The new GOLD 2026 classification includes, for the first time, patients who experience one moderate exacerbation in a year in the E category. This change may have substantial implications, as patients with one moderate exacerbation are more frequent than those with two or more moderate exacerbations or at least one severe exacerbation considered together, according to population-based studies. This reclassification implies that patients with one moderate exacerbation and elevated blood eosinophil counts may initiate triple therapy, and, by being classified as GOLD E, may become candidates for second-line preventive treatments, despite GOLD recommendations for escalation only after two or more moderate exacerbations or one severe exacerbation. The rationale for classifying patients with one moderate exacerbation as GOLD E should rely on evidence of the clinical impact of a single moderate exacerbation and the associated increased risk of poor outcomes. This review summarises evidence from large trials and epidemiological studies regarding these aspects and proposes a pragmatic approach to management for patients with one moderate exacerbation. In conclusion, the impact of a single moderate exacerbation is limited at a population level and although the risk of future exacerbations is higher than in patients with none, it remains low, usually below 50%. Decisions regarding escalation or initiation of preventive therapy in COPD should be individualised, considering additional risk factors such as age, symptom burden, lung function impairment, and comorbidities, as well as patient preferences and values.
Spain implemented a national asbestos ban in 2002 after decades of high industrial use. The long-term impact on pleural mesothelioma (PM) mortality remains incompletely characterised. This study evaluates age-, sex-, and cohort-specific mortality trends up to 2023 to assess regulatory effects. We analysed national mortality registry data spanning 1980-2023. Age-period-cohort (A-P-C) models were applied to quantify temporal trends, identify cohort and period effects, and examine sex-specific patterns. Local drifts and net drifts were estimated to assess age-specific changes in MPM mortality. Male mortality showed a biphasic pattern, peaking around 2001-2002, followed by a modest decline in age-standardised rates. Female mortality declined steadily across the study period. Pronounced birth cohort effects were observed, with an 85% risk reduction between 1944 and 1974 male cohorts, reflecting reductions in occupational exposures over successive generations. Age-specific trends indicate steep declines among younger age groups, contrasting with continued elevated mortality in older cohorts exposed during Spain's industrial peak. Period effects were significant in men but not in women. Overall, trends suggest that post-2002 regulatory measures are starting to lower mortality rates, especially in younger age groups. Spain is entering a transitional phase in which the long-term benefits of asbestos ban are becoming empirically evident. However, substantial mortality persists among older cohorts due to the prolonged latency of MPM. These findings underscore the value of early regulatory action and highlight the continued need for surveillance, clinical care, and legacy asbestos remediation to mitigate the long-term public health burden.
Chronic respiratory diseases (CRDs) represent a substantial component of the global burden of disease, contributing significantly to morbidity, mortality, and healthcare expenditure worldwide. This review synthesizes current evidence on the epidemiology, determinants, and both population-level and individual impacts of four major respiratory health conditions: asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and smoking; the latter is both a disease in itself and a major contributor to respiratory and non-respiratory morbidity. Despite distinct pathophysiological mechanisms, these conditions share common risk factors, including environmental exposures and socioeconomic determinants, which contribute to diagnostic and management challenges. This review examines the burden of these conditions at both individual and population levels, explores current and future trends, and highlights the critical need for coordinated public health strategies, primary prevention, and global policy interventions to mitigate their growing impact. Considering the interconnections between human, animal, and environmental health, a unifying framework of planetary respiratory medicine and One Health may provide solutions to the CRD burden by promoting lung health across the life course.
This narrative review summarizes current evidence and clinical experience regarding telemonitoring across major respiratory diseases and care settings, including chronic obstructive pulmonary disease (COPD), asthma, interstitial lung diseases, obstructive sleep apnea, as well as non-invasive ventilation and pulmonary rehabilitation programmes. Advances in connectivity, artificial intelligence (AI), and wearable devices are facilitating the early detection of clinical deterioration, personalized interventions, and improved self-management, thereby optimizing the use of healthcare resources. Strong evidence supports the benefits of telemonitoring in COPD, particularly in reducing exacerbations and hospital admissions, whereas results are more heterogeneous in asthma and emerging conditions such as interstitial lung diseases. Telemonitoring systems leverage AI-driven analytical frameworks and interoperable digital platforms to process and interpret large volumes of patient data, enabling both automated responses and targeted human interventions. Key challenges include ensuring patient engagement, addressing digital literacy and inequities in access, safeguarding data privacy, and integrating digital solutions into standard care and reimbursement frameworks. The COVID-19 pandemic accelerated the adoption of telemonitoring, confirming its feasibility and acceptability, but also revealed persistent gaps in long-term cost-effectiveness and implementation strategies. Future directions should focus on integrating telemonitoring with AI-supported, coordinated clinical decision-making, enhancing system interoperability, and above all, prioritizing equitable access to digital care. Telemonitoring is poised to become a central component of respiratory patient management, although its large-scale implementation will require overcoming existing technical, ethical, and organizational barriers to fully realize its clinical potential.
Spirometry is essential for the diagnosis, severity assessment and longitudinal monitoring of Chronic Obstructive Pulmonary Disease (COPD). However, the minimal important difference (MID) for key spirometric parameters such as forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) remains poorly defined, particularly in patients with severe COPD. This study aimed was to determine the MID for FEV1 and FVC in patients with severe COPD undergoing bronchoscopic lung volume reduction treatment. We retrospectively analyzed data from patients with severe COPD who underwent bronchoscopic lung volume reduction between 2009 and 2024 at the University Medical Center Groningen. Anchor-based methods were used to calculate the MID for FEV1 and FVC using the 6-minute walk distance and St. George's Respiratory Questionnaire (SGRQ) as anchors. A total of 543 patients with severe COPD were included, predominantly female (68%) with a mean age of 62±8 years and baseline FEV1 of 27%±8 predicted. Anchor-based analyses yielded MIDs of approximately 139mL (relative: 19%) for FEV1 and 349mL (16%) for FVC at 6 months, and 127mL (17%) for FEV1 and 379mL (17%) for FVC at 12 months. The overall estimated MID for FEV1 in our population of patients with severe emphysema was 133mL (18%) and for FVC 364mL (16%). While the MID should not be interpreted as a strict cut-off, consensus on its values is essential to facilitate comparability across studies and to guide appropriate sample size calculations. Validation of these estimates in other COPD populations would be valuable.
We investigated DLCO parameters at 22 years and associations with socio-demographic, health, and behavioral factors. We studied a total of 3350 participants in the 22-year follow-up of the 1993 Pelotas Birth Cohort. DLCO, alveolar volume (VA), and transfer coefficient (KCO) were modeled against perinatal factors and characteristics at 22 years using crude and adjusted linear regressions, stratified by sex. Maternal smoking during pregnancy was linked to lower DLCO (β=-1.0; 95%CI, -1.72, -0.28) and VA (β=-0.19; 95%CI, -0.33, -0.05) in men. Low birth weight showed lower DLCO (β=-1.21; 95%CI, -2.13, -0.29) and VA (β=-0.29; 95%CI, -0.47, -0.11) in women. Black participants showed lower VA in both sexes and higher KCO in men (β=0.29; 95%CI, 0.14, 0.44). Obesity linked to lower VA and higher KCO in both sexes. Male smokers ≥11cigarettes/day had lower DLCO (β=-4.80; 95%CI, -6.01, -3.59), VA (β=-0.40; 95%CI, -0.64, -0.17), and KCO (β=-0.51; 95%CI, -0.70, -0.32). Female smokers showed higher DLCO and VA but lower KCO (β=-0.25; 95%CI, -0.49, -0.01). Pulmonary diffusing capacity is shaped by early-life factors and modifiable exposures, including tobacco smoking and obesity. After adjusting for confounders, including time since the last cigarette, to minimize bias related to the absence of hemoglobin or carboxyhemoglobin information, associations remained evident. DLCO serves as an early marker of respiratory and systemic health, supporting prevention strategies and risk stratification in young adults.
Advanced respiratory diseases, particularly chronic obstructive pulmonary disease (COPD) and interstitial lung diseases (ILD), constitute an increasing challenge for healthcare systems due to their high prevalence, substantial symptom burden, and significant resource use. This consensus document, developed jointly by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Palliative Care (SECPAL), provides recommendations for a multidisciplinary, integrated model of care. Using the SIGN methodology and a systematic literature review, a multidisciplinary panel developed 70 evidence-based recommendations addressing key domains: identification of patients with palliative care needs; management of respiratory symptoms; strategies to improve quality of life; communication and shared decision-making; caregiver support; and coordination across care settings. A needs-based approach, rather than reliance on prognosis alone, is recommended to facilitate earlier recognition of patients with advanced COPD and ILD and to enable the timely integration of palliative care alongside disease-directed therapies. Adoption of these recommendations is expected to improve quality of life, reduce symptom burden and suffering, and optimize care for patients with advanced respiratory diseases.
Rheumatoid arthritis associated interstitial lung disease (RA-ILD) is a serious extra-articular manifestation, being the second cause of death in patients with RA. Usual interstitial pneumonia is the most frequent form of ILD with several factors resembling idiopathic pulmonary fibrosis. Early recognition of ILD through screening could change treatment strategies and prognosis in patients with RA. In this sense achieving articular activity remission included in the treat to target strategy becomes one of the most important factors not only to diminish the risk for developing ILD but also disease progression. Disease-modifying antirheumatic drugs (DMARDs) became the cornerstone for treating patients with RA-ILD together with antifibrotics for those with progressive pulmonary fibrosis. Therefore, this guideline aims to support early recognition and evidence -based management of this condition.
Diagnostic tools that stratify lung cancer (LC) risk can help prioritize care for patients at the highest risk and optimize time and procedures to achieve the final diagnosis. We have previously demonstrated that six tumour biomarkers (TBs) - CEA, CYFRA 21.1, CA 15-3, SCC Ag, ProGRP, and NSE - can help assess LC risk. We developed expert software that combines these TBs with clinical and imaging data to estimate LC risk. The diagnostic accuracy of this expert software was evaluated in a multicentre study. We prospectively recruited 2005 individuals referred to 12 reference hospitals in Spain and Portugal for suspicion of LC. The six TBs were determined and the expert software was applied to all patients and correlated with the final diagnosis. A final diagnosis of LC was made in 1392 patients. The expert software yielded 87.7% sensitivity, 75.5% specificity, 89.0% positive predictive value and 73.0% negative predictive value. Sensitivity increased with tumour size and extension. The software also provides histological information, correctly predicting cancer in 98.4% of small-cell LC and 93.2% of non-small-cell LC, which correlates with the histological diagnosis of 90% and 91.2%, respectively. The expert software developed provides excellent diagnostic accuracy for diagnosing LC. Accordingly, this software can help stratify the risk of LC and prioritize the evaluation of patients at higher risk, optimizing procedures based on risk and knowledge of the most likely histological type, and providing a valuable tool for risk stratification and clinical decision support, particularly in Rapid Diagnostic Units.
Respiratory syncytial virus (RSV) represents a major global public health challenge, with an especially high burden in low- and middle-income countries, many of which are located in Latin America. Worldwide, RSV is the leading cause of hospitalization in infants and young children due to lower respiratory tract infections (LRTIs). Beyond the acute illness, severe RSV disease is associated with substantial long-term respiratory morbidity, including recurrent wheezing and an increased risk of asthma later in childhood. These consequences underscore the significant clinical, social, and economic impact of RSV on children, families, and health systems, particularly in regions where healthcare access and surveillance infrastructure remain limited.
Obstructive sleep apnea (OSA) and venous thromboembolism (VTE) share multiple risk factors and comorbidities, and several studies have reported a frequent coexistence of both conditions. However, the prevalence and clinical relevance of OSA among patients with acute VTE remain incompletely characterized. Systematic review and meta-analysis including studies reporting OSA prevalence in patients with acute VTE. PRISMA recommendations were followed. Each step was performed by ≥2 investigators. We searched Pubmed/Cochrane/Embase until September 2024 using free/MeSH/Emtree terms related to VTE/PE/DVT and OSA. Quality of evidence was evaluated. A meta-analysis was conducted to estimate the pooled prevalence across the studies according to different criteria. Heterogeneity was assessed (I2 statistics) and subgroup, sensitivity and meta-regression analysis were conducted. From 5066 articles retrieved, 25 studies were eligible. Quality assessment of studies suggested low risk of bias for internal validity but frequent high risk of bias regarding external validity. Meta-analyses revealed an OSA prevalence defined by an apnea-hypopnea index (AHI)≥5, ≥15 and ≥30 of 70% (95%CI 63-76%), 41% (95%CI 32-50%) and 21% (95%CI 16-26%), respectively. Prevalence was 8% (95%CI 4-13%) in studies assessing a known diagnosis of OSA through screening of health records. Heterogeneity was high (I2>70%). Systematic sleep assessment in patients with VTE identifies a substantial burden of sleep-disordered breathing, with wide variability across studies. Mild AHI elevations should be interpreted cautiously, whereas moderate-to-severe OSA and hypoxemia-related phenotypes appear more clinically relevant. These findings support a targeted clinical evaluation and the need for prospective studies in this population.
Recent studies have shown that combined use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and cryobiopsy provides a higher diagnostic yield for mediastinal lesions as compared with EBUS-TBNA alone. Currently, cryoprobes with diameters of 1.1mm and 1.7mm have been reported to be used for mediastinal cryobiopsy. We conducted a randomized controlled trial to evaluate and compare the diagnostic safety and efficacy profile the two cryoprobes in mediastinal disease. Consecutive patients with mediastinal lesions (≥1cm in the short axis) were prospectively enrolled. After four passes of needle aspiration, participants underwent mediastinal cryobiopsy with 1.1-mm and 1.7-mm cryoprobes in a randomized order. The main endpoints included procedural success rate, diagnostic yield, and safety. A total of 137 patients were recruited and randomized. Both 1.1-mm and 1.7-mm probe cryobiopsies added diagnostic value to EBUS-TBNA. (94.2% vs 75.9%; p<0.001; 92.0% vs 75.9%; p<0.001; respectively). Supplementing EBUS-TBNA with either 1.1-mm or 1.7-mm probe-cryobiopsy resulted in no differences in overall diagnostic yield (94.2% vs 92.0%; p=0.48). Nevertheless, direct comparison revealed a significantly improved overall diagnostic yield with 1.1-mm cryoprobe relative to 1.7-mm cryoprobe, primarily due to technical failures associated with the latter (88.3% vs 79.6%; p=0.048). Additionally, 1.1-mm and 1.7-mm cryoprobes yielded mediastinal specimens of similar size. Both approaches were safe, with no serious adverse events reported. 1.1-mm cryoprobe demonstrates better performance in transbronchial mediastinal cryobiopsy vs 1.7-mm cryoprobe, making it a viable adjunct to traditional needle biopsy.
Pediatric acute respiratory distress syndrome (PARDS) is a critical condition associated with considerable morbidity and mortality. Trials in adults showed controversial results about neuromuscular blocking agents (NMBAs) use in adult acute respiratory distress syndrome. With limited data in PARDS, we sought to compare the outcomes of continuous cisatracurium infusion versus intermittent bolus administration in children with PARDS. This multicenter randomized controlled study was performed on patients with PARDS. Enrolled patients were categorized into: group I: patients treated with intermittent boluses of cisatracurium and group II: patients treated with intravenous infusion of cisatracurium for 24h. The primary outcome was the duration on mechanical ventilator (MV). Additional results included changes in ventilatory parameters, and length of pediatric intensive care unit (PICU) stay. Group II was associated with a significantly higher extubation from MV compared to group I, after accounting for death as a competing event. This association was confined to moderate-to-severe PARDS (subdistribution hazard ratio (SHR) 3.25, 95% CI 1.69-6.25, p<0.001) and not observed in mild PARDS. Similar with earlier PICU discharge, with stronger effect in moderate-to-severe disease (SHR 3.16, 95% CI 1.64-6.11, p<0.001). By day 7, patients with moderate-to-severe PARDS in group II showed lower fraction of inspired oxygen, mean airway pressure, and oxygenation index. In PARDS, cisatracurium infusion was associated with better oxygenation, earlier extubation from MV and shorter PICU stay compared to intermittent boluses, with benefits limited to moderate-to-severe disease. Outcomes were similar in mild PARDS.
The objectives of this study are to analyse whether liver transplant recipients (LTR) have a higher incidence of lung cancer (LC) compared to a population of high risk smokers enrolled in a LC screening program and to evaluate if LC screening results allow an early diagnosis in LTRs. We conducted a retrospective study comparing LC screening outcomes using low-dose computed tomography (LDCT) in 124 LTRs and 485 matched non-immunosuppressed controls. Matching criteria included age, sex, smoking history, active smoking status, and presence of emphysema. Tumour characteristics, staging, treatment, and survival were analysed. LC was diagnosed in 9.7% of LTRs and 4.5% of controls (p=0.11). LTRs more frequently presented with squamous cell carcinoma, while adenocarcinoma predominated in controls. Early-stage diagnosis (stage IA) was more common in LTRs (83.4% vs. 50%, p=0.056). Survival after diagnosis was comparable between groups in the first three years, although LTRs showed reduced long-term survival. Multivariate analysis identified cumulative tobacco exposure>35 pack-years (HR=3.0; p=0.003), and centrilobular emphysema (HR: 2.8; p=0.004) as independent risk factors for LC, liver transplantation showed an association close to significance (HR: 1.9; p=0.08). LTRs have a higher incidence of LC than matched non-immunosuppressed individuals. LDCT screening enables early detection and favourable outcomes. These findings support routine LC screening in high-risk LTRs, particularly those with significant smoking histories, and centrilobular emphysema.
Spirometry is the main diagnostic procedure for most respiratory diseases. This document sets out the principal recommendations for performing and interpreting the test in adult and pediatric populations, in accordance with current evidence-based guidelines and standards. It is important to be familiar with the indications and contraindications of the test, as well as the technical requirements of the equipment and the facilities where it is performed. The personnel responsible for conducting the test must have appropriate training in order to obtain maneuvers of sufficient quality for subsequent interpretation. The quality grade of each test must be determined before interpretation. Spirometric tests should be interpreted using updated reference values appropriate for each patient group, and in addition to assessing whether the measured values are within normal limits, spirometry can provide information suggestive of specific patterns indicative of airway disease, parenchymal lung disease, or even disorders of the chest wall. Performing spirometry after administration of a bronchodilator is also often required for the diagnosis of certain respiratory diseases, and standardization of this procedure is essential in order to interpret the changes in spirometric values after bronchodilation.
Venous Excess Ultrasound Score (VExUS) protocol has emerged as a non-invasive tool for assessing systemic congestion. Its utility in pulmonary embolism (PE) remains uncertain. This study aims to analyze VExUS findings in acute PE patients and determine their association with disease severity category. A prospective cohort study was conducted between May 2024 and May 2025. Patients with confirmed acute PE were included. Ultrasonographic assessment following the VExUS protocol was performed prior to or within 24h of antithrombotic therapy initiation. The primary outcome was the ordered association between PE severity and VExUS score analyzed using the Jonckheere-Terpstra test and ordinal logistic regression. Eighty patients were evaluated (43.8% women, mean age 66.7±14.3 years), of them: 28.8% had low risk, 42.5% intermediate-low risk, 21.3% intermediate-high risk, and 7.5% high risk PE. All patients in the low and intermediate-low risk groups had a VExUS score of 0, while intermediate-high and high risk patients had progressively higher scores (Jonckheere-Terpstra's J=1020, p<0.001). The portal vein pulsatility index was identified as the parameter most precisely associated with severity (OR 1.16; 95% CI: 1.06-1.26). Hepatic vein patterns also showed a significant association (S>D vs S<D or inverted S OR 16.57; 95% CI: 2.41-113.83). The IVC diameter and renal veins pattern did not demonstrate a significant association with PE severity. The assessment of venous congestion using the VExUS protocol in patients with acute PE demonstrates a direct association with risk category.
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