BACKGROUND:Idiopathic inflammatory myopathies (IIMs) are frequently complicated by interstitial lung disease (ILD). Although clinical heterogeneity is recognized, comparisons between patients with idiopathic inflammatory myopathy associated interstial lung disease (IIM-ILD) managed in pulmonology vs rheumatology centers remain limited. RESEARCH QUESTION:Do differences in clinical features, treatment strategies, lung function trajectories, and transplant-free survival among patients with IIM-ILD followed at pulmonology or rheumatology centers exist? STUDY DESIGN AND METHODS:We conducted a multicenter, observational, cohort study including 75 patients with IIM-ILD diagnosed between 2014 and 2024: 25 from 2 Italian pulmonology centers and 50 from a rheumatology center in Norway. All met IIM classification criteria, had ILD confirmed by high-resolution CT scan, and had serial pulmonary function tests. Associations of baseline features, imaging patterns, and treatments with referral center were assessed using logistic regression. Lung function trajectories were assessed with linear mixed-effects models and transplant-free survival with Cox regression. RESULTS:Patients with IIM-ILD from pulmonology centers were more often male, had more fibrotic ILD (OR, 5.61; 95% CI, 1.88-16.73; P = .002), had lower baseline diffusing capacity of the lungs for carbon monoxide (OR, 0.96; 95% CI, 0.93-0.99; P = .048), had less cutaneous (OR, 0.11; 95% CI, 0.03-0.40; P = .001) and musculoskeletal involvement, and used less rituximab (OR, 0.06; 95% CI, 0.01-0.23; P < .001) than patients from rheumatology centers. Despite baseline differences, both cohorts showed significant and comparable improvement in FVC and diffusing capacity of the lungs for carbon monoxide % predicted over a mean of 2.5 years. Transplant-free survival did not differ significantly between specialty centers. Factors associated with worse transplant-free survival included anti-MDA5 positivity (hazard ratio, 10.24; 95% CI, 1.70-61.66; P = .011), elevated C-reactive protein, and extensive lung fibrosis. INTERPRETATION:Our results show that although baseline presentation and treatment characteristics of patients with IIM-ILD differed between rheumatology and pulmonology cohorts, transplant-free survival was comparable. Including patients from both pulmonology and rheumatology in future clinical trials may enhance representativeness without compromising data consistency.

Background: Complex coronary artery disease frequently coexists with severe aortic stenosis. The prognostic impact of complete revascularization (CR) versus incomplete revascularization (IR) in patients undergoing complex and/or high-risk indicated percutaneous coronary intervention (CHIP) and transcatheter aortic valve implantation (TAVI) remains unclear. Methods: We analyzed 550 patients who underwent CHIP and transfemoral TAVI between 2013 and 2023 at 14 international centers. Patients were stratified by completeness of revascularization. The primary endpoint was a composite of all-cause death and unplanned cardiovascular (CV) hospitalization at 1 year. Results: CR was achieved in 299 patients (54.4%). Patients with IR more frequently had three-vessel disease, bifurcation lesions, left main disease, and need for mechanical support. Balloon-expandable valves were more frequently implanted in the CR cohort. Short-term outcomes were similar in the two groups. At 1 year, the incidence of the primary endpoint did not differ significantly between CR and IR groups (20.1 vs. 27.3%, hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.49-1.07). CV rehospitalizations were significantly reduced in the CR group (14.8 vs. 22.8%, HR 0.61, 95% CI 0.38-0.97) even after multivariable adjustment and excluding hospitalizations for repeat revascularization. Conclusions: In patients undergoing CHIP and TAVI, CR was associated with a reduction in CV hospitalizations. Further studies are needed to confirm this finding.

Diarrhoea is the primary cause of nintedanib discontinuation in idiopathic pulmonary fibrosis. We investigated predictors in 100 prospective patients; 46% experienced diarrhoea, defined as common terminology criteria for adverse events V.5.0 grade ≥1. In a multivariable model (area under the curve 0.9056), lower standardised body surface area (adjusted OR 0.20, 95% CI 0.06 to 0.55, p=0.004) emerged as a significant independent predictor. A linear mixed model showed that dose adjustments managed symptoms without compromising 12-month forced vital capacity or diffusing capacity of the lungs for carbon monoxide trajectories (p>0.05). Small body size influences drug tolerability, suggesting that simple anthropometric measures can aid in baseline risk stratification to improve adherence.

The use of non-invasive respiratory support (NIRS) for acute respiratory failure (ARF), particularly hypoxemic respiratory failure, has advanced in recent years, especially during the COVID-19 pandemic. NIRS modalities like high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and non-invasive ventilation (NIV) have shown efficacy, though evidence is inconsistent, especially for "de novo" acute hypoxemic respiratory failure (AHRF). This review outlines the physiological rationale for NIRS and offers practical guidance on tailoring treatment to individual patients. Successful AHRF management with NIRS requires a personalized approach, guided by clinical expertise. Further research is needed to refine patient selection and optimize NIRS application.

BACKGROUND:Although chronic diseases represent a growing global health priority, significant gaps remain in understanding the burden of multimorbidity. This study developed an original methodology to estimate the burden of thirty major chronic diseases at the individual patient level, in terms of Disability-Adjusted Life years (DALYs), Years Lived with Disability (YLD), and Years of Life Lost due to premature death (YLL). METHODS:The Disability weights (DWs) estimated by the Global Burden of Disease (GBD) study were integrated with information from healthcare databases. A panel of medical specialists established the criteria for assigning the level of severity, and thus a specific DW, to each chronic disease. The patient-centred YLD metric was estimated as the cumulative of the combined DWs over the previous ten years. We also measured the Disability Weight Fraction of each coexisting disease (DWF). We illustrated this method using healthcare databases from a large Italian region to assess the impact of chronic diseases and multimorbidity at progressive levels of analysis: health status of the regional chronic disease population, burden of individual chronic diseases and patient clinical complexity. RESULTS:Unlike the standard GBD estimates, the new method provided precise metrics for multimorbidity, as shown by the comparison on the disability calculated for 4 main chronic diseases. Real-world estimates from the new method highlighted that comorbidity accounted for most of the YLD: for instance, about 88% of the YLD of patients with heart failure was explained by concomitant conditions. DALYs were higher among females than males in most age groups. In the younger groups, psychiatric conditions explained approximately 40% and 25% of YLD among males and females, respectively. Finally, the patient-centred YLD metric was a good predictor of death (c-statistic = 0.779). CONCLUSIONS:This novel method provides insights into the measurement of multimorbidity, based on the disability fraction of each concomitant health condition, which is crucial for defining priority areas for healthcare interventions. The patient-centred estimates may serve to identify subgroups of chronic disease patients with specific healthcare needs and trajectories among a given population. Importantly, measuring the relative contribution of each disease to the patient's burden of multimorbidity favours the planning of multidisciplinary care pathways that are more responsive to individual needs.

Introduction Flexible bronchoscopy (FB) is widely used for diagnostic and therapeutic procedures in pulmonary medicine. However, FB can cause respiratory and haemodynamic complications, especially in patients with pre-existing lung and/or cardiovascular comorbidities. Despite the range of oxygenation and ventilatory approaches available to prevent these risks, evidence regarding their real-world application and clinical impact is limited. The OxyFOB study aims to assess the prevalence and outcomes of various oxygenation and ventilatory support strategies used during FB across Europe.Methods and analysis The OxyFOB study is a large, prospective, international, observational cohort study which aims to involve over 10 000 FB procedures across European centres. Eligible participants include all adults undergoing FB for diagnostic, therapeutic or procedural indications. Data are collected via a standardised electronic case report form and encompass demographic information, procedural details and clinical outcomes. The primary endpoint is the prevalence of oxygenation and ventilatory support strategies: conventional oxygen therapy, high-flow oxygen therapy, continuous positive airway pressure, non-invasive ventilation and invasive mechanical ventilation. Secondary outcomes include periprocedural respiratory and haemodynamic events, patient comfort, dyspnoea and postprocedural complications. Statistical analyses include descriptive statistics, subgroup comparisons and multivariate logistic regression.Ethics and dissemination The study has received ethical approval from the coordinating centre (protocol n. 22/2022 on the 20 January 2022, by the ‘Comitato Etico Sezione Area Centro - Regione Calabria’) and all participating sites. Informed consent is given from all patients or their legal representatives. Findings will be disseminated through peer-reviewed publications and presentations at international meetings. Data will be managed and made available on reasonable request to support further research.Trial registration number ClinicalTrials.gov ID: NCT05681962. Registered January 2023.

BACKGROUND:High-flow nasal therapy (HFNT) is a widely used non-invasive respiratory support technique, but data on its clinical application remain limited. This study aimed to assess clinicians' self-reported practices, perceptions and barriers regarding HFNT use in acute and chronic respiratory failure. METHODS:A cross-sectional web-based survey was disseminated among members of the European Respiratory Society's respiratory intensive care, rehabilitation and chronic care, and allied respiratory professionals assemblies from September to November 2023. Descriptive analysis was performed, with results presented as frequencies and percentages. RESULTS:A total of 1176 clinicians from 104 countries participated, primarily pulmonologists (78.3%) and respiratory therapists (9.7%). HFNT was most commonly used for de novo acute respiratory failure (56.2%) and interstitial lung disease exacerbations (56.3%), with lower utilisation for chronic obstructive pulmonary disease with hypercapnia (47.4%) and trauma/atelectasis (41.5%). Despite guideline recommendations, 67% of respondents initiated HFNT only after conventional oxygen therapy failure. HFNT was also frequently used for symptom relief in palliative care, despite limited supporting evidence. Respiratory distress was the primary clinical trigger for HFNT initiation, while the ROX (Respiratory Rate-Oxygenation) index was rarely used to guide escalation of care (32%). Barriers to HFNT adoption included equipment costs (23%), lack of funding (22%) and limited clinician knowledge (18%). HFNT use increased during the COVID-19 pandemic (84%), but long-term application for chronic respiratory failure remained rare (16%). CONCLUSIONS:This survey highlights significant variability in HFNT practices and a disconnect between guidelines and real-world implementation. Addressing financial and educational barriers may improve adherence to evidence-based recommendations.

INTRODUCTION:Chronic Obstructive Pulmonary Disease (COPD) is a debilitating condition marked by persistent airflow limitation, leading to increased morbidity and mortality. Acute exacerbations of COPD (AECOPD) can cause rapid deterioration, resulting in hypercapnic respiratory failure and respiratory acidosis. Non-invasive ventilation (NIV) is a key treatment for AECOPD, improving gas exchange, oxygenation, and reducing work of breathing while avoiding the risks of invasive mechanical ventilation (IMV). AREAS COVERED:This review highlights NIV role as a first-line therapy in AECOPD management, discussing its mechanisms, indications, and clinical benefits. Proper patient selection, tailored settings, and careful monitoring are crucial for optimizing outcomes and minimizing complications. EXPERT OPINION:The widespread use of NIV in AECOPD management raises concerns about staff expertise, as success depends on patient selection, ventilator settings, and monitoring. Identifying failure predictors is crucial to prevent delayed intubation and poor outcomes. Research should focus on training, reducing errors, and advancing technology, including Artificial Intelligence-driven automation to improve synchrony. Despite its increased use, especially during COVID-19, progress in staff education and technology remains limited. Enhancing clinician confidence and developing intelligent ventilator algorithms are key, but human expertise remains essential in ensuring effective and life-saving NIV application.

BACKGROUND: There is a lack of evidence to guide treatment of patients with a concomitant indication for transcatheter aortic valve implantation (TAVI) and complex, high-risk percutaneous coronary intervention (PCI). AIMS: We aimed to assess different strategies of PCI timing in this high-risk TAVI cohort. METHODS: The ASCoP registry retrospectively included patients with a clinical indication for both TAVI and PCI with at least 1 criterion of complex or high-risk PCI. The primary endpoint was a composite of all-cause death and unplanned rehospitalisation for cardiovascular causes. The secondary endpoint was a composite of all-cause death, stroke, acute myocardial infarction, major bleeding, major vascular complication and unplanned revascularisation. Multivariable analysis was used to adjust for possible confounders. RESULTS: A total of 519 patients were included: 363 (69.9%) underwent staged procedures and 156 (30.1%) concomitant TAVI and PCI. After 441 (interquartile range 182-824) days, the primary endpoint occurred in 151 (36.5%) cases, without any significant difference between the 2 groups (p=0.98), while the secondary endpoint occurred more frequently in the concomitant group (n=36 [25.8%] vs n=57 [17.4%]; p=0.014). CONCLUSIONS: In patients undergoing TAVI and complex/high-risk PCI, a concomitant strategy is associated with a higher rate of adverse events and increased procedural risk. (ClinicalTrials.gov: NCT05750927).

Background: Nosocomial lower respiratory tract infections (nLRTIs) are associated with unfavorable clinical outcomes and significant healthcare costs. nLRTIs include hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and other ICU-acquired pneumonia phenotypes. While risk factors for mortality in these infections are critical to guide preventive strategies, it remains unclear whether they vary based on their requirement of invasive mechanical ventilation (IMV) at any point during the hospitalization. Objectives: This study aims to identify risk factors associated with short- and long-term mortality in patients with nLRTIs, considering differences between those requiring IMV and those who do not. Methods: This multinational prospective cohort study included ICU-admitted patients diagnosed with nLRTI from 28 hospitals across 13 countries in Europe and South America between May 2016 and August 2019. Patients were selected based on predefined inclusion and exclusion criteria, and clinical data were collected from medical records. A random forest classifier determined the most optimal clustering strategy when comparing pneumonia site acquisition [ward or intensive care unit (ICU)] versus intensive mechanical ventilation (IMV) necessity at any point during hospitalization to enhance the accuracy and generalizability of the regression models. Results: A total of 1060 patients were included. The random forest classifier identified that the most efficient clustering strategy was based on ventilation necessity. In total, 76.4% of patients [810/1060] received IMV at some point during the hospitalization. Diabetes mellitus was identified to be associated with 28-day mortality in the non-IMV group (OR [IQR]: 2.96 [1.28–6.80], p = 0.01). The 90-day mortality-associated factor was MDRP infection (1.98 [1.13–3.44], p = 0.01). For ventilated patients, chronic liver disease was associated with 28-day mortality (2.38 [1.06–5.31] p = 0.03), with no variable showing statistical and clinical significance at 90 days. Conclusions: The risk factors associated with 28-day mortality differ from those linked to 90-day mortality. Additionally, these factors vary between patients receiving invasive mechanical ventilation and those in the non-invasive ventilation group. This underscores the necessity of tailoring therapeutic objectives and preventive strategies with a personalized approach.

This post-hoc analysis of a multinational, multicenter study aimed to describe and compare clinical characteristics, microbiology, and outcomes between immunosuppressed and non-immunosuppressed patients with nosocomial lower respiratory tract infections (nLRTI). The study utilized data from the European Network for ICU-related Respiratory Infections, including 1,060 adult ICU patients diagnosed with nLRTI. Descriptive statistics were used to compare baseline characteristics and pathogen distribution between groups. A Cox proportional hazards model stratified by immunosuppression status was applied to assess 28-day mortality risk, adjusting for disease severity and key clinical variables. Immunosuppression was observed in 24.9

Weaning from invasive mechanical ventilation (IMV) is a key element in the management of critically ill patients, encompassing the entire process of discontinuing IMV. Despite its importance, considerable uncertainties remain regarding the optimal strategies to achieve successful weaning. Early weaning is crucial, as IMV is associated with complications related to high mortality rates, such as prolonged weaning and intubation-associated pneumonia (IAP). This review aims to highlight the role of non-invasive respiratory supports (NIRSs), including non-invasive ventilation (NIV) and high-flow nasal cannulas (HFNCs), as a therapeutic bridge between IMV dependency and spontaneous breathing. NIV and HFNCs are recommended to prevent post-extubation respiratory failure (PERF) in high-risk and low-risk patients, respectively, and their combination appears effective in high-risk populations. On the other hand, NIV is not advised in established non-hypercapnic PERF, as it may increase mortality by delaying intubation; however, it can facilitate extubation in patients with hypercapnic respiratory failure. NIRSs may also benefit patients at high risk of post-operative pulmonary complications such as acute respiratory failure (ARF), with either NIV or HFNCs being appropriate. In light of this evidence, appropriate NIRSs selection and application may be pivotal in achieving successful weaning and better outcomes in critically ill patients.