Browsing by Author "Van Zyl-Smit, Richard"

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    A retrospective review of lung disease in adolescents living with human immunodeficiency syndrome
    (2025) Naicker, Janani; Van Zyl-Smit, Richard; Perumal, Rubeshan; Vanker, Aneesa
    Chronic lung disease (CLD) is common in adolescents living with Human Immunodeficiency Virus (ALHIV), many of whom have survived early childhood respiratory infections and immune dysregulation. Little is known about the characteristics of ALHIV with CLD. Understanding the characteristics of this population is key to guiding service design, informing preventative strategies, and identifying tailored therapeutic interventions for preserving lung function and optimizing respiratory health. Methods: We retrospectively reviewed the clinical records of a historical cohort of adolescents aged 12 years to 20 years, diagnosed with vertically transmitted HIV and presenting with chronic lung disease to the Adolescent Respiratory Clinic of Groote Schuur Hospital between 1 January 2015, and 1 January 2023. Demographic data, details on HIV diagnosis, treatment history, lung function data, radiological data, clinical history and examination data, and microbiological data were analysed. Results: Seventeen patient records were reviewed. The median age at first visit was 16.9 years (interquartile range (IQR)15.2 to 18.7), and 58.9% (10/17) were female. The median age at HIV diagnosis was 1.1 years (IQR 1- 2), with a median duration of ART treatment of 13.2 years (IQR,8.6- 15.6), reflecting early HIV diagnosis and treatment initiation. The median CD4 nadir was 243 cells/mm3 (IQR 140- 516) and 16/17 patients had more than two prior episodes of pulmonary tuberculosis (PTB). Growth stunting was a common feature with a median BMI 17.7 kg/m2 (IQR 16.4- 19.8) and 16 /17 participants plotting below the 50th population centile of height-for-age. Radiological evidence of bilateral lung disease with bronchiectasis and cavitation was ubiquitous. Haemophilus influenzae was isolated in 12/17 (70.6%) patients and Methicillin-resistant staphylococcus aureus (MRSA) in 2/17 (11.7%) patients). The median FVC as a percentage of predicted values was 51.7% (IQR, 41.1- 60.8) and the median pre- bronchodilator FEV1/FVC ratio was 65%, (IQR of 57.8 to 74.3). indicating mixed spirometric defects. There was no significant bronchodilator response in any of the participants. Conclusion: Among ALHIV with CLD, there was a high prevalence of both airway and parenchymal lung disease, as well as severe growth impairment. Prior PTB was a common respiratory insult, despite early ART initiation. More needs to be done to prevent PTB, reduce the burden of recurrent respiratory infections, and to preserve long-term respiratory health in this vulnerable population. What the study adds: This study characterised a cohort of adolescents living with HIV and chronic lung disease in South Africa. Prior tuberculosis was common, and extensive bilateral structural lung abnormalities were universal. A significant proportion of the cohort exhibited severe growth impairment. Taken together, this study identifies ALHIV and CLD as a population with a high burden of respiratory deficits. Evidence-based secondary prevention and therapeutic strategies are needed to ensure the long-term preservation of lung function in these individuals.
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    Difficulties and challenges in implementing screening for lung cancer in high-risk group patients in the respiratory clinic at Groote Schuur Hospital
    (2025) Emhemed, Mohamed; Van Zyl-Smit, Richard
    Introduction: Lung cancer is the leading cause of cancer related deaths in South Africa. The high prevalence of cigarette smoking in our population continues to contribute to the high burden of lung cancer. Screening high risk groups with annual low dose computed tomography (LDCT) has demonstrated the potential benefit of being able to identify individuals with early-stage disease and offer potential curative therapy from this deadly disease. Objective: To determine the barriers and challenges of implementing lung cancer screening in a group of high-risk patients with underling Chronic Obstructive Pulmonary Disease (COPD). Methods: We retrospectively analysed patient records of COPD patients attending the respiratory clinic at Groote Schuur Hospital, Cape Town in the year 2022. Eligibility for lung cancer screening included formal diagnosis of COPD, age 55-74 years, at least 30 pack year history of smoking or stopped smoking within the past 15 years, no history of lung cancer, good general health, fitness for surgery and patients' willingness to undergo further invasive investigations and treatment. Fitness for surgery was objectively determined by a modified Medical Research Council (mMRC) score less than 3 and FEV1 greater than one litre. Results: 116 patients with COPD were screened for eligibility for lung cancer screening. The mean (SD) age was 62.84(10.4) years and 56.1% were male. 44 (37.9%) patients were current smokers, 68 (58.6) were ex-smokers and 4 (3.5%) never smoked. Hypertension (46.6%) was the most common medical comorbidity, followed by previous tuberculosis (19.0%) and diabetes (7.8%). 16 (13.8%) patients were potentially eligible for lung cancer screening. 47 patients had a FEV1 < 1L, 54 participants had a mMRC of 3 and above and 38 patients were excluded because of age. Conclusion: Common clinical factors which made patients ineligible for lung cancer screening in our study are age and poor surgical candidates based on mMRC class and low FEV1. Tertiary service severe/multimorbid COPD clinics provide few patients for lung cancer screening, community-based service may provide a better yield of patients for active lung cancer screening.
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    Early sequelae of post COVID-19 lung disease in patients who were mechanically ventilated for severe COVID-19 pneumonia
    (2023) Singh, Nevadna; Van Zyl-Smit, Richard
    Introduction: COVID-19 resulted in an unprecedented worldwide spike in hospital and ICU admissions; predominantly for adult respiratory distress syndrome (ARDS). Survival rates for patients requiring mechanical ventilation in Cape Town during the waves driven by the ancestral strain and beta variant were approximately 30% during the first 3 waves of the pandemic. However, post-ICU admission sequelae and recovery trajectory in sub-Saharan Africa remain unknown. Methods: We systematically evaluated a cohort of COVID-19 ICU survivors at three months following hospital discharge. A retrospective single-centre study enrolled all COVID-19 pneumonia patients who were admitted to ICU for mechanical ventilation and followed up at the post-COVID-19 Lung Disease Clinic between 1 July 2020 and 30 December 2021. Results: A total of 26 patients were evaluated at 3 months after discharge from hospital following mechanical ventilation: 53% were male and 81% had at least one co-morbidity. Diabetes and hypertension were present in 42% and 54% of patients respectively. Persistent dyspnoea (89%) and fatigue (54%) were the most common post-COVID-19 symptoms. Median FEV1 and FVC were 73% (IQR 65-83) and 71% (IQR 61-77) of predicted values respectively, whilst median DLCO was 59% (IQR 41- 70) of predicted values. Abnormalities were confirmed in all patients (24/26) who underwent high resolution computer tomography (HRCT) of the chest, with ground glass opacities (46%) and interstitial thickening (58%) being most common. No significant risk factors for post-COVID-19 impairment were identified. Conclusion: At 3 months after hospitalization, patients who received mechanical ventilation for COVID-19 pneumonia frequently reported ongoing symptoms. Lung function was moderately impaired with a disproportionate reduction in DLCO, and radiographic abnormalities were common. Long term follow up is required to determine the natural history post severe-COVID-19 lung disease.
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    Outcomes of patients with COVID-19 Acute Respiratory Distress Syndrome requiring Invasive Mechanical Ventilation admitted to an Intensive Care Unit in South Africa
    (2022) Arnold-Day, Christel; Piercy, Jenna; Van Zyl-Smit, Richard
    Background Up to 30% of patients with COVID-19 pneumonia may require ICU admission or mechanical ventilation [Guan et al., 2020; Huang et al., 2020]. Data from low- and middle-income countries for COVID-19 ARDS are limited. Groote Schuur Hospital in Cape Town, South Africa expanded its ICU service to support patients with COVID-19 ARDS requiring invasive mechanical ventilation (IMV). We report on patients' characteristics and outcomes from two pandemic waves. Methods All patients with COVID-19 ARDS admitted to the ICU for IMV were included in this prospective cohort study. Data were collected from 5th April 2020 to 5th April 2021. Ethical approval was granted (HREC: 362/2020), consent was waived for deceased patients and deferred for survivors. Results Over the 12-month study period 461 patients were admitted to the designated COVID-19 ICU. Of these, 380 patients met study criteria and 377 had confirmed hospital discharge outcomes. The median age of patients was 51 years (range 17-71), 50.5% were female and the median BMI was 32kg/m2 (IQR 28-38). The median P/F ratio was 97 (IQR 71.5-127.5) after IMV was initiated. Comorbidities included diabetes (47.6%), hypertension (46.3%) and HIV infection (10%). Of the patients admitted, 30.8% survived to hospital discharge with a median ICU length of stay of 19.5 days (IQR 9- 36). Predictors of mortality after adjusting for confounders were: male (OR:1.79), increasing age (OR:1.04) and SOFA score (OR:1.29). Conclusion In a resource limited environment, escalation of ICU IMV support achieved a 30.8% hospital survival in patients with COVID-19 ARDS. The ability to predict survival remains difficult given this complex disease.
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    Pulmonary rehabilitation in Africa (community-driven citizen science approach): (a focus on COPD in low-resourced communities in South Africa)
    (2025) Isiagi, Moses; Van Zyl-Smit, Richard; Okop, Kufre Joseph
    Chronic Obstructive Pulmonary Disease (COPD) represents a significant global health challenge, particularly in low-and middle-income countries (LMICs), especially in Africa. Pulmonary rehabilitation (PR) is a well-established intervention to address COPD in High income countries (HICs) and has been incorporated into the healthcare systems in many settings. However, its implementation and population-level delivery in Africa are almost non-existent. This dissertation explored COPD management and PR services in low-resourced African settings, specifically focusing on a disadvantaged peri-urban community in South Africa. The study utilized a 3-pronged approach which we believe holds significant potential to investigate and perhaps, address these challenges. The purpose of this study was to examine the current state of PR services in low-resourced settings in LMICs, evaluate healthcare providers' clinical awareness and support in Africa, and explore COPD risk perceptions and prevention preference in the study setting. In addition, the study utilizes the findings and lessons learnt to support the development of community-driven PR implementation strategies in the disadvantaged African setting using a participatory approach. Methods: The methodology encompassed three distinct components: First, a systematic review was conducted to gain understanding and map the landscape of home-based and community-based PR programmes in low-resourced African settings registered with PROSPERO (CRD42023480324). Second, a cross-sectional virtual electronic survey was administered between January and March 2020, targeting African clinicians with Pan-African Thoracic Society and South African Thoracic Society networks. Finally, a participatory community-based Citizen science project was implemented in the Klipfontein health district, incorporating focus group discussions, Citizen science interviews, and advocacy workshops. Results: The study revealed a significant gap in research regarding PR programmes in African settings, with no published studies comparing home-based and community-based PR delivery models in the region. The closest relevant research was a Brazilian protocol for home-based cardiac rehabilitation. However, the survey of healthcare professionals from 23 countries demonstrated awareness and recognition of PR as an effective intervention for COPD. Despite significant implementation challenges, over 85% of the surveyed healthcare professionals expressed confidence in PR programmes' ability to improve symptoms and reduce patient exacerbation. Insights from Citizen science indicate limited community awareness of COPD, often confused with general respiratory conditions like asthma. Discussions and EpiCollect findings show that while communities recognize risk factors such as smoking and environmental exposure, there is a pressing need for targeted education about COPD before effectively implementing PR interventions. Furthermore, participants in the study were willing to participate in a community-driven PR intervention and listed important strategies that would make this intervention accessible, acceptable, and sustainable. Conclusion: This study presents a novel approach to COPD risk perception and PR implementation in resource-limited settings. The need for pulmonary rehabilitation is well documented and understood at a scientific and specialist pulmonologist level. Local logistics, training, funding, and staffing challenges hindered the implementation. Community-based "out-of-hospital" PR programmes are well-described in high-income countries. However, they are almost non- existent in low-income settings. At the patient level, the lack of awareness of the diagnosis, understanding and access to treatment may inadvertently be the most important factor limiting the access of patients with COPD to an effective PR intervention. While traditional 'medical science' methods have been instrumental in increasing access to PR in low-income settings, the potential of a more Citizen science approach with engagement at the community level with healthcare staff, patients, and community members is promising. This approach may facilitate the development and implementation of a better multilayered and acceptable programme to those who need it most (the vulnerable population in disadvantaged communities in Africa), offering hope for the future of COPD management in Africa.
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    The characteristics of intersitial lung disease patients attending Groote Schuur Hospital Respiratory clinic
    (2023) Soin, Gurveen; Van Zyl-Smit, Richard
    Rationale: Interstitial lung diseases (ILDs) encompass a myriad of clinical conditions posing diagnostic challenges in low-income settings. The incidence of Idiopathic pulmonary fibrosis (IPF) is unknown on the African continent. Groote Schuur Hospital (GSH) provides a tertiary referral and follow-up service for patients with suspected ILDs. We set out to determine the burden of IPF and progressive pulmonary fibrosis (PPF) in an African setting. Methods: All patients attending the GSH respiratory clinic with known or suspected ILD were identified over six months. Demographics, spirometry, high-resolution CT findings, histology, and final diagnosis and treatments were captured. IPF incidence was estimated using published population and medical insurance numbers, hospital referral area/pattern, and new IPF diagnoses over a full year period. The presence of PPF was determined by worsening clinical features and lung function in accordance with ATS/ERS guidelines. Results: A total of 103 patients (28 new and 75 follow-ups) were seen over six months. The follow-up patients were predominantly female (81%), diagnosed with systemic sarcoidosis (57%) & connective tissue disease-ILD (CT-ILD) 26%. Hypersensitivity pneumonitis accounted for 5% of follow-up patients, and only 2 IPF patients were in follow-up. CTD-ILD was the most common diagnosis in new patients: 43% and 29% had sarcoidosis. Five new patients were diagnosed with IPF during the 6-month study review and a total of 11 over 1 year. 31% of the CTD-ILD patients had systemic sclerosis SSC; 70% diffuse, and 30% limited. A further 25% had rheumatoid arthritis, and 13% had SLE. Six patients were confirmed to have hypersensitivity pneumonia. Thirteen patients met the criteria for PPF, and a further five patients had rates of decline over four months that, if projected to 12 months, would fulfil the PPF criteria. All 18 patients had an FVC decline of >100mls: mean(range) rate of decline 9.2% (5–22%). Conclusions: Specialised resources and diagnostic modalities to identify and manage ILD patients are required in low resourced settings. The burden of IPF is low but requires confirmation and is likely an underestimate. The potential need for anti-fibrotic treatment is impacted upon by the definition of FVC decline over 12 months.
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    The Effect of initiating corticosteroids on lung function and symptoms in patients with active pulmonary sarcoidosis
    (2025) Eknewir, Salaheddin; Van Zyl-Smit, Richard
    Background: Pulmonary sarcoidosis can lead to significant morbidity and mortality, and the use of corticosteroids is a common treatment strategy1,2. The expected response to corticosteroids with respect to lung function is highly variable and not studied in an African cohort. The primary objective of our study was to investigate the impact of corticosteroids on lung function in patients with active pulmonary sarcoidosis. Methods: We conducted a retrospective cohort study including all patients with active pulmonary sarcoidosis initiated on systemic corticosteroids documented in the Groote Schuur Hospital respiratory clinic registry. Patients with histologically proven pulmonary sarcoidosis in whom prednisone therapy was initiated were identified retrospectively from the Groote Schuur Hospital respiratory clinic registry. Data extracted from medical records included patient demographics and clinical characteristics, corticosteroid dosage, duration and recorded side effects, chest imaging, and pulmonary function testing across one year following steroid initiation. We analyzed the effect of prednisone on FVC and DLCO trajectory and reported the serial changes at 3 monthly intervals. Data is presented as mean (± SD) unless otherwise specified. Results: The study group comprised 42 patients, 30 females (71%) and 12 males (29%), with a mean age of 41.6 ± 9.8 years. The majority of patients (78.5%) were non-smokers. More than two-thirds of patients (69%) were diagnosed with Scadding II sarcoidosis. Routine lung function monitoring at 3 months showed a significant improvement in FVC with steroid therapy from 70.8(26.2) % to 77.5(25.5) % (mean change 6.3(11.3) %, p<0.001). Although not statistically significant, the FVC continued to improve numerically between month 3 (77.5%) and month 6, 79.0(23.5%). DLCO improved from 57.6(24.9) % at baseline to 61.0(33.0) % at 3 months to 68.9(28.1) % at 6 months (p<0.001) Weight changed over time with a mean (SD) increase of 8.3(7.0)kg at 9 months. Conclusions: Among patients with acute pulmonary sarcoidosis requiring immunosuppression therapy, prednisone improved FVC and DLCO, with most of the FVC effect occurring within 3 months after initiation. DLCO continued to improve to 6 months Weight gain positively correlated with cumulative prednisone dose over 9 months.
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    The relationship between clinical trial participation and inhaler technique errors in asthma and COPD patients
    (2020) Perumal, Rubeshan; Van Zyl-Smit, Richard
    Background Incorrect inhaler use is associated with poorer health outcomes, reduced quality of life, and higher healthcare utilisation in patients with asthma and COPD. Method We performed an observational study of pressurized metered-dose inhaler technique in patients with asthma or COPD. Patients were assessed using a six-point inhaler checklist to identify common critical inhaler technique errors. An inadequate inhaler technique was defined as the presence of one or more critical errors. A multivariate logistic regression model was used to determine the odds of an inadequate inhaler technique. Results During the 14-month study period, 357 patients were enrolled. At least one critical error was executed by 66.7% of participants, and 24.9% made four or more critical errors. The most common errors were: failure to exhale completely prior to pMDI activation and inhalation (49.6%), failure to perform a slow, deep inhalation following device activation (48.7%), and failure to perform a breathhold at the end of inspiration (47.3%). The risk of a critical error was higher in COPD patients (aOR 2.25, 95%CI 1.13 – 4.47). Prior training reduced error risk specifically when trained by a doctor (aOR 0.08, 95% CI 0.1 – 0.57) or a pharmacist (aOR 0.02, 95% CI 0.01 – 0.26) compared to those with no training. Previous clinical trial participation significantly reduced error risk and rate:< 3 trials (aOR 0.35, 95% CI 0.19 – 0.66) and ≥3 trials (aOR 0.17, 95% CI 0.07 – 0.42). The rate of critical errors was not significantly associated with age, sex, or prior pMDI experience. Conclusion This study found a high rate of critical inhaler technique errors in a mixed population of asthma and COPD patients; however, prior training and in particular, multiple previous clinical trial participation significantly reduced the risk of errors.