Respiration最新文献

Background: The TNM staging system is the cornerstone of lung cancer classification, providing a framework for prognosis and treatment planning in a universal nomenclature. The 9th edition of the TNM classification, released by the International Association for the Study of Lung Cancer (IASLC) and went into effect in January 2025, introduces refinements to lymph node (N) staging. Lymph node staging is performed minimally invasively using bronchoscopy with endobronchial ultrasound (EBUS). This article explores the latest updates on lymph node staging by EBUS and their implications for lung cancer management from the perspective of bronchoscopy.

Summary: The 9th edition of the TNM classification includes the subdivision of N2 lymph nodes into N2a single-station and N2b multiple-station involvement, but not the subdivision of N1 lymph nodes. This has implications not only for treatment but also for the number of lymph nodes sampled by EBUS. As there is no strict hierarchy of N2 lymph nodes, this poses challenges to the order in which N2 lymph nodes should be sampled. The development of a new thin EBUS device will enable sampling of peripheral N1 lymph nodes. This could influence future TNM classifications, given that there are pathological but not clinical differences in survival between purely peripheral and hilar N1 involvement.

Key messages: With respect to occult lymph node disease, EBUS remains fundamental in staging lung cancer. New technical developments will also enable sampling of peripheral N1 lymph nodes.

Introduction: Osteoprotegerin (OPG), a decoy receptor for receptor activator of NF-κB ligand (RANKL), serves as a biomarker for liver fibrosis severity. Our recent findings show OPG production in fibrotic lung tissue, though its specific cellular source and role in pulmonary fibrosis are unknown. We hypothesized that OPG is produced by fibroblasts and serves as a marker for pulmonary fibrosis progression.

Methods: We examined OPG expression in human and mouse control and fibrotic lung tissue and used primary human lung fibroblasts and murine precision-cut lung slices to study OPG production. Serum from idiopathic pulmonary fibrosis (IPF) patients and controls was analyzed to investigate correlations between OPG levels and disease status, as measured by lung function.

Results: OPG-protein levels were significantly higher in murine and human fibrotic lung tissue compared to control. OPG-protein levels in fibrotic mouse lung tissue correlated positively with collagen deposition. OPG-mRNA and protein production increased in mouse lung slices upon TGFβ stimulation. Isolated lung fibroblasts from IPF patients produced more OPG-protein than controls. Serum OPG levels in IPF patients negatively correlated with diffusing capacity to carbon monoxide. Serum OPG levels above 1,243 pg/mL were linked to disease progression in IPF patients.

Conclusion: OPG is produced by fibroblasts in lung tissue, associates with fibrosis, and may be a potential prognostic biomarker for IPF progression. Validation in a larger cohort is necessary to further explore OPG's role in pulmonary fibrosis and its potential for assessing fibrotic lung disease prognosis in individual patients.

Introduction: Previous studies yielded inconsistent results regarding whether bronchoscopic lung volume reduction using endobronchial valves (EBVs) improves pulmonary ventilation. The aim of this study was to evaluate changes in ventilation following EBV treatment using a novel technique for assessing specific pulmonary ventilation: X-ray velocimetry (XV LVAS, 4DMedical, Los Angeles, CA, USA).

Methods: Pulmonary ventilation was assessed using XV pretreatment and 6 weeks after treatment. The main outcome was mean specific ventilation (MSV) (mL/mL) which is defined as the volume change in a lung region (from start to end of inspiration), divided by the volume of that region at the start of inspiration.

Results: Nineteen patients were included (79% female, mean FEV₁: 30% of predicted, median RV: 207 %pred). After EBV treatment, RV decreased significantly by 0.90 L (interquartile range: -1.2 to -0.67, p < 0.001). EBV treatment resulted in a significant increase in MSV of the whole lung. When stratifying by treated and non-treated lungs, a significant increase in MSV was found in the treated lung, while a significant decrease was found for the non-treated (contralateral) side. No significant associations were found between changes in X-ray velocimetry (XV) measurements and changes in clinical outcomes.

Conclusion: For the first time, XV was utilized to measure specific pulmonary ventilation before and after EBV treatment. Our results demonstrate an overall increase in pulmonary ventilation across the whole lung, driven by an increase in the treated lung, despite a decrease in the non-treated lung. No association was observed between changes in pulmonary ventilation and changes in clinical outcomes.

Introduction: In patients with benign tracheal stenosis (TS) deemed inoperable, silicone stents is an effective alternative. Although both straight and hourglass-shaped stents are available, little is known on the specific suitability of each stent. We aimed to evaluate the potential clinical benefit of choosing a specific stent for each case.

Methods: We compared clinical outcomes in patients undergoing stent placement, in two groups: group 1, when only straight silicone stents were available and group 2, when we could choose either straight or hourglass stent, depending on the anatomic characteristics of the stenosis. A scoring system based on clinical/functional/bronchoscopic characteristics was used to evaluate complications severity.

Results: Between 2008 and 2023, 37 patients underwent tracheal stenting for PITS, comprising group 1 (n = 8) and group 2 (n = 29). No differences were observed between groups regarding stenosis type, location, length, or baseline dyspnoea. Group 2 demonstrated a significantly lower stent/patient ratio (1.24 vs. 1.87, p = 0.001) and higher rates of clinical success (29 vs. 6 cases, p = 0.014). The Complication Severity Index (CSI) was significantly lower in group 2 (0.8 vs. 1.3, p = 0.016). Patients bearing straight stents in group 2, had a lower stent/patient ratio compared with group 1 (1.50 vs. 1.87, p = 0.044) and improved outcomes (10 vs. 6 cases, p = 0.043), with a lower CSI (0.85 vs. 1.3, p = 0.025). In group 2, hourglass stents had a lower stent/patient ratio than straight stents (1.14 vs. 1.50, p = 0.038).

Conclusion: Choosing the fittest stent for each type of TS generates fewer complications and increased efficacy. Our results indicate that hourglass stents may comply better to annular TS.

Introduction: High-flow nasal oxygen therapy (HFNO) for acute respiratory failure (ARF) has been used in the intensive care units (ICUs), but more recently also on respiratory wards (RWs). Little data are available regarding in-hospital, short-term and long-term mortality in the latter setting.

Methods: We performed a retrospective analysis of patients ≥ 16 years old treated with HFNO on the RW between 01/2020 and 09/2022 with a follow-up until 09/2023. We grouped patients by main diagnosis and do-not-intubate (DNI) order. Cox proportional hazard models were used.

Results: We analyzed 145 HFNO patients (36% women, median age 70 years [quartile range {Q1-Q3} 62-79], BMI 25.8 [Q1-Q3: 22.6-28.5] kg/m2) with ARF mostly due to COVID-19 (n = 84, 57.9%), other pneumonia (n = 25, 17.2%), and mixed other diagnoses (n = 36, 25%). A total of 71 (48.9%) patients started HFNO on ICU and continued on the RW, treatment was tolerated in 94% of patients. In-hospital mortality was 24.8% (n = 35), of whom 33 patients had a DNI-order. The mortality rates after 30 days, 90 days, and 1 year were 30% (n = 44), 38% (n = 54), and 43% (n = 62). Long-term mortality did not differ between diagnostic groups (p > 0.05), a higher BMI was associated with lower mortality (hazard ratio [HR] 0.95 [95% CI 0.91-0.99]). A DNI-order and a palliative setting were associated with higher mortality (1 year: HR 3.03 [95% CI 1.15-7.69], p = 0.024 and HR 4.01 [2.21-7.26], p < 0.001).

Conclusion: In our cohort of patients with ARF treated with HFNO, the underlying diagnosis of ARF was not associated with an increased mortality risk. In DNI patients, RW HFNO allows for advanced care without burdening ICU resources.

Introduction: Current definitions of clinical remission (CR) use different tools and thresholds to define good asthma control. Their differential impact on CR rates in severe asthma is poorly understood.

Methods: Data from a real-world study in patients with SEA treated with benralizumab (imPROve Asthma, NCT04184284, total number of patients: 244 patients) were analyzed. Four-component CR (4-CR) was defined as no exacerbations, no systemic steroid treatment, stable or normal lung function, and good asthma control, for at least 12 months. The impact of 2 different asthma control measures (Asthma Control Questionnaire [ACQ] and Asthma Control Test [ACT]) with varying thresholds for good asthma control (ACQ: ≤1.5 or ≤0.75, ACT: ≥20 or ≥23) on CR rates was examined.

Results: Complete data on all remission criteria were available for 131 patients after 12 months of follow-up, and 85 patients after 24 months of follow-up. After 12 months, 4-CR criteria were fulfilled in 42.7% (ACQ-6 ≤1.5), 36.9% (ACT ≥20), 24.4% (ACQ-6 ≤0.75), and 21.5% (ACT ≥23) of the patients. After 24 months, 4-CR criteria were fulfilled in 39.2% (ACQ-6 ≤1.5), 31.8% (ACT ≥20), 22.8% (ACQ-6 ≤0.75), and 17.6% (ACT ≥23) of the patients.

Conclusion: CR is achievable in a substantial proportion of patients with SEA treated with benralizumab in a real-world setting. CR rates are strongly dependent on definitions of asthma control, with almost twice as high CR rates found using the ACQ-6 ≤1.5 criterion as compared with the ACT ≥23 criterion.

Introduction: Bronchial rheoplasty with non-thermal pulsed electric field (PEF) ablation has excellent developmental potential for the therapy of chronic bronchitis (CB) subtypes of chronic obstructive pulmonary disease (COPD). However, the volume of reported clinical studies is quite limited. Also, repeated and missed ablations are involved during the procedure, affecting the targeted therapy and PEF further development. Evaluating the feasibility, safety, and efficacy of a novel navigated PEF ablation system in the therapy of CB, promoting the COPD therapeutic field toward a new stage of greater precision and efficiency.

Methods: First, real-time navigated bronchial rheoplasty were performed in 18 live pigs by a novel navigated PEF ablation system (variable-diameter navigated PEF ablation catheter with a length of 1.4 m and an outer diameter of 1.5 mm) with 84 days of follow-up. Subsequently, bilateral bronchial rheoplasty was conducted in 4 patients with CB using this system. Changes in CAT scores, mMRC scores, CT tests, and lung function were explored during the 6-month follow-up. The feasibility, safety and efficacy of the technique were further evaluated.

Results: Real-time navigated bronchial rheoplasty was performed successfully in 18 live pigs without any serious complications. Pathologic results showed complete recovery of mild tissue inflammation during follow-up from 4 h to 28 days. In the clinical trial, a total of 8 PEFs were performed in 4 patients with CB subtype COPD, achieving a technical success rate of 100%. There were no device- or procedure-related serious adverse events within 6 months.

Conclusions: Precision-targeted ablation of patients with CB by a novel navigated PEF ablation system is a safe, feasible, and effective approach.

Introduction: Pulmonary vascular abnormalities coexist with interstitial lung disease (ILD), leading to a spectrum of physiologic impairments. We hypothesized that ILD patients with exercise intolerance have a heterogenous hemodynamic profile when assessed by invasive cardiopulmonary exercise testing (iCPET).

Methods: From January 2018 to December 2023, we prospectively performed iCPET for several conditions. The primary outcome of the study was to assess the hemodynamic phenotypes both at rest and during exercise of ILD patients with exercise intolerance, which cannot be fully explained by the severity of ILD.

Results: Of the 43 ILD patients included in the study, 10 (23%) had no pulmonary hypertension (PH), 16 (37%) had no PH with pulmonary vascular resistance (PVR) >2 WU, 7 (16%) had precapillary PH, 7 (16%) had postcapillary or combined pre- and postcapillary PH, and 3 (7%) had unclassified PH. Four (9%) patients had exercise PH. Forced vital capacity, diffusion capacity for carbon monoxide, peak oxygen consumption, and resting partial pressure of oxygen (PaO₂) were significantly lower across the no PH to precapillary PH spectrum. Peak exercise PaO₂ decreased (97 ± 25, 73 ± 15, and 62 ± 10 mm Hg, p = 0.001) while mPAP/CO slope (1.9 ± 1.1, 3.1 ± 2.1, and 5.1 ± 2.7, p = 0.009) and PAWP/CO slope (0.9 ± 0.7, 0.9 ± 0.7, and 3.0 ± 3.0, p = 0.007) increased from no PH, to no PH with high PVR, to precapillary PH. No associations were noted for gender, presence of fibrotic ILD and scleroderma, and mPAP/CO >3 WU across this spectrum.

Conclusion: Patients with ILD and exercise intolerance have several hemodynamic phenotypes with parameters that reveal worse exercise performance from no PH to no PH with elevated PVR to precapillary PH.

This is the 4th edition of the S2k cough Guideline (based on a structured consensus among a representative committee) of the German Respiratory Society (DGP) for specialists, written by respiratory, internal medicine, allergy, ear-nose-throat, gastroenterology specialists, speech therapists and physiotherapists - accredited by their respective scientific societies. Importantly, a patient representative was also involved. The Guideline was coordinated under the guidance of a representative from AWMF (Association of the Scientific Medical Societies in Germany). With regard to specific questions, we intend to supplement the cough guideline of the German Society of General and Family Medicine (DEGAM). Compared to the earlier versions 1-3 of the DGP cough guideline, which had the character of a monograph, the concept of this guidelines is completely new. In a modified Delphi process, the authors developed 12 key questions; they were answered in the guideline conference and the recommendations were graded strong), weak or insufficient on the basis of the available evidence. A brief scientific background to the respective questions was then compiled by expert groups of authors. In some cases, new diagnostic algorithms were created for acute, subacute and chronic cough. The significantly reduced scope and improved overview make the guideline easier to use in daily practice. It has also been incorporated into the Leila Pro smartphone Application and can be accessed using its convenient functions (see https://www.leila.de/de/).

Invasive mechanical ventilation remains a cornerstone in the treatment of critically ill patients suffering from acute respiratory failure, providing life-sustaining gas exchange while necessitating careful selection of modes and settings to maximize benefit and minimize harm. This guideline-derived review synthesizes updated, critically appraised, and evidence-based recommendations on choosing ventilatory modes and setting key parameters in adults with acute respiratory insufficiency. Building on a systematic GRADE process and presented digitally in the MAGICapp, the 2025 guideline for the German, Austrian, and Swiss healthcare context retains a pragmatic taxonomy of ventilatory modes and updates several clinical recommendations. In invasively ventilated patients with moderate-to-severe ARDS, early neuromuscular blockade is no longer favored; instead, early assisted strategies that allow spontaneous breathing are suggested when clinically appropriate. Pressure-controlled, minute ventilation-supporting modes that enable spontaneous breathing during both inspiration and expiration may be considered in hypoxemic respiratory failure, acknowledging very low certainty of evidence and notable heterogeneity across trials. For the first time, our guideline issues recommendations on adaptive ventilation modes. Some adaptive modes (e.g., ASV/INTELLiVENT-ASV) and neurally adjusted ventilatory assist may be considered on a case-by-case basis, whereas flow- and volume-proportional assist ventilation (e.g., PAV/PAV+) is not recommended given low-certainty evidence and frequent intolerance. Parameter recommendations emphasize lung-protective ventilation with VT ≈ 6 mL/kg predicted body weight (range 4-8 mL/kg), a plateau pressure ≤30 cm H₂O, and a driving pressure ≤14 cm H₂O. Positive end-expiratory pressure should be higher in moderate/severe ARDS and individualized using bedside physiology, while oxygen targets of SaO₂/SpO₂ 92-96% or PaO₂ 70-90 mm Hg balance hypoxemia and hyperoxia risks. Continuous cardiorespiratory monitoring and capnography for tube placement confirmation and trend assessment are endorsed. Collectively, these recommendations aim to support safe, effective, and implementable ventilatory care while transparently conveying where certainty of evidence remains limited.