Current Opinion in Pulmonary Medicine最新文献

Purpose of review: The application of mathematical algorithms for detecting lung abnormalities has been a challenge for decades. Occupational lung diseases, which often present as diffuse abnormalities, are primarily screened and diagnosed using chest radiographs and computed tomography (CT). This article reviews recent algorithmic advancements applied to these diagnostic tasks.

Recent findings: Significant progress has been made in artificial intelligence (AI) technologies, particularly with three-dimensional deep learning models based on convolutional neural networks (CNNs). For chest radiographs, promising approaches include the "eTóraxLaboral" platform for pneumoconiosis detection, CNNs enhanced with dark channel prior-inspired lesion area enhancement, and CNNs paired with CycleGAN. For CT imaging, transformer-based factorized encoders (TBFE), various CNN architectures (often combined with other techniques), and the recently developed Kolmogorov-Arnold Networks (KANs) for binary classification have shown strong performance. However, both chest radiograph and CT studies commonly rely on the International Labour Organization (ILO) International Classification of Radiographs of Pneumoconioses system (ILO/ICRP) for pneumoconiosis as a reference, which may limit AI development for CT in particular.

Summary: Recent advancements offer strong promise for computer-assisted diagnosis of pneumoconiosis using chest radiographs and CT scans. The standardization and integration of these technologies - especially with support from international organizations and collaborative studies - will be critical to achieving accurate, implementable screening tools for occupational lung disease.

Purpose of review: In this review, we discuss the under-recognition of harms associated with corticosteroid overuse in asthma and highlight the concept of corticosteroid stewardship as an approach to address these harms.

Recent findings: Adverse health effects of chronic systemic steroids to treat asthma are well known in the medical community. There is less familiarity with recent data showing similar harms from repeated short courses of systemic corticosteroids (SCS) to treat asthma flares and long-term use of high dose inhaled corticosteroids (ICS). In this review, we summarize recent advances in our knowledge of adverse effects of corticosteroid overuse in asthma, highlight recent calls for corticosteroids stewardship in asthma care, and describe effective systems-based strategies used to reduce corticosteroid overuse in asthma.

Summary: Those involved in primary care, acute care, and specialty care of asthma may use this review for an updated understanding of corticosteroid associated harms, and as a guide to both individual practitioner and health systems-based approaches to corticosteroid stewardship.

Purpose of review: Persistent inequities in lung transplant access arise from biologic constraints, geographic variation, and system-level practices that are not fully addressed by urgency-based allocation alone. The recent implementation of continuous distribution and the Composite Allocation Score (CAS) represent a major policy shift intended to improve fairness and transparency in lung allocation. This review examines whether early evidence supports these goals and identifies remaining challenges.

Recent findings: Early national and multicenter analyses demonstrate increased transplant rates and reduced waitlist mortality under CAS without compromise in short-term posttransplant survival. Continuous geographic scoring and biologic disadvantage adjustments appear to improve access for short-statured candidates, women, and some sensitized patients. However, disparities persist for blood group O recipients, highly sensitized candidates, and patients listed at centers with conservative acceptance practices. Increased travel distance and rising allocation out of sequence (AOOS) highlight emerging transparency and logistical concerns.

Summary: Continuous distribution represents a meaningful advance in equity and transparency in lung allocation, but allocation reform alone cannot eliminate disparities arising from biologic limitation, geographic variation, or center-level practices. Ongoing monitoring, policy refinement, and system-wide standardization are essential to ensure equitable and ethical use of donor lungs.

Purpose of review: The application of GLP-1 receptor agonists as metabolic modulators is one the most exciting and advancing areas in medicine today. Early studies suggest a positive signal in asthma care in both obese and nonobese patients highlighting their multimodal utility across multiple disease phenotypes.

Recent findings: Asthmatic patients living with obesity are more likely to experience poor disease control, higher exacerbation rates and poor response to conventional asthma therapies. While weight loss interventions have repeatedly shown benefits in these patients, recent studies demonstrate that modulating insulin resistance may lead to improvement of asthma control, independent of weight. Recent translational/mechanistic/observational studies and meta-analyses provide a basis for pursuing GLP1RAs as putative asthma add-on therapies. This represents a novel area of treatment at the overlap between the inflammatory and metabolic nexus, potentially leading to better outcomes in uncontrolled asthma.

Summary: GLP-1RAs are receiving attention as potentially exciting therapies for treatment of asthma patients with comorbid obesity and/or diabetes mellitus; however, the exact mechanisms underpinning their utility in these cohorts are poorly understood. Further randomised controlled and pragmatic trials are needed to define their potential benefits/harms, mechanisms of action and where GLP1RAs might fit into existing treatment pathways for uncontrolled asthma.

Purpose of review: We discuss opportunities to improve lung cancer screening (LCS) diagnostic efficiency, which necessitates simultaneous focus on both diagnosis of early-stage lung cancer and reduction of diagnostic errors during diagnostic evaluation.

Recent findings: Recent efforts have focused on three distinct targets for improving LCS diagnostic efficiency: Eligibility and uptake, Adherence to annual screening, and Diagnostic evaluation of concerning findings. There has been ongoing debate regarding who should be screened and how to consider lung cancer risk factors, even as LCS uptake remains suboptimal. LCS annual adherence has emerged as an important quality metric, as it is associated with increased early-stage lung cancer detection. Finally, optimization of the diagnostic pathway once concerning findings are identified via LCS is necessary to minimize exposing those without cancer to the harms of invasive diagnostic testing. Efforts to improve pulmonary nodule risk assessment, the nonmalignant resection rate, and lung cancer overdiagnosis will be crucial.

Summary: Improving LCS diagnostic efficiency requires a careful balance between prioritizing lung cancer sensitivity (i.e., ability to diagnose early-stage lung cancers) and avoiding both false negatives (i.e., failure to diagnose an early-stage lung cancer) and false positives (i.e., unnecessary performance of invasive testing for benign lesions).

Purpose of review: Achieving long-term survival after lung transplantation remains a major challenge. Outcome determinants have expanded beyond pathophysiology to include quality of life and patient-reported outcomes. This review summarizes key prognostic factors associated with outcomes and suggests integrated strategies to improve them.

Recent findings: The primary determinants of long-term survival are chronic lung allograft dysfunction (CLAD), infection, and malignancy. Various agents have been investigated for preventing and treating CLAD. Beyond these, managing comorbidities such as renal failure, metabolic disorders, and gastrointestinal dysfunction is crucial. Furthermore, patient-reported outcomes involving both physical and psychosocial aspects (e.g., frailty and sleep disturbance) have emerged as vital prognostic markers. To manage these multifaceted risks, real-time data pipelines (e.g., the Quality in Lung Transplant Initiative) and remote tools including home spirometry facilitate early detection of graft dysfunction. Multidisciplinary interventions, including rehabilitation, adherence support, and artificial intelligence-driven technologies, have shown promise in improving outcomes.

Summary: Improving long-term outcomes in lung transplantation requires a comprehensive approach that extends beyond traditional CLAD management. Structured, multicomponent programs integrating data-driven surveillance with multidisciplinary care provide a robust model for early detection and intervention for graft failure and comorbidities, ultimately prolonging survival and quality of life.

Purpose of review: Nonpharmacological strategies, including pulmonary rehabilitation (PR), are increasingly recognized as essential components of asthma management, particularly for individuals with persistent symptoms, poor asthma symptom control, or complex disease. This review summarize recent evidence on PR and related behavioural, lifestyle, and digital interventions, and explores emerging models to improve access and long-term effectiveness.

Recent findings: Current evidence demonstrate that PR improves asthma control, exercise capacity, quality of life, and several patient-reported outcomes across multiple asthma phenotypes. Benefits extend to those with obesity-associated asthma, elevated airway inflammation, and high psychosocial burden. Early data also suggest reductions in exacerbation frequency and steroid requirements. Nevertheless, PR remains markedly underutilized. Digital self-management interventions show promising, albeit inconsistent effects on asthma control, with adherence being a critical determinant of success. New models combining synchronous (real-time) supervision with modular digital components may address major access barriers and provide scalable support.

Summary: Although underutilized in routine care, PR and other structured nonpharmacological strategies offer clinically meaningful benefits for individuals with asthma. Flexible, digitally enabled delivery models aligned with disease complexity may help to expand reach, promote earlier intervention and support sustained behavioural change. Future work should prioritize phenotype-specific effectiveness, long-term outcomes and implementation frameworks.

Purpose of review: This review aggregates, analyzes, and summarizes the current understanding of the lung microbiome as it relates to pneumonia. We will review the composition and function of a healthy lung microbiome and conceptualize dysbiosis associated with pneumonia. Finally, we discuss how the lung microbiome impacts the diagnosis, prognostication and pathogenesis, and recovery from pneumonia.

Recent findings: The most tangible benefit of studying the lung microbiome has been the identification of pathogenic organisms in suspected pneumonia; however, as there is a growing body of evidence that suggest the lung microbiome is critical to pneumonia. Generally, detection of potential pathogens such as Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pneumoniae, and Escherichia coli can be found even when sampling the lung microbiome of healthy individuals, yet it is unclear what determines the transition from potential pathogens present as bystanders to pathogens driving the development of pneumonia. Analysis of the lung microbiome suggests that the loss of "oral commensals" (bacteria found in the oral microbiome) in the lower airways is associated with the development of pneumonia and may provide diagnostic and prognostic insights.

Summary: The lung microbiome is a rich and dynamic ecosystem comprised of numerous bacterial, fungal, and viral taxa that may contribute to pneumonia pathogenesis. There is increasing evidence that the lung microbiome may provide insight into factors that determine the pathogenicity of respiratory microbes and the susceptibility of individuals to those pathogens.

Purpose of review: To describe key studies on community-acquired pneumonia (CAP) published in the last 12-18 months including the new American Thoracic Society (ATS) Guideline update.

Recent findings: The new ATS guidelines have recommendations regarding imaging, interpretation of viral detection in the upper airways, duration of antibiotics and corticosteroid therapy. Since publication, there have been key studies in several areas, particularly with corticosteroids and macrolides for therapy as well as the usefulness of diagnostic tests.

Summary: The use of corticosteroids has become less clear with the findings of the REMAP-CAP study and are probably only indicated in a very small subset of patients. New pathogen diagnostic tools find new pathogens, but do not seem to improve patient outcomes. Patients should not be put at risk by withholding empiric antibiotic therapy in the setting of detection of a virus in upper airways samples.

Purpose of review: There is an undisputable knowledge-to-care implementation gap in chronic obstructive pulmonary disease (COPD) management. Integrated disease management (IDM), a multidisciplinary approach to prevent and manage chronic diseases, has been identified as one potential solution to address this gap. The purpose of this review is to examine the recent evidence base and discuss the nuances of IDM in COPD care.

Recent findings: IDM in COPD has been implemented in the real world setting in diverse geospatial contexts in the last 5 years. IDM teams are predominantly embedded in primary care clinics and consist of 2-8 multidisciplinary team members. Interventions delivered by IDM COPD teams have been highly variable, making it difficult to definitively conclude 'how many' and 'which intervention' or 'combination of interventions' is needed to achieve positive clinical outcomes. Health service utilization and patient symptom scores are the common outcomes examined, and IDM COPD teams invariably achieved positive outcomes.

Summary: IDM represents a promising approach to the gaps in COPD guideline implementation and may help reduce care fragmentation. IDM teams have been shown to improve clinical outcomes, and also improve patient and provider satisfaction. A strong implementation plan that is theoretically grounded and considers all relevant contextual factors is more likely to result in successful implementation of an effective IDM team.