Expert review of respiratory medicine最新文献

Introduction: Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) associated with the risk of accidents at work or while driving. OSA treatment decreases EDS, but some patients remain sleepy despite optimal control of OSA. Patients who do not tolerate or refuse OSA treatment may be symptomatically treated for EDS. Solriamfetol and pitolisant are wake-promoting agents (WPA) recently approved for use in sleepy OSA patients accepting or refusing OSA treatment.

Areas covered: This narrative review provides updated information on: how to assess EDS in OSA patients, epidemiology, and management of residual EDS in treated OSA patients and the results of recent studies using new WPAs in patients accepting or refusing CPAP treatment. Literature was accessed from PubMed between 1 December 2024 and 6 January 2025.

Expert opinion: The new WPAs are useful drugs with a favorable safety profile to be included as a possible therapeutic option for sleepy OSA patients. However, it is still uncertain which subgroups of patients should be treated for the symptom of EDS while maintaining a low-risk profile in terms of the consequences of OSA on health. Until such data is available, use of WPA in OSA patients should be managed by Sleep Specialists.

Introduction: Ischemic stroke (IS)-associated pneumonia is a leading cause of mortality after stroke, driven by peripheral immune imbalance. This systematic review evaluates immunosuppression markers associated with pneumonia following IS in clinical studies. Methods: Following PRISMA guidelines, we searched PubMed/MEDLINE, EMBASE, and LILACS databases until March 2024. Inclusion criteria comprised clinical studies assessing IS-related immunosuppression and pneumonia, excluding in vitro and animal studies. Study quality was assessed using the Newcastle-Ottawa Scale.

Results: A total of 32 studies met the inclusion criteria, analyzing 1,833 post-stroke patients. Findings indicate that increased interleukin-6 (IL-6), interleukin-10 (IL-10), and C-reactive protein (CRP) levels, alongside decreased repulsive guidance molecule A (RGM-A), are early indicators of post-stroke pneumonia. Meta-analysis was not conducted due to heterogeneity in study methodologies and populations.

Conclusions: Elevated IL-6, IL-10, and CRP levels, along with reduced RGM-A, are associated with post-stroke pneumonia, emphasizing the role of immune dysregulation in its pathophysiology. Despite promising findings, further studies with standardized detection techniques are needed to enhance diagnostic accuracy and improve patient prognosis. The variability in study methodologies presents a limitation to drawing definitive conclusions.

Background: Ultrathin bronchoscopy (UTB) is commonly used to diagnose peripheral pulmonary lesions due to its small diameter. However, there is no consensus on its comparison with conventional bronchoscopy (CB) combined with various guiding modalities.

Methods: A comprehensive literature search was performed to identify studies comparing UTB and CB, extracting data on diagnostic yield, operating time, complications, pathological diagnoses, and lesion size. Protocol registration: identifier CRD42024554649. PRISMA guidelines were followed.

Results: This meta-analysis included 11 studies with 2,640 patients. UTB demonstrated a significantly higher diagnostic yield (70.5% vs. 57.6%, p = 0.005), particularly with rEBUS and fluoroscopy (p = 0.02). UTB had a higher complication rate, but the difference was not significant (p = 0.37). It also had a shorter operative time than CB-GS (p = 0.007). UTB showed a significant advantage in diagnosing malignant tumors, especially adenocarcinoma and metastatic cancer (p = 0.02, p = 0.03). Both techniques were comparable in diagnosing benign conditions, but UTB outperformed CB in all lesion size categories (p < 0.01).

Conclusions: UTB's smaller diameter likely provides a diagnostic advantage over CB and CB-GS by enabling deeper and more accurate access to peripheral lung regions.

Introduction: All over the world, viral pneumonia has a significant impact on morbidity and mortality, especially among vulnerable populations. The most common respiratory viruses causing pneumonia include influenza virus, respiratory syncytial virus, adenoviruses and rhinovirus. The COVID-19 pandemic has changed the landscape of viral pneumonia and has reshaped our understanding of the role of viruses in this disease. We are now more aware of the importance of early diagnosis, the impact of co-infections, the effects of viral variants, and the long-term consequences of post-viral pneumonia.

Areas covered: We discuss the latest scientific evidence regarding epidemiology, diagnosis, treatment, and prevention of viral pneumonia. This review summarizes findings from a PubMed search on respiratory viruses in community-acquired pneumonia.

Expert opinion: Our experience during the COVID-19 pandemic has changed our perspective on respiratory viruses and their role in viral pneumonia. Diagnostic advances have been made, co-infections have received greater recognition, immune responses to viral infections are better understood, and approaches to treating viral pneumonia have expanded. Despite this progress, however, research on the impact of respiratory viruses on pneumonia must continue to pursue the development of new antivirals and vaccines, and investigate the long-term sequelae, especially in cases of severe viral pneumonia.

Introduction: Pneumonia is a common occurrence at the end of life (EOL). However, clear definitions and consensual guidelines for managing this condition are lacking. Diagnosing EOL pneumonia and deciding whether to treat it with antibiotics can be challenging.

Area covered: This special report provides a narrative review of epidemiological data, diagnostic tools for EOL pneumonia, guidance on antibiotic use, and ethical considerations in this context. Literature from 2000 to 2024 was analyzed using PubMed and Cochrane databases.

Expert opinion: At the EOL, respiratory symptoms must be managed to improve patients' quality of life. Bacterial pneumonia can be difficult to diagnose, and the benefits of antibiotics on respiratory symptoms remain uncertain. At an individual level, adverse events may impact EOL quality, while at a population level, overprescribing antibiotics contributes to antimicrobial resistance. A multidisciplinary approach is therefore essential. Treatment goals should be established with the patient or their healthcare representative. If antibiotics are prescribed, they should be initiated for a limited duration with daily reassessments. If the set goals are not achieved or if adverse events occur, antibiotics should be discontinued. Palliative care measures should also be introduced as early as possible.

Introduction: Household disinfectants and cleaning products (HDCPs), which involve a complex mixture of chemical ingredients, are commonly used in homes. HDCPs significantly contribute to chemical exposure in the indoor environment by releasing particles and volatile organic compounds while being used, potentially harming the respiratory health of those exposed.

Areas covered: We provide an overview of scientific literature, especially from the last five years, regarding the (i) effects of using of HDCPs on adults' respiratory health; (ii) associations between prenatal or childhood exposure to HDCPs and children respiratory health. Finally, we discuss on standard and innovative methods of HDCP exposure assessment.

Expert opinion: Recent literature provides further evidence on the harmful role of HDCPs on respiratory health in both adults and children. Exposure to HDCPs is a modifiable asthma risk factor that requires more consideration, in order to reduce asthma-related morbidity, and to improve and maintain an optimal control of the disease. Further research is essential to deepen the current knowledge, particularly by using innovative methods of exposure assessment to HDCPs, which could enhance the exposure characterization in both adults and children, and contribute to identify HDCP's chemical compounds leading to a risk for respiratory health.

Introduction: Lung cancer is responsible for premature cancer deaths in women and is the first cause of cancer deaths in women in many countries. The problem of lung cancer in women seems to be underestimated in many aspects, including low participation in clinical trials and screening tests.

Areas covered: Current research progress has contributed to a better understanding of the issue and makes it possible to describe the problem in a new light. In our paper, the problem of lung cancer in women was discussed in a broad aspect, taking into account women's health, the harmful effects of smoking and the current diagnostic and treatment process. The results of treatment also differ in relation to sex. All these aspects of the diversity of women's lung cancer were presented on the basis of newest and most comprehensive literature.

Expert opinion: Lung cancer in women is and will remain an important health problem worldwide, which is justified by epidemiological data, basic research and treatment results.

Background: Elevated serum tumor-associated antigens (TAAs) were reported to be common in patients with interstitial lung disease (ILD) and correlated with pulmonary involvement or malignancy development. However, there were no adequate longitudinal studies on the association between elevated TAAs and various types of ILDs in Chinese patients.

Research design and methods: The treatment-naïve ILD patients were retrospectively enrolled. The clinical, laboratory, imaging characteristics, and prognosis were analyzed and compared among those with normal and different number of elevated TAAs.

Results: An increase of at least one TAA was present in 169/308 (54.87%) of our patients. Both baseline alveolar and interstitial scores were much higher, and lung involvement tended to be worse during follow-up in patients with two and three or more elevated TAAs than in normal TAAs. Patients with three or more elevated TAAs had the highest interstitial scores and a higher all-cause mortality during follow-up than those with one elevated TAA or normal TAAs. The occurrence of malignancy was similar in all patients.

Conclusion: Elevated TAAs were present in 54.87% of ILD patients and associated with lung interstitial lesions, which might be a marker for lung involvement progression, while not for malignancy development in ILD.

Background: Asthma remains a public health concern in the United States, with mortality disproportionately affecting demographic groups. This study aimed to describe national trends in asthma mortality from 1999 to 2020 and identify demographic and regional disparities.

Research design and methods: We retrospectively analyzed mortality data from the CDC WONDER database using International Classification of Diseases, Tenth Revision (ICD-10) codes J45 and J46. Age-adjusted mortality rates (AAMRs) were calculated by sex, race, age group, US Census region, state, and urban-rural classification. Joinpoint regression was employed to detect changes over time.

Results: A total of 82,686 asthma-related deaths were identified (37.2% males, 62.8% females). Overall, the AAMR declined from 1.72 in 1999 to 1.14 in 2020. Joinpoint analysis revealed a significant decline from 1999 to 2009, a plateau from 2009 to 2014, a further decline from 2014 to 2018, and a significant increase from 2018 to 2020. Non-Hispanic Black individuals (AAMR 2.73) and older adults (≥65 years) had the highest mortality rates, with females exhibiting higher rates than males (1.30 vs 0.95).

Conclusions: Despite declining trends, persistent disparities in asthma mortality underscore the need for targeted interventions, improved healthcare access, and ongoing surveillance.

Background: Immunomodulators tocilizumab and baricitinib have been used for the treatment of severe COVID-19, however, there are only few published studies comparing their efficacy.

Research design and methods: All consecutive non-ICU hospitalized severe COVID-19 patients who received baricitinib or tocilizumab, were included retrospectively. Primary outcomes were mortality or intubation on day 14, time to oxygen therapy weaning and duration of hospitalization. Safety was measured as treatment-related adverse events.

Results: 321 hospitalized patients with severe COVID-19 were included (mean age 62.4 years ± 14.7); 241 (75.1%) received baricitinib (mean age 64.2 years ± 15.2) and 80 (24.9%) tocilizumab (mean age 57.3 ± 11.7). Patients who received baricitinib presented significantly lower risk of mortality or intubation on day 14, compared to the tocilizumab group after adjusting for age, sex, vaccination, Charlson comorbidity index, body mass index, remdesivir administration and WHO ordinal scale at enrollment (OR: 0.42, 95% CI: 0.20-0.86). In the augmented inverse-probability weighting regression, the protective role of baricitinib remained statistically significant (OR: 0.76, 95% CI: 0.66-0.88). No difference in secondary bacterial infections was detected, but tocilizumab was associated with significant higher rate of liver injury (Odds Ratio, 95%CI, p < 0.001).

Conclusions: Our study suggests survival and safety are significantly better for baricitinib compared to tocilizumab in severe COVID-19. Clinical randomized trials are needed for confirmation.