Daily Respiratory Research Analysis
A UK multicentre RCT found no clinical or economic benefit of extracorporeal CO2 removal for acute hypoxaemic respiratory failure, supporting non-use outside trials. An international pediatric bronchiectasis registry revealed substantial regional variation in causes, bacteriology, and care quality, identifying actionable gaps. A European analysis estimated substantial RSV hospitalisation rates in older adults, informing vaccination strategies and underscoring under-ascertainment in routine data.
Summary
A UK multicentre RCT found no clinical or economic benefit of extracorporeal CO2 removal for acute hypoxaemic respiratory failure, supporting non-use outside trials. An international pediatric bronchiectasis registry revealed substantial regional variation in causes, bacteriology, and care quality, identifying actionable gaps. A European analysis estimated substantial RSV hospitalisation rates in older adults, informing vaccination strategies and underscoring under-ascertainment in routine data.
Research Themes
- Critical care ventilation and extracorporeal support
- Pediatric bronchiectasis epidemiology and care quality
- RSV disease burden in older adults and vaccination policy
Selected Articles
1. Extracorporeal carbon dioxide removal for the treatment of acute hypoxaemic respiratory failure: the REST RCT.
In a 51-ICU pragmatic RCT (n=412), ECCO2R-facilitated lower tidal volume ventilation did not reduce 90-day mortality versus standard care (41.5% vs 39.5%; RR 1.05). No short- or long-term benefits were found; costs were higher and complications potentially significant, leading authors to advise against ECCO2R outside future trials.
Impact: This high-quality multicentre RCT provides definitive negative evidence on ECCO2R in hypoxaemic respiratory failure, guiding de-implementation and resource allocation.
Clinical Implications: Do not use ECCO2R to facilitate ultra-low tidal volumes for acute hypoxaemic respiratory failure outside clinical trials; standard lung-protective ventilation remains preferred.
Key Findings
- 90-day mortality: 41.5% (ECCO2R) vs 39.5% (standard); RR 1.05 (95% CI 0.83–1.33).
- No improvement in ventilator-free days, long-term outcomes, or quality of life.
- Higher costs and potentially significant complications with ECCO2R; trial stopped early for futility.
Methodological Strengths
- Multicentre randomized, allocation-concealed, pragmatic design across 51 ICUs.
- Comprehensive outcomes including costs, long-term morbidity, and quality of life.
Limitations
- Trial stopped early, potentially underpowered to detect modest effects.
- Open-label design; only 6% of screened patients enrolled; heterogeneity in usual care.
Future Directions: Investigate whether specific subgroups or higher 'dose' ECCO2R exposure benefit, using standardized core outcomes and early HRQoL measurement.
BACKGROUND: In patients who require mechanical ventilation for acute hypoxaemic respiratory failure, further reduction in tidal volumes, compared with conventional low tidal volume ventilation, may improve outcomes. OBJECTIVE: To determine whether using extracorporeal carbon dioxide removal improves outcomes in patients with acute hypoxaemic respiratory failure and is cost-effective. DESIGN: A multicentre, randomised, allocation-concealed, open-label, pragmatic clinical trial. SETTING: Fifty-one intensive care units across the United Kingdom. PARTICIPANTS: Four hundred and twelve adult patients receiving mechanical ventilation for acute hypoxaemic respiratory failure, of a planned sample size of 1120. INTERVENTIONS: Lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal for at least 48 hours ( MAIN OUTCOME MEASURES: All-cause mortality 90 days. Secondary outcomes included ventilator-free days; adverse events; extracorporeal membrane oxygenation use; long-term mortality; health-related quality of life; health service costs; long-term respiratory morbidity. RESULTS: The trial was stopped early because of futility and feasibility. The 90-day mortality rate was 41.5% in the extracorporeal carbon dioxide removal group versus 39.5% in the standard care group (risk ratio 1.05, 95% confidence interval 0.83 to 1.33; difference 2.0%, 95% confidence interval - 7.6% to 11.5%;
2. First results from the international paediatric bronchiectasis registry (Child-BEAR-Net Registry) describing multicountry variations in childhood bronchiectasis and its management: a multicentre, cross-sectional study.
In 408 children across eight countries, post-infectious causes (31%) and immunodeficiencies (19%) predominated, with 38% having ≥3 exacerbations and 49% hospitalized in the prior year. There were striking regional differences in lower-airway bacteriology, treatments (eg, azithromycin, inhaled steroids), lung function, and radiographic severity, and only 47% saw a paediatric physiotherapist.
Impact: First international pediatric bronchiectasis registry quantifies global heterogeneity and care gaps, directly informing guideline implementation and quality improvement.
Clinical Implications: Standardize diagnostic panels, prioritize access to pediatric physiotherapy, and tailor antimicrobial/anti-inflammatory strategies to regional bacteriology and comorbid profiles.
Key Findings
- Across 408 children, 31% post-infectious and 19% immunodeficiency etiologies; 38% had ≥3 exacerbations and 49% were hospitalized in the prior year.
- Marked regional differences in airway pathogens (e.g., H. influenzae 70% in Australia vs 16% in Albania–Türkiye–Ukraine; P. aeruginosa 24% in South Africa).
- Care quality gaps: only 47% saw a pediatric physiotherapist; radiographic cystic bronchiectasis 45% in South Africa vs 2% in Australia.
Methodological Strengths
- Multicountry, multicentre registry with standardized data elements.
- Direct comparison across predefined geographic regions with key quality-of-care indicators.
Limitations
- Cross-sectional design limits causal inference; potential selection bias to tertiary centers.
- Incomplete lung function data in some regions; unmeasured confounders.
Future Directions: Prospective longitudinal follow-up to link care processes with outcomes; implement and evaluate physiotherapy access and macrolide stewardship interventions across regions.
BACKGROUND: Despite increasing recognition of bronchiectasis worldwide, there are no multicountry data characterising bronchiectasis in children. We aimed to describe clinical features, comparing inter-country and regional variations, and describe indices of overall quality-of-care standards assessed against international consensus statements for children and young people with bronchiectasis. METHODS: Child-BEAR-Net is an international collaborative paediatric bronchiectasis network across several continents. Using our International Paediatric Bronchiectasis Registry data from secondary and tertiary hospitals across eight countries, we conducted a multicentre, cross-sectional cohort study of all patients in the registry younger than 18 years diagnosed with bronchiectasis. Data were grouped into four geographical regions: Australia, South Africa, Greece-Italy-Spain, and Albania-Türkiye-Ukraine. Patients with cystic fibrosis or a history of heart or lung transplantation were excluded. We assessed baseline clinical characteristics, causes, treatments, and quality-of-care indicators, and compared findings across regions. Data were analysed using descriptive statistics and non-parametric tests for between-group comparisons. FINDINGS: Between June 1, 2020, and Feb 9, 2024, 408 patients were enrolled (median age at diagnosis 6·0 years [IQR 3·2-9·0]; 229 (56%) male and 179 (44%) female patients). The most common underlying causes were post-infection (127 [31%]), primary and secondary immunodeficiencies (79 [19%]), and known genetic disorders (55 [13%]). Common comorbidities included asthma (70 [17%]), otorhinolaryngeal disorders (58 [14%]), and congenital major airway malformation (51 [13%]). In the previous 12 months, 106 (38%) had at least three exacerbations and 89 (49%) required hospitalisation at least once. 107 (27%) of 400 reported daily sputum. Lung function was normal in 133 (59%) of 227 patients but with considerable between-group differences (median forced vital capacity Z score ranged from -0·12 [-0·95 to 0·65] in Australia to -1·54 [-3·39 to -0·04] in South Africa). We found marked inter-group differences in lower airway bacteria (Haemophilus influenzae in 56 [70%] of 80 patients in Australia to three [16%] of 19 in Albania-Türkiye-Ukraine; Pseudomonas aeruginosa in eight [24%] of 34 in South Africa to one [5%] in Albania-Türkiye-Ukraine), treatment (long-term azithromycin for 47 [50%] of 94 in Greece-Italy-Spain to 15 [19%] of 79 in Albania-Türkiye-Ukraine; and inhaled corticosteroids for 48 [61%] in Albania-Türkiye-Ukraine to 28 [22%] of 126 in Australia), and radiographic markers (cystic bronchiectasis in 49 [45%] of 109 in South Africa to three [2%] of 126 in Australia [p<0·0001]). In quality-of-care standard markers, the recommended panel of investigations was done in 66-95% of patients; only 78 (47%) of 167 saw a paediatric physiotherapist in the previous 12 months. INTERPRETATION: Our study presents the first internationally derived paediatric registry data highlighting geographical variations in cause, lung function, bacteriology, and treatment in children and young people with bronchiectasis, as well as the need to improve quality care. FUNDING: None.
3. Estimating the respiratory syncytial virus-associated hospitalisation burden in older adults in European countries: a systematic analysis.
Using a systematic review, surveillance, and modelling, adjusted RSV hospitalisation rates in ≥60-year-olds were 2.2–6.4× higher than unadjusted. Direct estimates ranged from 193/100,000 (Netherlands/Finland) to 414/100,000 (Denmark), with ensemble predictions of 223–317/100,000 across 23 more countries; in-hospital CFR ranged 6.7–10.1%.
Impact: Timely, policy-relevant burden estimates for older adults across Europe accounting for under-ascertainment, directly informing RSV vaccination and resource planning.
Clinical Implications: Health systems should anticipate substantial RSV admissions among older adults and consider vaccination strategies and surveillance improvements that correct under-ascertainment.
Key Findings
- Adjusted RSV hospitalisation rates in ≥60-year-olds were 2.2–6.4 times higher than unadjusted estimates.
- Country estimates: Netherlands/Finland ~193 per 100,000 person-years; Denmark 414 per 100,000; ensemble predictions 223–317 per 100,000 in 23 additional countries.
- Estimated in-hospital case fatality ratio ranged from 6.73% (Spain) to 10.14% (Switzerland).
Methodological Strengths
- Combines systematic review, surveillance, and ensemble modelling with explicit adjustment for under-ascertainment.
- Provides both direct and modelled country-level estimates with uncertainty intervals.
Limitations
- Sparse direct data in many countries; modelling assumptions may not capture all heterogeneity.
- hCFR available for limited settings; diagnostic practices vary over time and place.
Future Directions: Expand standardized RSV testing and surveillance in older adults and validate model predictions prospectively to refine vaccine impact assessments.
BACKGROUND: With respiratory syncytial virus vaccines recently approved for use among older adults, country-level respiratory syncytial virus (RSV) disease burden estimates are needed to inform local RSV immunisation strategy. We aimed to estimate country-level RSV hospitalisation burden in older adults in Europe. METHODS: We compiled data on RSV hospitalisation burden in adults aged ≥ 60 years in Europe from published studies (systematic review: PROSPERO CRD42024516945), surveillance data, and unpublished data from international collaborators. We adjusted for diagnostic testing, clinical specimens, and case definitions through statistical modelling techniques and generated country-level hospitalisation rate estimates; for countries with no available data, we developed an ensemble model to predict RSV hospitalisation rates. We also estimated RSV in-hospital case fatality ratio (hCFR) for countries with available data. RESULTS: We included 14 studies (3 unpublished studies). The adjusted RSV-associated hospitalisation rates were overall 2.2 to 6.4 times higher than unadjusted estimates. Among 5 countries with available data, adjusted annual RSV hospitalisation rates ranged from 193/100,000 person-years in the Netherlands (95% confidence interval [CI]: 125-304) and Finland (141-274) to 414/100,000 in Denmark (322-514). The RSV hospitalisation rates predicted by the ensemble model in 23 additional countries ranged from 223/100,000 to 317/100,000 person-years. RSV hCFR ranged from 6.73% (4.63-9.69) in Spain to 10.14% (4.91-19.79) in Switzerland. CONCLUSIONS: This study addresses knowledge gaps in RSV hospitalisation burden among older adults in Europe while highlighting the importance of adjusting for RSV case under-ascertainment. These findings might be relevant for country's considerations of RSV immunisation strategies for older adults.