95% confidence interval [CI] 14.1-33.7) compared to the usual group (11.4 months [95% CI 5.4-17.3] (log-rank test: P = .023). Male gender was a strong predictor of 1-year mortality. Conclusions: The palliative-intervention group received earlier pharmacologic intervention for symptom relief. Healthcare utilization was not increased despite greater dyspnea-related disability.

Health-related quality of life in a multiracial Asian interstitial lung disease cohort.

Background: Understanding health-related quality of life (HRQL) in patients with interstitial lung disease (ILD) provides insight into disease burden and treatment effects on patients' well-being. We examined HRQL in a multiracial Asian ILD cohort using the King's brief ILD (K-BILD) and EuroQol 5-dimension-3-level (EQ5D-3L) questionnaires and their associations with several clinical variables. Methods: This was a single-centre cross-sectional study of ILD patients in a university-affiliated tertiary public hospital in Singapore. All patients completed two self-administered HRQL questionnaires upon study entry, and their clinical information was retrieved from electronic medical records. Results: Ninety-nine patients (56% male, 75% Chinese) were included. The median (interquartile range) age was 63 (54-72) years. The most common ILD diagnosis was connective tissue disease-related ILD (n=51, 52%), followed by idiopathic pulmonary fibrosis (n=27, 27%). The mean (standard deviation) scores for the EQ5D-3L utility value, EQ5D Visual Analogue Scale (VAS) and K-BILD total were 0.806 (0.284), 75.1 (12.8) and 63.9 (14.3), respectively. A moderate correlation was found between the EQ5D-3L and K-BILD total and domain scores. The HRQL scores also correlate moderately with the modified Medical Research Council dyspnoea scale (mMRC) scores. There was a weak-to-moderate correlation between HRQL and forced vital capacity (FVC), carbon monoxide diffusing capacity (DLCO) and Charlson comorbidity index. Multiple linear regression showed a significant association of K-BILD total [beta coefficient 0.244, 95% confidence interval (CI): 0.075-0.414; P=0.005], K-BILD 'breathlessness and activities' (beta coefficient 0.448, 95% CI: 0.192-0.703; P=0.001), and the 'psychological' domain (beta coefficient 0.256, 95% CI: 0.024-0.488; P=0.031) with DLCO %pred after adjustment for age, sex, BMI, race, smoking history, comorbidities, FVC %pred and ILD diagnosis. Non-Chinese race was a predictor of better K-BILD 'psychological' domain (beta coefficient 8.680, 95% CI: 0.656-16.704; P=0.034) after adjustment. Conclusions: HRQL is significantly impaired in ILD patients, and low DLCO is a strong predictor of this impairment.

Comparing hospital-resource utilization by an enhanced pneumonia surveillance programme for COVID-19 with pre-pandemic pneumonia admissions - a Singaporean hospital's experience.

Introduction. During the early days of coronavirus disease 2019 (COVID-19) in Singapore, Tan Tock Seng Hospital implemented an enhanced pneumonia surveillance (EPS) programme enrolling all patients who were admitted from the Emergency Department (ED) with a diagnosis of pneumonia but not meeting the prevalent COVID-19 suspect case definition.Hypothesis/Gap Statement. There is a paucity of data supporting the implementation of such a programme.Aims. To compare and contrast our hospital-resource utilization of an EPS programme for COVID-19 infection detection with a suitable comparison group.Methodology. We enrolled all patients admitted under the EPS programme from TTSH's ED from 7 February 2020 (date of EPS implementation) to 20 March 2020 (date of study ethics application) inclusive. We designated a comparison cohort over a similar duration the preceding year. Relevant demographic and clinical data were extracted from the electronic medical records.Results. There was a 3.2 times higher incidence of patients with an admitting diagnosis of pneumonia from the ED in the EPS cohort compared to the comparison cohort (P<0.001). However, there was no significant difference in the median length of stay of 7 days (P=0.160). Within the EPS cohort, stroke and fluid overload occur more frequently as alternative primary diagnoses.Conclusions. Our study successfully evaluated our hospital-resource utilization demanded by our EPS programme in relation to an appropriate comparison group. This helps to inform strategic use of hospital resources to meet the needs of both COVID-19 related services and essential 'peace-time' healthcare services concurrently.

Pneumonia surveillance and its attendant clinical risk stratification for COVID-19 in low-risk patients.

OBJECTIVES: The objective of the study is to determine the prevalence of COVID-19 in the context of a secondary pneumonia surveillance program targeted at low-risk patients and to identify clinical characteristics associated with COVID-19. STUDY DESIGN: This study design is a retrospective cohort study. METHODS: This study is conducted in Tan Tock Seng Hospital, a University affiliated 1600-bed public hospital in Singapore. Patients with pneumonia admitted under our Enhanced Pneumonia Surveillance (EPS) program from 7 February 2020 to 20 March 2020 were included. Relevant clinical variables were collated. RESULTS: Of 1295 patients admitted under our EPS program, 47 (3.6%) patients tested positive for COVID-19. The prevalence of a radiologist-reported normal chest X-ray (CXR) in the COVID-19-positive group was 62.8% compared with 6.2% in the COVID-19-negative group. In patients with a normal CXR, a low normal white blood cell (WBC) count and minimal C-reactive protein (CRP) elevation were associated with COVID-19. CONCLUSIONS: The pick-up rate of COVID-19 in low-risk patients with pneumonia is 3.6%. However, at least 7.9% of patients who were isolated had a normal CXR. For patients with pneumonia-like illness at presentation but a normal CXR, higher WBC and CRP values may guide early deisolation. Ultimately, this informs resource allocation for both COVID-19 and non-COVID-19 clinical services.

Impact of an interstitial lung disease service in the diagnosis and management of interstitial lung disease in Singapore.

INTRODUCTION: The current gold standard for diagnosing interstitial lung disease (ILD) involves an ILD clinic evaluation, followed by discussion in a multidisciplinary meeting (MDM). However, there is a paucity of data on the impact of ILD MDMs on the diagnosis and management of ILDs in Southeast Asia. We studied the clinical impact of the ILD service on the diagnosis and management of ILDs at a university-affiliated tertiary hospital in Singapore. METHODS: A single-centre retrospective review was done on 97 consecutive patients referred for evaluation to the ILD service from March 2016 to August 2017. RESULTS: Mean age of the patients was 67 ± 11 years. Gender distribution was almost equal (52% male), with a majority of never-smokers (63%). Mean forced vital capacity (FVC) was 1.81 ± 0.66 L (66% ± 20% predicted). The three commonest referral diagnoses were ILD of uncertain classification (n = 38, 39%), connective tissue disease-associated ILD (CTD-ILD) (n = 24, 25%) and idiopathic pulmonary fibrosis (IPF) (n = 16, 17%). Following evaluation by the ILD service, there was a change of diagnosis in 60 (62%) patients and a change of management in 71 (73%) patients. The majority of consensus MDM diagnoses were IPF (n = 35, 36%), CTD-ILD (n = 30, 30%) and others (n = 15, 15%). There was a significant prognostic separation between the IPF and non-IPF diagnoses made following evaluation by the ILD service. CONCLUSION: The ILD service allowed for more precise subtyping of various ILDs. This is particularly useful for IPF patients, who can benefit from antifibrotic therapies.