Expert review of respiratory medicine最新文献

Introduction: COPD is the 3^rd leading cause of death worldwide, affecting an estimated 212.3 million people. More than 80% of this burden occurs in low- and middle-income countries. One of the major reasons for this growing burden, is the lack of awareness of COPD among all levels.

Areas covered: In this review article, we studied the level of awareness of COPD among lay people, health care providers and policy makers in the LMICs. Search engines including Google Scholar, PubMed, and Scopus were used for relevant articles. Articles spanning from 1990 to March 2024 were screened on COPD awareness in LMICs and its treatment implications using a combination of key words.

Expert opinion: We report that the overall awareness of COPD is low at all levels. There are several reasons such as poverty, illiteracy, societal beliefs, cultural beliefs, and misconceptions. This is associated with increase in suffering, deaths, and economic loss, due to poor adaption correct prescription and compliance to treatment. And very little is being done to improve the current status. COPD needs to be highlighted in the national programs in LMICs.

Introduction: The availability of cystic fibrosis transmembrane conductance regulator (CFTR) modulators opens the possibility of discontinuing some chronic pulmonary therapies to decrease cystic fibrosis (CF) treatment burden. However, CFTR modulators may not adequately address neutrophilic inflammation, which contributes to a self-perpetual cycle of viscous CF sputum, airway obstruction, inflammation, and lung function decline.

Areas covered: This review discusses the emerging role of neutrophil extracellular traps in CF and its role in CF sputum viscosity, airway obstruction, and inflammation, based on a literature search of PubMed (1990-present). We summarize clinical trials and real-world studies that support the efficacy of dornase alfa (Pulmozyme) in improving lung function and reducing pulmonary exacerbation in people with CF (PwCF), and we discuss the potential role of dornase alfa in reducing airway inflammation. We also examine the findings of short-term trials evaluating the discontinuation of mucoactive therapy in PwCF receiving CFTR modulators.

Expert opinion: Long-term studies are needed to assess the impact of discontinuing mucoactive therapy in PwCF who are clinically stable while receiving CFTR modulatory therapy. Treatment decisions should take into account the severity of underlying lung disease. People with advanced CF will likely require ongoing mucoactive therapy.

Introduction: Patients with chronic obstructive pulmonary disease (COPD) are frequently colonized and infected by respiratory pathogens. Identifying these infectious etiologies is critical for understanding the microbial dynamics of COPD and for the appropriate use of antimicrobials during exacerbations.

Areas covered: Traditional methods, such as bacterial and viral cultures, have been standard in diagnosing respiratory infections. However, these methods have significant limitations, including lack of sensitivity and prolonged turnaround time. Modern molecular approaches offer rapid, sensitive, and specific detection, though they also come with their own challenges. This review explores and evaluates the clinical utility of the latest advancements in detecting bacterial and viral respiratory infections in COPD, encompassing molecular techniques, biomarkers, and emerging technologies.

Expert opinion: In the evolving landscape of COPD management, integrating molecular diagnostics and emerging technologies holds great promise. The enhanced sensitivity of molecular techniques has significantly advanced our understanding of the role of microbes in COPD. However, many of these technologies have primarily been developed for pneumonia diagnosis or research applications, and their clinical utility in managing COPD requires further evaluation.

Introduction: Chronic obstructive pulmonary disease (COPD) has traditionally been diagnosed based on the criterion of an FEV₁/FVC <0.70. However, this definition has limitations as it may only detect patients with later-stage disease, when pathologic changes have become irreversible. Consequently, it potentially omits individuals with early-stage disease, in whom the pathologic changes could be delayed or reversed.

Areas covered: This narrative review summarizes recent evidence regarding early-stage COPD, which may not fulfill the spirometric criteria but nonetheless exhibits features of COPD or is at risk of future COPD progression.

Expert opinion: A comprehensive approach, including symptoms assessment, various physiologic tests, and radiologic features, is required to diagnose COPD. This approach is necessary to identify currently underdiagnosed patients and to halt disease progression in at- risk patients.

Introduction: There are no validated decision-making algorithms concerning severe asthma (SA) management. Future risks are crucial factors and can be derived from SA trajectories.

Areas covered: The future severe asthma-decision trees should revisit current knowledge and gaps. A focused literature search has been conducted.

Expert opinion: Asthma severity is currently defined a priori, thereby precluding a role for early interventions aiming to prevent outcomes such as exacerbations (systemic corticosteroids exposure) and lung function decline. Asthma 'at-risk' might represent the ultimate paradigm but merits longitudinal studies considering modern interventions. Real exacerbations, severe airway hyperresponsiveness, excessive T2-related biomarkers, noxious environments and patient behaviors, harms of OCS and high-doses inhaled corticosteroids (ICS), and low adherence-to-effectiveness ratios of ICS-containing inhalers are predictors of future risks. New tools such as imaging, genetic, and epigenetic signatures should be used. Logical and numerical artificial intelligence may be used to generate a consistent risk score. A pragmatic definition of response to treatments will allow development of a validated and applicable algorithm. Biologics have the best potential to minimize the risks, but cost remains an issue. We propose a simplified six-step algorithm for decision-making that is ultimately aiming to achieve asthma remission.

Introduction: Pleural effusion is common in clinical practice, and its differential diagnosis remains challenging for clinicians. This study investigates the diagnostic value of apolipoprotein E (apoE) in patients with undetermined pleural effusion.

Methods: This prospective, double-blind study enrolled 152 patients with undiagnosed pleural effusion. Their pleural fluid apoE levels were measured, and a receiver operating characteristics (ROC) curve was used to evaluate the diagnostic accuracy of apoE. Decision curve analysis (DCA) was used to assess apoE's net benefit. Subgroup analyses were performed to investigate the effect of age on the diagnostic accuracy of apoE.

Results: Among the included participants, 23 had heart failure (HF). HF patients had the lowest apoE level among pleural effusion patients. The area under the curve (AUC) of apoE for HF was 0.79 (95% CI: 0.69-0.89). At the threshold of 40 mg/L, the sensitivity and specificity of apoE were 0.96 (95% CI: 0.87-1.00) and 0.33 (95% CI: 0.25-0.42), respectively. The decision curve for apoE was above reference lines. The AUC of apoE decreased in older patients.

Conclusion: Pleural fluid apoE has moderate diagnostic value for HF and has net benefits in patients with undiagnosed pleural effusion. The diagnostic accuracy of apoE decreases with age.

Background: To determine the effects of informing smokers of their spirometric lung-age (SLA) on smoking cessation (SC) rates and tobacco consumption.

Research design and methods: An interventional study was conducted in real-life through a humanitarian event led by the Red Crescent on 9 January 2022, in Hammam-Sousse (Sousse, Tunisia). The study comprised four steps: i) Medical questionnaire (general questionnaire, Fagerström test for cigarette dependence, SC motivation questionnaire); ii) Measurement of spirometric data; iii) SLA estimation and its announcement to participants; and iv) Self-reported evaluation of smoking behavior three months later through telephonic recall. Smokers were divided into groups (nondependent vs. dependent groups and insufficient/moderate motivation vs. high/very high motivation groups) and categories (ceased smoking, reduced consumption, maintained stable or increased consumption).

Results: Fifty-two smokers were included (94% were males). Three months after the event, i) 9 (17%) smokers ceased smoking, ii) 39 (75%) smokers reduced their daily smoking consumption by 12 ± 8 cigarettes/day, and iii) 4 (8%) smokers maintained stable (n = 3) or increased (n = 1) consumption.

Conclusions: Informing smokers of their SLA led 92% of them to cease smoking or reduce their consumption. Announcing SLA could be an effective motivational tool and an easy-to-understand concept to help smokers cease their habit.

Introduction: Small-cell lung cancer (SCLC) accounts for 15% of lung cancers and has a dismal prognosis due to early dissemination and acquired chemoresistance. The initial good response to chemotherapy is followed by refractory relapses within 1-2 years. Mechanisms leading to chemoresistance are not clear and progress is poor.

Areas covered: This article reviews the current evidence of the resistance of SCLCs at the cellular level including alteration of key proteins and the possible presence of cancer stem cells (CSCs). Without compelling evidence for cellular mechanisms and clinical failures of novel approaches, the study of SCLC has advanced to the role of 3D tumor cell aggregates in chemoresistance.

Expert opinion: The scarcity of viable tumor specimen from relapsed SCLC patients has hampered the investigations of acquired chemoresistance but a panel of nine SCLC circulating tumor cell (CTC) cell lines have revealed characteristics of SCLC in the advanced refractory states. The chemoresistance of relapsed SCLC seems to be linked to the spontaneous formation of large spheroids, termed tumorospheres, which contain resistant quiescent and hypoxic cells shielded by a physical barrier. So far, drugs to tackle large tumor spheroids are in preclinical and early clinical development.

Introduction: There has been an increasing amount of research on the consequences of e-cigarette use for respiratory outcomes, which is significant for public health and respiratory medicine. We discuss recent findings and lay out implications for prevention and treatment.

Areas covered: Based on literature searches using several databases (PubMed, Web of Science, Google Scholar) for keywords, including synonyms, 'e-cigarettes,' with 'pulmonary function,' 'oxidative stress,' and 'inflammation,' we review studies on acute effects of e-cigarette use for measures of pulmonary function and discuss selected laboratory studies on mechanisms of effect, focusing on processes with known relation to respiratory disease; oxidative stress and inflammation. We discuss available studies that have tested the effectiveness of communication strategies for prevention of e-cigarette use oriented to different audiences, including nonsmoking adolescents and adult smokers.

Expert opinion: We conclude that the evidence presents a mixed picture. Evidence is found for adverse consequences of e-cigarette use on measures of lung function and two disease-related biological processes, sometimes but not always less than for cigarette smoking. How to best communicate these results to a complex audience of users, from younger susceptible adolescents to long-term adult smokers interested in quitting, is a question of significant interest and empirically validated communication strategies are greatly needed.

Introduction: In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined.

Areas covered: This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed.

Expert opinion: The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.