Current Opinion in Pulmonary Medicine最新文献

Purpose of review: Chronic obstructive pulmonary disease (COPD) is thought of as a disease caused by tobacco exposure, but numerous occupational exposures have been identified as risk factors for development of disease and exacerbations, although these remain underappreciated and underdiagnosed. We highlight evidence of occupational exposures and how they relate to COPD, while also looking at gaps in how the changing workplace might affect the occupational COPD landscape.

Recent findings: Historical exposures linked to COPD included inorganic dusts like coal and silica and organic dusts like cotton and wood. Other data associated agricultural exposures, cleaning agents, air pollution, and construction work with COPD. As the workplace has evolved to include more work from home and growing industries like ridesharing and delivery, items like radon and indoor and outdoor air quality must be factored into the equation as occupational exposures with the potential to cause COPD and increase its morbidity. Despite this, causal conclusions with many risk factors are challenging due to the complex interaction between patient susceptibilities and environmental factors, both occupation-related and nonoccupation related.

Summary: Additional studies are needed, not only to better evaluate occupational exposures and COPD pathogenesis, but also to look at more solution-oriented areas like precision medicine and interventions targeting a healthier workplace.

Purpose of review: Exertional dyspnea and exercise intolerance remain key patient-related outcomes in chronic obstructive pulmonary disease (COPD). Improvement in treatment strategies is pendant further understand of their underpinnings across the spectrum of disease severity.

Recent findings: Emerging literature has been reviewed based on a conceptual framework that relates ventilatory demand to capacity under the modulating influence of sub-cortical and cortical centers (symptom perception and affective interpretation). Evidence supporting these fundamental tenets is critically appraised, focusing on mechanistic and interventional studies that shed novel light on the sources of heightened and/or mechanically constrained ventilation. Mechanistic studies using proxies of the inspiratory neural drive (e.g., diaphragm electromyography) were particularly informative, as well as interventional trials aimed at decreasing afferent stimulation and/or symptom perception via pharmacological (e.g., low-dose opiates in selected patients, high flow oxygen, oral nitrate) and nonpharmacological (e.g., novel exercise training paradigms, inspiratory muscle training, breathing techniques) interventions.

Summary: Therapeutic and rehabilitative strategies to lessen dyspnea's devastating impact on quality of life should minimize demand in the setting of reduced capacity and increased sensation awareness in COPD. The most successful attempts so far have amalgamated pharmacological and nonpharmacological approaches tailored to the main underlying mechanisms on an individual basis.

Purpose of review: This review aims to highlight the importance of timely initiation of home noninvasive ventilation (homeNIV) for patients with chronic hypercapnic respiratory failure (CHRF) due to chronic obstructive pulmonary disease (COPD). As emerging evidence continues to show substantial benefits in reducing mortality and hospitalizations, it's crucial to identify which patients will benefit most and to provide clear guidance on implementing homeNIV effectively.

Recent findings: Recent research supports the use of high intensity homeNIV for CHRF secondary to COPD, showing marked reductions in hospitalizations and mortality. However, despite its proven benefits, homeNIV is underutilized, often due to significant barriers related to payor policies and gaps in knowledge by those most likely to be evaluating and managing patients with advanced COPD. The literature also reveals ongoing debate about the optimal timing and setting for starting homeNIV, whether in outpatient clinics or directly after hospital discharge.

Summary: The evidence suggests that homeNIV should be more widely used, with a focus on early initiation and careful titration to normalize PaCO 2 over time. By addressing the barriers to its broader use, we can improve outcomes for patients with CHRF due to COPD.

Purpose of review: Nutritional intake plays a major role in the management of lung health. This review provides the latest perspective on how dietary choices can modulate lung function in patients with chronic obstructive pulmonary disease (COPD) and asthma.

Recent findings: The pathophysiology of COPD and asthma is driven by oxidative stress and inflammation of the airways, which is exacerbated by modifiable risk factors such as cigarette smoking and diet. Various foods can influence patient symptoms; highly processed foods increase the production of reactive oxygen species that augment airway inflammation, whereas foods rich in antioxidants, fiber and protein combat oxidative stress and muscle wastage. Patients with COPD or asthma are at increased risk of developing metabolic comorbidities, including cachexia and obesity that complicate disease phenotypes, leading to greater symptom severity. While clinical findings suggest a role for antioxidant and macronutrient support of lung function, comprehensive translational and clinical studies are necessary to better understand the mechanisms underlying nutrient interaction and lung structure-function.

Summary: Understanding the nutritional requirements that protect lung health and support weight management in COPD and asthma is imperative to providing personalized dietary recommendations and reducing patient morbidity.

Purpose of review: The diagnosis of chronic obstructive pulmonary disease (COPD) encompasses heterogeneous pathophysiological mechanisms which can shape an individual patient's experience. This paper reviews available therapeutic options for the clinician intending to individualize care toward patient goals.

Recent findings: The contemporary targeted interventions for COPD include the novel phosphodiesterase inhibitor ensifentrine, the interleukin-4 receptor (IL4R alpha subunit) antibody dupilumab, augmentation therapy for alpha-1 antitrypsin deficiency. Other interventions promoting physical and mental well being include re-envisioned pulmonary rehabilitation, self-management, targeting of comorbidities such as sarcopenia, and virtual health coaching interventions to expand patient access. Opioids did not relieve dyspnea and did not change total step count.

Summary: Advances in precision therapy are complemented by the discovery of novel pathophysiology pathways and behavioral and rehabilitation interventions as a holistic view of COPD management emerges. The management of COPD continues to evolve with new tools including precision medicine and individualized care. Comorbidities remain important determinants of health, yet their prevalence and impact are underestimated.

Purpose of review: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are important events in the natural course of COPD, as they increase morbidity and mortality. Acute pulmonary embolism may mimic the symptoms of COPD exacerbations. However, the exact prevalence of pulmonary embolism in unexplained exacerbations of COPD is unclear based on the current data. This review provides a practical approach to patients with COPD complaining of worsening respiratory symptoms.

Recent findings: A randomized clinical trial has shown that a routine pulmonary embolism diagnostic work-up does not improve care of patients with acute exacerbations of COPD. However, review of the recent literature suggests that a nonnegligible proportion of otherwise unexplained exacerbations of COPD may be caused by pulmonary embolism. To date, nevertheless, there are limited studies developing and validating clinical models that might aid in the identification of patients requiring additional tests for the diagnosis of pulmonary embolism.

Summary: Until new evidence becomes available, we believe that a routine diagnostic strategy for pulmonary embolism is not appropriate for patients with acute exacerbations of COPD. Recommendations for routine pulmonary embolism diagnostic work-up necessitate further development of prognostic models and conduct of clinical trials that assess important health outcomes.

Purpose of review: To present an overview of the impact of climate change upon human respiratory health.

Recent findings: Climate change is directly impacting air quality. Particulate matter clearly increases mortality rates. Ozone, a longstanding suspect in climate-related injury, turns out not to have the major impact that had been projected at current levels of exposure. The key factors in global warming have been clearly identified, but while these factors collectively cause deleterious changes, a close look at the literature shows that it is unclear to what extent each factor individually is a driver of a specific process. This article summarizes some of those studies.

Summary: A better understanding of which components of climate change most impact human health is needed in order to re-define environmental standards. PM 2.5 needs to be broken down by chemical composition to study the differential impacts of different sources of PM 2.5 . The detection and study of climate-related changes in respiratory infectious diseases is in a state of relative infancy.

Purpose of review: Bronchodilator responsiveness (BDR) is often considered a key feature distinguishing asthma from chronic obstructive pulmonary disease (COPD). However, recent evidence suggests that BDR alone may not be a reliable discriminator between these conditions. There is still no consensus on BDR definitions and testing protocols. Additionally, it remains unclear whether BDR is linked to a specific COPD phenotype or influences treatment responses. Our review of recent literature attempts to clarify some of these issues.

Recent findings: A significant proportion of COPD patients demonstrate BDR, but the variability in testing procedures and definitions makes it challenging to draw any definite conclusion. There is no evident association between BDR and specific COPD characteristics. A few studies suggest that BDR may be associated with marginally better treatment response and disease outcomes in COPD. The impact of recent changes in BDR definitions on clinical practice remains to be fully understood.

Summary: There is still no clear, clinically relevant threshold to define BDR. BDR is an unreliable discriminator to differentiate asthma from COPD and is not consistently linked to any specific COPD phenotype, treatment response, or disease outcomes. Further research is needed to refine the definitions and implications of BDR in COPD.