Preclinical functional metrics show that lung aeration and ventilation vary by age, sex, and mouse strain. The pathological interpretation of these depends on changes from baseline, without that comparison they are not useful for quantitative assessment. https://bit.ly/3SwI7N3.
There is growing interest in the role of vitamin D in respiratory disorders. Its action as the main regulator of calcium and bone metabolism is well established, but vitamin D is also thought to influence inflammation, immunity and host defence. Accumulating evidence associates vitamin D insufficiency with poorer respiratory outcomes. This narrative review summarises the current literature on the role of vitamin D in inflammatory mechanisms associated with asthma, COPD, interstitial lung disease, lung cancer, tuberculosis and acute respiratory tract infections. It outlines the existing evidence supporting the immunomodulatory and anti-inflammatory effects of vitamin D in respiratory disease. Results from the current literature are mixed, with clinical trial data not always aligning with a plausible mechanistic rationale or data from observational studies. Future large randomised controlled trials, targeting vitamin D deficient cohorts and assessing outcomes over longer durations are needed to provide clarity on the clinical utility of vitamin D supplementation in respiratory disease.
Ultrasound can be used as an adjunct by the medical intensivist to diagnose a wide range of pathology in the intensive care unit. Ocular ultrasound's strengths include accessibility, safety profile and familiarity for the intensivist. Estimation of intracranial pressure through optic nerve sheath diameter may be of particular utility. Other applications include its role as a tool in the creation of a differential diagnosis for vision loss both spontaneously and in trauma. Ocular ultrasound does not replace consultation with an ophthalmologist and/or neurologist, or other forms of advanced neuroimaging, but it does provide a quick and safe evaluation while the intensivist is deciding the best course for their patient's ocular complaint.
ROHHAD is a rare, life-threatening paediatric disorder often overlooked and misdiagnosed. Chronic unexplained hypoventilation in children should raise suspicion. Early recognition and diagnosis are crucial to enable timely treatment and improve prognosis. https://bit.ly/4drYzWY.
ACS-like presentations may rarely be the first sign of occult lung cancer. Interval changes on coronary angiography and atypical myocardial imaging should prompt consideration of metastatic cardiac involvement and a multidisciplinary diagnostic approach. https://bit.ly/48XvNLi.
Children with neurodisability experience a high burden of respiratory morbidity, which remains a leading cause of hospitalisation, long-term lung disease and reduced quality of life. Respiratory problems in this population often reflect shared underlying neuro-pulmonary pathophysiology that evolves across a child's development. In this narrative review, we describe how respiratory vulnerability arises from three interacting domains: dysregulated central control of breathing; impaired neuromuscular activation and coordination; and altered respiratory mechanics related to abnormal tone, weakness, posture and chest wall restriction. Early functional impairment in these systems compromises ventilation, airway protection and airway clearance, establishing baseline respiratory vulnerability. Over time, secondary clinical features such as sleep disordered breathing, pulmonary aspiration, secretion retention and recurrent infection may come to dominate the respiratory phenotype and contribute to progressive lung injury, including restrictive lung disease and bronchiectasis. We synthesised evidence linking neuro-pulmonary mechanisms to clinical presentations and highlight challenges in assessment where standard investigations are limited. By integrating mechanistic understanding with history-led clinical reasoning, we identify opportunities for proactive, anticipatory respiratory care across childhood and during the transition to adult services. This review aims to support earlier recognition of respiratory risk factors and to promote pathophysiology-informed strategies to preserve long-term respiratory health in children with neurodisability.
Chronic cough is a highly prevalent debilitating condition. Chronic cough can be unexplained despite investigations (unexplained chronic cough) or persist despite guideline-based management of treatable traits (refractory chronic cough). Individuals with refractory and unexplained chronic cough (RUCC) often share similar clinical characteristics, including a dry cough, persistent urge-to-cough and throat irritation. Most individuals with RUCC display cough reflex hypersensitivity, coughing in response to chemical, thermal and mechanical triggers. Compared to controls, individuals with RUCC cough at lower concentrations of inhaled stimuli (hypersensitivity) and have increased cough responses across concentrations (hyperresponsiveness). Neuro-pulmonary mechanisms are also supported by treatment responses in RUCC to neuromodulatory medications and behavioural cough control therapy. Mechanisms leading to RUCC are complex but likely involve alterations in the neuro-pulmonary axis in the peripheral and central nervous system. Mechanisms are not fully understood, but RUCC may relate to alterations in airway receptors on vagus nerve terminals, (ATP) release and/or metabolism and plasticity of airway sensory nerves. A wide network of midbrain and higher cortical centres are involved in processing of airway sensations and top-down cough control. Top-down inhibitory control of cough may be altered in RUCC.
Paediatric asthma is a heterogenous clinical syndrome where objective tests aid, but do not replace, clinical judgment. In 2026, the challenge is determining which biomarkers and tests are most informative for different patients and purposes. This review summarises current evidence supporting key diagnostic and monitoring tools for childhood asthma (age 5-16 years): exhaled nitric oxide fraction (F ENO), spirometry with bronchodilator reversibility (BDR), and additional investigations such as peak expiratory flow variability, blood eosinophils, allergen sensitisation and bronchial challenge. Recent British Thoracic Society/National Institute for Health and Care Excellence/Scottish Intercollegiate Guidelines Network and European Respiratory Society guidelines emphasise the need for objective confirmation of asthma, but differ in the degree of diagnostic certainty and test prioritisation. F ENO is now the leading inflammatory biomarker in routine paediatric care, valued for its noninvasive nature, ease and high specificity at elevated thresholds, especially for type 2 asthma. Its sensitivity, however, is modest, so it should not be relied upon as a stand-alone rule-out test. Spirometry remains a core physiological assessment, although its diagnostic accuracy alone is limited, and evidence supporting BDR thresholds in children is not robust. Additional tests should be used selectively, particularly when initial investigations are negative, discordant or technically challenging, or when severe asthma requires phenotype driven therapy. Biomarkers also play an important role in monitoring and severe asthma care, including predicting response to biologics. Emerging approaches like breathomics, alarmin-based biomarkers, and multi-omic profiling are discussed. Overall, biomarkers have enhanced the precision of paediatric asthma assessment, especially in severe cases, but their greatest value is in complementing, not replacing, thorough clinical evaluation.
Recurrent invasive fungal infection in adults should prompt evaluation for thymoma even with preserved immunoglobulins. In vascularly invasive mediastinal masses, diagnosis requires careful imaging interpretation and anatomically guided biopsy planning. https://bit.ly/3NX79U0.
In hyperleukocytic CML, serial PFTs showed supranormal D LCO and D LCO/V A, likely from pulmonary vascular engorgement and hyperviscosity. Abnormalities normalised with cytoreduction, underscoring the diagnostic value of PFTs in haematologic emergencies. https://bit.ly/3ORAUpo.
Immune checkpoint inhibitors have transformed lung cancer therapy, offering durable tumour control and improved survival. Yet their success has revealed a paradox: checkpoint inhibitor-related pneumonitis (CIP), an unpredictable immune-mediated complication that can damage the lungs. CIP differs from cytotoxic therapy-induced pneumonitis, arising from immune dysregulation rather than direct tissue injury, and presents with diverse clinical and radiological patterns. Incidence ranges from 2.5% in trials to nearly 20% in real-world practice, reflecting biological variability and inconsistent recognition. This viewpoint reviews persistent gaps in understanding CIP, including mechanisms, risk prediction, early detection, and management. CIP appears multifactorial, involving T-cell-driven inflammation, age-related immune changes, and possible environmental or infectious triggers. Risk stratification remains limited, although emerging biomarkers and tumour- or therapy-related factors show potential. Diagnosis relies primarily on exclusion, supported by imaging and bronchoalveolar lavage. Investigational tools, including radiomics and artificial intelligence, demonstrate potential to detect subclinical changes and classify CIP patterns, offering promise for earlier and more objective recognition in the future. Addressing these gaps requires prospective, multidisciplinary research, standardised frameworks, and collaborative registries. CIP represents both a clinical challenge and a scientific opportunity: understanding its mechanisms and improving early recognition may optimise immunotherapy safety, efficacy, and ultimately patient survival and quality of life.
CDK4/6 inhibitors, including ribociclib, may cause organising pneumonia that closely mimics lung cancer on CT and FDG-PET. Histological confirmation is essential in discordant cases. https://bit.ly/48nGZ3t.
Foreign body inhalation carries potential for significant morbidity and mortality. Technological advances in imaging and flexible endoscopes have challenged the status of rigid bronchoscopy as the gold standard for inhaled foreign body management. This review of the assessment and management of inhaled foreign bodies focuses on tracheobronchial foreign bodies in children. Myths surrounding clinical assessment, use of radiography and procedures for addressing foreign bodies are sequentially deconstructed using evidence from the literature. If foreign body aspiration is suspected, prompt intervention is required to minimise sequelae of delayed diagnosis. The threshold for bronchoscopy should be low, with rigid techniques remaining the gold standard, and maintenance of these skills essential.
Acute respiratory tract infections represent a significant burden in primary care, with antibiotics often prescribed unnecessarily. This contributes to the escalating threat of antimicrobial resistance (AMR) by increasing the burden of infectious diseases and mortality risk. This is a report from a joint European Society of Clinical Microbiology and Infectious Diseases/European Respiratory Society research seminar held in November 2023 to discuss the role of in vitro diagnostic tests to combat AMR in community-acquired respiratory tract infections. We review the diagnostic tools available and in development, and the challenges related to their assessment, implementation in clinical settings and their overall impact on AMR.
Emerging evidence suggests that metabolic dysregulation is a central driver in the pathogenesis of pulmonary disorders, extending beyond structural or immunological failures. This review synthesises current research on the specific alterations of glucose and lipid metabolism within the context of asthma, COPD, pulmonary fibrosis and lung cancer. We highlight how these metabolic alterations fuel disease progression and identify them as promising targets for novel biomarkers and therapeutic interventions. Finally, we outline critical future directions, emphasising the need to distinguish between causality and consequence, and the importance of mapping metabolic fluxes at the single-cell level.
The advent of immune checkpoint inhibitors (ICIs) has revolutionised the management of lung cancer, transforming it from a historically immune-resistant malignancy into a paradigm for durable immunotherapy response. This review provides a comprehensive overview of the biological and clinical foundations of checkpoint regulation in the lung and their implications for patient care. We first explore the unique pulmonary immune environment, where continuous exposure to environmental antigens necessitates a delicate balance between tolerance and defence. Within this context, immune checkpoints, such as programmed cell death protein 1 (PD-1) and its ligand PD-L1 as well as cytotoxic T-lymphocyte-associated protein 4, maintain physiological self-tolerance but can be subverted by tumour cells to evade immune surveillance. Emerging inhibitory receptors, including LAG-3, TIGIT and TIM-3, contribute additional layers of immune regulation and resistance, highlighting opportunities for combinatorial therapeutic strategies. The clinical section summarises pivotal trials establishing ICIs as the standard of care across metastatic, locally advanced and early-stage lung cancer. These agents now span the full disease continuum, from neoadjuvant and adjuvant to perioperative and consolidation settings. We also address the management of immune-related adverse events and the need for precision in patient selection through biomarkers, such as PD-L1 expression, tumour mutational burden and circulating immune signatures. Finally, we discuss ongoing challenges, including mechanisms of primary and acquired resistance, and emerging approaches integrating spatial multi-omics, dynamic immune monitoring and microbiome profiling. Together, these advances are reshaping lung cancer immunotherapy towards a more precise, adaptive and durable model of care.
This issue of Breathe focuses on molecules in pulmonary medicine https://bit.ly/4u8bWSg.
Thoracic ultrasound (TUS) is a key bedside tool for detecting pleural effusion and pneumothorax, offering high sensitivity, portability and radiation-free assessment. However, its reliability is limited by operator dependency and variable training, posing challenges in emergency, intensive care and resource-limited settings. Artificial intelligence (AI) has emerged as a potential adjunct to support TUS interpretation, with deep learning algorithms showing promising accuracy in research studies. Evidence suggests AI may perform well for straightforward cases, yet performance declines significantly during external validation and for complex or low-quality images, precisely where clinical decision support is most needed. Five potential scenarios for AI application are identified: emergency triage, intensive care unit monitoring, post-procedural safety checks, deployment in resource-limited environments, and educational feedback for trainees. Despite these opportunities, current AI systems remain immature: methodological limitations, operator-dependence and lack of real-world outcome data constrain safe clinical adoption. Rigorous prospective trials, multisite validation, standardised reporting, and integration of quality assurance are essential before routine use. At present, AI-assisted TUS should be regarded as a research and educational tool rather than a substitute for clinical judgment. Thoughtful development and cautious implementation are required to transform AI from an experimental promise into a reliable, patient-centred clinical resource.
Respiratory diseases remain a leading health burden across Europe, yet national strategies are often fragmented or absent. The International Respiratory Coalition's Lung Facts platform offers a comprehensive, up-to-date resource for epidemiological and economic data for major respiratory conditions across 53 European countries. This viewpoint outlines the platform's development and the types of data available, including disease burden, societal costs and risk factor attribution. It also demonstrates how national coalitions are using it to advocate for respiratory health policies. By providing accessible, country-specific information in visual formats, Lung Facts supports benchmarking, evidence-based advocacy and planning of national respiratory strategies. The platform is a dynamic tool intended to strengthen respiratory health policy and empower stakeholders to act on the growing burden of lung disease.
