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Hypersensitivity pneumonitis (HP) is an immune‐mediated interstitial lung disease (ILD) relating to specific occupational, environmental or medication exposures. Disease behaviour is influenced by the nature of exposure and the host response, with varying degrees of lung inflammation and fibrosis seen within individuals. The differentiation of HP from other ILDs is important due to distinct causes, pathophysiology, prognosis and management implications. This Thoracic Society of Australia and New Zealand (TSANZ) position statement aims to provide an up‐to‐date summary of the evidence for clinicians relating to the diagnosis and management of HP in adults, in the Australian and New Zealand context. This document highlights recent relevant findings and gaps in the literature for which further research is required. [ABSTRACT FROM AUTHOR]

SUMMARY OF KEY POINTS In this review, we have discussed several important developments in 2023 in Interstitial Lung Disease (ILD). The association of pollution with genetic predispositions increased the risk of Idiopathic Pulmonary Fibrosis (IPF). An interesting comorbidity of malnutrition was not adequately recognized in ILD. Novel genes have been identified in IPF involving predominantly short telomere length and surfactant protein production leading to alveolar epithelial cell dysfunction. Genetics also predicted progression in IPF. Crosstalk between vascular endothelial cells and fibroblasts in IPF mediated by bone morphogenic protein signalling may be important for remodelling of the lung. A novel modality for monitoring of disease included the 4‐min gait speed. New treatment modalities include inhaled pirfenidone, efzofitimod, for sarcoidosis, and earlier use of immunosuppression in connective tissue disease‐ILD. [ABSTRACT FROM AUTHOR]

Background and Objective: Lymphangioleiomyomatosis (LAM) is a rare neoplastic disease associated with the functional tumour suppressor genes TSC1 and TSC2 and causes structural destruction in the lungs, which could potentially increase the risk of lung cancer. However, this relationship remains unclear because of the rarity of the disease. Methods: We investigated the relative risk of developing lung cancer among patients diagnosed with LAM between 2001 and 2022 at a single high‐volume centre in Japan, using data from the Japanese Cancer Registry as the reference population. Next‐generation sequencing (NGS) was performed in cases where tumour samples were available. Results: Among 642 patients diagnosed with LAM (sporadic LAM, n = 557; tuberous sclerosis complex‐LAM, n = 80; unclassified, n = 5), 13 (2.2%) were diagnosed with lung cancer during a median follow‐up period of 5.13 years. All patients were female, 61.5% were never smokers, and the median age at lung cancer diagnosis was 53 years. Eight patients developed lung cancer after LAM diagnosis. The estimated incidence of lung cancer was 301.4 cases per 100,000 person‐years, and the standardized incidence ratio was 13.6 (95% confidence interval, 6.2–21.0; p = 0.0008). Actionable genetic alterations were identified in 38.5% of the patients (EGFR: 3, ALK: 1 and ERBB2: 1). No findings suggested loss of TSC gene function in the two patients analysed by NGS. Conclusion: Our study revealed that patients diagnosed with LAM had a significantly increased risk of lung cancer. Further research is warranted to clarify the carcinogenesis of lung cancer in patients with LAM. [ABSTRACT FROM AUTHOR]

Background and Objective Methods Results Conclusion Sarcoidosis can manifest with atypical findings on chest computed tomography (CT). Cysts are a rare manifestation of lung sarcoidosis. The aim of the study was to describe a series of patients with cystic sarcoidosis and their clinical‐radiological characteristics and progression.In this retrospective, bicentric study we recruited all patients affected by sarcoidosis with lung cystic lesions at chest CT. We collected clinical characteristics, pulmonary tests and tracked number, distribution and size of the cysts at diagnosis and at the last evaluation.Twelve patients (6 males, median age 53 years) were identified (prevalence: 1.9%; 95% Confidence Interval: 0.8%–2.9%). All patients presented multiple cystic lesions (median number: 14 [range: 2–216]) with a bilateral distribution in 10/12, micronodules and nodules in 11/12 and fibrotic lesions in 4/12. Seven patients had normal lung function test, three had an obstructive syndrome, one had a restrictive syndrome and one had coexistence of both. During follow‐up (median: 10 years [range 1–16 years]), an increase of the number of cysts was observed in four patients. At last evaluation, 3/12 patients experienced a decline of forced vital capacity >10% and 3/12 patients a decline of diffusing capacity for carbon monoxide (DLCO) >10%. A lower DLCO at diagnosis, and the presence of nodules or fibrotic lesions on CT were associated with an increase in the number of cysts.Cystic lung lesions are rare in patients with sarcoidosis and do not influence long term prognosis. [ABSTRACT FROM AUTHOR]

SUMMARY OF KEY POINTS: Air pollutants have various effects on human health in environmental and occupational settings.Air pollutants can be a risk factor for incidence, exacerbation/aggravation and death due to various lung diseases, including asthma, chronic obstructive pulmonary disease (COPD), hypersensitivity pneumonitis or pneumonia (HP), pulmonary fibrosis such as pneumoconiosis and malignant respiratory diseases such as lung cancer and malignant pleural mesothelioma.Environmental and occupational respiratory diseases are crucial clinical and social issues worldwide, although the burden of respiratory disease due to environmental and occupational causes varies depending on country/region, demographic variables, geographical location, industrial structure and socioeconomic situation.The correct recognition of environmental and occupational lung diseases and taking appropriate measures are essential to their effective prevention. [ABSTRACT FROM AUTHOR]

Lung transplantation is a well‐established treatment for advanced lung disease, improving survival and quality of life. Over the last 60 years all aspects of lung transplantation have evolved significantly and exponential growth in transplant volume. This has been particularly evident over the last decade with a substantial increase in lung transplant numbers as a result of innovations in donor utilization procurement, including the use donation after circulatory death and ex‐vivo lung perfusion organs. Donor lungs have proved to be surprisingly robust, and therefore the donor pool is actually larger than previously thought. Parallel to this, lung transplant outcomes have continued to improve with improved acute management as well as microbiological and immunological insights and innovations. The management of lung transplant recipients continues to be complex and heavily dependent on a tertiary care multidisciplinary paradigm. Whilst long term outcomes continue to be limited by chronic lung allograft dysfunction improvements in diagnostics, mechanistic understanding and evolutions in treatment paradigms have all contributed to a median survival that in some centres approaches 10 years. As ongoing studies build on developing novel approaches to diagnosis and treatment of transplant complications and improvements in donor utilization more individuals will have the opportunity to benefit from lung transplantation. As has always been the case, early referral for transplant consideration is important to achieve best results. [ABSTRACT FROM AUTHOR]

Background and Objective: When multiple complex air pollutants are combined in real‐world settings, the reliability of estimating the effect of a single pollutant is questionable. This study aimed to investigate the combined effects of changes in air pollutants on small airway dysfunction (SAD). Methods: We analysed Korea National Health and Nutrition Examination Survey (KNHANES) V–VIII database from 2010 to 2018 to elucidate the associations between annual changes in air pollutants over a previous 5‐year period and small airway function. We estimated the annual concentrations of five air pollutants: NO2, O3, PM2.5, SO2 and CO. Forced expiratory flow between 25% and 75% of vital capacity (FEF25%–75%) <65% was defined as SAD. Using the quantile generalized‐Computation (g‐Computation) model, the combined effect of the annual changes in different air pollutants was estimated. Results: A total of 29,115 individuals were included. We found significant associations between SAD and the quartiles of annual changes in NO2 (OR = 1.10, 95% CI = 1.08–1.12), O3 (OR = 1.03, 95% CI = 1.00–1.05), PM2.5 (OR = 1.03, 95% CI = 1.00–1.05), SO2 (OR = 1.04, 95% CI = 1.02–1.08) and CO (OR = 1.16, 95% CI = 1.12–1.19). The combined effect of the air pollutant changes was significantly associated with SAD independent of smoking (OR = 1.31, 95% CI = 1.26–1.35, p‐value <0.001), and this trend was consistently observed across the entire study population and various subgroup populations. As the estimated risk of SAD, determined by individual‐specific combined effect models, increased and the log odds for SAD increased linearly. Conclusion: The combined effect of annual changes in multiple air pollutant concentrations were associated with an increased risk of SAD. [ABSTRACT FROM AUTHOR]

Background and Objective: Next‐generation sequencing (NGS) analysis is considered standard for lung cancer diagnosis in clinical practice. Little is known about the feasibility of NGS using tumour tissue sampled with a 1.1 mm‐diameter cryoprobe. We aimed to investigate the suitability of specimens obtained by transbronchial cryobiopsy (TBC) using a 1.1 mm‐diameter cryoprobe for NGS analysis. Methods: Patients with lung cancer who underwent TBC using a 1.1 mm‐diameter cryoprobe for NGS testing between October 2020 and April 2023 were enrolled. A 4.0‐ or 3.0 mm‐diameter bronchoscope with radial probe endobronchial ultrasound and virtual bronchoscopic navigation was used to detect peripheral lung lesions. All procedures were performed under fluoroscopic guidance. Data were analysed retrospectively. Results: A total of 56 patients underwent TBC using a 1.1 mm cryoprobe for NGS testing, during the study period. Most patients (98%) were in the advanced stage of lung cancer (recurrent or inoperable disease of stages III or IV). The diagnostic yield of NGS for DNA and RNA sequencing was 95% each (53 of 56). Moderate bleeding was noted in three patients (5%) and none of the study patients developed life‐threatening complications, such as pneumothorax or lung infection. Conclusion: TBC using a 1.1 mm‐diameter cryoprobe is a useful and safe tool for NGS analysis, for both DNA and RNA sequencing. [ABSTRACT FROM AUTHOR]

The article discusses the need for equitable access to clinical trials for individuals with respiratory conditions, particularly those who live outside major cities. It highlights the disproportionate burden of respiratory diseases on people in rural and remote areas, citing examples from Asia, the United States, and Australia. The article emphasizes the importance of clinical trials in providing early access to new therapies and technologies, but notes that participation rates are lower in regional areas due to the concentration of trial sites in major cities. It suggests that teletrials, which use telehealth to enable remote access to clinical trials, could be a solution to this issue. The article references the successful implementation of teletrials in other specialties, such as oncology, and discusses the potential benefits of teletrials in respiratory medicine, including increased diversity of participants, decreased recruitment time, enhanced retention, and reduced costs for patients. It also highlights the investment and infrastructure development for teletrials in Australia, which could serve as a model for other jurisdictions. The article concludes by urging respiratory clinical triallists to seize the opportunities presented by teletrials to expand access to clinical trials for individuals with respiratory diseases who live outside major cities. [Extracted from the article]

The article discusses the implications of the 28th Conference of the Parties (COP28) of the United Nations Framework Convention on Climate Change (UNFCCC) for lung disease. It highlights the significant impact of climate change on respiratory diseases, such as increased air pollution and extreme weather events, which can exacerbate conditions like asthma and chronic obstructive pulmonary disease (COPD). The article emphasizes the importance of climate change mitigation for respiratory health and the need for global efforts to reduce greenhouse gas emissions. It also mentions the recent COP28 UAE Declaration on Climate and Health, which recognizes the adverse impacts of climate change on health and calls for action to protect respiratory health. However, the article notes that COP28 failed to achieve the necessary level of ambition to mitigate climate change and protect vulnerable populations. It concludes by highlighting the role of healthcare providers, individuals, and leaders in promoting cleaner energy, supporting policies for environmental health, and preparing healthcare systems for the impacts of climate change. [Extracted from the article]

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This article, titled "Profiling markers of silicosis in a Victorian cohort of engineered stone workers," discusses the ongoing issue of silicosis, a lung disease caused by exposure to silica dust, particularly in the context of engineered stone workers. The study aims to understand the disease better by determining the silica load and identifying proteins present in the bronchoalveolar lavage fluid (BALF) of silicosis patients compared to non-diseased controls. The researchers found that there was no significant relationship between silica load and lung function measures. They also identified several proteins that may contribute to disease initiation and progression, potentially serving as biomarkers or therapeutic targets. [Extracted from the article]

The article discusses the activities and initiatives undertaken by the Forum of International Respiratory Societies (FIRS) in support of World Lung Day 2024 with the theme 'Clean Air and Healthy Lungs for All.' FIRS focused on tobacco control, bronchiectasis awareness, and lung cancer detection, emphasizing the importance of early intervention and access to healthcare. The article highlights the need for global efforts to ensure clean air and respiratory health for all, aligning with the goals of FIRS and the Asian Pacific Society of Respirology (APSR). [Extracted from the article]

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This article discusses the benefits of exercise in managing chronic lung disease. The authors share their personal experiences with exercise and how it has positively impacted their health. They also highlight the role of pulmonary rehabilitation in improving dyspnea and psychological well-being in patients with chronic lung disease. However, barriers to accessing pulmonary rehabilitation and maintaining exercise programs exist in many healthcare systems. The article emphasizes the importance of educating patients and clinicians about the benefits of physical activity, particularly in conditions where current treatments have limited impact on symptoms and quality of life. [Extracted from the article]

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This document is a quarterly editorial from the journal Respirology, highlighting three published articles that are of ongoing educational value. The first article discusses supranormal lung function, which is associated with a reduced risk for chronic lung diseases. The second article explores racial and ethnic disparities in antifibrotic therapy for idiopathic pulmonary fibrosis. The third article compares the outcomes of two treatments for severe asthma. These articles provide valuable insights into lung health and the impact of disparities in respiratory diseases. Further research is needed to confirm these findings and address the identified disparities. [Extracted from the article]

The World Health Organization (WHO) has released a fungal priority pathogen list (FPPL) to prioritize fungal pathogens based on their research and development needs and public health importance. The list categorizes 19 major invasive fungal pathogens into critical, high, and medium priority, with over half of them posing significant threats to respiratory patients. It is important for respiratory physicians to understand the clinical presentations, diagnostic methods, and treatment options for these infections in order to reduce morbidity and mortality. The FPPL aims to drive improvements in laboratory capacity, surveillance systems, and public health interventions to address these priority fungal pathogens. [Extracted from the article]

Interventional pneumology (IP) has rapidly developed over the past 120 years, evolving from a diagnostic procedure to a therapeutic option for lung diseases. IP techniques such as endobronchial ultrasound and cryobiopsy have revolutionized the diagnosis and staging of lung diseases. Additionally, IP procedures have shown promise in treating conditions such as chronic obstructive pulmonary disease (COPD) and severe asthma. However, the acceptance of IP by payers and the lack of training structures for new developments remain challenges. Overall, IP is expected to become increasingly recognized and offer effective diagnostic and therapeutic methods for lung patients. [Extracted from the article]

The approach taken to find a solution The Activating Primary Care COPD Patients with Multimorbidity (APCOM) program, is a self-management support program aimed to improve patient activation, COPD-related quality of life, COPD knowledge, inhaler device technique and self-management capacity of their multimorbidity. There was also a significant improvement ( I p i = 0.001) in the accuracy of patients' inhaler device technique, with 20 patients performing the technique correctly at 6 months follow-up compared to five patients at baseline. The Tuberculosis Diagnostic Clinic regularly convenes a group of radiologists and internists to decide on the activity of the tuberculosis status of problematic patients who are sputum TB Genexpert negative yet manifest with possible tuberculosis. Keywords: asthma; COPD; COVID-19; lung cancer; respiratory infections; tuberculosis EN asthma COPD COVID-19 lung cancer respiratory infections tuberculosis 807 816 10 07/21/23 20230801 NES 230801 B Background b : In conjunction with the Annual Scientific Congress of the APSR held in Seoul, South Korea in November 2022, a workshop was held which brought together representatives from the APSR, Union APR, WHO SEARO and WHO WPRO. [Extracted from the article]

This position statement, updated from the 2015 guidelines for managing Australian and New Zealand children/adolescents and adults with chronic suppurative lung disease (CSLD) and bronchiectasis, resulted from systematic literature searches by a multi‐disciplinary team that included consumers. The main statements are:Diagnose CSLD and bronchiectasis early; this requires awareness of bronchiectasis symptoms and its co‐existence with other respiratory diseases (e.g., asthma, chronic obstructive pulmonary disease).Confirm bronchiectasis with a chest computed‐tomography scan, using age‐appropriate protocols and criteria in children.Undertake a baseline panel of investigations.Assess baseline severity, and health impact, and develop individualized management plans that include a multi‐disciplinary approach and coordinated care between healthcare providers.Employ intensive treatment to improve symptom control, reduce exacerbation frequency, preserve lung function, optimize quality‐of‐life and enhance survival. In children, treatment also aims to optimize lung growth and, when possible, reverse bronchiectasis.Individualize airway clearance techniques (ACTs) taught by respiratory physiotherapists, encourage regular exercise, optimize nutrition, avoid air pollutants and administer vaccines following national schedules.Treat exacerbations with 14‐day antibiotic courses based upon lower airway culture results, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients with severe exacerbations and/or not responding to outpatient therapy are hospitalized for further treatments, including intravenous antibiotics and intensive ACTs.Eradicate Pseudomonas aeruginosa when newly detected in lower airway cultures.Individualize therapy for long‐term antibiotics, inhaled corticosteroids, bronchodilators and mucoactive agents.Ensure ongoing care with 6‐monthly monitoring for complications and co‐morbidities.Undertake optimal care of under‐served peoples, and despite its challenges, delivering best‐practice treatment remains the overriding aim. [ABSTRACT FROM AUTHOR]

Background and Objective: Pulmonary hypertension is a life‐limiting complication of interstitial lung disease (ILD‐PH). We investigated whether treatment with phosphodiesterase 5 inhibitors (PDE5i) in patients with ILD‐PH was associated with improved survival. Methods: Consecutive incident patients with ILD‐PH and right heart catheterisation, echocardiography and spirometry data were followed from diagnosis to death, transplantation or censoring with all follow‐up and survival data modelled by Bayesian methods. Results: The diagnoses in 128 patients were idiopathic pulmonary fibrosis (n = 74, 58%), hypersensitivity pneumonitis (n = 17, 13%), non‐specific interstitial pneumonia (n = 12, 9%), undifferentiated ILD (n = 8, 6%) and other lung diseases (n = 17, 13%). Final outcomes were death (n = 106, 83%), transplantation (n = 9, 7%) and censoring (n = 13, 10%). Patients treated with PDE5i (n = 50, 39%) had higher mean pulmonary artery pressure (median 38 mm Hg [interquartile range, IQR: 34, 43] vs. 35 mm Hg [IQR: 31, 38], p = 0.07) and percentage predicted forced vital capacity (FVC; median 57% [IQR: 51, 73] vs. 52% [IQR: 45, 66], p=0.08) though differences did not reach significance. Patients treated with PDE5i survived longer than untreated patients (median 2.18 years [95% CI: 1.43, 3.04] vs. 0.94 years [0.69, 1.51], p = 0.003) independent of all other prognostic markers by Bayesian joint‐modelling (HR 0.39, 95% CI: 0.23, 0.59, p < 0.001) and propensity‐matched analyses (HR 0.38, 95% CI: 0.22, 0.58, p < 0.001). Survival difference with treatment was significantly larger if right ventricular function was normal, rather than abnormal, at presentation (+2.55 years, 95% CI: −0.03, +3.97 vs. +0.98 years, 95% CI: +0.47, +2.00, p = 0.04). Conclusion: PDE5i treatment in ILD‐PH should be investigated by a prospective randomized trial. [ABSTRACT FROM AUTHOR]

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Background and objective: The major contributing risk factors to airflow obstruction (AO) in China remain largely unknown. We examined the environmental and lifestyle risk factors of unrecognized AO in the baseline of a population‐based cohort drawn from 115 urban and rural communities across 12 provinces in China. Methods: Amongst 46,285 adults recruited from 2005 to 2009, 3686 were identified with AO on spirometry (defined by the ratio of forced expiratory volume in the first second to forced vital capacity <0.7) and without known chronic lung disease. These cases were age‐ and sex‐matched to 11,129 controls with normal spirometry and no chronic lung disease from the same community. Conditional multivariable adjusted OR and population attributable fraction (PAF) were calculated for each identified risk factor and their combined effect. Results: Compared to controls, smoking initiation age <20 years (OR 1.22 [95% CI 1.01–1.48]), smoking duration ≥40 years (OR 1.82 [1.50–2.22]), low vegetables (OR 1.86 [1.67–2.07]) and fruits (OR 1.14 [1.02–1.29]) intake, cooking with biomass fuels (OR 2.54 [2.32–2.78]) and poor kitchen ventilation (OR 1.37 [1.19–1.58]) were significantly associated with elevated risks of unrecognized AO. The combined effect of these lifestyle factors significantly elevated the odds by 25 fold (18.6–34.3). The addition of prior tuberculosis and low socioeconomic status further increased the odds to 40.1 (28.2–57.0) and the PAF to 66.7% (51.1–78.1). Conclusion: Smoking, unhealthy diet, biomass cooking fuels and low socioeconomic status are strongly associated with AO. Addressing these risk factors could substantially reduce the burden of AO in China. [ABSTRACT FROM AUTHOR]

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Background and objective: Artificial stone benchtops are a popular kitchen product, but dust from their preparation and installation contains respirable crystalline silica, which causes silicosis. Silicosis is a preventable, permanent lung disease. The aim of this study was to assess mental health in workers from the artificial stone benchtop industry at risk of silicosis. Methods: Workers from the artificial stone benchtop industry undergoing assessment for silica‐associated disease were included. Information on demographics; occupational, medical and smoking history; modified Medical Research Council dyspnoea scale; Perceived Stress Scale (PSS‐10) questionnaire; spirometry; and chest x‐ray was collected. Univariate and multivariate regression analyses were conducted. Results: Of the 547 participants, the majority were men, aged under 45 years, in the industry for less than 10 years. With each increase of dyspnoea score, PSS‐10 scores increased. Higher PSS‐10 scores were also observed in those no longer in the industry, with a history of anxiety or depression, attending assessment early in the programme and a medium exposure duration. Participants who used an interpreter reported lower stress. No difference was observed across job title, age, sex, smoking, spirometry or chest x‐ray categories after multivariate analysis. Conclusion: This study identified workers with dyspnoea as likely to report higher stress. Other factors, such as leaving the industry, early attendance and a history of anxiety or depression, are also helpful in identifying workers at risk of poorer mental health outcomes. This study describes psychological stress scores in silica‐exposed workers from the artificial stone benchtop industry and identifies predictors of elevated stress. See relatedEditorial [ABSTRACT FROM AUTHOR]

Chronic obstructive pulmonary disease (COPD) is caused by exposure to noxious particles and gases. Smoking is the main risk factor, but other factors are also associated with COPD. Occupational exposure to vapours, gases, dusts and fumes contributes to the development and progression of COPD, accounting for a population attributable fraction of 14%. Workplace pollutants, in particular inorganic dust, can initiate airway damage and inflammation, which are the hallmarks of COPD pathogenesis. Occupational COPD is still underdiagnosed, mainly due to the challenges of assessing the occupational component of the disease in clinical settings, especially if other risk factors are present. There is a need for specific education and training for clinicians, and research with a focus on evaluating the role of occupational exposure in causing COPD. Early diagnosis and identification of occupational causes is very important to prevent further decline in lung function and to reduce the health and socio‐economic burden of COPD. Establishing details of the occupational history by general practitioners or respiratory physicians could help to define the occupational burden of COPD for individual patients, providing the first useful interventions (smoking cessation, best therapeutic management, etc.). Once patients are diagnosed with occupational COPD, there is a wide international variation in access to specialist occupational medicine and public health services, along with limitations in workplace and income support. Therefore, a strong collaboration between primary care physicians, respiratory physicians and occupational medicine specialists is desirable to help manage COPD patients' health and social issues. [ABSTRACT FROM AUTHOR]

Silicosis not a disease of the past. It is an irreversible, fibrotic lung disease specifically caused by exposure to respirable crystalline silica (RCS) dust. Over 20,000 incident cases of silicosis were identified in 2017 and millions of workers continue to be exposed to RCS. Identified case numbers are however a substantial underestimation due to deficiencies in reporting systems and occupational respiratory health surveillance programmes in many countries. Insecure workers, immigrants and workers in small businesses are at particular risk of more intense RCS exposure. Much of the focus of research and prevention activities has been on the mining sector. Hazardous RCS exposure however occurs in a wide range of occupational setting which receive less attention, in particular the construction industry. Recent outbreaks of silicosis associated with the fabrication of domestic kitchen benchtops from high‐silica content artificial stone have been particularly notable because of the young age of affected workers, short duration of RCS exposure and often rapid disease progression. Developments in nanotechnology and hydraulic fracking provide further examples of how rapid changes in technology and industrial processes require governments to maintain constant vigilance to identify and control potential sources of RCS exposure. Despite countries around the world dealing with similar issues related to RCS exposure, there is an absence of sustained global public health response including lack of consensus of an occupational exposure limit that would provide protection to workers. Although there are complex challenges, global elimination of silicosis must remain the goal. See relatedEditorial [ABSTRACT FROM AUTHOR]

This article explores the different terms used to describe the study and treatment of diseases of the lungs and respiratory system. The author notes that they have been referred to as both a respiratory physician and a pulmonologist, and wonders if there is a true difference in the meaning of these terms. The author discovers that "respirology" is a new word derived from Latin and Greek roots meaning "to breathe" and "knowledge," while "pulmonology" and "pneumology" refer to the study and treatment of medical conditions of the lungs and respiratory system. The author concludes that while there may be slight differences in literal meaning, these terms can be used interchangeably in everyday practice. The article also discusses the decision to adopt the term "respirology" for the Asian Pacific Society of Respirology and its official journals. [Extracted from the article]

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Coronavirus disease 2019 (COVID‐19) caused by infection with severe acute respiratory syndrome coronavirus 2 was first detected in Wuhan, China, in late 2019 and continues to spread worldwide. Persistent questions remain about the relationship between the severity of COVID‐19 and comorbid diseases, as well as other chronic pulmonary conditions. In this systematic review and meta‐analysis, we aimed to examine in detail whether the underlying chronic obstructive pulmonary diseases (COPD), asthma and chronic respiratory diseases (CRDs) were associated with an increased risk of more severe COVID‐19. A comprehensive literature search was performed using five international search engines. In the initial search, 722 articles were identified. After eliminating duplicate records and further consideration of eligibility criteria, 53 studies with 658,073 patients were included in the final analysis. COPD was present in 5.2% (2191/42,373) of patients with severe COVID‐19 and in 1.4% (4203/306,151) of patients with non‐severe COVID‐19 (random‐effects model; OR = 2.58, 95% CI = 1.99–3.34, Z = 7.15, p < 0.001). CRD was present in 8.6% (3780/44,041) of patients with severe COVID‐19 and in 5.7% (16,057/280,447) of patients with non‐severe COVID‐19 (random‐effects model; OR = 2.14, 95% CI = 1.74–2.64, Z = 7.1, p < 0.001). Asthma was present in 2.3% (1873/81,319) of patients with severe COVID‐19 and in 2.2% (11,796/538,737) of patients with non‐severe COVID‐19 (random‐effects model; OR = 1.13, 95% CI = 0.79–1.60, Z = 0.66, p = 0.50). In conclusion, comorbid COPD and CRD were clearly associated with a higher severity of COVID‐19; however, no association between asthma and severe COVID‐19 was identified. [ABSTRACT FROM AUTHOR]

The natural history of COPD is complex, and the disease is best understood as a syndrome resulting from numerous interacting factors throughout the life cycle with smoking being the strongest inciting feature. Unfortunately, diagnosis is often delayed with several longitudinal cohort studies shedding light on the long 'preclinical' period of COPD. It is now accepted that individuals presenting with different COPD phenotypes may experience varying natural history of their disease. This includes its inception, early stages and progression to established disease. Several scenarios regarding lung function course are possible, but it may conceptually be helpful to distinguish between individuals with normal maximally attained lung function in their early adulthood who thereafter experience faster than normal FEV1 decline, and those who may achieve a lower than normal maximally attained lung function. This may be the main mechanism behind COPD in the latter group, as the decline in FEV1 during their adult life may be normal or only slightly faster than normal. Regardless of the FEV1 trajectory, continuous smoking is strongly associated with disease progression, development of structural lung disease and poor prognosis. In developing countries, factors such as exposure to biomass and sequelae after tuberculosis may lead to a more airway‐centred COPD phenotype than seen in smokers. Mechanistically, COPD is characterized by a combination of structural and inflammatory changes. It is unlikely that all patients share the same individual or combined mechanisms given the heterogeneity of resultant phenotypes. Lung explants, bronchial biopsies and other tissue studies have revealed important features. At the small airway level, progression of COPD is clinically imperceptible, and the pathological course of the disease is poorly described. Asthmatic features can further add confusion. However, the small airway epithelium is likely to represent a key focus of the disease, combining impaired subepithelial crosstalk and structural/inflammatory changes. Insufficient resolution of inflammatory processes may facilitate these changes. Pathologically, epithelial metaplasia, inversion of the goblet to ciliated cell ratio, enlargement of the submucosal glands and neutrophil and CD8‐T‐cell infiltration can be detected. Evidence of type 2 inflammation is gaining interest in the light of new therapeutic agents. Alarmin biology is a promising area that may permit control of inflammation and partial reversal of structural changes in COPD. Here, we review the latest work describing the development and progression of COPD with a focus on lung function trajectories, exacerbations and survival. We also review mechanisms focusing on epithelial changes associated with COPD and lack of resolution characterizing the underlying inflammatory processes. [ABSTRACT FROM AUTHOR]

Background and objective: The lack of useful biomarkers reflecting the disease state limits the management of Mycobacterium avium complex lung disease (MAC‐LD). We clarified the associations between serum KL‐6 level, disease progression and treatment response. Methods: Resected lung tissues from MAC‐LD patients were immunostained for KL‐6. We compared serum KL‐6 levels between MAC‐LD and healthy control or bronchiectasis patients without nontuberculous mycobacterial lung disease (NTM‐LD). Serum KL‐6 level was assessed in a prospective observational study at Keio University Hospital between May 2012 and May 2016. We investigated associations between serum KL‐6 level and disease progression and treatment response in patients untreated for MAC‐LD on registration (n = 187). Results: The KL‐6+ alveolar type 2 cell population in the lung and serum KL‐6 level were significantly higher in MAC‐LD patients than in controls. Serum KL‐6 level in bronchiectasis patients without NTM‐LD showed no significant increase. Of the 187 patients who did not receive treatment on registration, 53 experienced disease progression requiring treatment. Multivariable Cox analysis revealed that the serum KL‐6 level (aHR: 1.18, P = 0.005), positive acid‐fast bacilli smear (aHR: 2.64, P = 0.001) and cavitary lesions (aHR: 3.01, P < 0.001) were significantly associated with disease progression. The change in serum KL‐6 (ΔKL‐6) was significantly higher in the disease progression group; it decreased post‐treatment, reflecting the negative sputum culture conversion. Conclusion: Serum KL‐6 level is associated with disease progression and treatment response. Longitudinal assessment combined with AFB smear status and presence of cavitary lesions may aid MAC‐LD management. Serum Krebs von den Lungen‐6 (KL‐6) level is a useful serum biomarker that predicts disease progression and treatment response inMycobacterium avium complex lung disease (MAC‐LD). Single and longitudinal assessment of serum KL‐6 level may aid the management of MAC‐LD and help establish management strategies for MAC‐LD. [ABSTRACT FROM AUTHOR]

Background and objective: Temporal trends of healthcare use in the period before a diagnosis of pulmonary fibrosis are poorly understood. We investigated trends in respiratory symptoms and LR HRU in the 10 years prior to diagnosis. Methods: We analysed a primary care clinical cohort database (UK OPCRD) and assessed patients aged ≥40 years who had an electronically coded diagnosis of pulmonary fibrosis between 2005 and 2015 and a minimum 2 years of continuous medical records prior to diagnosis. Exclusion criteria consisted of electronic codes for recognized causes of pulmonary fibrosis such as CTD, sarcoidosis or EAA. Results: Data for 2223 patients were assessed. Over the 10 years prior to diagnosis of pulmonary fibrosis, there was a progressive increase in HRU across multiple LR‐related domains. Five years before diagnosis, 18% of patients had multiple healthcare contacts for LR complaints; this increased to 79% in the year before diagnosis, with 38% of patients having five or more healthcare contacts. Conclusion: There are opportunities to diagnose pulmonary fibrosis at an earlier stage; research into case‐finding algorithms and strategies to educate primary care physicians is required. [ABSTRACT FROM AUTHOR]

Exercise training is playing an increasing role in lung cancer care. Lung cancer is associated with significant burden to the individual and healthcare system. There is now substantial evidence that exercise training is safe, feasible and effective at improving several outcomes in people with lung cancer, especially in those with NSCLC. Exercise is beneficial across the lung cancer disease and treatment pathway, including in patients with early stage disease before and after surgery, and in patients with advanced disease. This review describes the impact of lung cancer and lung cancer treatment on patient health outcomes and summarizes the aims, safety, feasibility and effects of exercise training in the context of both early stage and advanced stage lung cancer. The paper also includes a discussion of current topical discussion areas including the use of exercise in people with bone metastases and the potential effect of exercise on suppression of tumour growth. Finally, seven clinical questions are included, which are a priority to be addressed by future research over the next decade as we strive to progress the field of lung cancer and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Coal mine lung dust disease (CMDLD) and artificial stone (AS) silicosis are preventable diseases which have occurred in serious outbreaks in Australia recently. This has prompted a TSANZ review of Australia's approach to respiratory periodic health surveillance. While regulating respirable dust exposure remains the foundation of primary and secondary prevention, identification of workers with early disease assists with control of further exposure, and with the aims of preserving lung function and decreasing respiratory morbidity in those affected. Prompt detection of an abnormality also allows for ongoing respiratory specialist clinical management. This review outlines a medical framework for improvements in respiratory surveillance to detect CMDLD and AS silicosis in Australia. This includes appropriate referral, improved data collection and interpretation, enhanced surveillance, the establishment of a nationwide Occupational Lung Disease Registry and an independent advisory group. These measures are designed to improve health outcomes for workers in the coal mining, AS and other dust‐exposed and mining industries. [ABSTRACT FROM AUTHOR]

Background and objective: People living with pulmonary fibrosis (PF) report unmet needs for information and support. Lung Foundation Australia (LFA) have developed the Peer Connect Service to facilitate telephone support for people with PF across Australia. This project documented the experiences of participants and the resources required to support the service. Methods: Consenting participants took part in semi‐structured interviews by telephone. Primary peers (peers who agreed to initiate contact) and secondary peers (eligible patients who sought a peer match) were interviewed. Thematic analysis was undertaken by two independent researchers. Data were collected on the number of matches and contacts required to establish each match. Results: Interviews were conducted with 32 participants (16 primary peers, 15 secondary peers and 1 who was both), aged from 53 to 89 years with 56% being male. Major themes included the value of shared experiences, providing mutual support and the importance of shared personal characteristics (e.g. gender and hobbies) in allowing information and emotional support needs to be met. Participants saw face‐to‐face contact with peers as highly desirable whilst acknowledging the practical difficulties. Primary peers were cognizant that their role was not to provide medical advice but to listen and share experiences. In the 12‐month period, 60 peer matches were made, each match requiring a minimum of seven staff contacts. Conclusion: The Peer Connect Service provides a unique opportunity for people with PF to share experiences and offer mutual support. This telephone matching model may be useful in providing peer support for individuals with rare diseases who are geographically dispersed. [ABSTRACT FROM AUTHOR]

AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD‐associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD‐related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD‐related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non‐pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand. [ABSTRACT FROM AUTHOR]

Chronic lung diseases represent a significant global burden. Their increasing incidence and complexity render a comprehensive, multidisciplinary and personalized approach to each patient, critically important. Most recently, unique biochemical pathways and disease markers have been identified through large‐scale metabolomic studies. Metabolomics is the study of metabolic pathways and the measurement of unique biomolecules in a living system. Analysing samples from different compartments such as bronchoalveolar lavage fluid (BALF) and plasma has proven useful for the characterization of a number of pathological conditions and offers promise as a clinical tool. For example, several studies using mass spectrometry (MS) have shown alterations in the sphingolipid metabolism of chronic obstructive pulmonary disease (COPD) sufferers. In this article, we present a practical review of the application of metabolomics to the study of chronic lung diseases (CLD): COPD, idiopathic pulmonary fibrosis (IPF) and asthma. The insights, which the analytical strategies employed in metabolomics, have provided to the dissection of the biochemistry of CLD and future clinical biomarkers are explored. [ABSTRACT FROM AUTHOR]

Background and objective: The optimal oxygen supplementation needed to avoid tissue hypoxia in patients with pulmonary hypertension (PH) remains unclear. This study aimed to identify the arterial oxygen tension (PaO2) level needed to avoid tissue hypoxia which results in a poor prognosis in patients with PH. Methods: We retrospectively analysed the data for 1571 right heart catheterizations in patients suspected of having PH between 1983 and 2017 at our institution. Examinations were classified according to mean pulmonary arterial pressure (mPAP), cardiac index (CI) and the presence of lung disease, pulmonary arterial hypertension (PAH) or chronic thromboembolic PH (CTEPH). The PaO2 levels needed to avoid tissue hypoxia were compared in each subgroup. Results: The estimated PaO2 equivalent to a mixed venous oxygen tension (PvO2) of 35 mm Hg (tissue hypoxia) was 63.2 mm Hg in all patients, 77.0 mm Hg in those with decreased CI (<2.5 L/min/m2) and 57.0 mm Hg in those with preserved CI. Multivariate regression analysis identified mPAP, CI and PaO2 to be independent predictors of extremely low PvO2. Similar results were observed regardless of the severity of PH or the presence of lung disease, PAH or CTEPH. The PaO2 level needed to avoid tissue hypoxia was higher in patients with mild PH and decreased CI than in those with severe PH and preserved CI (70.2 vs 61.5 mm Hg). Conclusion: These findings indicate that a decreased CI rather than increased mPAP induces tissue hypoxia in PH. Patients with PH and decreased CI may need adjustment of oxygen therapy at higher PaO2 levels compared with patients with preserved CI. Patients with pulmonary hypertension and a decreased cardiac index (CI) often have tissue hypoxia, which results in a poor prognosis, even though their arterial oxygen tension (PaO2) is ≥60 mm Hg. Conventional oxygen supplementation might be insufficient, and adequate oxygenation and medical treatment that could increase CI are important for these patients. [ABSTRACT FROM AUTHOR]

Despite silica dust exposure being one of the earliest recognized causes of lung disease, Australia, USA, Israel, Turkey and other countries around the world have recently experienced significant outbreaks of silicosis. These outbreaks have occurred in modern industries such as denim jean production, domestic benchtop fabrication and jewellery polishing, where silica has been introduced without recognition and control of the hazard. Much of our understanding of silica‐related lung disease is derived from traditional occupations such as mining, whereby workers may develop slowly progressive chronic silicosis. However, workers in modern industries are developing acute and accelerated silicosis over a short period of time, due to high‐intensity silica concentrations, oxidative stress from freshly fractured silica and a rapid pro‐inflammatory and pro‐fibrotic response. Appropriate methods of screening and diagnosis remain unclear in these workers, and a significant proportion may go on to develop respiratory failure and death. There are no current effective treatments for silicosis. For those with near fatal respiratory failure, lung transplantation remains the only option. Strategies to reduce high‐intensity silica dust exposure, enforced screening programmes and the identification of new treatments are urgently required. See relatedEditorial [ABSTRACT FROM AUTHOR]

1 Dong Kang Hospital, Korea B Background b : Paradoxical response of tuberculosis is worsening of pre-existing tuberculous lesions or developing new lesions, although overall treatment response is good. P6-4: Endobronchial mass occurred during treatment of tuberculosis: Two cases Tuberculosis culture of bronchoscopic specimen was negative, interferon-gamma release assay(IGRA) was positive and chest computed-tomography(CT) suggests inflammatory lesion. [Extracted from the article]

And After 9 months from treatment, CT scan shows only TB destroyed lung and no active lesions with continuous negative culture negative conditions. Yeongha Ryu 1, Wonhyun Kim 1 1 Dong Kang Hospital, Korea B Background b : Paradoxical response of tuberculosis is worsening of pre-existing tuberculous lesions or developing new lesions, although overall treatment response is good. Tuberculosis culture of bronchoscopic specimen was negative, interferon-gamma release assay(IGRA) was positive and chest computed-tomography(CT) suggests inflammatory lesion. [Extracted from the article]

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Background and objective: Osteopontin (OPN) is a pleiotropic cytokine involved in the proliferation of pulmonary artery smooth muscle cells (PA‐SMC). OPN is upregulated in the lungs of patients with pulmonary hypertension (PH) associated with pulmonary fibrosis, suggesting that the lung is a source of OPN. We hypothesized that OPN lung expression is elevated in Group I pulmonary arterial hypertension (PAH) and is correlated to haemodynamics. Methods: Microarray analysis (Affymetrix) was performed after RNA was extracted from explanted lungs in 15 patients with Group I PAH who underwent lung transplantation (LTx) and 11 normal controls. PA pressure levels were recorded intraoperatively, immediately before starting LTx. Serum OPN levels were measured in subjects with PAH, Group II PH and normal controls on the day of right heart catheterization. Results: OPN was among the top five upregulated genes in PAH compared to normal controls, which was confirmed by reverse transcription polymerase chain reaction (RT‐PCR). OPN expression was similar and equally elevated in different subtypes of PAH. A strong significant correlation was observed between mean pulmonary arterial pressure and OPN gene expression. Ingenuity pathway analysis showed the involvement of OPN in functions and networks relevant to angiogenesis, cell death and proliferation of PA‐SMC. OPN serum levels did not differ in subjects with Group I PAH and Group II PH. Conclusion: In the lungs of patients with severe PAH, OPN is highly expressed and the level of expression is significantly correlated to disease severity. OPN may play an important role in the vascular remodelling process of PAH. See relatedEditorial Osteopontin (OPN), a pleiotropic cytokine, was identified among the top five upregulated genes in the lung explants from patients with Group I pulmonary arterial hypertension, compared to normal controls. Its expression correlated strongly to haemodynamic severity. Ingenuity pathway analysis showed the involvement of OPN in functions and networks relevant to vascular remodelling. [ABSTRACT FROM AUTHOR]

Background and objective: Sleep‐disordered breathing (SDB) has been reported as highly prevalent in idiopathic pulmonary fibrosis (IPF) and other interstitial lung disease (ILD) populations. Nocturnal oxygen desaturation (NOD), or the total sleep time spent with SpoO2 < 90% (TST < 90), can occur both with and without associated apnoeas, and is common in ILD. This study aimed to characterize abnormal SDB and extent of TST < 90 in ILD patients and evaluate relationships between TST < 90 and markers of disease severity, development of pulmonary hypertension (PH) and mortality. Methods: Consecutive, newly referred ILD patients attending a specialist clinic underwent polysomnography (PSG). Serial lung function tests, echocardiography and other clinical variables were recorded. Predictors of PH and mortality were evaluated using logistic regression and Cox proportional hazards regression analyses. Results: A total of 92 ILD patients (including 44 with IPF) underwent PSG. At least mild obstructive sleep apnoea (OSA) was observed in 65.2%, with rapid eye movement (REM)‐related events occurring frequently. At least 10% TST < 90 (designated 'significant NOD') was present in 35.9% of patients, and was associated with PH at baseline echocardiography. Multiple indices of hypoxaemia during sleep, including significant NOD, predicted the development of new or worsening PH. TST < 90 predicted overall and progression‐free survival. Conclusion: Nocturnal oxygen saturation is associated with poorer prognosis in ILD patients and may contribute towards the pathogenesis of pulmonary vascular disease. [ABSTRACT FROM AUTHOR]

Background and objective: Aerosol transmission of Pseudomonas aeruginosa has been suggested as a possible mode of respiratory infection spread in patients with cystic fibrosis (CF); however, whether this occurs in other suppurative lung diseases is unknown. Therefore, we aimed to determine if (i) patients with bronchiectasis (unrelated to CF) or chronic obstructive pulmonary disease (COPD) can aerosolize P. aeruginosa during coughing and (ii) if genetically indistinguishable (shared) P. aeruginosa strains are present in these disease cohorts. Methods: People with bronchiectasis or COPD and P. aeruginosa respiratory infection were recruited for two studies. Aerosol study: Participants (n = 20) underwent cough testing using validated cough rigs to determine the survival of P. aeruginosa aerosols in the air over distance and duration. Genotyping study:P. aeruginosa sputum isolates (n = 95) were genotyped using the iPLEX20SNP platform, with a subset subjected to the enterobacterial repetitive intergenic consensus polymerase chain reaction (ERIC‐PCR) assay to ascertain their genetic relatedness. Results: Aerosol study: Overall, 7 of 20 (35%) participants released P. aeruginosa cough aerosols during at least one of the cough aerosol tests. These cough aerosols remained viable for 4 m from the source and for 15 min after coughing. The mean total aerosol count of P. aeruginosa at 2 m was two colony‐forming units. Typing study: No shared P. aeruginosa strains were identified. Conclusion: Low viable count of P. aeruginosa cough aerosols and a lack of shared P. aeruginosa strains observed suggest that aerosol transmission of P. aeruginosa is an unlikely mode of respiratory infection spread in patients with bronchiectasis and COPD. Our study shows that patients with bronchiectasis and chronic obstructive pulmonary disease (COPD) can release potentially infectious aerosols during coughing; however, no shared stains of Pseudomonas aeruginosa were identified in our study. The results suggest that aerosol transmission is an unlikely mode of cross‐infection in patients with bronchiectasis and COPD. Watch the video abstract See related Editorial [ABSTRACT FROM AUTHOR]

Chronic respiratory diseases (CRD) are characterized by exertional dyspnoea, exercise limitation and reduced health‐related quality of life (QoL). Exercise training is essential for improving symptoms, physical function and QoL. Current research available supports the effectiveness of exercise training in patients with chronic obstructive pulmonary disease (COPD), cystic fibrosis and interstitial lung disease (ILD). However, recent studies have also shown safety and effectiveness of exercise training in patients with pulmonary arterial hypertension (PAH) and asthma. Despite the lack of clinical guidelines for exercise training in PAH, a recent Cochrane review has reported improvements in functional capacity and effective reductions in mean pulmonary arterial pressure. In the other CRD, a number of Cochrane reviews, supported by numerous randomized controlled trials, have been published outlining the benefits of different types of exercise training. The aim of this review is to establish the principles and modalities of personalized exercise training and the effects of exercise training across a number of CRD. In addition, this review provides information on personalized exercise prescription for CRD patients with co‐morbidities. [ABSTRACT FROM AUTHOR]

Pulmonary rehabilitation (PR) is beneficial for people with several forms of chronic respiratory disease. Given the existing limitations on availability of PR services, it is important to identify participants who are most likely to benefit from it. Identification of criteria for patient referral to PR is challenging, as chronic respiratory diseases and their medical and psychosocial co‐morbidities place a complex and multifaceted burden on patients. Although research studies have attempted to identify key parameters predictive of 'responsiveness to PR', to date no firm physiological, psychosocial or other criteria exist by which optimal patient candidacy can be determined. Moreover, individual factors do not reliably predict successful multidimensional PR outcomes. In general, individuals who remain symptomatic with dyspnoea, fatigue and exercise intolerance; who have difficulty performing activities of daily living (ADL); and who are having difficulty coping with or managing their disease despite optimized pharmacological therapy are potential candidates for PR. Patient assessment and outcome measurement are core essential features of PR. To be considered as a PR programme, rehabilitation programmes must demonstrate, at a minimum, assessment and outcome measurement in regard to exercise capacity, dyspnoea and health‐related quality of life. Additional parameters, including physical activity, nutritional status, tobacco use status, patient knowledge and self‐efficacy, performance of ADL, fatigue, disease exacerbations, hospitalizations and other urgent healthcare utilization, and behavioural outcomes, including coping styles, patient satisfaction and programme metrics, are other relevant and important aspects of patient assessment and outcome measurement that should be considered and undertaken in PR, where feasible. [ABSTRACT FROM AUTHOR]