Expert review of respiratory medicine最新文献

Introduction: Pneumonia remains a leading cause of morbidity and mortality, particularly in critically ill patients with acute respiratory failure (ARF). This review discusses prevention strategies for pneumonia-induced ARF, categorized into primary, secondary, and tertiary prevention.

Areas covered: A literature search was conducted through PubMed covering the years 2000-2024, using the keywords 'acute respiratory failure,' pneumonia prevention," 'risk stratification,' and 'preventive strategies.' Primary prevention focuses on reducing pneumonia risk through vaccination, smoking cessation, and comorbidity management. Secondary prevention involves early detection, risk assessment using clinical tools like the Pneumonia Severity Index (PSI) biomarkers, such as procalcitonin and C-reactive protein, appropriate antibiotic use, and emerging machine learning tools for real-time stratification. Tertiary prevention focuses on optimizing care with noninvasive respiratory support, lung-protective ventilation strategies, and ventilator bundles for intubated patients. Emerging therapies, including targeted use of corticosteroids and other immunomodulatory agents, are also discussed as promising adjuncts to current standards of care.

Expert opinion: While these prevention strategies show potential, continued research is necessary to refine these interventions, explore newer therapies and evaluate long-term outcomes. Implementation of these strategies aim to reduce the impact of pneumonia-induced ARF on healthcare systems and improve patient survival and quality of care.

Introduction: Idiopathic pulmonary fibrosis (IPF) isa chronic, progressive lung disease characterized by distorted alveolar structureand reduced lung compliance, and impaired ventilation-perfusion. Small airwaydisease (SAD) is  often termed a 'quietzone' due to its asymptomatic nature. Around 30-40% of IPF patients exhibit SAD,which is associated with worse prognosis, higher fibrosis and emphysema scores,and elevated mortality risk. We used PubMed and Google Scholar for literaturesearch.

Areas covered: This review explores thepathophysiology of small airways in IPF, focusing on 1. risk factors, includingage, gender, smoking and occupational dust exposure, and ozone. 2. Diagnosticchallenges: SAD is difficult to detect through traditional spirometry or high-resolutioncomputed tomography  imaging due to resolutionlimitations.  3. Early physiologicalchanges of small airways include airway wall thickening, lumen distortion, andreduced terminal bronchioles, preceding microscopic fibrosis, occurs in the earlyprocess of IPF. 4. Pathological mechanisms: The review examines the underlyingmechanisms driving small airway disease in IPF.

Expert opinion: A comprehensive approach is essential to improve the understanding andmanagement of SAD in IPF. Priorities include identifying therapeutic targets,advanced imaging and functional assessments. Forced oscillation technique should be introduced for early detection for smallairway abnormalities in IPF.

Introduction: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality worldwide, primarily due to persistent airflow limitation from tobacco and biomass smoke exposure. While inhaled corticosteroids (ICS) combined with long-acting bronchodilators, namely long-acting β₂-adrenoreceptor agonists (LABA) and long-acting muscarinic antagonists (LAMA), are recommended for symptom control and exacerbation reduction, their effect on mortality remains uncertain. Recent randomized controlled trials (RCTs) suggest potential mortality benefits with triple ICS/LABA/LAMA therapy, though findings are not definitive.

Methods: We conducted a systematic review and network meta-analysis (NMA) to evaluate the impact of ICS-containing therapies on all-cause mortality in COPD. Searches were performed across ClinicalTrials.gov, Cochrane Library, EMBASE, MEDLINE, and SCOPUS, focusing on RCTs measuring mortality as an efficacy outcome.

Results: A total of 42,784 COPD patients from five high-quality studies were included. Pairwise meta-analysis showed a significant reduction in all-cause mortality with ICS-containing therapies (RR 0.80, 95% CI 0.68-0.95), particularly with ICS/LABA and ICS/LABA/LAMA combinations. The NMA ranked ICS/LABA/LAMA as the most effective treatment (SUCRA 0.89).

Conclusions: This study provides compelling evidence that ICS-containing therapies, particularly triple therapy, significantly reduce all-cause mortality in COPD patients. Future research should identify patient subgroups most likely to benefit while minimizing adverse effects.

Registration: PROSPERO registration ID: CRD42024607568.

Background: NT-proBNP, traditionally used to assess heart failure, is increasingly recognized for its prognostic value in other diseases. This study evaluates its value in pneumonia.

Research design and methods: We conducted a retrospective cohort study of adult patients hospitalized for pneumonia at Wan Fang Hospital (2017-2021) to investigate whether elevated NT-proBNP levels predicted poorer outcomes. Logistic regression identified risk factors for 28-day mortality, while the Cox regression model identified predictors of post-discharge survival.

Results: Among 2,805 patients (79.6 ± 13.4 years, female 45%), the 28-day mortality rate was 18.2%, and the median post-discharge follow-up time was 359 days. Moderately (increased but <10000 pg/mL) and severely (>10000 pg/mL) elevated NT-proBNP levels had higher 28-day mortality compared to normal NT-proBNP; adjusted odds ratios: 2.24 (1.34-3.75, p = 0.002) and 3.57 (2.03-6.27, p < 0.001). Moderately and severely elevated NT-proBNP levels related to shorter survival time than normal NT-proBNP levels; adjusted hazard ratios 1.60 (1.28-2.00, p < 0.001) and 2.03 (1.56-2.63, p < 0.001). All ratios were adjusted with comorbidities, sex, age, and clinical and laboratory tests.

Conclusions: Elevated NT-proBNP levels predict higher 28-day mortality and shorter survival time in patients with pneumonia across most subpopulations. This marker holds potential as a prognostic biomarker for pneumonia, especially in high-risk patients.

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality globally, particularly in low- and middle-income countries like India. This study aims to analyze regional trends and project future burden of COPD in India using data from the Global Burden of Disease (GBD) 1990-2021.

Methods: This analysis utilized data from the GBD study to assess age-standardized prevalence (ASPR), incidence (ASIR), disability-adjusted life years (DALYs) (ASDR), and mortality rates (ASMR) for COPD across Indian states. Joinpoint regression was used to analyze temporal trends, while ARIMA models predicted future incidence rates.

Results: In 2021, the highest ASIR was observed in Rajasthan at 306.28, and the highest ASMR was observed in Uttarakhand at 227.19. Projections suggest that the ASIR for COPD in India will decrease from 265.16 in 2022 to 258.19 by 2031. The heatmap analysis identified states like Uttarakhand and Rajasthan as having the highest DALYs attributable to COPD risk factors, including air pollution and tobacco use.

Conclusion: COPD remains a public health challenge in India, with regional variability. Targeted interventions addressing air pollution, smoking cessation, and improved healthcare access are essential to mitigate the disease's future burden, particularly in high-risk regions.

Introduction: Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive scarring and reduced survival. The development of IPF is influenced by rare and common genetic variants, cigarette smoking, aging, and environmental exposures. Among the two dozen genetic contributors, the MUC5B promoter variant (rs35705950) is the dominant risk factor, increasing the risk of both familial and sporadic IPF and accounting for nearly 50% of the genetic predisposition to the disease.

Areas covered: This review provides an expert perspective on the genetic underpinnings of IPF rather than a systematic analysis, emphasizing key insights into its genetic basis. The articles referenced in this review were identified through targeted searches in PubMed, Scopus, and Web of Science for studies published between 2000 and 2023, prioritizing influential research on the genetic factors contributing to IPF. Search terms included 'idiopathic pulmonary fibrosis,' 'genetics,' 'MUC5B,' 'telomere dysfunction,' and 'surfactant proteins.' The selection of studies was guided by the authors' expertise, focusing on the most relevant publications.

Expert opinion: The identification of genetic variants not only highlights the complexity of IPF but also offers potential for earlier diagnosis and personalized treatment strategies targeting specific genetic pathways, ultimately aiming to improve patient outcomes.

Introduction: Interstitial lung disease (ILD) is a broad group of conditions characterized by fibrosis of the lung parenchyma. Idiopathic pulmonary fibrosis (IPF) is the most common subvariant. IPF is marked by considerable symptom burden of dyspnea, cough and fatigue that is often refractory to optimal disease-directed treatment.

Areas covered: In this narrative review, we searched MEDLINE for articles related to the current evidence regarding management of chronic dyspnea, cough, and fatigue as three of the most prevalent and distressing symptoms associated with IPF and other ILDs. Each symptom shares common features of multi-factorial etiology and a lack of safe and effective pharmacological therapies. Both corticosteroids and opioids have been utilized in this context, yet there is insufficient evidence of therapeutic benefit and considerable risk of harms. Whilst some may benefit from symptom-directed pharmacological management, usage must be carefully monitored. Use of non-pharmacological strategies, such as breathing techniques and speech therapy represent low risk and low-cost option, yet broader validation of these therapies' effectiveness is needed.

Expert opinion: Symptom management in IPF and other ILDs requires an iterative and individualized approach. Leveraging the expertise of multidisciplinary teams within an integrated care setting is an important opportunity to maximize health outcomes.