PURPOSE OF REVIEW Thoracic ultrasound has continued to expand beyond simple bedside triage into a quantitative, procedure-guiding and increasingly artificial intelligence-augmented tool across pleural and respiratory medicine. This review summarizes the literature published over the past year, highlighting developments in effusion characterization, pneumothorax diagnosis, image-guided pleural procedures, artificial intelligence, training standards, critical care applications, malignant pleural effusion management, and diaphragm/interstitial lung disease assessment. RECENT FINDINGS Elastography and contrast-enhanced ultrasound have moved from exploratory to comparative and multicentre randomized evaluation for effusion characterization and biopsy guidance. Meta-analyses have reaffirmed the superiority of point-of-care ultrasound over chest radiography for both pneumothorax and thoracentesis guidance. Artificial intelligence tools have shown that they can close the acquisition-skill gap for novice operators, although automated interpretation (particularly B-line quantification) remains inconsistent against expert consensus. A new UK national training standard for pleural procedures has been published, alongside the first validated thoracic-specific competency assessment tool. A large multicentre randomized trial found that a point-of-care ultrasound-driven diagnostic pathway did not improve early discharge rates in emergency department patients with dyspnoea, an important negative finding. Diaphragm and quantitative lung ultrasound continue to accumulate evidence as noninvasive markers of interstitial lung disease severity and ventilator weaning readiness. SUMMARY The past year's literature confirms thoracic ultrasound's trajectory from a purely diagnostic adjunct towards a quantitative, procedure-integrated and artificial intelligence-supported modality, while also delivering important cautionary and negative findings that temper enthusiasm and clarify where evidence remains immature.
Purpose of review More than a century after Jacobaeus, medical thoracoscopy is being reshaped by demands for precise pleural diagnosis, adequate tissue for molecular characterisation, combined local treatment and efficient care. This review uses its historical evolution to examine current indications, instruments, biopsy strategies, anaesthetic design and service models, with emphasis on recent evidence. Recent findings Rigid and semirigid thoracoscopy achieve similarly high diagnostic yield but differ in access, force transmission, tissue size, pain and sedative requirements. Recent studies favour needs-led sampling: standard forceps for most visible lesions, with cryobiopsy or advanced tools when depth, invasion, fibrosis or molecular profiling is limiting. Trials support selective rather than routine use of pleurodesis, indwelling catheters, regional blocks, high-flow oxygen or first-line thoracoscopy for pleural infection. Image enhancement, artificial intelligence, hybrid instruments and single-use platforms remain promising but incompletely validated. Summary Medical thoracoscopy should remain a targeted pleural procedure that preserves spontaneous ventilation while integrating diagnosis, adequate tissue acquisition, selected therapy and pathway efficiency. Technology and anaesthetic intensity should be matched to clinical need and adopted only when they improve measurable patient or system outcomes.
Purpose of review Persistent air leak remains a major source of morbidity after lung resection and in secondary spontaneous pneumothorax, yet management is still commonly driven by duration rather than mechanism. This review examines recent advances in objective air leak assessment, pressure-dependent leak physiology, localization, and phenotype-directed intervention. Recent findings Digital drainage improves reproducible measurement of air leak trajectory, although no universal threshold predicts healing or permits tube removal. Pressure-dependent air leaks related to residual pleural space or lung-thoracic cavity mismatch may resolve after reducing drainage intensity or removing the tube in selected patients. Computed tomography and ventilation SPECT/CT can support anatomical and functional localization when targeted treatment is planned. Recent studies support individualized low-pressure drainage, autologous blood patch or glucose pleurodesis, and bronchoscopic valves, spigots, blood patching, sealants, or plugs, but most comparative evidence remains limited and heterogeneous. Summary Persistent air leak should be classified by air leak trajectory, lung expansion, pleural pressure behavior, anatomical source, infection, and operative fitness. Phenotype-directed escalation may reduce unnecessary procedures while identifying patients who require early bronchoscopic or surgical source control.
PURPOSE OF REVIEW:Sleep-disordered breathing (SDB) is an increasingly recognized contributor to WHO Group 3 pulmonary hypertension (PH). This review examines the epidemiology and pathophysiology linking SDB to PH, evaluates the evidence base for sleep-directed therapies in modifying pulmonary hemodynamics, and highlights emerging treatment modalities that may be able to alter disease course. RECENT FINDINGS:The mechanisms underlying SDB-related PH are multifactorial, including recurrent nocturnal hypoxemia, altered intrathoracic pressures, and obesity-driven metabolic and inflammatory dysregulation. Positive airway pressure therapy remains the cornerstone of treatment of SDB-related PH, though mandibular advancement devices and hypoglossal nerve stimulation offer viable alternatives. Hypoxic burden, rather than apnea-hypopnea index alone, is increasingly recognized as a better predictor for cardiovascular and pulmonary vascular outcomes in SDB. Long-term oxygen therapy provides hemodynamic benefit in patients with resting hypoxemia, though evidence is limited in those with isolated nocturnal desaturation. SUMMARY:SDB is an underdiagnosed and clinically important contributor to PH. Early identification and treatment, particularly with positive airway pressure therapy when indicated, can meaningfully reduce pulmonary arterial pressures. Future research should prioritize prospective trials examining the direct impact of glucagon-like peptide-1 receptor agonists and bariatric surgery on pulmonary hemodynamics and standardize the use of hypoxic burden as a clinical endpoint.
PURPOSE OF REVIEW:This review addresses the management of restless legs syndrome (RLS) when first-line gabapentinoid therapy fails or is not tolerated. We provide an update on treatment options in the context of the 2025 American Academy of Sleep Medicine (AASM) guideline, which substantially reorganized the treatment hierarchy for RLS. RECENT FINDINGS:The 2025 AASM guideline elevated all gabapentinoids and intravenous ferric carboxymaltose to strong first-line recommendations while repositioning dopamine agonists away from routine long-term use because of augmentation and impulse control disorder risk. Emerging data suggest the ferritin and transferrin saturation thresholds guiding iron repletion may be more permissive than previously appreciated, extending benefit to a broader range of patients. Long-term registry data now extending to 5 years show that low-dose opioids remain effective and largely stable over time in RLS, a pattern distinct from the dose escalation seen in chronic pain, and a mechanistic rodent model has identified a dopaminergic pathway distinct from nociceptive pain pathways that may underlie this difference. Device-based tonic motor activation has emerged as a well tolerated, conditionally recommended nonpharmacologic option, including as an adjunct that may enable opioid dose reduction. SUMMARY:The management of gabapentinoid-refractory RLS is no longer a single default step toward dopamine agonist therapy. Clinicians now have a broader set of well supported options, including expanded intravenous iron candidacy, low-dose opioids, and device-based therapy, that should be selected through a shared decision-making process weighing the durability and risks specific to each patient.
