Current Opinion in Pulmonary Medicine最新文献

Purpose of review: Management of pleural infection remains heterogeneous worldwide. This review highlights current controversies in therapeutic strategies for pleural infection, focusing particularly on recent studies and their implications.

Recent findings: The introduction of intrapleural therapy combining alteplase [a tissue plasminogen activator (tPA)] and deoxyribonuclease (DNase) has revolutionized treatment practices, though the optimal delivery and dosing regimen is an area of active investigation. Variations to simplify administration protocols and/or to lower the required drug doses have been published. Most were exploratory studies, but the variations showed maintained therapeutic efficacy.Whether intrapleural alteplase/DNase or video-assisted thoracoscopic surgery (VATS) is superior is a topic of debate. Retrospective comparative analyses between the two revealed no clear benefits on all-cause mortality from either approach. Pilot randomized trials have been published and further full-scale, head-to-head trials are underway.

Summary: Effective management of pleural infection involves adequate pleural drainage and appropriate antibiotic use. This review outlines the current evidence (and its limitations) and highlights knowledge gaps in optimizing the therapeutic strategies.

Purpose of review: A resurgence of pneumococcal pneumonia has been observed after a marked reduction in the early COVID-19 pandemic. Penicillin-nonsusceptible Streptococcus pneumoniae is regarded as a WHO priority pathogen.

Recent findings: Overall antibiotic resistance rates in S. pneumoniae have increased due to increase in antibiotic consumption and changes in serotype distribution, partly driven by the rollout of pneumococcal vaccination. Isolates from pneumococcal pneumonia have higher resistance rates than those from invasive pneumococcal disease. New antibiotics have been approved for treatment of community-acquired pneumonia, and are active against multidrug-resistant S. pneumoniae . Pneumococcal vaccines in both children and adults are effective in reducing the burden of pneumococcal pneumonia in adults, though some circulating vaccine and nonvaccine serotypes are driving antibiotic resistance.

Summary: Continual surveillance of serotype and resistance patterns of S. pneumoniae causing pneumonia in adult populations is important after the introduction of new pneumococcal vaccines. Novel pneumococcal vaccine platforms are needed to overcome the threats of serotype replacement and antibiotic resistance.

Purpose of review: To describe the associations between asthma and relevant comorbidities, and appraise the latest evidence on the management strategies of asthmatics with comorbid conditions.

Recent findings: Conditions such as allergic rhinitis, chronic rhinosinusitis with and without nasal polyps, gastroesophageal reflux disease, obesity, chronic obstructive pulmonary disease, bronchiectasis, anxiety and depression have been linked to worse outcomes in asthma. Recognition and treatment of these conditions is important in asthma, particularly in those with uncontrolled or severe asthma. Biologics for asthma have been effective in those with chronic rhinosinusitis with nasal polyps and chronic obstructive pulmonary disease (COPD), with emerging evidence in bronchiectasis. Weight loss programs with diet and exercise improve asthma control. Anxiety and depression are often unrecognized in patients with asthma.

Summary: Comorbid conditions have been recognized as important factors in the diagnosis and treatment of asthma, particularly in patients who have severe disease and remain uncontrolled. Comorbidities in asthma are correlated with poor quality of life and asthma control, increased healthcare utilization and their treatment is associated with improved outcomes.

Purpose of review: Asthma is a common global respiratory disease characterized by airway inflammation. It is a heterogenous group of disorders with overlapping biological mechanisms. This review will discuss the current state of the use of biomarkers in asthma with an eye to the future. The identification of biomarkers has advanced our understanding of inflammatory pathways in asthma and aided in development of targeted therapies. However, even with similar inflammatory biomarkers, not all patients respond uniformly. Thus, further research into novel biomarkers in asthma is needed.

Recent findings: Recent literature highlights several key themes in biomarker research for asthma. Biomarkers can be derived from various sources, including sputum, blood, urine, and exhaled breath. Historically, studies have focused on eosinophilic inflammation, yet total blood eosinophil counts do not capture asthma pathology and treatment responses. Recent investigations explore eosinophil activity as well as eosinophil subpopulations based on surface protein expressions. Mast cell involvement, their mediators, and club cell secretory protein are further being examined across different asthma molecular phenotypes.

Summary: The complexity of inflammatory pathways in asthma, influenced by various factors, underscores the inadequacy of relying on a single biomarker at one time point. Continued research is essential to identify appropriate biomarkers.

Purpose of review: Mucosal-associated invariant T-cells (MAIT) have been associated with lung cancer and pulmonary infections. The treatment of patients with cancer or infections includes host-directed therapies (HDTs). MAIT play a role in shaping the 'milieu interne' in cancer and infections and this review addresses the biology of MAIT in pulmonary pathophysiology.

Recent findings: MAIT represent an attractive target for therapy in pulmonary malignancies and infections. T-cells are often difficult to exploit therapeutically due to the diversity of both T-cell receptor (TCR) repertoire and its ligandome. MAIT-cells are restricted by the major histocompatibility complex class I-related gene protein (MR1) that presents nondefined tumor-associated targets, bacterial products, vitamin and drug derivates. Due to their plasticity in gene expression, MAIT are able to conversely switch from IFN-γ to IL-17 production. Both cytokines play a key role in protective immune responses in infections and malignancies. MAIT-derived production of interleukin (IL)-17/TGF-β shapes the tumor micro-environment (TME), including tissue re-modelling leading to pulmonary fibrosis and recruitment of neutrophils. MAIT contribute to the gut-lung axis associated with clinical improved responses of patients with cancer to checkpoint inhibition therapy. MAIT are at the crossroad of HDTs targeting malignant and infected cells. Clinical presentations of overt inflammation, protective immune responses and tissue re-modeling are reviewed along the balance between Th1, Th2, Th9, and Th17 responses associated with immune-suppression or protective immune responses in infections.

Summary: MAIT shape the TME in pulmonary malignancies and infections. Drugs targeting the TME and HDTs affect MAIT that can be explored to achieve improved clinical results while curbing overt tissue-damaging immune responses.

Purpose of review: We highlight the evolving understanding of the burden of respiratory syncytial virus (RSV) in older adults and recent data on the three new vaccines.

Recent findings: As well as a greater recognition of the amount of RSV infection in adults, and especially over 60 years of age, there has been a significant amount of study detailing the postacute burden including excess cardiovascular disease and loss of physical and cognitive functioning. Three new RSV vaccines now have published data for two seasons, and while direct comparison is not possible due to differences in the timing, methodology and populations studies, all show good efficacy with no serious side effects of concern.

Summary: RSV causes a substantial amount of morbidity and mortality in older adults with both acute and longer term impacts. With effective vaccines now available clinicians should be advocating with their patients to prevent RSV infection.

Purpose of review: Significant progress has been made in our understanding of the acute and chronic clinical and radiological manifestations of coronavirus-19 (COVID-19). This article provides an updated review on pulmonary COVID-19, while highlighting the key imaging features that can identify and distinguish acute COVID-19 pneumonia and its chronic sequelae from other diseases.

Recent findings: Acute COVID-19 pneumonia typically presents with manifestations of organizing pneumonia on computed tomography (CT). In cases of severe disease, patients clinically progress to acute respiratory distress syndrome, which manifests as diffuse alveolar damage on CT. The most common chronic imaging finding is ground-glass opacities, which commonly resolves, as well as subpleural bands and reticulation. Pulmonary fibrosis is an overall rare complication of COVID-19, with characteristic features, including architectural distortion, and traction bronchiectasis.

Summary: Chest CT can be a helpful adjunct tool in both diagnosing and managing acute COVID-19 pneumonia and its chronic sequelae. It can identify high-risk cases and guide decision-making, particularly in cases of severe or complicated disease. Follow-up imaging can detect persistent lung abnormalities associated with long COVID and guide appropriate management.

Purpose of review: Biologics have proven safe and effective for severe asthma. Their introduction has offered hope for patients and prescribers with a growing list of novel medications and indications. While 'step-up' indications for biologic initiation are well described in guidelines, 'step-down' strategy remains poorly understood and thus guidance is limited. In this opinion article we aim to focus on recent practice changing evidence for stepping-down severe asthma management, tools for the assessment of biologic efficacy, propose a framework for the step-down of biologic and nonbiologic therapies and suggest topics of interest for future research.

Recent findings: Clinical tools have been developed to aid in assessing biologic response. Some patients experience marked improvement and may enter a period of clinical remission or even complete remission. Following positive response, add-on therapy may safely be approached for taper or withdrawal.

Summary: There is limited consensus but growing evidence for stepping-down therapies in patients who achieve clinical response and/or remission after biologic initiation. Further structured guidance would benefit clinicians who face clinical uncertainty when deciding to step-down therapy in patients with well controlled asthma.

Purpose of review: This review provides a comprehensive overview of the non-T asthma phenotypes. Asthma is an umbrella term that defines a complex group of heterogenous airway disorders, which are broadly categorized into predominantly T2 or non-T2 phenotypes depending on the presence and levels of airway and systemic biomarkers associated with a T2 inflammatory response. Individuals with predominant T2 asthma have greater numbers of peripheral blood eosinophils, exhaled nitric oxide and IgE. These patients have more atopy and earlier onset asthma. In contrast, the absence or low levels of these biomarkers define non-T2 asthma. This is a heterogenous group with a later onset of asthma that is also more commonly associated with obesity and with females.

Recent findings: This article summarizes new information regarding the plasticity that exists between T2 and non-T2 mechanisms, including their role in exacerbation-prone and nonexacerbating asthma, and many of the risk factors associated with the non-T2 phenotype, such as viral infections, ambient air pollution exposure, smoking, genetic and metabolic factors. It also provides new information on the immunological and metabolic mechanisms associated with non-T2 asthma. We also discuss how to manage this asthma phenotype and how treatment responses differ for these patients.

Summary: Non-T2 asthma defines a heterogenous group of asthma phenotypes. However, acknowledging that the absence of T2 biomarkers is influenced by several factors is important and can longitudinally change in relation to exacerbations, particularly in children.