Multidisciplinary Respiratory Medicine最新文献

Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by motor neuron degeneration and eventual respiratory failure, often first manifesting during sleep. Timely detection of nocturnal respiratory impairment is critical for initiating noninvasive ventilation (NIV), one of the few therapies proven to improve survival. Although polysomnography (PSG) is the reference standard, it is not always readily available in clinical practice.

Case presentation: We describe a 62-year-old man with spinal-onset ALS who underwent home sleep apnea testing (HSAT) for respiratory assessment. Although standard metrics were within normal limits, careful manual analysis of respiratory signals revealed diaphragmatic dysfunction through position-dependent desaturation and paradoxical breathing. NIV was initiated, resulting in improvements in sleep quality and daytime functioning.

Conclusions: This case illustrates the value of HSAT as a pragmatic and accessible tool for early detection of respiratory involvement in ALS, particularly when combined with detailed waveform inspection in setting where PSG is unavailable. Additionally, it emphasizes the importance of individualized NIV titration and interface optimization to ensure adherence and therapeutic benefit.

Background: Interstitial lung disease (ILD) is a common extramuscular manifestation of idiopathic inflammatory myopathies (IIM). Progressive pulmonary fibrosis (PPF) can develop in a subset of patients with IIM-associated interstitial lung disease (IIM-ILD) and is associated with poor outcomes. This study aimed to evaluate the utility of blood-based biomarkers associated with PPF in patients with IIM-ILD.

Methods: We retrospectively reviewed 54 consecutive patients diagnosed with IIM-ILD between January 2018 and December 2023. Patients were categorized as having PPF or not based on 2022 ATS/ERS/JRS/ALAT guideline criteria within 1 year after the diagnosis of IIM-ILD. Lung-specific macromolecules and systemic inflammatory and nutritional indices were calculated using laboratory data obtained at the initial evaluation. These included Krebs von den Lungen-6 (KL-6), surfactant protein-D, C-reactive protein-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), aggregate index of systemic inflammation (AISI), fibrosis-4 index, prognostic nutritional index, and geriatric nutritional risk index. Receiver operating characteristic curve analysis was used to determine optimal cutoff values, and logistic regression analyses were performed to identify factors associated with PPF.

Results: Of the 54 patients, 32 were classified as having PPF and 22 as not having PPF. The PPF group showed significantly lower hemoglobin levels and significantly higher platelet counts, neutrophil counts, C-reactive protein, and serum KL-6 levels than the non-PPF group. Several systemic inflammatory indices, including CAR, NLR, MLR, PLR, SII, SIRI, and AISI, were significantly higher in the PPF group. AISI showed the highest discriminative ability among the evaluated biomarkers, with an area under the curve of 0.786 and an optimal cutoff value of 278. In multivariable logistic regression analysis, serum KL-6 ≥626 U/mL and AISI ≥278 were independently associated with PPF, with adjusted odds ratios of 6.480 (95% confidence interval [CI]: 1.440-29.200; p = 0.015) and 9.940 (95% CI: 2.260-43.600; p = 0.002), respectively.

Conclusions: AISI and serum KL-6 may serve as accessible, non-invasive blood-based biomarkers associated with fibrotic progression in patients with IIM-ILD.

Background: If ultrasound dedicated software for the identification and quantification of interstitial syndrome is equal or superior to experts observation is still being explored. The primary objective of this study was to compare the performance of an automatic method based on a dedicated software algorithm with that of expert clinicians in terms of B-lines quantification.

Methods: Adult patients with acute respiratory failure who were deeply sedated, paralysed and mechanically ventilated were prospectively enrolled within 48 hours from ICU admission and underwent lung ultrasound by a trained physician. For each patient, 12 clips were stored, one for each thoracic region. The clips were then analyzed automatically using a built-in automatic recognition system and visually by two experts. A score of 0 was assigned if fewer than two B-lines were detected, a score of 1 if three or more B-lines were detected and a score of 2 if coalescent B-lines were detected.

Results: A total of 40 patients were included in the study. Out of the 480 clips analysed, 54.2% had a lung score of 0, 6.8% had a lung score of 1, 8.8% had a lung score of 2 and 20.2% had a lung score of 3. The agreement between the experts in detecting the scores 0, 1, 2 was excellent (ICC = 0.82) in 383 (79.8%) clips. The agreement between the automatic system and the experts was poor (ICC = 0.33), with a significant difference (p < 0.001).

Conclusions: In mechanically ventilated patients with acute respiratory failure, an automatic B-lines quantification system did not present an acceptable accuracy compared to expert consensus for B-lines counting, probably due to the coexistence of consolidation and pleural effusion.

Introduction: In-hospital cardiac arrest is associated with poor outcomes, yet peri-procedural code status discussions before bronchoscopy may be inconsistent, particularly in patients with elevated procedural risk.

Methods: We conducted an anonymous online survey of a convenience sample of hospital-based pulmonologists in Germany and Switzerland between April and July 2025. The survey assessed routine practices and attitudes regarding peri-procedural code status discussions, risk stratification, and management of patients with pre-existing No-CPR status. Owing to distribution through multiple channels and secondary forwarding, a precise response rate could not be calculated.

Results: A total of 148 pulmonologists participated (mean age 47.8 years; 94.6% board-certified). Discussions regarding CPR preferences were conducted almost always or most of the time before high-risk bronchoscopies by 67.6% of respondents, but were rarely or almost never performed before low-risk procedures by 72.0%. Respondents more frequently reported procedural risk than patient-related factors as a trigger for these discussions. Peri-procedural No-CPR status was considered controversial by 44.9%, and responsibility for these discussions varied among respondents. Only 25% reported formal institutional training.

Conclusions: Substantial variability exists in peri-procedural code status practices before bronchoscopy. Clearer responsibilities and structured guidance are needed to better align care with patient preferences.

Background: Inadequate endotracheal tube (ETT) cuff sealing permits microaspiration of subglottic secretions, driving ventilator-associated pneumonia and perioperative respiratory complications. Standard cylindrical and tapered cuffs remain susceptible to microchannel formation and leakage. This pilot study evaluated a novel ETT with a 90-mm self-expanding viscoelastic cuff (V-Cuff®) operating at ambient pressure compared to standard and specialty ETTs in vitro.

Methods: Five ETTs of each type-standard cylindrical (Ruschelit®), specialty tapered (Shiley Evac/TaperGuard®), and V-Cuff®-were tested at 37°C in a 3D-printed tracheal model with 5 cmH₂O positive end-expiratory pressure (PEEP). Evaluations included upper and lower pressure threshold assessments (UPTA and LPTA) and simulated swallowing (80 mmHg, 2s) and coughing (125 mmHg, 3s). Continuous and categorical outcomes were analyzed using Mann-Whitney U and Fisher's Exact tests, respectively.

Results: Under 5 cmH₂O PEEP, the standard ETT leaked immediately at 0 mmHg on UPTA. Both specialty and V-Cuff® ETTs tolerated supracuff pressures >90 mmHg on UPTA (p<0.001 vs. standard). On LPTA, air leak occurred at a mean of 5 ± 0.71 mmHg (standard) and 12 ± 1.22 mmHg (specialty), whereas the V-Cuff® showed no leakage at pressures >90 mmHg (p=0.008 vs. standard and specialty). During simulated swallowing and coughing, all standard and specialty ETTs leaked (5/5), while the V-Cuff® maintained complete seal integrity without leakage (0/5; p=0.008).

Conclusions: In this pilot in vitro study, the V-Cuff® ETT demonstrated superior airway sealing under all static and dynamic conditions compared to standard and tapered-cuff ETTs. These preliminary findings suggest the improved seal may reduce tracheal soiling, though prospective clinical validation is required to confirm reductions in aspiration-related complications.

Background: The overlap between asthma and obesity is becoming an increasing health concern, as overweight and obesity are linked to a higher risk of developing asthma and a greater disease burden.

Objective: To assess the association between obesity and hospital-related complications, as well as early readmission rates, in asthmatic patients.

Methods: This prospective observational cohort study was conducted at the Department of Chest Diseases, Ain Shams University Hospitals, between January 2024 and January 2026. A total of 75 adult patients were included and classified into three BMI groups: normal weight, overweight, and obese (n = 25 each). Clinical characteristics, pulmonary function tests, and in-hospital outcomes were assessed.

Results: Asthma severity increased with BMI, with severe asthma present in 96.0% of obese patients compared with 20.0% of overweight patients and none of the normal-weight patients (p < 0.001). Obese patients had lower pre-FEV₁ % predicted (47.5 ± 21.1%) than both overweight (58.5 ± 12.4%) and normal weight patients (65.2 ± 13.5%) (p = 0.003). They also had lower oxygen saturation and longer hospital stay (p < 0.001). ICU admission occurred only in obese patients (40.0%), with 20.0 % requiring mechanical ventilation. BMI correlated with longer hospital stay and lower oxygen saturation (p < 0.001). Predictors of ICU admission included obesity, severe asthma, ventilatory support, lower oxygen saturation, and reduced FEV₁.

Conclusion: Higher BMI was associated with increased asthma severity, poorer control, impaired lung function, and worse clinical outcomes, including longer hospital stay and greater need for intensive care. These findings highlight the value of weight management and comprehensive care in improving outcomes for obese patients with asthma.

Subglottic stenosis (SGS) is a chronic fibroinflammatory condition that causes pathological narrowing of the airway between the vocal cords and the trachea, with symptoms ranging from dyspnea to stridor and respiratory failure. The causes are heterogeneous: traumatic iatrogenic forms (such as prolonged intubation), autoimmune (e.g., granulomatosis with polyangiitis), post-viral (including COATS related to COVID-19), and idiopathic (iSGS), the latter affecting primarily adult Caucasian women with no obvious predisposing factors. All forms share a common pathogenetic core: epithelial damage, immune activation, chronic inflammation, and progressive fibrosis. Recent molecular studies, however, reveal that different variants of SGS exhibit distinct biological signatures, suggesting the existence of molecular subtypes with differentiated clinical courses. The emerging approach therefore aims for a biomarker-based classification for precision medicine. Future treatments may include targeted immunotherapies (e.g., IL-17A/IL-23 inhibitors), anti-fibrotic drugs, and epithelial regeneration strategies, alongside current surgical techniques to improve long-term prognosis.

Background: Sedation has become an essential component of modern interventional pulmonology, accompanying the progressive expansion of bronchoscopic procedures from conventional diagnostic bronchoscopy to advanced diagnostic and therapeutic airway interventions. Despite its increasing relevance, sedation practices remain heterogeneous, and dedicated national recommendations specifically addressing interventional pulmonology are still lacking in many countries.

Methods: A national cross-sectional survey was conducted among physicians involved in interventional pulmonology practice through the Accademia di Ecografia Toracica (ADET) network. The questionnaire consisted of 29 structured items covering organizational models, pharmacological strategies, monitoring approaches, and safety-related aspects of procedural sedation. Responses were analyzed descriptively using proportions, medians, and interquartile ranges. Agreement was operationally defined as a Likert score of 4-5 in at least 70% of responses.

Results: Forty-one responses were included in the final analysis. Sedation was routinely integrated into procedural activity in most centers, although relevant variability emerged regarding sedation management, monitoring practices, and anesthesiology involvement. The strongest agreement concerned the need for national recommendations to standardize sedation practices (80.5% agreement), followed by recognition that anesthesiologist presence is required during high-risk interventional procedures (73.2%). Substantial agreement emerged regarding pulmonologist-led moderate sedation in selected settings (68.3%), while capnography did not reach clear consensus (44.7%). Limited anesthesia availability was considered a relevant organizational factor by 63.2% of respondents.

Conclusions: Among participating clinicians, sedation was widely integrated into routine interventional pulmonology practice but remained organizationally heterogeneous. The survey identified broad agreement regarding the need for national harmonization and dedicated anesthesiology support for high-risk procedures. Given the network-based recruitment strategy and the absence of procedural volume data, these findings should be considered exploratory and hypothesis-generating rather than fully representative of national practice.

Background: Severe asthma affects approximately 3-5% of the pediatric asthmatic population and is associated with substantial clinical, economic, and psychosocial burdens. Despite major advances in biological therapies, standardized guidance for their optimal use in children and adolescents remains limited.

Objective: To establish experts' consensus on the management of severe pediatric asthma through a Delphi process promoted by the Italian Society of Pediatric Allergy and Immunology (SIAIP), with particular focus on biological therapy selection, monitoring, and response assessment.

Methods: A modified Delphi process involving 50 pediatric asthma experts was conducted. Twenty-seven statements addressing epidemiology, pathophysiology, biomarkers, biological therapies, monitoring strategies, and response definitions were developed through iterative rounds. Consensus was defined as ≥80% agreement (scores 4-5 on a 5-point Likert scale).

Results: All 27 statements achieved consensus (agreement range: 82-100%; mean scores: 4.1-4.9). Complete consensus was reached on key issues, including the need for endotype-based therapy selection, the predominance of type 2 inflammation in severe pediatric asthma, the role of currently available biological therapies (omalizumab, mepolizumab, dupilumab, tezepelumab), multidimensional response assessment (clinical, functional, and biological), and the importance of patient and family engagement. Strong consensus also supported the use of Core Outcome Measures for Severe Asthma (COMSA) for monitoring, classification of responders/super-responders /non-responders, and the predictive value of selected biomarkers, including blood eosinophil counts (≥300 cells/µL), FeNO, and baseline oral corticosteroid dose.

Conclusions: This Delphi Consensus provides expert-endorsed, evidence-based recommendations for the management of severe pediatric asthma, emphasizing personalized selection of biological therapy guided by biomarkers and systematic response monitoring using standardized outcome measures.

Background: Rhinitis is a common medical condition characterized by different phenotypes. Allergic (AR) and non-allergic (NAR) rhinitis share common type 2 inflammation. The present Italian educational activity investigated the clinical characteristics and treatments of patients with rhinitis managed by Italian otorhinolaryngologists.

Methods: Globally 117 well-matched otorhinolaryngologists attended this educational activity. This initiative consisted of a preliminary questionnaire to participants, one educational webinar, a field training session, and one in-person meeting. Demographic and clinical parameters, and treatments (previous and current) were collected.

Results: The otorhinolaryngologists collected data of 1238 patients with rhinitis (814 with AR and 424 with NAR). Nasal obstruction was the most common symptom, present in 88% of patients. Quality of life was impaired in about 80% of patients. Concomitant presence of nasal obstruction and impaired quality of life was associated with more severe symptoms. Intranasal corticosteroids (INCS) were the preferred treatment for participants. This educational initiative changed participants' attitudes and increased the percentage of INCS prescriptions, mainly for budesonide, and the use of INCS cycles.

Conclusions: The present iterative educational initiative yielded practical insights into the clinical characteristics of patients with type 2 rhinitis. Nasal obstruction and impaired quality of life are common clinical characteristics among patients visited. A close link between inflammation and associated symptoms justifies the frequent use of INCS. In this context, budesonide was perceived as a valuable option in managing AR and NAR patients.