Expert review of respiratory medicine最新文献

Introduction: The bidirectional communication between the lungs and the central nervous system, known as the lung - brain axis, has emerged as an important framework for understanding systemic mechanisms influencing neurological health. Increasing evidence indicates that pulmonary inflammation, respiratory microbiota alterations, and environmental exposures can modulate neuroinflammation, blood - brain barrier integrity, and microglial activation.

Areas covered: This review summarizes current experimental and clinical evidence describing the molecular, microbial, and neuroimmune mechanisms underlying the lung - brain axis. Particular emphasis is placed on the role of the respiratory microbiota across the upper and lower airways and its interaction with immune signaling pathways. In addition, the neurological consequences of pulmonary diseases and infections, including asthma and COVID-19, are discussed, highlighting neuroanatomical, humoral, and immunological routes linking pulmonary and brain physiology.

Expert opinion: Emerging data suggest that the respiratory system functions as an immunometabolic interface capable of influencing neuroimmune regulation and brain function. Integrative approaches combining respiratory microbiota profiling, immune biomarkers, and neuroimaging may help clarify causal mechanisms and support the development of novel diagnostic and therapeutic strategies for neurological and post-infectious conditions.

Introduction: Artificial intelligence (AI) methods - including machine learning, deep learning, and explainable AI - are increasingly applied to pulmonary function testing (PFT) to enhance interpretation, standardize procedures, and support clinical decision making.

Areas covered: This narrative review synthesizes evidence on AI contributions to diagnostic classification, quality control, signal analysis, and predictive modeling in PFT. AI systems have demonstrated improved accuracy and reproducibility versus unaided clinicians for tasks such as ventilatory pattern classification, smallairway dysfunction detection, methacholine challenge prediction, and automated spirometry quality assessment. Explainable AI methods increase clinician trust and interreader concordance. Key limitations include variable algorithm performance, limited interpretability, dependence on the quality and representativeness of training data, and insufficient integration of comprehensive clinical context. Priority development areas are assembling large, diverse, and standardized datasets aligned with American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines; implementing biasdetection and mitigation strategies; defining clinically meaningful endpoints for validation; advancing explainability frameworks; and ensuring interoperability across PFT platforms.

Expert opinion: Multidisciplinary collaboration among clinicians, engineers, and information technology specialists is essential for safe, ethical, and effective deployment. AI is a powerful adjunct for PFT interpretation but should remain a decisionsupport tool pending rigorous realworld validation.

Introduction: COPD is a progressive respiratory condition marked by persistent airflow limitation and chronic inflammation, mainly caused by cigarette smoking. Although current inhaled therapies improve symptoms and reduce exacerbations, they do not substantially modify disease progression, emphasizing the need for novel therapeutic approaches.

Areas covered: This review provides a comprehensive overview of the effectiveness and mechanisms of biologic therapies in the management of COPD. We discuss the mechanistic rationale, clinical efficacy, and limitations of currently approved and emerging biologics, highlighting their relevance to distinct inflammatory endotypes of COPD. The role of small-airway disease in COPD is highlighted, together with advances in drug formulation and inhaled delivery technologies. Challenges related to drug delivery, particularly the influence of particle size on distal airway deposition, are examined, along with recent innovations in nanotechnology and comparative considerations of systemic versus inhaled therapeutic approaches. Relevant literature was identified through searches of PubMed (MEDLINE), Embase, Web of Science, and Google Scholar. Studies available in print or online up to June 2025 were considered.

Expert opinion: Biologic therapies offer promise for selected COPD phenotypes; however, their long-term impact will depend on precision medicine, optimized airway-targeted delivery, and integration with established inhaled treatments to achieve meaningful disease modification.

Introduction: Ideal respiratory health and chronic respiratory disease exist on a continuum. Between these two extremes lies an intermediate state of impaired respiratory health, characterized by clinical phenotypes that exist along the causal pathway. Identifying individuals with intermediate phenotypes of impaired respiratory health offers an opportunity to intercept progression to chronic respiratory disease.

Areas covered: In this review, we identify parameters associated with impaired respiratory health, including respiratory symptoms and illnesses, abnormal lung physiology, imaging abnormalities, and blood biomarkers. We then synthesize evidence linking these parameters to future respiratory impairment.

Expert opinion: Drawing inspiration from advances in cardiovascular disease prevention, the respiratory field must adopt a holistic framework that considers the likely shared biologic mechanisms underpinning chronic lung diseases. Effective disease prevention depends on a multi-omic approach that integrates clinical, physiologic, imaging, and molecular data to identify individuals at increased risk for chronic respiratory disease. Prospective evaluation of these at-risk individuals can be utilized to evaluate the impact of targeted preventative strategies.

Introduction: Cystic Fibrosis (CF) is an autosomal recessive disorder caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene, leading to defective chloride ion transport and multisystem disease. The introduction of CFTR modulators, particularly elexacaftor/tezacaftor/ivacaftor (ETI), has significantly improved life expectancy and quality of life for people with CF (pwCF). As survival increases, an aging CF population faces different new challenges.

Areas covered: This review aims to highlight emerging challenges and comorbidities in an aging CF population to ensure sustained benefits from recent therapeutic advancements. The review includes the discussion of the changes in lung function, nutrition, cardiometabolic diseases, malignancy risk and psychosocial health. A structured literature search was conducted using PubMed, focusing on articles published between 2000 and 2025, including recent clinical trials and international guidelines. National registry data has also been reviewed.

Expert opinion: With CFTR modulators progress rapidly, the future focus should shift to refining and optimizing CF care. Standard practice should involve a multidisciplinary, proactive and preventative strategy to manage co-morbidities, ensuring the ultimate goal moving from simply extending pwCF's life to ensuring a high quality of life throughout their lifespan.

Introduction: Primary ciliary dyskinesia (PCD) is a rare genetic disorder characterized by impaired motile ciliary function, resulting in defective mucociliary clearance and chronic sinopulmonary disease. Although lower airway manifestations are well known, sinonasal disease is often underrecognized or undertreated outside specialist centers, particularly in adults and in settings without routine Ear-Nose-Throat evaluation.

Areas covered: Despite its clinical burden, standardized diagnostic and therapeutic protocols for sinonasal disease in PCD are limited. This review synthesizes current knowledge on the pathophysiology, clinical presentation, diagnostic approaches, and management strategies for sinonasal involvement in PCD based on recent publications. Additionally, the review highlights the burden of disease and its impact on quality of life, role of genotype-phenotype correlations, and the emerging need for disease-specific outcome measures.

Expert opinion: Despite growing evidence, diagnosis and management remain inconsistent due to a lack of standardized tools and guidelines. Multidisciplinary care and implementation of validated outcome measures are essential to optimize clinical follow-up and improve quality of life in this population. Future advances in imaging, microbiome profiling, and personalized interventions are needed. Furthermore, defining a standardized criteria for sinonasal exacerbations and integrating upper airway outcomes into clinical studies will be critical for advancing both research and patient care.

Introduction: Chronic obstructive pulmonary disease (COPD) is a chronic condition that affects millions of people worldwide. The majority of patients with COPD have multiple coexisting chronic diseases, such as cardiovascular diseases, osteoporosis, lung cancer, and metabolic syndrome, a phenomenon that is known as multimorbidity. The coexistence of these diseases with COPD complicates diagnosis, treatment, and prognosis.

Areas covered: This review explores the underlining mechanisms that connect COPD and multimorbidity, such as shared risk factors and pathophysiological pathways. It also highlights the challenges in managing multimorbid patients and emphasizes the fact that the complexity of comorbidities may require a multidisciplinary approach in COPD management.

Expert opinion: Managing COPD in the context of multimorbidity requires a multidisciplinary approach. This approach should combine pharmacological and non-pharmacological treatments for COPD, adhere to evidence-based guidelines for managing comorbidities, and target modifiable shared risk factors to improve overall patient outcomes.

Introduction: To evaluate the efficacy and safety of Rituximab (RTX) in the treatment of pulmonary hypertension (PH) in patients with connective tissue diseases (CTDs).

Methods: A systematic review of the published literature was performed according to the PRISMA guidelines. Eligible articles were clinical trials, cohort studies, case series, and case reports of adult patients with CTD-PH treated with RTX. The selected languages were English and French.

Results: Six studies fulfilled the selection criteria and two of them were prospective. Most patients were from the U.S.A. and Russia. The predominant sex was female (85.9%), and the age of the included patients ranged from 29 years to 67 years. PH was confirmed by right heart catheterization in 3 studies. The CTDs associated with PH were systemic sclerosis (3 cases), adult-onset Still's disease (one case), systemic lupus erythematosus (one case) and mixed connective tissue disease (one case). The mean number of infusions was 4.2. The mean follow-up period across all studies was 18.3 months. Clinical and paraclinical parameters before and after RTX infusions were evaluated and showed improvement. RTX for the treatment of CTD-PH appeared to be well tolerated.

Conclusions: RTX seemed to be effective and safe in the treatment of CTD-PH.Systematic review registration: PROSPERO, ID: CRD420251037839.

Background: Respiratory Syncytial Virus (RSV) is a major cause of severe respiratory illness in infants, older adults, and immunocompromised individuals. However, data on physicians' knowledge and attitudes toward RSV and its prevention in Türkiye are limited. The aim of this study was to evaluate the knowledge and attitudes of physicians in Türkiye about RSV.

Research design and methods: A cross-sectional online survey was conducted among physicians in Türkiye between October and November 2024.

Results: A total of 1270 physicians (median age: 35; 62.44% female) participated, 30.5% of whom specialized in Infectious Diseases (ID). While 43.54% correctly identified RSV symptoms, only 15.9% recognized high-risk groups, and 49.7% were familiar with associated clinical conditions. ID specialists had significantly greater knowledge of symptoms (p = 0.015) and complications (p < 0.001) compared to other physicians. Overall, 51.57% perceived the national RSV burden as high. However, only 40.31% were aware of prevention tools. Although 51.88% knew about FDA-approved RSV vaccines, just 21.54% knew they were not yet available in Türkiye. Among vaccine-aware participants, most would recommend it to elderly (85.28%), while fewer supported maternal vaccination (58.87%).

Conclusions: These findings reveal that despite higher knowledge among ID physicians, overall awareness of RSV and its prevention is inadequate.

Introduction: Excessive daytime sleepiness has traditionally been regarded as the hallmark symptom of obstructive sleep apnea (OSA), yet nearly half of individuals with OSA do not report significant sleepiness. While treatments are well established for sleepy patients, their role in non-sleepy individuals remains relatively underexplored.

Areas covered: This review discusses the limitations of current tools used to measure sleepiness, evaluates the evidence for various treatment options for OSA in non-sleepy populations, and outlines key considerations for shared decision-making. We examine noninvasive therapies including positive airway pressure (PAP), oral appliance therapy, and weight loss interventions only.

Expert opinion: Randomized controlled trials have not demonstrated cardiometabolic benefits of PAP therapy in non-sleepy individuals with OSA, though these studies are limited by poor PAP adherence and imprecise tools for identifying high-risk patients. As such, a pragmatic trial of PAP may be a reasonable strategy in non-sleepy people with moderate-to-severe OSA, cardiovascular comorbidities, or other OSA-related complications; provided patients are counseled about the challenges of adherence and the uncertain benefits in this population. Looking ahead, management of non-sleepy OSA will likely be guided by individualized, risk-based approaches incorporating physiological endotyping, objective biomarkers of cardiovascular risk, and patient preferences.