Expert review of respiratory medicine最新文献

Introduction: Malignant pleural effusions (MPE) affect many patients with advanced malignant disease and lead to significant symptomatic burden. Management is primarily focused on controlling symptoms. IPCs are considered an alternative treatment strategy to chemical pleurodesis and in randomized clinical trials, are shown to have comparable outcomes with regards to symptom management such as dyspnea score and quality of life, and are associated with shorter length of hospital stay. Additional studies have examined the optimal drainage strategy for IPCs and the combination of IPC and pleurodesis. The most common complication is infection, and management differs based on the specific infection type. For many patients, IPCs are likely a cost-effective option for management of MPE compared to alternative approaches.

Areas covered: This review article details the role of the indwelling pleural catheter (IPC) for symptom control, strategies for management, removal, complications, cost-effectiveness, and future directions.

Expert opinion: There are various management options for MPE, each with their own advantages and disadvantages. Management should be personalized, with full knowledge of the patient's life expectancy, pleural space physiology, risks and benefits of each approach, and most importantly patient preferences.

Background: Chronic obstructive pulmonary disease (COPD) is a major public health challenge in Colombia, particularly among older adults. Although ICS/LABA combinations like fluticasone/salmeterol (FSC) are widely used, dual bronchodilation with umeclidinium/vilanterol (UMEC/VI) may offer clinical and economic advantages.The objective of this paper is to evaluate the long-term cost-effectiveness of UMEC/VI versus FSC in patients with moderate to severe COPD from the perspective of the Colombian healthcare system.

Methods: A Markov model with four health states (moderate, severe, very severe COPD, and death) simulated the disease course over a lifetime horizon. Clinical efficacy and utilities were derived from randomized trials and meta-analyses; costs were sourced from national databases. Deterministic and probabilistic sensitivity analyses assessed uncertainty. The economic advantage of UMEC/VI was primarily driven by its ability to reduce moderate and severe exacerbations, which represent nearly 88% of total COPD-related healthcare costs in Colombia.

Results: UMEC/VI yielded 8.74 additional QALYs compared to FSC, with an incremental cost of $7,039 USD, resulting in an ICER of $805 per QALY-well below Colombia's WTP threshold of $5,180. Sensitivity analyses confirmed model robustness; UMEC/VI remained cost-effective in 64% of simulations.

Conclusion: UMEC/VI is a highly cost-effective alternative to FSC for moderate to severe COPD in Colombia, offering improved clinical outcomes and economic value for resource-constrained health systems.

Introduction: Pulmonary hypertension associated with congenital heart disease (PAH-CHD) represents one of the leading causes of pediatric pulmonary hypertension. Within this entity, patients can be classified into distinct subgroups, each characterized by specific clinical features, pathophysiological mechanisms, and therapeutic approaches.

Areas covered: This review provides an update of the current PAH-CHD classification and outlines management strategies in accordance with the most recent international recommendations. Particular attention is given to the ongoing debate regarding operability in patients with open shunts and some degree of increased pulmonary vascular resistance, and key gaps in knowledge are highlighted.

Expert opinion: In PAH-CHD, treatment strategies are relatively straightforward in patients with low PVR, where shunt closure is recommended, and in Eisenmenger syndrome, where shunt patency is maintained and pulmonary vasodilators are indicated; however, the management of patients with open shunts and moderately elevated PVR remains highly challenging. Operability in this intermediate group is currently determined by invasive hemodynamic assessment, despite methodological limitations, highlighting the urgent need for reliable noninvasive markers and prospective clinical studies in late-referred patients. Emerging therapies such as sotatercept, along with the development of novel biomarkers to assess pulmonary vascular disease severity may have the potential to redefine operability criteria and expand therapeutic options.

Introduction: Up to 40% of patients with COPD have an eosinophilic phenotype, which increases the risk of acute exacerbations. Mepolizumab, an anti - IL-5 monoclonal antibody, has shown mixed results. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of mepolizumab 100 mg in eosinophilic COPD.

Methods: Following PRISMA and Cochrane guidelines, we searched PubMed, Embase, and Cochrane Central through 18 May 2025. Randomized controlled trials comparing mepolizumab 100 mg versus placebo in eosinophilic COPD were included. The primary outcome was the annualized rate of moderate or severe exacerbations. Data were pooled using random-effects models.

Results: Four RCTs (1,953 patients) were included. Mepolizumab reduced annualized rate of moderate or severe exacerbations (Rate Ratio 0.80; 95% CI: 0.73-0.89; p < 0.00001) and prolonged time to first exacerbation (HR 0.78; 95% CI: 0.69-0.88; p < 0.0001). Sensitivity analysis excluding METREX showed fewer exacerbations requiring ED visits or hospitalization (Rate Ratio 0.63; 95% CI: 0.46-0.86; p = 0.004). Patient-reported outcomes did not improve. Safety was favorable, with reduced serious adverse events, including deaths (RR 0.84; 95% CI: 0.73-0.98; p = 0.03).

Conclusions: Mepolizumab reduces exacerbations with good safety in eosinophilic COPD, though without improvement in quality-of-life outcomes.

Introduction: Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), is a common cause of death in humans worldwide. The slow growth rate of Mtb (~20 hours) makes progress in research slow and diagnosis difficult.

Areas covered: Imaging technologies that can quantify viability and infectious load can have a profound impact on progress toward new therapeutics and vaccines and allow rapid diagnosis. Although imaging can quantify bacterial loads throughout an entire animal in real-time, sensitivity is a key limitation. Fluorescent and bioluminescent recombinant strains have been used within the TB field and in other bacteria but have a threshold of ~10³ bacteria in mice. Reporter enzyme fluorescence (REF) is a new and very sensitive Mtb imaging technology that uses BlaC, a highly specific surface-localized β-lactamase, in combination with fluorogenic or bioluminescent probes. As such, REF can reduce the threshold to 10-100 bacteria in vivo and detect 10 bacteria within 10 minutes in vitro.

Expert opinion: Recombinant reporter systems for imaging bacteria should continue to improve and may reach similar thresholds, but at present, REF remains the most sensitive approach. Furthermore, new more sensitive probes can be readily developed, suggesting that REF will ultimately allow detection of single bacteria in an infected host.

Introduction: Spatially resolved omics has reconceptualized the bronchial wall as a mosaic of epithelial - immune microenvironments whose local molecular circuits drive asthma heterogeneity and medication responsiveness.

Areas covered: We searched PubMed, Embase, Web of Science, and Scopus (January 2005 - July 2025) using platform-specific and disease-related keywords and identified studies that employed spatial transcriptomics, multiplex-imaging proteomics, or spatial metabolomics on human airway biopsies, ex vivo lung slices, and murine asthma models. We synthesize niches revealed by Visium-HD, Xenium, CosMx SMI, MERFISH, Imaging Mass Cytometry, MIBI, and high-resolution MALDI-MSI - IL-13-rich goblet-cell hubs, mast-cell - smooth-muscle loops, IL-17-driven neutrophil pockets, and fibroblast-remodeling zones. These investigations expose chemokine, alarmin, and lipid gradients that delineate disease-defining niches overlooked by dissociation-based assays, thereby uncovering therapeutic targets.

Expert opinion: Spatial omics links molecular programmes to micro-anatomy with near-single-cell accuracy and is poised for integration into precision-medicine pipelines. Cost-effective, high-throughput 'spatial biopsies,' combined with graph-based artificial intelligence, are expected to stratify patients for biologic therapies within five years. Nonetheless, broad clinical adoption will require reduced assay costs, mitigation of RNA diffusion, harmonized FFPE workflows, and multi-omic integration across global cohorts to produce reproducible, clinically actionable airway atlases capable of personalizing prevention and treatment.

Introduction: Traditional dogma suggests that acute pulmonary embolism (PE) occurs rarely in children <18 years. However, in the emergency department (ED) setting, the frequency of PE diagnosis in children with signs or symptoms that raise suspicion for PE is unknown. This uncertainty is fueled by the lack of prospective studies of PE exclusion and diagnosis in children. Children occasionally die unexpectedly from an acute PE that was missed during the initial evaluation by a physician. However, over-testing also carries risks.

Areas covered: This review addresses the risks of over-testing and radiation exposure, and the use of clinical criteria to assess the pretest probability of PE to decide when to test for this condition in children. We discuss what is known about the theoretical test threshold and the unstructured and structured pretest probability of PE assessment in children. Additionally, we review the theory behind the D-dimer assay and the current literature that has reported the diagnostic accuracy of the D-dimer for PE in children.

Expert opinion: We propose a hypothetical clinical algorithm that incorporates the use of a prediction rule that relies upon both unstructured and structured pretest probability assessments, coupled with the D-dimer to safely rule out the diagnosis of PE in children without the use of radiation.

Background: To identify the prevalence, clinical and imaging characteristics, and the risk factors for bronchiectasis in IBD.

Research design and methods: We retrospectively enrolled IBD patients from 1 January 2020 to 1 July 2022. Chest HRCT was evaluated for the presence and severity of bronchiectasis. The clinical characteristics were compared between the IBD patients with and without bronchiectasis.

Results: Among the 429 IBD patients, 34.5% showed bronchiectasis on chest HRCT. Four main imaging characteristics of bronchiectasis showed in IBD patients: multiple lobe involvement: 72.3% (107/148) of the patients had ≥2 lobes involved; Central predominance (>50%) in distribution; Mostly cylindrical bronchiectasis (>90%); Mild severity in most cases with Smith score <4 and Bhalla score of one point. Multi-factor logistic regression analysis showed that age of IBD onset ≥35 years (OR = 2.05, 95%CI 1.26-3.32), history of immunosuppressant therapy (OR = 3.93, 95%CI 2.12-7.27), ESR > 20 mm/h (OR = 2.01, 95%CI 1.21-3.33) and positive ASCA (OR = 1.37, 95% CI 1.06-1.77) were independently associated with the presence of bronchiectasis in IBD.

Conclusions: More than 1/3 IBD patients in our cohort presented bronchiectasis on chest HRCT, with almost no respiratory symptoms and the mild degree of bronchiectasis, which is easily overlooked. IBD patients may need routine chest HRCT scanning for bronchiectasis.

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.