Expert review of respiratory medicine最新文献

Introduction: The co-existence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), or the overlap syndrome, is common and associated with a distinct pattern of nocturnal hypoxemia and worse clinical outcomes than either disease alone. Consequently, identifying who and how to treat these patients is essential.

Areas covered: Treatment is recommended in all patients with OSA and symptoms or systemic hypertension, but determining symptoms attributable to OSA can be challenging in patients with COPD. Treatment should be considered in asymptomatic patients with moderate to severe OSA and COPD with pulmonary hypertension and comorbid cardiovascular and cerebrovascular disease, especially if marked hypoxic burden. CPAP is effective, but in patients with the overlap syndrome and daytime hypercapnia, high-intensity noninvasive ventilation aiming to lower PaCO2 may have additional benefits. Additionally, in those with severe resting daytime hypoxemia, supplemental oxygen improves survival and should be added to positive airway pressure. The role of alternative non-positive airway pressure therapies in the overlap syndrome needs further study.

Expert opinion: Both COPD and OSA are heterogeneous disorders with a wide range of disease severity and further research is needed to better characterize and prognosticate patients with the overlap syndrome to personalize treatment.

Introduction: Asthma is a common chronic respiratory disease affecting 262 million people globally, causing half a million deaths each year. Poor asthma outcomes are frequently due to non-adherence to medication, poor engagement with asthma services, and a lack of objective diagnostic tests. In recent years, technologies have been developed to improve diagnosis, monitoring, and care.

Areas covered: Technology has impacted asthma care with the potential to improve patient outcomes, reduce healthcare costs, and provide personalized management. We focus on current evidence on home diagnostics and monitoring, remote asthma reviews, and digital smart inhalers. PubMed, Ovid/Embase, Cochrane Library, Scopus and Google Scholar were searched in November 2023 with no limit by year of publication.

Expert opinion: Advanced diagnostic technologies have enabled early asthma detection and personalized treatment plans. Mobile applications and digital therapeutics empower patients to manage their condition and improve adherence to treatments. Telemedicine platforms and remote monitoring devices have the potential to streamline asthma care. AI algorithms can analyze patient data and predict exacerbations in proof-of-concept studies. Technology can potentially provide precision medicine to a wider patient group in the future, but further development is essential for implementation into routine care which in itself will be a major challenge.

Introduction: Chronic obstructive pulmonary disease (COPD) is the third most common cause of death worldwide and 24% of the patients die within 5 years of diagnosis.

Areas covered: The epidemiology of mortality and the interventions that reduce it are reviewed. The increasing global deaths reflect increases in population sizes, increasing life expectancy and reductions in other causes of death. Strategies to reduce mortality aim to prevent the development of COPD and improve the survival of individuals. Historic changes in mortality give insights: improvements in living conditions and nutrition, and later improvements in air quality led to a large fall in mortality in the early 20^th century. The smoking epidemic temporarily reversed this trend.Older age, worse lung function and exacerbations are risk factors for death. Single inhaler triple therapy; smoking cessation; pulmonary rehabilitation; oxygen therapy; noninvasive ventilation; and surgery reduce mortality in selected patients.

Expert opinion: The importance of addressing the global burden of mortality from COPD must be recognized. Steps must be taken to reduce it, by reducing exposure to risk factors, assessing individual patients' risk of death and using treatments that reduce the risk of death. Mortality rates are falling in countries that have adopted a comprehensive approach to COPD prevention and treatment.

Introduction: Sleep has important effects on breathing and gas exchange that may have negative consequences in patients with chronic obstructive pulmonary disease (COPD). COPD and obstructive sleep apnea (OSA) are highly prevalent and may coexist, which is referred to as the overlap syndrome.

Areas covered: The probability of OSA-COPD overlap represents the balance of protective and promoting factors such as hyperinflation and fluid retention; thus, different clinical COPD phenotypes influence the likelihood of comorbid OSA. The clinical presentation of OSA-COPD overlap is nonspecific, and the diagnosis requires clinical awareness to identify patients needing overnight studies. Both COPD and OSA are associated with a range of overlapping physiological and biological disturbances including hypoxia and inflammation that contribute to cardiovascular comorbidities. The management of OSA-COPD overlap patients differs from those with COPD alone and the survival of overlap patients treated with positive airway pressure (PAP) is superior to those untreated.

Expert opinion: The recognition of OSA-COPD overlap has important clinical relevance because of its impact on outcomes and management. Management of the overlap should address both sleep quality and disordered gas exchange. PAP therapy has demonstrated reductions in COPD exacerbations, hospitalizations, healthcare costs and mortality in overlap patients.

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of morbidity and mortality worldwide. The lung damage in COPD is associated with an enhanced chronic inflammatory response in the airways and lung tissue to harmful particles or gases. Early detection and treatment of COPD can help manage symptoms and slow the progression of the disease.

Areas covered: Status of knowledge regarding early diagnosis, definition of pre-COPD, possible new tools for early diagnosis, possibilities of early treatment, and the results of studies in this population are discussed. Literature search (2014-2024) was done in PubMed, EMBASE, and WoS databases using the keywords COPD, early diagnosis, treatment, smoking, prevention; with additional search of literature in found articles.

Expert opinion: No early case-finding programs have been proposed or validated, so we still have many patients diagnosed in the late stage of the disease. Clinically manifest COPD is characterized as typically progressive and irreversible with current therapeutic options. If we aim to reduce the mortality and morbidity from COPD we should target these steps: Prevention; Early diagnosis; Form registries of persons at risk for COPD development; Diagnose preclinical COPD; and discover new preventive therapeutic interventions.

Introduction: Pleural lesions may have heterogeneous presentation and causes. In recent years, there have been significant advances in pleural lesions diagnostics. The aim of this review is to provide an overview of the state-of-the-art, and recent updates for diagnostic modalities and monitoring regimes for pleural lesions.

Areas covered: A literature search was conducted through PubMed and Web of Science for relevant articles published from 1 January 2000- 1 March 2023. This article critically appraises the radiological modalities and biopsy techniques that are employed in pleural lesions diagnostics, including chest radiography, thoracic ultrasound, computed tomography, F-fluorodeoxyglycose positron emission tomography, magnetic resonance imaging, percutaneous, and thoracoscopic pleural biopsies with reference to their strengths, limitations, and clinical use. The review asserts also the available literature regarding monitoring algorithms.

Expert opinion: Despite the recent advances in the field, there are several key areas for improvement, including the development and validation of minimal invasive methods and tools for risk stratification, the integration of multi-omics technologies, the implementation of standardized, evidence-based diagnostic and monitoring guidelines and increased focus on research and patient-centric approaches. The broad establishment of dedicated pleural clinics may significantly assist toward this direction.

Background: Clinical guidance on the identification and management of connective tissue disease-associated interstitial lung disease (CTD-ILD) is needed for optimal clinical practice. We aimed to develop clinical algorithms for identifying and managing three common CTD-ILDs: those associated with systemic sclerosis (SSc-ILD), rheumatoid arthritis (RA-ILD), and polymyositis/dermatomyositis (PM/DM-ILD).

Research design and methods: Meetings were held October-November 2023 to create consensus-based algorithms for identifying and managing SSc-ILD, RA-ILD, and PM/DM-ILD in clinical practice, based on expert consensus statements for identification and management of CTD-ILD previously derived from a Delphi process.

Results: We developed clinical algorithms for SSc-ILD, RA-ILD, and PM/DM-ILD that highlight both commonalities and differences in the identification and management of these CTD-ILDs. Importantly, ILD should be suspected in patients with SSc, RA, or PM/DM who have respiratory symptoms. Chest high-resolution computed tomography has utility for screening, diagnosis and assessment of severity. Furthermore, regular follow-up and multidisciplinary management are important. Disease-specific considerations include unique risk factors such as anti-topoisomerase I antibodies in SSc-ILD, high-titer cyclic citrullinated peptide antibodies in RA, anti-aminoacyl tRNA synthetase antibodies in PM/DM, and anti-melanoma differentiation-associated gene 5 antibody in DM.

Conclusions: These algorithms may help physicians to identify and manage patients with SSc-ILD, RA-ILD, or PM/DM-ILD.

Introduction: The Exacerbation of Chronic Obstructive Pulmonary Disease (ECOPD), especially if leading to hospitalization, increases the risk of death. Our scoping review aims to identify updated mortality risk factors for both short- and long-term periods.

Areas covered: A comprehensive search, covering the period from January 2013 to February 2024, was performed to identify eligible studies that consider factors associated with death in hospitalized ECOPD. We considered short-term mortality, up to one year (including in-hospital mortality, IHM) and long-term mortality over one year, without time limits. We excluded studies concerning the intensive care area.

Expert opinion: We considered 38 studies, 32 and 8 reporting data about short- and long-term mortality, respectively. Two studies consider both periods. Several factors, some already known, others newly identified, have been evaluated and discussed. Some of these were related to the characteristics and severity of COPD (age, body mass index, lung impairment), and some considered the response to ECOPD. In this last context, we focused on the increasing role of biomarkers in predicting the mortality of patients, particularly IHM. Our factors associated with a worse prognosis may be helpful in clinical practice to identify patients at risk and, subsequently, determine a personalized approach.

Introduction: Cardiopulmonary exercise testing (CPET) is nowadays used to study the exercise response in healthy subjects and in disease. Ventilatory efficiency is one of the main determinants in exercise tolerance, and its main variables are a useful tool to guide pathophysiologists toward specific diagnostic pathways, providing prognostic information and improving disease management, treatment, and outcomes.

Areas covered: This review will be based on today's available scientific evidence, describing the main physiological determinants of ventilatory efficiency at rest and during exercise, and focusing also on how CPET variables are modified in specific diseases, leading to the possibility of early diagnosis and management.

Expert opinion: Growing knowledge on CPET interpretation and a wider use of this clinical tool is expected in order to offer more precise diagnostic and prognostic information to patients and clinicians, helping in the management of therapeutic decisions. Future research could be able to identify new and more simple markers of ventilatory efficiency, and to individuate new interventions for the improvement of symptoms, such as exertional dyspnea.

Introduction: Progressive pulmonary fibrosis (PPF) is a manifestation of a heterogenous group of underlying interstitial lung disease (ILD) diagnoses, defined as non-idiopathic pulmonary fibrosis (IPF) progressive fibrotic ILD meeting at least two of the following criteria in the previous 12 months: worsening respiratory symptoms, absolute decline in forced vital capacity (FVC) more than or equal to 5% and/or absolute decline in diffusing capacity for carbon monoxide (DLCO) more than or equal to 10% and/or radiological progression.

Areas covered: The authors subjectively reviewed a synthesis of literature from PubMed to identify recent advances in the diagnosis and characterisation of PPF, treatment recommendations, and management challenges. This review provides a comprehensive summary of recent advances and highlights future directions for the diagnosis, management, and treatment of PPF.

Expert opinion: Recent advances in defining the criteria for PPF diagnosis and licensing of treatment are likely to support further characterisation of the PPF patient population and improve our understanding of prevalence. The diagnosis of PPF remains challenging with the need for a specialised ILD multidisciplinary team (MDT) approach. The evidence base supports the use of immunomodulatory therapy to treat inflammatory ILDs and antifibrotic therapy where PPF develops. Treatment needs to be tailored to the specific underlying disease and determined on a case-by-case basis.