Expert review of respiratory medicine最新文献

Introduction: Polypharmacy can be considered the norm in elderly patients, because older individuals experience an increasing number of concomitant respiratory and non-respiratory diseases other than asthma, carrying the risk of drug-to-drug-interactions and drug-to-comorbidities interactions. In this context, asthma in older adults, conventionally aging >65 years of age, cannot be adequately managed without considering their individual characteristics, as these challenge the traditional therapeutic algorithms/management strategies commonly applied to younger populations.

Areas covered: The current article aims at addressing pitfalls and advantages of current pharmacological strategies in older individuals with asthma. Comorbidities become more common with increasing age and are also more frequent in adults with asthma than in those without it. Multiple medications are often needed to control asthma symptoms and prevent asthma exacerbations, and older patients with asthma may also take multiple medications for common comorbidities and complex health conditions, such as chronic cardiometabolic diseases. Polypharmacy is an emerging concern in the elderly population.

Expert opinion: A patient-centered approach is crucial and polypharmacy in asthma requires careful management. A multidisciplinary approach will allow for a more holistic care and will ensure that all aspects of a patient's health are considered, optimizing medication management.

Introduction: Chronic Obstructive Pulmonary Disease (COPD) significantly predisposes the elderly to pneumonia, presenting a complex interplay of pulmonary dysfunction and infection risk.

Areas covered: This article reviews the substantial epidemiologic impact, elucidates the interlinked pathophysiology of COPD and pneumonia, and examines the microbial landscape shaping infection in these patients. It also evaluates management protocols and the multifaceted clinical challenges encountered during treatment.

Expert opinion: Delving into the latest research, we underscore the criticality of preventive measures such as vaccination and present an integrated approach to managing Community-Acquired Pneumonia (CAP) in the COPD demographic. The review also proposes strategic directions for future investigations aimed at enhancing patient outcomes through a deeper understanding of the COPD-pneumonia nexus.

Introduction: Preschool wheeze and school-aged asthma present a large healthcare burden. Both conditions are now recognized to be heterogeneous, with similar symptom presentation but likely different underlying lung pathology.

Areas covered: Current treatment options for preschool wheeze are constrained by extrapolations from the management of school-aged children with asthma. While most cases of asthma at school age are caused by classical atopic, eosinophilic, Type-2 driven asthma, only a quarter of preschool children with wheeze fall into this category. Targeting treatment to specific underlying mechanisms resulting in preschool wheeze may alter the progression to school age asthma. Novel biologics have revolutionized the management of severe, treatment-resistant school age asthma, but a limited evidence base limits their use in young children. There are several potential future non-steroid-based treatment options in development, of which bacterial lysates show the most promise.

Expert opinion: Effective treatment of preschool wheeze may preserve lung function into later life, which may alter the progression trajectory toward school age asthma. Endotype-driven management will enable more effective treatment of both preschool wheeze and school age asthma.

Introduction: Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in the CF transmembrane regulator (CFTR) gene, leading to progressive lung disease and systemic complications. Lung disease remains the primary cause of morbidity and mortality, making early detection of lung function decline crucial. The Lung Clearance Index (LCI), derived from the multiple breath washout (MBW) test, has emerged as a sensitive measure for identifying early airway disease.

Areas covered: This review examines the technical aspects and clinical relevance of LCI, its advantages over traditional lung function tests, and its application in CF clinical trials. A focused literature review highlights LCI's utility in evaluating treatment efficacy and its potential integration into routine CF care.

Expert opinion: LCI is more sensitive than spirometry for detecting early lung function decline and is predominantly used in pediatric settings. Its use is expanding in adult CF populations as advances in treatment allow adults to maintain stable lung function. In clinical trials, LCI is widely recognized as an outcome measure. While implemented into clinical care in many centers in Europe, this is not yet the case in North America. Faster testing protocols and point-of-care interpretation tools will support LCI's integration into routine CF monitoring.

Introduction: Chronic obstructive pulmonary disease (COPD) is traditionally perceived as Th1-inflammation, but some patients have Th2-inflammation. A high fraction of exhaled nitric oxide (FE_NO) is seen in asthma with Th2-inflammation, justifying FE_NO as a point-of-care biomarker. The use of FE_NO in COPD is much less frequent. We aimed to review the evidence in favor of FE_NO measurement in COPD and discuss its potential usefulness in clinical settings.

Areas covered: This review covers nitric oxide production in the airways and FE_NO measurements in COPD patients during stable conditions and acute exacerbation. It discusses why COPD patients may have both low and high FE_NO levels and the potential clinical utility of FE_NO.

Expert opinion: There is good evidence that FE_NO increases with an exacerbation irrespective of the initial low or high baseline value. However, there is insufficient evidence to establish a fixed cutoff value for elevated FE_NO in COPD today. Instead, a personal baseline FE_NO level should be established when the patient is in a stable phase of the disease, which will subsequently set high and low FE_NO levels in a personalized manner. In the future, home monitoring of FE_NO could help identify exacerbations early, allowing proper action to be taken.

Background: The effectiveness of diaphragmatic electrical stimulation (DES) compared to mechanical ventilation (MV) in improving clinical outcomes such as quality-of-life (QOL) and hospital stay remains inconsistent.

Methods: We conducted a systematic review and meta-analysis by searching PubMed, Scopus, Google Scholar, LILACS, and IEEE Xplore. We included comparative studies (randomized controlled trials and observational studies) of DES administered via the phrenic nerve or intramuscular electrodes, compared with MV in adults with diaphragmatic paralysis or paresis. Two authors independently extracted data and assessed bias, with discrepancies resolved by a senior author. Results were pooled using the inverse variance method.

Results: Out of 1,290 articles, nine were included in the systematic review, totaling 852 subjects. In spinal cord injury (SCI), one study reported lower mortality with DES, while three found no difference compared to MV. In these patients, DES was associated with shorter hospital stay, similar QOL, and heterogeneous results on respiratory infections. In amyotrophic lateral sclerosis (ALS), DES was associated with higher mortality and similar QOL compared to MV. Most SCI studies had a serious risk of bias.

Conclusion: DES shows potential in reducing hospital stay and respiratory infections in SCI but is associated with higher mortality in ALS.