Expert Review of Respiratory Medicine最新文献

Introduction: Interstitial lung disease (ILD) is the leading cause of mortality in idiopathic inflammatory myopathies or myositis. Clinical characteristics, including the course of ILD, rate of progression, radiological and pathohistological morphologies, extent and distribution of inflammation and fibrosis, responses to treatment, recurrence rate, and prognosis, are highly variable among myositis patients. A standard practice for ILD management in myositis patients has not yet been established.

Areas covered: Recent studies have demonstrated the stratification of patients with myositis-associated ILD into more homogeneous groups based on the disease behavior and myositis-specific autoantibody (MSA) profile, leading to better prognoses and prevention of the burden of organ damage. This review introduces a new paradigm in the management of myositis-associated ILD based on research findings from relevant literature selected by a search of PubMed as of January 2023, as well as expert opinions.

Expert opinion: Managing strategies for myositis-associated ILD are being established to stratify patients based on the severity of ILD and the prediction of prognosis based on the disease behavior and MSA profile. The development of a precision medicine treatment approach will provide benefits to all relevant communities.

Introduction: Persistent breathlessness (breathlessness persisting despite optimal treatment for the underlying condition and resulting in disability) is a prevalent syndrome associated with chronic and life-limiting conditions. Improving the clinical recognition and assessment of persistent breathlessness is essential to ensure people are provided with the best treatment for optimal symptom control.

Areas covered: This overview focuses on the impact of persistent breathlessness on patients, carers and the health system. It highlights the importance of identifying persistent breathlessness in clinical consultations, suggests steps to recognize this syndrome and discusses the evidence for non-pharmacological and pharmacological treatments in this context. Future research directions are also suggested.

Expert opinion: Persistent breathlessness is often invisible because 1) people may not engage with the health system and 2) both clinicians and patients are reluctant to discuss breathlessness in clinical consultations. Improving the recognition and assessment of this syndrome is critical to facilitate meaningful conversations between patients and clinicians and ensure patient-centered care. Non-pharmacological strategies are key to improving symptom management and health outcomes. Regular, low-dose, sustained-release morphine may help further reduce breathlessness in people who remain symptomatic despite disease-specific and non-pharmacological therapies.

Introduction: Several immunological alterations that occur during pulmonary diseases often mimic alterations observed in the aged lung. From the molecular perspective, pulmonary diseases and aging partake in familiar mechanisms associated with significant dysregulation of the immune systems. Here, we summarized the findings of how aging alters immunity to respiratory conditions to identify age-impacted pathways and mechanisms that contribute to the development of pulmonary diseases.

Areas covered: The current review examines the impact of age-related molecular alterations in the aged immune system during various lung diseases, such as COPD, IPF, Asthma, and alongside many others that could possibly improve on current therapeutic interventions. Moreover, our increased understanding of this phenomenon may play a primary role in shaping immunomodulatory strategies to boost outcomes in the elderly. Here, the authors present new insights into the context of lung-related diseases and describe the alterations in the functioning of immune cells during various pulmonary conditions altered with age.

Expert opinion: The expert opinion provided the concepts on how aging alters immunity during pulmonary conditions, and suggests the associated mechanisms during the development of lung diseases. As a result, it becomes important to comprehend the complex mechanism of aging in the immune lung system.

Introduction: Bronchiectasis is a very heterogeneous disease. This heterogeneity has several consequences: severity cannot be measured by a single variable, so multidimensional scores have been developed to capture it more broadly. Some groups of patients with similar clinical characteristics or prognoses (clinical phenotypes), and even similar inflammatory profiles (endotypes), have been identified, and these have been shown to require a more specific treatment.

Areas covered: We comment on this 'stratified' model of medicine as an intermediate step toward the application of the usual concepts on which precision medicine is based (such as cellular, molecular or genetic biomarkers, treatable traits and individual clinical fingerprinting), whereby each subject presents certain specific characteristics and receives individualized treatment.

Expert opinion: True precision or personalized medicine is based on concepts that have not yet been fully achieved in bronchiectasis, although some authors are already beginning to adapt them to this disease in terms of pulmonary and extrapulmonary etiologies, clinical fingerprinting (specific to each individual), cellular biomarkers such as neutrophils and eosinophils (in peripheral blood) and molecular biomarkers such as neutrophil elastase. In therapeutic terms, the future is promising, and some molecules with significant antibiotic and anti-inflammatory properties are being developed.

Introduction: The diagnosis of Idiopathic pulmonary fibrosis (IPF) requires the careful exclusion of secondary causes of interstitial lung disease (ILD), and the collaboration among different specialists is considered paramount to establish a diagnosis with high diagnostic confidence. The multidisciplinary discussion (MDD) has assumed an increasing importance over the years in the different phases of the IPF diagnostic work-up.

Areas covered: The role of MDD in the diagnosis and management of IPF will be described. Practical insights will be provided into how and when to perform MDD based on the available scientific evidence. Current limitations and future perspectives will be discussed.

Expert opinion: In the absence of high diagnostic confidence, agreement between different specialists during MDD is recognized as a surrogate indicator of diagnostic accuracy. Often, despite a lengthy evaluation, the diagnosis remains unclassifiable in a significant percentage of patients. MDD therefore appears to be pivotal in attaining an accurate diagnosis of ILDs. The discussion among different specialists can also include other specialists, such as rheumatologists and thoracic surgeons, in addition to the core group of pulmonologists, radiologists, and pathologists. Such discussions can allow greater diagnostic accuracy and have important effects on management, pharmacologic therapies, and prognosis.

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a real-time, minimally invasive procedure for sampling intrathoracic lymph nodes. Herein, we discuss EBUS-guided procedures, their benefits, and drawbacks in diagnosing sarcoidosis.

Areas covered: We first describe the utility of various endosonographic imaging techniques like B-mode, elastography, and doppler imaging. We then review the diagnostic yield and safety of EBUS-TBNA and compare it with the other available diagnostic modalities. Subsequently, we discuss the technical aspects of EBUS-TBNA influencing the diagnostic yield. Recent advances in EBUS-guided diagnostics like EBUS-guided intranodal forceps biopsy (EBUS-IFB) and EBUS-guided transbronchial mediastinal cryobiopsy (EBMC) are reviewed. Finally, we summarize the advantages and disadvantages associated with EBUS-TBNA in sarcoidosis and provide an expert opinion on the optimal use of this procedure in patients with suspected sarcoidosis.

Expert opinion: EBUS-TBNA is a minimally invasive, safe procedure with a good diagnostic yield, and should be the preferred diagnostic modality for sampling intrathoracic lymph nodes in patients with suspected sarcoidosis. For optimal diagnostic yield, EBUS-TBNA should be combined with endobronchial biopsy (EBB) and transbronchial lung biopsy (TBLB). Newer endosonographic techniques like EBUS-IFB and EBMC might obviate the need for EBB and TBLB due to their superior diagnostic yield.

Introduction: Pulmonary exacerbations are common events in children with cystic fibrosis (CF) and are usually treated with oral antibiotics on an outpatient basis. Even these mild clinical events are clinically meaningful and contribute to the progression of lung disease.

Areas covered: This review discusses the challenges in diagnosing pulmonary exacerbations in children in the absence of a standardized definition. It describes an approach to the management of these events and emphasizes knowledge gaps and areas of future research directions. Information to write this narrative review was collected from 1) a PubMed search [keywords: exacerbation, children, cystic fibrosis] that was not limited by date 2) a hand search of references of retrieved literature 3) personal expertise of the literature and the management of cystic fibrosis.

Expert opinion: Pulmonary exacerbations require prompt diagnosis and management to preserve lung function. More work is needed to understand the impact of CFTR modulators on the frequency and severity of these events and how they influence approaches to management. In a new era of CF care, there is a need to incorporate sensitive outcome measures into clinical care to inform treatment decisions and track treatment response.

Background: Central airway obstruction (CAO) are common abnormality that usually needing interventional bronchoscopy, and sometimes multiple rounds of treatment. However, there were few studies explore the safety of it.

Research design & methods: The records of patients who underwent interventional bronchoscopy because of CAO at Respiratory department between 1 January 2010, and 31 December 2020 were revised. The patients' clinical characteristics, information about bronchoscopy and incidence of complications were collected and analyzed.

Results: There were totally 1,482 bronchoscopy procedures conducted in the 733 CAO patients. And the incidence of major complications in the retreatment group was significantly lower than that in the first treatment group ((4.77% vs. 1.87%, χ² = 9.78, df = 1, p < 0.01), so did the incidence of severe bleeding (2.46% vs. 0.40%, χ² = 11.20, df = 1, p < 0.01). However, there was some variability between the two groups in age and anesthesia type. A short interval time, more treatment times, and general anesthesia were related to a lower incidence of hemorrhage. For patients who were previously bleeding, the incidence of hemorrhage was significantly higher than the incidence in the non-bleeding patients (42.93% vs. 16.33%, respectively; χ² = 57.54, df = 1, p < 0.01).

Conclusion: For the patients with CAO, repeated interventional bronchoscopy treatment was safe, and it should be treated with discretion when retreat the patients once bleeding during previous therapeutic bronchoscopy.