Respiratory syncytial virus (RSV) poses a significant health risk to pregnant women, infants, and older adults, yet vaccine uptake remains suboptimal globally. This study aimed to explore the barriers and facilitators influencing RSV vaccine acceptance among pregnant women and older adults in Hong Kong. A qualitative design was employed, involving semi-structured interviews with pregnant women and older adults in Hong Kong. The interview guide was informed by the Theoretical Domains Framework (TDF) to capture behavioural determinants across 14 domains. Data were analyzed using thematic analysis, combining deductive coding based on TDF domains with inductive identification of emergent themes. Barriers and facilitators were further categorized to facilitate interpretation. Of the 24 participants included in this study, 9 expressed willingness to receive RSV vaccination, while 15 expressed unwillingness. Commonly reported barriers included financial concerns, worries about potential side effects, and limited knowledge about RSV and its vaccines. Trust in healthcare professionals and government authorities was commonly recognized as a facilitator. Additional facilitators included the availability of fee waivers or subsidies, access to more comprehensive vaccine information, and influence from community members, family, and friends. Knowledge gaps, safety concerns, financial considerations, and social influence were recurring themes in RSV vaccination decision-making, while trust in healthcare providers and government authorities was a salient facilitator. Future research should apply behavioural frameworks to design and evaluate targeted interventions that can be scaled within Hong Kong’s healthcare system.
Community-acquired pneumonia (CAP) presents a severe burden in developing regions, requiring precise triage. Traditional severity scores like CURB-65 often predict mortality rather than the immediate need for intensive care. The SMART-COP score proves to be a promising alternative for early triaging. A prospective, longitudinal observational study was conducted among 123 adult CAP patients at a teaching hospital in Manipal, Karnataka, India. Clinical, laboratory, and radiological data were collected to calculate the SMART-COP score within 24 hours of admission. Primary evaluated outcomes included Intensive Respiratory or Vasopressor Support (IRVS) requirement, intensive care unit (ICU) length of stay, and in-hospital mortality. The cohort’s mean age was 61.33 ± 15.98 years. A significant majority (77.2%) needed ICU admission, with 58.5% requiring IRVS (56.9% intensive respiratory support, 24.4% inotropes). The in-hospital mortality rate was 14.6%, with mean admission SMART-COP score being 4.15 ± 2.61. SMART-COP significantly outperformed CURB-65 in predicting IRVS (AUROC 0.901 vs. 0.805; DeLong’s p = 0.007). Spearman’s correlation revealed a weak-to-moderate positive relationship between the admission score and ICU duration among admitted patients (rho = 0.315; p = 0.002). A count-based negative-binomial regression model demonstrated that every 1-point score increase was associated with a rate ratio of 1.34 for expected ICU days across the cohort. Multivariable regression confirmed that acute physiological instability independently drove the requirement for IRVS, superseding chronic comorbidities. This single-centre validation study indicates that the SMART-COP score is a useful bedside triage instrument. Routine application at the primary care level may assist in early risk stratification and timely referral.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2026 introduces the concept of “disease stability” (DS), classifies patients with ≥1 moderate exacerbation in the previous year as Group E, and recommends long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA) or inhaled corticosteroid (ICS) + LABA + LAMA for Group E, LABA + LAMA for Group B, and bronchodilator monotherapy for Group A. This study evaluated DS in patients whose inhaled therapy was aligned with the GOLD 2026 initial treatment strategy and explored associated factors. This retrospective analysis of real-world data included patients enrolled between 1 November 2017 to 30 June 2024. Based on adherence to the initial inhaled therapy recommendations outlined in the GOLD 2026 report, patients were categorised as either aligned or non-aligned; the non-aligned group was further divided into under-treated and over-treated subgroups. DS was defined as the absence of exacerbations, no symptom deterioration, and a decline in FEV1 of less than 60 mL during 1 year of follow-up. A total of 1277 patients were enrolled, of whom 475 (37.2%) achieved DS during the 1-year follow-up. Among patients in the aligned group, 238 (41.0%) achieved DS. Compared with the non-aligned group, the aligned group showed a lower incidence of clinically important deterioration (CID) in the CAT score, fewer future exacerbations, and a higher rate of DS. Subgroup analysis showed that the aligned group had higher odds of DS than the under-treated group, whereas no significant difference was observed compared with the over-treated group. Among patients in GOLD Groups B and E, alignment with the GOLD 2026 recommendations was associated with a higher rate of DS and a lower risk of exacerbations and CID. Influenza or pneumococcal vaccination showed a modest positive association with DS, whereas current smoking and a history of exacerbations were negatively associated with DS among patients receiving GOLD 2026-aligned initial therapy. Alignment with GOLD 2026 initial treatment recommendations was associated with improved DS, particularly in GOLD Groups B and E. Current smoking and a history of exacerbations reduced the likelihood of achieving DS, whereas influenza or pneumococcal vaccination showed a modest positive association with DS.
Severe asthma (SA) affects approximately 10% of the global asthma population. Symptoms and exacerbations lead to reduced quality of life and increased hospitalisations. Patients with uncontrolled disease often experience increased risks due to delays in referral, assessment, and treatment initiation. The aim of this study was to establish multinational consensus on the preferred approach to time-clocked care in the management of SA from primary through to specialist care. A modified Delphi methodology was used. A steering committee convened and developed 63 consensus statements across five key topics related to SA diagnosis, referral, and management. The statements were created into a four-point Likert scale online survey and distributed to healthcare professionals experienced in SA care across five countries. The threshold for consensus was set at 75%. Responses were collated anonymously, and 500 responses were received from across France, Germany, Italy, Spain, and the United States. The majority had ≥ five years of experience in role. Consensus was achieved for 53/63 statements (85%). There was agreement on the necessity of timely SA care, with 95% of respondents supporting that time-clocked care is essential. An aspirational 18-week target from referral to implementation of care, including biologic therapy initiation, was established. Based on these findings, a SA care timeline was proposed. This consensus provides an aspirational framework for improving the SA care pathway from primary through to specialist care. Implementing the timeline into local health systems is hoped to facilitate earlier referral, treatment initiation, and follow-up to improve patient outcomes.
Asthma is a leading chronic respiratory condition in children, and primary care plays a pivotal role in its management. Evidence on primary care–based interventions for paediatric asthma remains fragmented. This rapid review synthesised global evidence on primary care interventions for paediatric asthma and their clinical, health service and implementation outcomes. Following Cochrane Rapid Review methodology and PRISMA guidelines, PubMed, Ovid EMBASE, and PsycINFO were searched for English-language studies published between January 2015 and February 2026 that reported interventions for children aged 4–18 years in primary care. Two reviewers independently screened studies, extracted data and appraised methodological quality using the Joanna Briggs Institute checklists. Narrative synthesis was conducted due to heterogeneity. Sixteen studies were included. Interventions were multifaceted and targeted asthma assessment, treatment and self-management. These included tailored education for children, families and healthcare providers (n = 9), guideline-based assessment and decision-support tools (n = 6), written asthma action plans (n = 5), digital health tools (n = 5), and pharmacy- or nurse-led reviews (n = 4). Use of standardised tools, such as the Asthma Control Test (ACT) and the Childhood Asthma Control Test (C-ACT), improved the identification of poorly controlled asthma and prompted treatment adjustments. Educational interventions consistently improved inhaler technique, asthma knowledge and quality of life, whereas digital health interventions demonstrated mixed effects on asthma control and treatment engagement. Written asthma action plans were generally implemented within multifaceted interventions, limiting the assessment of their independent effects. Several interventions were associated with reduced emergency department visits, hospitalisations and school absenteeism. Primary care–based paediatric asthma interventions are multifaceted and associated with improved asthma control, self-management and healthcare utilisation. These findings support integrating guideline-based assessment, education, and team-based care into routine primary care practice. However, further research is needed to clarify the independent effectiveness of digital support tools and written asthma action plans.
Asthma self-management, supported by a personalised asthma action plan (PAAP), improves clinical outcomes. In Malaysia, only about 14% of adult patients with asthma were counselled on asthma action plan. We developed a pictorial-PAAP to facilitate asthma self-management. This study aimed to compare the effectiveness of the pictorial-PAAP with a text-based PAAP (text-PAAP). We recruited 180 adult asthma patients who were treated with daily inhaled corticosteroids and able to understand Malay or English from four urban public primary care clinics in Klang District, Selangor, Malaysia. Patients enrolled were randomly assigned to receive either a pictorial-PAAP or a text-PAAP with a 1:1 allocation. Those who agreed to participate in the study had their baseline assessment conducted before being handed a sealed envelope with allocated asthma action plan within. Subsequently, the treating doctors or pharmacist opened the sealed envelope and counselled the patients according to the arm they were allocated to. The study outcomes were measured at baseline, 3-, 6- and 12-months using a questionnaire. The primary outcome was asthma control, and the secondary outcomes were reliever medication use, adherence to controller medication, acute exacerbations, asthma-related emergency visits, and asthma-related hospital admissions, workdays lost due to asthma and use of PAAP. Generalized Estimating Equation (GEE) analysis was used to investigate the effectiveness of the intervention. Mean age of participants was 44.93 years (SD 13.59); 63.9% were <50 years, 80.0% were females, 57.8% were Malay, 84.4% had secondary or tertiary education, 72.8% were married, 91.1% were from low-income households, and 27.2% had inadequate health literacy. Baseline sociodemographic and clinical characteristics of the participants were similar between groups. Over time asthma control improved in both groups. At baseline, 3-, 6- and 12 months, the proportion of well controlled asthma in the pictorial-PAAP and the text-PAAP group was 20.0, 28.7, 40.7, 64.3, and 21.1, 28.9, 45.5, 44.6% respectively. Both groups demonstrated significant reductions in the proportion with ≥1 asthma attacks, asthma-related emergency visits, hospital admissions, and leave from work and medical certificate issued at all follow-up points compared with baseline (p < 0.05). In both groups, PAAP usage peaked at 3 months and declined thereafter, but even at 12-month remained significantly greater than at baseline (p < 0.05). Controller medication adherence increased significantly at 3- and 12-month in both groups (baseline, 3- and 12-month: text-PAAP: 34.4, 63.3, 67.9%, pictorial-PAAP: 34.4, 70.1, 65.9%; p < 0.05). Reliever medication use decreased significantly at 6- and 12-month in the pictorial-PAAP group (baseline, 6- and 12-month: 87.8,73.3, 69.0%; p < 0.05), and all follow-up points in the text-PAAP group (baseline, 3-, 6- and 12-month: 87.8, 83.8, 70.5, 74.7%; p < 0.05). Generalized estimating equation analysis showed a higher likelihood of achieving good control in the pictorial-PAAP group than the text-PAAP group at 12-month follow-up (OR = 2.645, 95%CI:1.232–5.679, p = 0.013). Both groups demonstrated improvement in asthma control over the 12-months follow-up. The pictorial-PAAP group had significantly higher odds of achieving well controlled asthma than the text-PAAP group at 12 months. Primary care physicians should consider offering pictorial-PAAP to facilitate patient self-management.
Referral of people with chronic respiratory disease to pulmonary rehabilitation (PR) remains low despite program benefits. We aimed to explore patient and health professional (HP) experiences of the PR referral process, to identify and co-design strategies to support referral. Focus groups and qualitative interviews were conducted in Phase 1, and a co-design workshop in Phase 2. Phase 1 included 14 people with lived experience and 10 HPs. Participants reported different experiences of the referral process highlighting patient expectation of only brief information about PR at the time of referral. Resources to promote PR awareness and knowledge, referral feedback, and HP education were developed in Phase 2 with inputs from two people with lived experience, three HPs and PR clinicians. In this study, participants identified new strategies to support referral to PR including the use of referral acknowledgement and focussed end rehabilitation feedback, and novel suggestions for HP education.
Breathlessness is a common symptom in clinical practice, yet evidence for cost-effective strategies to diagnose the underlying health conditions causing breathlessness remains limited. Using Swedish population data with individuals with moderate to severe breathlessness, we developed an artificial intelligence (AI) reinforcement learning model to identify optimal, low-cost diagnostic pathways for breathlessness tailored to subgroups based on sex and smoking exposure. Sixteen clinically relevant conditions were defined, along with their diagnostic tests and standard healthcare costs. The AI-based approach successfully produced efficient and low-cost diagnostic pathways for breathlessness with high diagnostic yield. The optimal sequences were overall similar between the subgroups. For all participant subgroups, the AI-derived pathways initially identified (or order of effectiveness in relation to costs) clinical evaluations of body mass index, anxiety and depression, physical activity levels, and spirometry. Subsequent steps included diffusing capacity measurements, chest computer tomography, and hemoglobin assessment. Overall, investigations of the lungs were prioritized ahead of investigations of the heart. This strategy has the potential to streamline the evaluation of breathlessness, reduce unnecessary testing, lead to an earlier diagnosis at lower cost, and support more targeted clinical management.
Chronic respiratory diseases (CRDs) substantially contribute to India’s non-communicable disease burden, especially in rural populations. Peak expiratory flow rate (PEFR) is useful for community-based respiratory screening in resource-limited settings. This community-based cross-sectional study assessed the prevalence and risk factors of impaired expiratory airflow among rural adults aged ≥30 years in Western India. Data were collected through house-to-house visits using a structured questionnaire administered by trained ASHA workers. Information regarding sociodemographic, environmental risk factors and comorbidities was obtained. PEFR was measured using peak flow meters following standard guidelines. A total of 11,359 rural adults participated in the study. Overall, 9.17% of participants had suspected PEFR impairment. The prevalence of PEFR impairment was significantly higher among older adults, males, smokers, underweight individuals, participants using unclean cooking fuel, and those with CRDs, hypertension, or diabetes mellitus. Community-based PEFR screening conducted by ASHA workers may represent a cost-effective strategy for early identification of airflow limitation in rural primary-care settings.
Cardiovascular disease is major determinant of morbidity and mortality in chronic obstructive pulmonary disease (COPD), yet cardiopulmonary risk remains underrecognized and insufficiently addressed, particularly in low- and middle-income countries (LMICs). We developed a multidisciplinary consensus to provide practical recommendations for the identification, assessment, and management of cardiopulmonary risk in COPD, adapted to healthcare systems in emerging countries. A modified Delphi process was conducted by a six-member steering committee and a multidisciplinary panel of 21 experts in pulmonology, cardiology and internal medicine. Clinical questions were developed from unmet needs in COPD care and informed by a systematic literature review of studies published between January 2020 and September 2025. Recommendations were graded according to the Scottish Intercollegiate Guidelines Network (SIGN) methodology and refined through two Delphi rounds with consensus defined as ≥80% agreement. Thirteen recommendations achieved consensus, including 12 (92.3%) with very strong consensus (≥90% agreement) and one (7.7%) with strong consensus (80-90% agreement). The recommendations address three clinical domains: identification and assessment of respiratory and cardiovascular comorbidities, targeted diagnostic testing, and implementation of evidence-based pharmacological and non-pharmacological interventions. This modified Delphi consensus provides a practical framework to support systematic cardiopulmonary risk assessment and individualized management of COPD. Although developed for Mexico, its resource-sensitive approach may facilitate implementation across Latin America and other low- and middle-income countries facing similar healthcare challenges.
The Global Initiative for Obstructive Lung Disease (GOLD) has produced yearly recommendations for the diagnosis and management of patients with COPD since 2001. Here, we summarize the key recommendations of the GOLD 2026 document for a primary care audience, highlighting what has changed and what has not since the last document in 2025. Specifically, this document discusses changes (if any) in the following domains: (1) definition of COPD; (2) burden of disease; (3) causes and risk factors; (4) clinical presentation; (5) diagnosis; (6) initial assessment and follow-up, including the new concepts of disease activity, stability and clinical control; (7) prevention, with particular emphasis on vaccinations; (8) pharmacological and non-pharmacological treatment; (9) exacerbation; (10) Multimorbidity and its syndemic origins; and, finally (11) artificial intelligence and emerging technologies in COPD.
Comprehensive respiratory health management for populations with elevated respiratory and lung cancer-related risk remains a guideline-recommended component of comprehensive respiratory prevention, yet uptake has not been systematically characterized. Using vaccination as a sentinel marker of healthcare engagement, we examined 2020-2024 BRFSS data on influenza and pneumococcal vaccination among U.S. adults classified as healthy controls, current smokers without COPD, individuals with COPD who were former or never smokers, and current smokers with COPD. Adults with both current smoking and COPD showed a substantial prevention gap. Despite high clinical vulnerability, this Dual Risk group had lower vaccination uptake than the COPD-only group, particularly among adults aged 45-64 years. In multivariable models, current smoking was associated with attenuation of the expected disease-prompting effect observed among non-smoking individuals with COPD. Mediation analysis suggested that healthcare access barriers, especially absence of a personal healthcare provider and lack of routine checkups, explained much of the vaccination disparity, whereas broader socioeconomic indicators explained less. Although vaccination uptake is not a direct measure of low-dose computed tomography screening, it may serve as a sentinel marker of primary care engagement and missed opportunities for respiratory prevention. Findings should be interpreted cautiously given the cross-sectional design, potential age-related confounding for pneumococcal vaccination under pre-2024 CDC recommendations, and the broader BRFSS smoking definition compared with clinical screening criteria. Integrating vaccination assessment, smoking cessation services, and appropriate screening referral through primary care, pharmacies, and cessation clinics may reduce missed opportunities among high-risk adults.
Chronic obstructive pulmonary disease (COPD) requires sustained self-management, and health literacy may play an important role in patients' ability to understand, implement, and maintain disease-management behaviors. However, the effectiveness of self-management interventions incorporating health literacy-sensitive components in COPD remains unclear. We conducted a systematic review and meta-analysis of randomized controlled trials evaluating health literacy-sensitive self-management interventions for adults with COPD. Health literacy-sensitive self-management interventions were defined as self-management programs incorporating explicitly identifiable strategies intended to reduce literacy-related barriers or to support patients in obtaining, understanding, appraising, or applying COPD-related health information in daily self-management. Nine databases were searched from inception to August 30, 2025. Thirty-one randomized controlled trials involving 4759 participants were included. Outcomes included 6 min walk distance (6MWD), forced expiratory volume in 1 s as a percentage of predicted value (FEV₁% predicted), St George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (mMRC) dyspnea score, COPD Assessment Test (CAT), and self-management-related outcomes. Risk of bias was assessed using the Cochrane Risk of Bias tool, and pooled effects were calculated using fixed- or random-effects models according to heterogeneity. Compared with usual care, self-management interventions with health literacy-sensitive components were associated with improvements in 6MWD (MD = 44.81 m, 95% CI 17.48-72.14; p = 0.001), FEV₁% predicted (MD = 7.43, 95% CI 6.31-8.55; p < 0.00001), SGRQ total score (MD = -6.80, 95% CI -9.80--3.80; p < 0.00001), mMRC score (MD = -0.40, 95% CI -0.61--0.19; p = 0.0002), CAT score (MD = -3.78, 95% CI -5.49--2.07; p < 0.0001), and self-management-related outcomes (SMD = 1.50, 95% CI 1.34-1.67; p < 0.00001). Substantial heterogeneity was observed for several outcomes, particularly 6MWD, SGRQ, mMRC, CAT, and self-management-related outcomes. Health literacy-sensitive self-management interventions were associated with improvements in exercise capacity, pulmonary function, symptom burden, dyspnea, health-related quality of life, and self-management-related outcomes in patients with COPD. However, the evidence should be interpreted with caution because eligible interventions were defined by the presence of explicitly identifiable health literacy-sensitive strategies embedded within self-management programs, rather than by isolated health-literacy enhancement alone, and substantial heterogeneity and variable methodological quality were present across studies. More rigorously designed and standardized trials are needed to clarify the specific contribution of health literacy-sensitive strategies and their long-term effectiveness in COPD care.
Digital inhalers can assess and support medication adherence and inhalation technique and may predict exacerbations, yet real-world evidence on their use, implementation, and clinical impact remains limited. To date, no standardized registry exists to systematically capture digital inhaler use across the full spectrum of asthma severity. To reach an expert consensus on a minimal and feasible dataset for a registry (AURORA) of asthma patients using digital inhalers. A three-round modified Delphi process was conducted involving 15 Dutch experts in asthma care, medication adherence, digital health, regulatory science, and healthcare policy. In Rounds 1 and 2, candidate variables were evaluated via an online Delphi platform, with predefined consensus thresholds for inclusion and exclusion. Patient perspectives were incorporated through structured interviews. Final consensus was achieved during an online meeting in Round 3 (≥66% agreement required). Of 92 variables considered, 18 were classified as core and 45 as optional. Core variables covered key domains, including patient demographics, asthma control, medication type, digital inhaler characteristics, medication adherence, inhaler technique, and patient satisfaction. Optional variables provide flexibility to support implementation across different healthcare settings. This modified Delphi study established a consensus-based national registry framework specifically focused on digital inhaler use in asthma. The AURORA registry provides a standardized and feasible foundation for generating real-world evidence to support future research, personalized treatment decisions, and the optimization of escalation strategies in routine asthma care.
Shared decision-making (SDM) is a collaborative process in which healthcare providers and patients work together to make informed healthcare choices, significantly reducing unnecessary antimicrobial prescriptions by aligning treatment decisions with both clinical evidence and patient values. There is limited qualitative research exploring physicians’ perspectives on its implementation in the study area. This study aims to explore physicians’ perspectives and experience of SDM in the management of Acute Respiratory Tract Infections (ARTIs) at public primary healthcare centres. Purposive sampling was applied to recruit physicians from selected primary healthcare centres in the Amhara region of Ethiopia. The sample size was determined using the concept of data saturation. The data were collected through semi-structured interviews and analysed using thematic analysis with the assistance of NVivo software (version 14). Twenty physicians were interviewed, and four main themes were identified: (1) awareness and understanding of SDM; (2) perceived value of SDM; (3) barriers to implementing SDM; (4) facilitators to enhance SDM implementation. The study found that, despite its recognised benefits, SDM is not yet a routine practice in primary healthcare centres in the study area due to identified barriers. Addressing these challenges and implementing the solutions suggested by participants will be essential to realise the full benefits of SDM and strengthen antimicrobial resistance mitigation efforts.
Dyspnea is a complex symptom measured using subjective patient-reported ratings. Continuous, automated dyspnea measurements are needed, especially in critical care and trauma settings with impaired patient communication. We prospectively enrolled 54 pulmonary rehabilitation subjects. Participants completed two treadmill walking trials, during which dyspnea measurements were collected at one-minute intervals automatically using physiologic sensors and patient-reported ratings of perceived breathlessness and exertion (RPB and RPE). The sensor data were used to train machine learning models using either 19 or 7 features to generate an objective dyspnea score (ODS). Classification performance was assessed on a held-out test set, compared against patient-reported RPB and RPE. The model trained on 7 features performed best, resulting in a correlation between predicted and actual scores (percent accuracy) of 0.84 (78.7%) for RPE and 0.86 (83.6%) for RPB. Our system incorporating ODS accurately predicts patients’ subjective dyspnea scores and is promising for automated, real-time dyspnea measurement.
To evaluate and compare the risks of cardiometabolic comorbidities and all-cause mortality between individuals with preserved ratio impaired spirometry (PRISm) and those with chronic obstructive pulmonary disease (COPD). A systematic literature search was conducted across CNKI, Wanfang Database, VIP Database, SinoMed, PubMed, Embase, Web of Science, and the Cochrane Library from inception to February 2026 to identify observational studies comparing PRISm (FEV1/FVC ≥ 0.70 and FEV1 < 80% predicted) with COPD (FEV1/FVC < 0.70). Meta-analysis was performed using RevMan 5.4. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects models, and subgroup analyses were conducted by geographic region. Twenty-two observational studies (n = 343,849) were included, involving 125,776 participants with PRISm and 218,073 with COPD. Compared with COPD, PRISm was associated with significantly higher risks of cardiometabolic conditions, including diabetes [OR = 1.56, 95% CI (1.34-1.82)], obesity [OR = 1.72, 95% CI (1.10-2.68)], and hypertension [OR = 1.15, 95% CI (1.09-1.21)] (P < 0.05). No significant differences were found regarding heart failure, coronary heart disease, or all-cause mortality (P > 0.05). Subgroup analyses revealed that diabetes risk was higher in Western populations (P = 0.002), while all-cause mortality was lower in the PRISm group than in the COPD group specifically among Asian populations (P < 0.001). PRISm is associated with higher risks of hypertension, diabetes, and obesity compared with COPD, highlighting cardiometabolic dysfunction as an important clinical feature. Although the all-cause mortality risk of PRISm was comparable to that of COPD, ethnic heterogeneity was observed in its clinical characteristics. These findings suggest that PRISm may represents a clinically important and heterogeneous lung function phenotype requiring greater clinical attention.
BACKGROUND:Asthma, a common chronic respiratory disease worldwide, is strongly influenced by several attributable risk factors. OBJECTIVE:To systematically examine global asthma burden trends attributable to major risk factors from 1990 to 2021 and forecast changes to 2050. METHODS:Using 2021 GBD data, we estimated global asthma DALYs and age-standardized DALY rates (ASDRs) attributable to high BMI, smoking, occupational exposure, and NO₂ pollution, and explored their relationships with the Socio-demographic Index (SDI). Bayesian age-period-cohort (BAPC) modeling was used for forecasting, with 1990-2010 data serving as the training set for backtesting trends from 2011 to 2021, and with prediction accuracy evaluated with the mean absolute percentage error (MAPE). RESULTS:During 1990-2021, asthma burden related to most risk factors declined globally and across SDI quintiles. Backtesting confirmed BAPC model reliability (MAPE: high BMI 5.44%, smoking 1.16%, occupational asthmagens 3.35%). Worldwide, smoking-related burden declined most sharply: ASDR fell from 41.95 in 1990 to 16.19 in 2021 per 100,000 (-61.41%, estimated annual percentage change [EAPC] = -3.13). NO₂ pollution and occupational asthma burdens dropped 48.45% and 45.57%, respectively. High BMI showed the smallest reduction (-21.99%, EAPC = -0.85) and showed an increase in low-middle SDI regions (EAPC = 0.25). ASDRs for high BMI (ρ = -0.27), occupational risks, and smoking correlated negatively with SDI; NO₂ ASDR showed a significant positive correlation with SDI (ρ = 0.56, P < 0.001). By 2050, high BMI is projected to be the only risk factor with a continuously rising burden, with its ASDR rising from 39.42 in 2021 to 53.79 per 100,000 ( + 36.45%). CONCLUSION:Despite declines in asthma burden from all four factors, high BMI poses a growing threat with significant regional disparities. Future strategies should be tailored by SDI region and high-risk population, prioritizing surveillance and intervention for high BMI to counter its rising disease risk.
BACKGROUND:Pulmonary rehabilitation (PR) is a key component in managing chronic respiratory diseases (CRDs). Primary care, often the first point of contact for people with CRD, is well-positioned to facilitate referral to PR, yet referral rates are low. This systematic review aimed to identify the key components of primary care interventions to support referral to PR and synthesise their effect on referral rate. METHODS:Five electronic databases were searched to identify studies of any design that reported interventions implemented in primary care to support referral to PR for people with CRD. Interventions could target people with CRD and/or healthcare professionals. Screening, quality appraisal using the Downs and Black checklist, and data extraction were conducted independently by two reviewers. Interventions were mapped to the Expert Recommendations for Implementing Change (ERIC) taxonomy-a framework of 73 strategies seeking to enhance the adoption, implementation, and sustainability of evidence-based interventions. RESULTS:Thirteen studies were included, employing a range of quasi-experimental, observational, and randomised designs. Overall, the studies were of moderate quality (mean total score 14, range 10 to 25 out of 27). Interventions incorporated a mean of 12 ERIC strategies across five domains, most commonly education and training, interactive assistance, clinician support, and audit and feedback. Impact of interventions on referral rates was minimal (n = 3 randomised controlled trials, pooled mean difference 0%, 95% confidence interval -0.24 to 0.25). INTERPRETATION:Multi-component interventions, including numerous implementation strategies, have achieved minimal improvement in PR referral rates from primary care. Understanding how strategies are delivered and applied, rather than simply the number of strategies or the combination they are used in, may be important for operationalisation of referral focussed interventions. Addressing the behavioural processes underpinning referral decisions, together with the use of theory-informed, context-specific approaches may enhance effectiveness of referral focussed interventions.
Bronchiectasis is a common chronic respiratory disease with rising prevalence, hospitalisation rates, and mortality. It is estimated to affect approximately 1 in 200 adults, imposing a substantial symptom burden and significant healthcare costs, largely driven by exacerbations. Although diagnosis and long-term management are usually led by respiratory specialists, most patient care interactions occur in primary care, including the management of multimorbidity and acute exacerbations. In December 2025, the European Respiratory Society (ERS) published updated global clinical practice guidelines for adult bronchiectasis. This article summarises the 2025 ERS recommendations with a specific focus on their implementation in primary care practice. Key priorities include improving early recognition and reducing diagnostic delay, undertaking standardised investigations to identify underlying causes and treatable traits, and recognising features associated with poor outcomes that warrant specialist referral. The guidance emphasises the importance of sputum microbiology, including testing for non-tuberculous mycobacteria, and targeted blood investigations such as immunoglobulins and allergic bronchopulmonary aspergillosis serology. Core management strategies relevant to primary care are reviewed, including airway clearance techniques, pulmonary rehabilitation, and evidence-based use of inhaled therapies. The article outlines best practice for the management of acute exacerbations, highlights differences from asthma and COPD care, and clarifies the limited role of inhaled corticosteroids in bronchiectasis. The identification and monitoring of patients who may benefit from long-term antibiotic therapy, including those with Pseudomonas aeruginosa infection, are also discussed. By translating specialist guideline recommendations into a primary care context, this summary aims to support timely diagnosis, optimise ongoing management, and improve outcomes for adults with bronchiectasis.
