Current Respiratory Medicine Reviews - Volume 17, Issue 2, 2021

Asthma is a complex and highly heterogeneous disorder, having many clinical phenotypes and underlining mechanisms, a broad spectrum of severity, and variable response to controller therapy. Intensive research has been focused on the identification and validation of the most appropriate biomarkers in the clinical management of asthma, mostly addressed to severe and refractory cases. The use of reliable biomarkers in severe asthma can contribute to a better understanding of disease biology, diagnosis and screening, by a refined characterization of particular phenotypes and endotypes, assessment of severity, control, and prognosis. There is an increasing interest to validate biomarkers able to indicate the adequate therapeutic choice from the class of biological agents, most of them targeting T2 inflammation. Using a reliable and validated biomarker, the clinician can monitor the response to initial therapy and early identify a severe phenotype. The aim of this paper is to review the clinical utility of relevant biomarkers currently used in asthma management. Indication for more advanced and efficient therapy, such as monoclonal antibodies and selection of the optimal molecule, is based on biomarkers and clinical criteria, according to the most recent experts’ recommendations. Peripheral blood eosinophils are considered an important biomarker for the selection and identification of responders to anti-eosinophil biological therapy. Real-life long-term studies to confirm the precise use and cutoffs of the already approved biomarkers for T2 phenotypes and to identify reliable biomarkers for non- T2 severe asthma are still unmet needs in asthma management.

The article provides an overview of modern concepts of induced sputum analysis and a description of the methodology and protocols for the collection of induced sputum in adults and children. This paper describes the cellular composition of induced sputum in healthy people and in patients with asthma in detail, analyses the significance of the sputum eosinophil count as a prognostic and diagnostic criterion and the role of other cells, such as neutrophils, macrophages, basophils. In this article, we review a number of asthma biomarkers of inflammation and remodeling of the airways in asthma, which can be determined in sputum (anaphylatoxin C3a, clusterin, periostin). In addition, we summarize recent data about asthma phenotypes and describe the possibilities of using induced sputum analysis as a diagnostic and therapeutic tool for personalized anti-inflammatory therapy for asthma.

Aim: The aim of the study was to present existing evidence regarding the association between bronchial asthma and lung cancer risk, the impact of lung cancer treatment on asthma control as well as the impact of pre-existing asthma on lung cancer survival. Methods: A narrative review of all the relevant published literature has been conducted. Results: Published evidence suggests that patients with bronchial asthma are at a higher risk of developing lung cancer with an estimated odds ratio for squamous and small cell lung carcinoma at 1.69 and 1.71, respectively, within 2 years of asthma diagnosis. Interestingly, regular use of inhaled corticosteroids may protect asthmatics against lung cancer. Chemotherapy may temporarily relieve asthma symptoms. Pneumonitis is a common adverse reaction in asthmatics receiving immunotherapy for lung cancer treatment. Lung radiotherapy in asthma patients predisposes to eosinophilic alveolitis and pneumonia. Asthmatics are considered high-risk candidates for invasive surgical procedures because they carry a high risk of perioperative airway hyper responsiveness. Asthma is associated with a reduced lung cancer survival compared to other pulmonary co-morbidities. Conclusion: Literature shows that bronchial asthma is associated with increased lung cancer risk and worse survival rates. Chemotherapy may relieve asthma symptoms. However, asthmatics are prone to complications related to lung cancer surgery or radiotherapy treatment. ore randomised controlled studies are required to strengthen the positive association between bronchial asthma and lung cancer, taking into consideration that there may be confounders that may influence the results. Finally, further studies must be conducted to investigate the impact of immunotherapy and specific radiotherapy modalities on asthma control.

Obstructive pulmonary diseases are a group of respiratory conditions characterized by airflow limitation. They are prevalent in the population and lead to significant morbidity and mortality. The two most commonly encountered conditions are asthma and Chronic Obstructive Pulmonary Disease (COPD). Although, for many years, the two conditions were regarded as separate, it was realized that some patients may have an overlap between these illnesses. This observation led to the identification of asthma-COPD overlap (ACO) syndrome. ACO is an umbrella term that is used “to collectively describe patients who have persistent airflow limitation together with clinical features that are consistent with both asthma and COPD”. Its importance in the field of respiratory medicine is increasing every year as there are more data that underline the importance of its timely diagnosis and management. The current review is a timely update of the advances in our understanding of ACO.

Obesity and asthma are two conditions that are considered a global health problem. There has been an increased number of obese patients and different factors contribute to the development of this disease, such as changes in lifestyle, poor physical activity, and genetics. Obesity, as a co-morbidity, could contribute to the aggravation of asthma or the progress and exacerbation. This could lead to asthma-related hospitalizations and ICU admissions. Understanding the pathophysiology of those two diseases is helpful in the decision-making process of the management. The main goal of the therapy is reducing the exacerbation symptoms and or the ICU length-stay, which could depend on the type of mechanical ventilation used on the patient.

Background: Approximately 3-10% of all asthmatics are refractory with severe disease, although they use optimal preventive treatment. This is reflected as a disproportionate increase in the cost of health care. Thus, bronchial thermoplasty has been developed as an add-on therapy for these refractory asthmatics. Objective: This review aims to give an update on bronchial thermoplasty in severe asthma regarding pathophysiological mechanisms of action, patient selection, procedural details, history, evidence- based effectiveness, safety and cost-effectiveness, place in management, and challenges in current clinical practice. Methods: A thorough search for the eligible and recent studies and reviews on bronchial thermoplasty and asthma has been conducted in PubMed. Results: In bronchial thermoplasty, radiofrequency energy delivered to bronchial airway walls leads to ablation of the airway smooth muscles that cause bronchoconstriction. Several large trials and a real-world study confirm its safety, and effectiveness, as shown by considerable reduction in asthma exacerbations, emergency department visits and hospitalizations as well as improvement in asthma-related quality of life, maintained up to 5 years. These improvements are more significant in more severe airway obstruction. Bronchial thermoplasty is more cost-effective if hospitalization and emergency department care cost high, but the procedure costs low. Properly performed patient identification, implementation and follow-up are critical for successful and safe outcomes with the procedure. Conclusion: A 10-year research and clinical experience has proved the long-term safety, and effectiveness of bronchial thermoplasty for improving asthma control and quality of life in severe asthma. Predictors of response (e.g. biomarkers, responder endotype/phenotype) remain to be studied further and better qualified.

Background: Pleuroscopy (medical thoracoscopy) is a minimally invasive procedure to inspect and perform a biopsy of the pleural space as well as to perform therapeutic interventions; pleural fluid drainage and pleurodesis. Materials and Methods: In a retrospective study in Kasra Hospital, Tehran,Iran, the patients with exudative pleural effusion of unknown etiology who underwent pleuroscopy, were evaluated. These patients had negative smears and cultures for infective agents. Also, the cytological review was negative for malignancy. Results: 62 patients had undergone pleuroscopy, of which 29 (46.7) were men. After the final evaluation, 47 patients (75.8%) had a definite pathologic diagnosis, of which 39 patients (82.9%) had cancer. Through these 39 cases, 18 cases (46.1%) had a history of the previously confirmed cancer, in which pleural pathology was consistent with the initial diagnosis. In 21 cases (53.9%), metastatic cancers were detected without a previous history. From a total of 47 cases with definite pathologic diagnosis, 8 cases (17%) had histopathologic evidence of granulomatous lesions consistent with tuberculosis, and 15 patients (24%) showed non-specific inflammatory lesions. There was no morbidity and mortality among these patients. Discussion: Considering that pleuroscopy is a safe procedure with high diagnostic accuracy, malignancy is the most common finding in the exudative pleural effusion of unknown etiology, which increases the importance of this procedure in these cases to prevent wasting time and smear-negative anti-TB treatment.

Background: Chronic Obstructive Pulmonary Disease (COPD) is complicated by the presence of frequent and recurrent acute exacerbations. The patients are asymptomatic and stable in the early stages. They develop weakness of primary respiratory muscles and use accessory muscles, which lead to postural changes. The forward head posture is very common in COPD patients due to increased usage of accessory muscles and aging changes. Kinesiotaping application has been used to correct posture and lung function recently. Objective: The aim of this paper is to review the evidence on the effect of Kinesiotaping on lung function and posture in COPD patients. Methods: The research articles published in the major databases including Web of Science, Pubmed, and Google Scholar, were searched from January 2010 to January 2021 to be included in the review. Twenty-one articles were retrieved and six articles were selected for the review based on the inclusion criteria. Results: The studies indicate that Kinesiotaping of the thoracic wall in COPD patients has an immediate effect on accessory inspiratory muscle activity, chest expansion, pulmonary function, and postural alignment. Further research is required to determine the long-term effects of this special taping method in comparison with conventional therapy in COPD patients. Conclusion: The application of kinesiotaping as an adjunct to conventional breathing exercises in COPD patients helps in improving lung function, posture and reduces the perception of dyspnea.

Background: The prevalence of fungal infections has been increasing in recent years. Cystic fibrosis (CF) is a genetic disorder that affects organs such as the intestines, liver, pancreas, and especially the lungs. Introduction: Fungal pathogens are becoming a challenge in CF. Advanced medical science is associated with longer life expectancy in some patient groups. Method: A review was conducted on studies found on online databases, including Google Scholar, PubMed, and Scopus. Internet-based searches were performed on these databases for cystic fibrosis, respiratory infections, and fungal infection profiling to identify all relevant studies published between 2010 and 2020. Result: Fungal pathogens most frequently isolated from the respiratory tract include the Aspergillus genus, the Candida genus, Scedosporium apiospermum, and the Rasamsonia genus. In cystic fibrosis, these organisms usually colonize the respiratory and intestinal tracts and cause hypersensitivity responses and invasive diseases. Conclusion: Fungus-patient interactions are complicated and depend on various factors. Moreover, the emergence of drug-resistant species is a serious health issue, and the development of new treatments is crucial.

Objective: We designed novel practical simulation models for VATS lung nodule palpation and vessel dissection, and subsequently evaluated the performances of the residents in our thoracic surgery program to account for the appropriate level of difficulty and grade the learning experience. Methods: Artificial lung nodules were formed by injecting sheep heart lung blocks with either cyanoacrylate or construction grade silicone diluted with synthetic thinner. Artificial lung and vessel environment was formed using a sponge, with a tube balloon placed inside a tunnel within the sponge and fixed with a flexible glue. Both models were placed in a standard laparoscopy training box, and both conventional and minimally invasive surgery instruments were used as applicable per the attendee's discretion. Results: In the lung nodule simulation, among 4 residents (postgraduate year (PGY) 1, 3, 4 and 4), the average time to palpating the first nodule was 57 seconds,and the average time of whole lung palpation was 7,7 minutes. In the vascular dissection model, of the five residents (PGY 4, 3, 3, 3, 1), median distance dissected at the first attempt was 3,1 cm (1-4,7), and it was shorter in the second attempt, 2,5 cm (2-3,2). Median dissection duration was shorter in the second attempt (5 vs. 3 minutes). All residents were able to complete the dissection of the balloon from the sponge within 9 attempts. Conclusion: Surgical simulation models can be created with minimal resources, allowing for enough difficulty to maintain engagement and accomplish progressive skill through practice. As clinics shift case volume to minimally invasive procedures, resident exposure to open cases can become more scarce; so simulation training in thoracic surgery can not be perceived as a luxury, it has to be accessible even though the learning environment does not have resources to invest in virtual reality sets or computerized simulators.